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1.
Am Heart J ; 221: 165-176, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31955812

RESUMO

AIMS: Patients with non-ischemic systolic heart failure have an increased risk of sudden cardiac death (SCD). Myocardial fibrosis, detected as late gadolinium enhancement (LGE) with cardiac magnetic resonance (CMR), has been shown to predict all-cause mortality. We hypothesized that LGE can identify patients with non-ischemic heart failure who will benefit from ICD implantation. METHODS AND RESULTS: In this prospective observational sub-study of the Danish Study to Assess the Efficacy of ICDs in Patients with Nonischemic Systolic Heart Failure on Mortality (DANISH), 252 patients underwent CMR. LGE was quantified by the full width/half maximum method. The primary endpoint was all-cause mortality. LGE could be adequately assessed in 236 patients, median age was 61 years and median duration of heart failure was 14 months; there were 108 patients (46%) randomized to ICD. Median follow-up time was 5.3 years. Median left ventricular ejection fraction on CMR was 35%. In all, 50 patients died. LGE was present in 113 patients (48%). The presence of LGE was an independent predictor of all-cause mortality (HR 1.82; 95% CI 1.002-3.29; P = .049) after adjusting for known cardiovascular risk factors. ICD implantation did not impact all-cause mortality, for either patients with LGE (HR 1.18; 95% CI 0.59-2.38; P = .63), or for patients without LGE (HR 1.00; 95% CI 0.39-2.53; P = .99), (P for interaction =0.79). CONCLUSION: In patients with non-ischemic systolic heart failure, LGE predicted all-cause mortality. However, in this cohort, LGE did not identify a group of patients who survived longer by receiving an ICD.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Insuficiência Cardíaca Sistólica/terapia , Coração/diagnóstico por imagem , Miocárdio/patologia , Idoso , Dinamarca , Feminino , Fibrose , Humanos , Imagem por Ressonância Magnética , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mortalidade , Medição de Risco
3.
Med Clin North Am ; 103(5): 931-943, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31378335

RESUMO

Cardiac implantable electronic devices (CIEDs) provide lifesaving therapy for the treatment of bradyarrhythmias, ventricular tachyarrhythmias, and advanced systolic heart failure. Advances in CIED therapy have expanded the number of patients receiving permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices. These devices improve quality of life and, in many cases, reduce mortality. However, limitations remain in the management of patients who require CIED therapy. This article provides a broad overview of CIED therapy in the management of the cardiac patient.


Assuntos
Bradicardia/terapia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca Sistólica/terapia , Taquicardia Ventricular/terapia , Dispositivos de Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Humanos , Marca-Passo Artificial , Qualidade de Vida
4.
Clin Res Cardiol ; 108(10): 1117-1127, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30874886

RESUMO

AIMS: In the IN-TIME trial, automatic daily implant-based multiparameter telemonitoring significantly improved clinical outcomes in patients with chronic systolic heart failure and implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D). We compared IN-TIME results for ICD and CRT-D subgroups. METHODS: Patients with LVEF ≤ 35%, NYHA class II/III, optimized drug treatment, no permanent atrial fibrillation, and a dual-chamber ICD (n = 274) or CRT-D (n = 390) were randomized 1:1 to telemonitoring or no telemonitoring for 12 months. Primary outcome measure was a composite clinical score, classified as worsened if the patient died or had heart failure-related hospitalization, worse NYHA class, or a worse self-reported overall condition. RESULTS: The prevalence of worsened score at study end was higher in CRT-D than ICD patients (26.4% vs. 18.2%; P = 0.014), as was mortality (7.4% vs. 4.1%; P = 0.069). With telemonitoring, odds ratios (OR) for worsened score and hazard ratios (HR) for mortality were similar in the ICD [OR = 0.55 (P = 0.058), HR = 0.39 (P = 0.17)] and CRT-D [OR = 0.68 (P = 0.10), HR = 0.35 (P = 0.018)] subgroups (insignificant interaction, P = 0.58-0.91). CONCLUSION: Daily multiparameter telemonitoring has a potential to reduce clinical endpoints in patients with chronic systolic heart failure both in ICD and CRT-D subgroups. The absolute benefit seems to be higher in higher-risk populations with worse prognosis.


Assuntos
Terapia de Ressincronização Cardíaca/métodos , Desfibriladores Implantáveis , Insuficiência Cardíaca Sistólica/terapia , Volume Sistólico/fisiologia , Telemedicina/métodos , Idoso , Causas de Morte/tendências , Feminino , Seguimentos , Alemanha/epidemiologia , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento
5.
Circ Arrhythm Electrophysiol ; 12(3): e007022, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30866666

RESUMO

Background Patients with nonischemic systolic heart failure are at an increased risk of sudden cardiac death, but more discriminating tools are needed to identify those patients likely to benefit from implantable cardioverter-defibrillator (ICD) implantation. Whether right ventricular (RV) ejection fraction (RVEF) can identify patients with nonischemic systolic heart failure more likely to benefit from ICD implantation is not yet known. Methods In this post hoc analysis of the DANISH trial (Danish Study to Assess the Efficacy of ICDs in Patients with Nonischemic Systolic Heart Failure on Mortality), patients with nonischemic systolic heart failure randomized to ICD or control underwent cardiovascular magnetic resonance. RV systolic dysfunction was defined as RVEF ≤45%. Cox regression assessed the effects of RV function and ICD implantation on all-cause mortality, sudden cardiac death, and cardiovascular death. Results Overall, 239 patients had interpretable images of RV volume. Median RVEF was 51%, RV systolic dysfunction was present in 75 (31%) patients, and 55 (23%) patients died. RVEF was an independent predictor of all-cause mortality, hazards ratio 1.34 per 10% absolute decrease in RVEF (95% CI, 1.05-1.70), P=0.02. There was a statistically significant interaction between RVEF and the effect of ICD implantation ( P=0.001). ICD implantation significantly reduced all-cause mortality in patients with RV systolic dysfunction, hazards ratio 0.41 (95% CI, 0.17-0.97), P=0.04 but not in patients without RV systolic dysfunction, hazards ratio 1.87 (95% CI, 0.85-3.92), P=0.12, ( P=0.01 for the difference in effect of ICD between RV groups). Conclusions In this post hoc analysis of the DANISH trial, ICD therapy was associated with survival benefit in patients with biventricular heart failure. These findings need confirmation in a prospective study. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00542945.


Assuntos
Cardioversão Elétrica/instrumentação , Insuficiência Cardíaca Sistólica/terapia , Volume Sistólico , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Direita/terapia , Função Ventricular Esquerda , Função Ventricular Direita , Idoso , Tomada de Decisão Clínica , Morte Súbita Cardíaca/etiologia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Dinamarca , Feminino , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Imagem Cinética por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Recuperação de Função Fisiológica , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/mortalidade , Disfunção Ventricular Direita/fisiopatologia
6.
Card Electrophysiol Clin ; 11(1): 141-146, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30717846

RESUMO

Cardiac resynchronization therapy has been proven to be clearly beneficial for patients with heart failure, a prolonged QRS duration, and a left ventricular ejection fraction ≤35%. Ejection fraction cutoff, however, is arbitrary and very likely excludes many patients who could benefit from cardiac resynchronization. This article describes the major detrimental effects of left bundle branch block and summarizes the data regarding the potential beneficial effects of cardiac resynchronization in patients with a left ventricular ejection fraction greater than 35%.


Assuntos
Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca Sistólica/terapia , Bloqueio de Ramo , Humanos , Estudos Prospectivos , Volume Sistólico
8.
J Heart Lung Transplant ; 37(11): 1285-1288, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30197209

RESUMO

Emerging clinical evidence has suggested that short-term mechanical augmentation of cardiac output (CO) may not consistently improve mortality in patients with cardiogenic shock (CS), despite improvements in hemodynamics. Such failures could reflect the underlying complexity of the mechanisms that contribute to malperfusion and organ dysfunction in CS. Distinct molecular and physiologic shock endophenotypes likely exist among patients with CS, with hemodynamic aberrations as the inciting insult but not necessarily the primary drivers of clinical outcomes. We propose that building a framework that moves away from the current "hemodynamic model" in preference for a "mechanistic disease-modifying model" of CS may facilitate progress toward reducing the stagnant mortality rates in this population. Such a therapeutic paradigm shift in patients with chronic systolic heart failure-the shift away from strategies that augment CO to those that modulate the systemic responses to low CO-has been one of the single most important shifts in contemporary cardiovascular medicine.


Assuntos
Débito Cardíaco/fisiologia , Insuficiência Cardíaca Sistólica/fisiopatologia , Coração Auxiliar , Hemodinâmica/fisiologia , Modelos Cardiovasculares , Choque Cardiogênico/fisiopatologia , Causas de Morte , Doença Crônica , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/terapia , Ventrículos do Coração/fisiopatologia , Humanos , Insuficiência de Múltiplos Órgãos/mortalidade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Oxigênio/sangue , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico/mortalidade
9.
BMJ Open ; 8(7): e022185, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30068620

RESUMO

OBJECTIVES: Patients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre. DESIGN: A single-centre, retrospective, cohort study. SETTING: Conducted in an academic emergency department (ED) between January 2010 and January 2015. Patients' charts were queried via the hospital's electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population. PARTICIPANTS: A total of 174 patients, of which 87 (50%) were patients with CHF. PRIMARY AND SECONDARY OUTCOMES: The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups. RESULTS: Patients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p<0.001). ED length of stay was found to be lower in patients with CHF (15.12±24.45 hours vs 18.17±26.13 hours, p=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p=0.149). CONCLUSION: Patients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.


Assuntos
Serviço Hospitalar de Emergência , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência de Múltiplos Órgãos/mortalidade , Sepse/mortalidade , Centros de Atenção Terciária , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca Sistólica/fisiopatologia , Insuficiência Cardíaca Sistólica/terapia , Mortalidade Hospitalar , Humanos , Líbano/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/fisiopatologia , Insuficiência de Múltiplos Órgãos/terapia , Avaliação de Resultados da Assistência ao Paciente , Estudos Retrospectivos , Sepse/fisiopatologia , Sepse/terapia , Sinais Vitais
10.
Eur Heart J ; 39(39): 3584-3592, 2018 10 14.
Artigo em Inglês | MEDLINE | ID: mdl-30060125

RESUMO

Aims: The impact of tricuspid regurgitation (TR) in patients with left ventricular systolic dysfunction on presentation and clinical outcome is uncertain due to confounding comorbidities and mediocre regurgitation ascertainment. Methods and results: In a cohort of patients with left ventricular systolic dysfunction (ejection fraction, EF < 50%) and functional TR (assessed quantitatively), we matched TR grade-groups for age, sex, EF, and TR velocity. Association of quantified TR (effective regurgitant orifice, ERO, severe if ≥0.4 cm2) to clinical presentation and outcome was analysed. In the 291 cohort patients (age 70 ± 12 years) with left ventricular dysfunction (EF 31 ± 10%), functional TR ERO was 0.26 ± 0.3 cm2. Presentation with right heart failure was strongly related to TR quantified severity [adjusted odds ratios were 4.15 (1.95-8.84), P = 0.0002 for moderate TR and 6.86 (3.34-14.1), P < 0.0001 for severe TR]. Effective regurgitant orifice ≥0.4 cm2 was associated with increased mortality [hazard ratio 1.6 (1.17-2.2), P = 0.003] unadjusted and after comprehensive adjustment [hazard ratio 1.8 (1.16-2.8), P = 0.009]. Furthermore, ERO ≥0.4 cm2 was associated with increased cardiac events (mortality, new atrial fibrillation or heart failure) unadjusted [hazard ratio 1.9 (1.3-2.7), P = 0.002] and after comprehensive adjustment [hazard ratio 2.2 (1.1-4.6), P = 0.02]. Conclusion: Tricuspid regurgitation, even moderate, is associated at diagnosis with more severe heart failure presentation. While moderate TR is associated with heart failure at presentation, our quantitative data show that the threshold associated with reduced survival and more cardiac events is ERO ≥0.4 cm2. These data emphasize the clinical impact of functional TR and warrant large cohort-analysis and clinical trials of treatment of TR associated with left ventricular dysfunction.


Assuntos
Insuficiência Cardíaca Sistólica , Insuficiência da Valva Tricúspide , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/mortalidade , Insuficiência da Valva Tricúspide/terapia
11.
JACC Heart Fail ; 6(5): 413-420, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29724363

RESUMO

OBJECTIVES: This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. BACKGROUND: Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. METHODS: Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. RESULTS: Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). CONCLUSIONS: Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans.


Assuntos
Afro-Americanos/estatística & dados numéricos , Cardiologistas/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Insuficiência Cardíaca Diastólica/terapia , Insuficiência Cardíaca Sistólica/terapia , Afro-Americanos/etnologia , Idoso , Feminino , Disparidades em Assistência à Saúde/etnologia , Insuficiência Cardíaca Diastólica/etnologia , Insuficiência Cardíaca Diastólica/mortalidade , Insuficiência Cardíaca Sistólica/etnologia , Insuficiência Cardíaca Sistólica/mortalidade , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
13.
J Interv Card Electrophysiol ; 53(1): 31-39, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29627954

RESUMO

PURPOSE: In order to increase the responder rate to CRT, stimulation of the left ventricular (LV) from multiple sites has been suggested as a promising alternative to standard biventricular pacing (BIV). The aim of the study was to compare, in a group of candidates for CRT, the effects of different pacing configurations-BIV, triple ventricular (TRIV) by means of two LV leads, multipoint (MPP), and multipoint plus a second LV lead (MPP + TRIV) pacing-on both hemodynamics and QRS duration. METHODS: Fifteen patients (13 male) with permanent AF (mean age 76 ± 7 years; left ventricular ejection fraction 33 ± 7%; 7 with ischemic cardiomyopathy; mean QRS duration 178 ± 25 ms) were selected as candidates for CRT. Two LV leads were positioned in two different branches of the coronary sinus. Acute hemodynamic response was evaluated by means of a RADI pressure wire as the variation in LVdp/dtmax. RESULTS: Per patient, 2.7 ± 0.7 veins and 5.2 ± 1.9 pacing sites were evaluated. From baseline values of 998 ± 186 mmHg/s, BIV, TRIV, MPP, and MPP-TRIV pacing increased LVdp/dtmax to 1200 ± 281 mmHg/s, 1226 ± 284 mmHg/s, 1274 ± 303 mmHg, and 1289 ± 298 mmHg, respectively (p < 0.001). Bonferroni post-hoc analysis showed significantly higher values during all pacing configurations in comparison with the baseline; moreover, higher values were recorded during MPP and MPP + TRIV than at the baseline or during BIV and also during MPP + TRIV than during TRIV. Mean QRS width decreased from 178 ± 25 ms at the baseline to 171 ± 21, 167 ± 20, 168 ± 20, and 164 ± 15 ms, during BIV, TRIV, MPP, and MPP-TRIV, respectively (p < 0.001). CONCLUSIONS: In patients with AF, the acute response to CRT improves as the size of the early activated LV region increases.


Assuntos
Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca Sistólica/diagnóstico , Insuficiência Cardíaca Sistólica/terapia , Hemodinâmica/fisiologia , Volume Sistólico/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estimulação Cardíaca Artificial/métodos , Estimulação Cardíaca Artificial/mortalidade , Estudos de Coortes , Feminino , Insuficiência Cardíaca Sistólica/mortalidade , Humanos , Masculino , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/terapia , Seleção de Pacientes , Prognóstico , Estudos Prospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento , Remodelação Ventricular/fisiologia
14.
J Interv Card Electrophysiol ; 52(1): 77-89, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29541969

RESUMO

PURPOSE: Implantable cardioverter-defibrillators (ICDs) improve survival of systolic heart failure (HF) patients who are at risk of sudden cardiac death (SCD). We recently showed that electrocardiographic (ECG) global electrical heterogeneity (GEH) is independently associated with SCD in the community-dwelling cohort and developed GEH SCD risk score. The Global Electrical Heterogeneity and Clinical Outcomes (GEHCO) study is a retrospective multicenter cohort designed with two goals: (1) validate an independent association of ECG GEH with sustained ventricular tachyarrhythmias and appropriate ICD therapies and (2) validate GEH ECG risk score for prediction of sustained ventricular tachyarrhythmias and appropriate ICD therapies in systolic HF patients with primary prevention ICD. METHODS: All records of primary prevention ICD recipients with available data for analysis are eligible for inclusion. Records of ICD implantation in patients with inherited channelopathies and cardiomyopathies are excluded. Raw digital 12-lead pre-implant ECGs will be used to measure GEH (spatial QRST angle, spatial ventricular gradient magnitude, azimuth, and elevation, and sum absolute QRST integral). The primary endpoint is defined as a sustained ventricular tachyarrhythmia event with appropriate ICD therapy. All-cause death without preceding sustained ventricular tachyarrhythmia with appropriate ICD therapy will serve as a primary competing outcome. The study will draw data from the academic medical centers. RESULTS: We describe the study protocol of the first multicenter retrospective cohort of primary prevention ICD patients with recorded at baseline digital 12-lead ECG. CONCLUSION: Findings from this study will inform future trials to identify patients who are most likely to benefit from primary prevention ICD. TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT03210883.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis/estatística & dados numéricos , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/terapia , Vetorcardiografia/métodos , Centros Médicos Acadêmicos , Idoso , Estudos de Coortes , Eletrocardiografia/métodos , Feminino , Seguimentos , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Taquicardia Ventricular/mortalidade , Resultado do Tratamento
15.
JACC Heart Fail ; 6(4): 308-316, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29598935

RESUMO

OBJECTIVES: This study compares and contrasts the recommended indications for cardiac resynchronization therapy (CRT) according to the most recent guidelines from international cardiology societies. BACKGROUND: CRT has been shown to reduce morbidity and mortality in selected patients with systolic heart failure. Cardiology societies provide guidelines regarding the indications for CRT. As evidence evolves, it is challenging for the guideline committees to review the impact of newer evidence in a timely fashion. METHODS: Six of the most recent international guidelines providing recommendation concerning CRT implantation ranging from 2011 to 2017 were reviewed. These included guidelines from 2 European, 1 North American, 1 Canadian, and 1 Australian/New Zealand societies and the National Institute for Health and Care Excellence guidelines, specific to the United Kingdom. RESULTS: Although international societies provide consistent recommendations for most CRT indications, differences are found in recommendations for several important patient populations. Specifically, divergent recommendations exist regarding QRS duration, bundle branch morphology, patients in atrial fibrillation, choice of device type (CRT pacemakers vs. CRT defibrillators), and selected patients who are likely to be dependent on right ventricular pacing. The timing of publication of specific guidelines appears to play an essential role in explaining these disparities. CONCLUSIONS: Despite general consistency in international guideline recommendations, there remain certain patient populations for whom there are variations in recommendations concerning eligibility for CRT and selection of the most appropriate device in the individual patient.


Assuntos
Bloqueio de Ramo/terapia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca Sistólica/terapia , Internacionalidade , Guias de Prática Clínica como Assunto , American Heart Association , Austrália , Bloqueio de Ramo/complicações , Bloqueio de Ramo/fisiopatologia , Canadá , Dispositivos de Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Eletrocardiografia , Europa (Continente) , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/fisiopatologia , Humanos , Nova Zelândia , Seleção de Pacientes , Índice de Gravidade de Doença , Sociedades Médicas , Reino Unido , Estados Unidos
18.
Pol Merkur Lekarski ; 45(270): 220-225, 2018 Dec 28.
Artigo em Inglês | MEDLINE | ID: mdl-30693906

RESUMO

Identification of demographic and clinical factors which influence prognosis is crucial in patients with heart failure and cardiac resynchronization therapy (CRT). MATERIALS AND METHODS: The study included 223 patients with CRT (177 males), mean age 64.6±9.7 years, including 98 patients (43.9%) with defibrillation function (CRT-D) and 58 (26.0%) with permanent atrial fibrillation (AF). Of 223, n=72 patients (32.3%) had CRT implanted after the age of 70. The mean follow-up was 37±19 months. Mortality rates and other clinical factors according to age were assessed in multivariable analysis of CRT patients follow-up. RESULTS: Total mortality was 30.9%. Mortality rate was similar in subjects aged ≤70 and >70 (HR:1.41, 95%CI:0.70-2.82). The female gender was the strongest clinical factor of best prognosis (HR:0.12,95%CI:0.03-0.59, p=0.0088). Lower mortality was also associated with higher left ventricular ejection fraction (HR:0.94,95%CI:0.90-0.98, p=0.0031). Coronary disease (HR:2.09,95%CI:1.10-3.99, p=0.0245), chronic kidney disease (HR:3.00, 95%CI:1.47-6.12, p=0.0024)and higher NYHA class (HR:2.28, 95%CI:1.18-4.40, p=0.0137) were factors of increased mortality. For patients >70 years old, gender was not a survival determining factor and mortality was lower in regard to hypertension or permanent AF. Only chronic kidney disease was significantly associated with higher mortality in patients >70 years old (HR:6.74, 95%CI:1.90-23.9). The use of defibrillation function had no influence on survival rate at any age. CONCLUSIONS: In patients with cardiac resynchronization therapy female gender was not associated with mortality and was the factor of better prognosis. For subjects aged >70 a worse prognosis was related to renal insufficiency.


Assuntos
Fibrilação Atrial , Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca Sistólica , Insuficiência Cardíaca , Idoso , Feminino , Insuficiência Cardíaca Sistólica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Fatores de Risco , Resultado do Tratamento , Função Ventricular Esquerda
19.
Int J Cardiovasc Imaging ; 34(4): 553-560, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29098525

RESUMO

Heart failure (HF) is associated with morbidity and mortality. Real-time three-dimensional echocardiography (RT3DE) may offer additional prognostic data in patients with HF. The study aimed to evaluate the prognostic value of real-time three-dimensional echocardiography (RT3DE). This is a prospective study that included 89 patients with HF and left ventricular ejection fraction (LVEF) < 0.50 who were followed for 48 months. Left atrium and ventricular volumes and functions were evaluated by RT3DE. TDI and two-dimensional echocardiography parameters were also obtained. The endpoint was a composite of death, heart transplantation and hospitalization for acute decompensated HF. The mean age was 55 ± 11 years, and the LVEF was 0.32 ± 0.10. The composite endpoint occurred in 49 patients (18 deaths, 30 hospitalizations, one heart transplant). Patients with outcomes had greater left atrial volume (40 ± 16 vs. 32 ± 12 mL/m2; p < 0.01) and right ventricle diameter (41 ± 9 vs. 37 ± 8 mm, p = 0.01), worse total emptying fraction of the left atrium (36 ± 13% vs. 41 ± 11%; p = 0.03), LVEF (0.30 ± 0.09 vs. 0.34 ± 0.11; p = 0.02), right ventricle fractional area change (34.8 ± 12.1% vs. 39.2 ± 11.3%; p = 0.04), and greater E/e' ratio (19 ± 9 vs. 16 ± 8; p = 0.04) and systolic pulmonary artery pressure (SPAP) (50 ± 15 vs. 36 ± 11 mmHg; p < 0.01). In multivariate analysis, LVEF (OR 4.6; CI 95% 1.2-17.6; p < 0.01) and SPAP (OR 12.5; CI 95% 1.8-86.9; p < 0.01) were independent predictors of patient outcomes. LVEF and the SPAP were independent predictors of outcomes in patients with HF.


Assuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Hemodinâmica , Adulto , Idoso , Área Sob a Curva , Intervalo Livre de Doença , Feminino , Insuficiência Cardíaca Sistólica/mortalidade , Insuficiência Cardíaca Sistólica/fisiopatologia , Insuficiência Cardíaca Sistólica/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Variações Dependentes do Observador , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Reprodutibilidade dos Testes , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Função Ventricular Esquerda
20.
J Intensive Care Med ; 33(2): 128-133, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29141525

RESUMO

BACKGROUND: Acute heart failure (AHF) is one of the leading causes of admission to emergency department (ED); severe hypoxemic AHF may be treated with noninvasive ventilation (NIV). Despite the demonstrated clinical efficacy of NIV in relieving symptoms of AHF, less is known about the hyperacute effects of bilevel positive airway pressure (BiPAP) ventilation on hemodynamics of patients admitted to ED for AHF. We therefore aimed to assess the effect of BiPAP ventilation on principal hemodynamic, respiratory, pulse oximetry, and microcirculation indexes in patients admitted to ED for AHF, needing NIV. METHODS: Twenty consecutive patients admitted to ED for AHF and left ventricular systolic dysfunction, needing NIV, were enrolled in the study; all patients were treated with NIV in BiPAP mode. The following parameters were measured at admission to ED (T0, baseline before treatment), 3 hours after admission and initiation of BiPAP NIV (T1), and after 6 hours (T2): arterial blood oxygenation (pH, partial pressure of oxygen in the alveoli/fraction of inspired oxygen ratio, Paco2, lactate concentration, HCO3-), hemodynamics (tricuspid annular plane systolic excursion, transpulmonary gradient, transaortic gradient, inferior vena cava diameter, brain natriuretic peptide [BNP] levels), microcirculation perfusion (end-tidal CO2 [etco2], peripheral venous oxygen saturation [SpvO2]). RESULTS: All evaluated indexes significantly improved over time (analysis of variance, P < .001 in quite all cases.). CONCLUSIONS: The BiPAP NIV may rapidly ameliorate several hemodynamic, arterial blood gas, and microcirculation indexes in patients with AHF and left ventricular systolic dysfunction.


Assuntos
Acidose Respiratória/terapia , Pressão Positiva Contínua nas Vias Aéreas/métodos , Insuficiência Cardíaca Sistólica/terapia , Hemodinâmica , Hipercapnia/terapia , Hipóxia/terapia , Insuficiência Respiratória/terapia , Disfunção Ventricular Esquerda/terapia , Acidose Respiratória/sangue , Acidose Respiratória/etiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Serviço Hospitalar de Emergência , Feminino , Insuficiência Cardíaca Sistólica/sangue , Insuficiência Cardíaca Sistólica/complicações , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Humanos , Concentração de Íons de Hidrogênio , Hipercapnia/sangue , Hipercapnia/etiologia , Hipóxia/sangue , Hipóxia/etiologia , Modelos Lineares , Masculino , Microcirculação , Análise Multivariada , Peptídeo Natriurético Encefálico/sangue , Ventilação não Invasiva , Oximetria , Estudos Prospectivos , Insuficiência Respiratória/sangue , Insuficiência Respiratória/etiologia , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico por imagem
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