Telemonitoramento da Insuficiência Cardíaca - A Experiência de um Centro / Telemonitoring in Heart Failure - A Single Center Experience

Resumo Fundamento A evolução natural da insuficiência cardíaca é uma pior progressiva e internações hospitalares recorrentes. São necessárias estratégias para se detectar descompensações em tempo hábil. O uso do telemonitoramento da insuficiência cardíaca é inconsistente. Objetivos Este estudo tem o objetivo de avaliar o impacto desse programa de telemonitoramento (PTM) em internações hospitalares e admissões em serviços de emergência. Métodos Este é um estudo retrospectivo observacional que analisou dados de todos os pacientes que se cadastraram no PTM de janeiro a 2018 a dezembro de 2019. Foram coletados dados demográficos, clínicos e relacionados ao PTM. O número de internações hospitalares e admissões em serviços de emergência do ano anterior e posterior ao cadastro foram comparados, utilizando-se o teste de Wilcoxon. Um p-valor bilateral de <0,05 foi considerado significativo. Resultados Um total de 39 pacientes foram cadastrados, com uma média de idade de 62,1 ± 14 anos e predominância de pacientes do sexo masculino (90%). As causas mais comuns de insuficiência cardíaca foram cardiomiopatia isquêmica e dilatada. A fração de ejeção média foi de 30% e o tempo mediano da duração da doença foi de 84 meses (FIQ 33-144). Pacientes que foram cadastrados por menos de um mês foram excluídos, com um total de 34 pacientes analisados. Os pacientes foram acompanhados no PTM por um período mediano de 320 dias. O número de admissões em serviços de emergência foi reduzido em 66% (p<0,001) e o número de internações hospitalares por insuficiência cardíaca foi reduzido em 68% (p<0,001). O PTM não teve impacto no número de internações hospitalares por outras causas. Conclusões Este estudo sugere que o PTM poderia reduzir a utilização de serviços de saúde em pacientes com insuficiência cardíaca.

Abstract Background The natural history of heart failure is a progressive decline and recurrent hospital admissions. New strategies to timely detect decompensations are needed. The use of telemonitoring in heart failure is inconsistent. Objectives This study aimed to evaluate the impact of this telemonitoring program (TMP) in hospitalizations and emergency department admissions. Methods This is a retrospective observational study, that analyzed data of all the patients who enrolled in the TMP program from January 2018 to December 2019. Demographic, clinical, and TMP-related data were collected. The number of hospitalizations and emergency department admissions from the year before and after enrollment were compared, using the Wilcoxon test. A two-sided p<0.05 was considered significant. Results A total of 39 patients were enrolled, with a mean age of 62.1 ± 14 years and a male predominance (90%). The most common causes of heart failure were ischemic and dilated cardiomyopathy. The mean ejection fraction was 30% and the median time of disease duration was 84 months (IQR 33-144). Patients who were enrolled for less than one month were excluded, with a total of 34 patients analyzed. Patients were followed in the TMP for a median of 320 days. The number of emergency department admissions was reduced by 66% (p<0.001), and the number of hospitalizations for heart failure was reduced by 68% (p<0.001). The TMP had no impact on the number of hospitalizations for other causes. Conclusions This trial suggests that a TMP could reduce health service use in patients with heart failure.

Avaliação de pacientes com insuficiência cardíaca admitidos em hospital secundário / Evaluation of patients with heart failure admitted to a secondary hospital

Objetivo: Elaborar um perfil clínico e epidemiológico de pacientes com insuficiência cardíaca descompensada, de acordo com a etiologia da descompensação, e analisar o desfecho clínico dentre os diferentes grupos etiológicos encontrados. Métodos: Estudo retrospectivo e observacional. Os pacientes foram reunidos em seis grupos, conforme etiologia de descompensação, e comparados de acordo com dados coletados. Realizaram-se verificação por meio da análise de variância e teste exato de Fisher. Obteve-se significância estatística por meio do valor de p <0,10. Resultados: Foram analisados 123 prontuários de pacientes admitidos entre 2016 e 2018. A maior causa de descompensação da doença foi a má aderência ao tratamento (32,5%). Além disso, a doença foi responsável por maior tempo de internação (13,5 dias) e número de óbitos (seis). Conclusão: Otimizando-se os cuidados e o acompanhamento desses pacientes, pode haver um importante impacto sobre a incidência, as complicações e a frequência de descompensações. (AU)

Objective: To develop a clinical and epidemiological profile of patients with decompensated heart failure according to the etiology of decompensation and to analyze the clinical outcome among the different etiological groups found. Methods: This is a retrospective, observational study. Patients were divided in six groups according to etiology of decompensation and were compared according to data collected. Variance analysis and Fisher's exact test were performed. Statistical significance was obtained by means of p-value <0.10. Results: We analyzed 123 medical records of patients admitted between 2016 and 2018. The greatest cause of decompensation was the poor adherence to treatment (32.5%). In addition, the disease was responsible for longer hospitalization time (13.5 days) and number of deaths (six). Conclusion: Optimizing care and follow-up of these patients can have an important impact on the incidence, complications, and frequency of decompensation. (AU)

Integração dos cuidados paliativos no planejamento assistencial ao paciente com insuficiência cardíaca crônica / Integration of palliative care in care planning for patients with chronic heart failure

A Insuficiência Cardíaca é o desfecho final comum às doenças de origem cardiovascular. Cerca de 23 milhões de pessoas no mundo são afetadas por esta patologia. Como parte integrante do tratamento são indicados os cuidados paliativos para prevenção e alívio do sofrimento. Nesse cenário de múltiplas interações surgem desafios que influenciam o planejamento da assistência. Objetivos: apreender a percepção dos profissionais de saúde acerca dos fatores intervenientes à integração dos cuidados paliativos no processo de planejamento assistencial ao binômio paciente/familiar com insuficiência cardíaca crônica, e discutir os limites e as possibilidades de integração dos cuidados paliativos neste contexto. Método: estudo qualitativo, descritivo e exploratório, realizado com profissionais experientes na assistência aos pacientes com insuficiência cardíaca em cuidados paliativos, em uma instituição federal de referência para o tratamento de doenças cardiovasculares no Rio de Janeiro, Brasil. Os dados foram coletados entre julho de 2020 e julho de 2021. Foram realizadas entrevistas semiestruturadas e o conteúdo analisado a partir da análise de conteúdo temática. Resultados: a partir da percepção dos profissionais os maiores desafios vivenciados pelos indivíduos que necessitam desses cuidados se encontram na esfera social com repercussão para as demais áreas da vida. Na macropolítica, evidenciou-se a necessidade de estruturação de serviços de atenção domiciliar especializados na assistência a esse perfil de pacientes. Fragilidades na formação dos profissionais sobre esse tema, a alta rotatividade na instituição, somado a sobrecarga de trabalho, foram percebidos como fatores desafiadores para o alcance da qualidade assistencial. Considerações finais: A realidade identificada nesse estudo pode ser a mesma enfrentada em outras instituições do país, apontando possíveis necessidades de intervenção por meio do fortalecimento de políticas públicas. Ainda é preciso investir na construção de diretrizes mais claras que unam os cuidados paliativos em cada fase da insuficiência cardíaca.

Heart failure is the final outcome common to cardiovascular diseases. About 23 million people worldwide are affected by this pathology. As an integral part of the treatment, palliative care is indicated for the prevention and relief of suffering. In this scenario of multiple interactions, challenges arise that influence care planning. Objectives: to understand the perception of health professionals about the factors involved in the integration of palliative care in the care planning process for the patient/family with chronic heart failure, and to discuss the limits and possibilities of integrating palliative care in this context. Method: qualitative, descriptive and exploratory study, carried out with experienced professionals in the care of patients with heart failure in palliative care, in a federal institution of reference for the treatment of cardiovascular diseases in Rio de Janeiro, Brazil. Data were collected between July 2020 and July 2021. Semi-structured interviews were conducted and the content analyzed using thematic content analysis. Results: from the perception of professionals, the greatest challenges experienced by individuals who need this care are in the social sphere with repercussions for other areas of life. In macropolitics, the need for structuring home care services specialized in assisting this profile of patients was evidenced. Weaknesses in the training of professionals on this topic, the high turnover in the institution, added to the workload, were perceived as challenging factors for achieving quality of care. Final considerations: The reality identified in this study may be the same faced in other institutions in the country, pointing out possible intervention needs through the strengthening of public policies. It is still necessary to invest in the construction of clearer guidelines that unite palliative care in each phase of heart failure.

La insuficiencia cardíaca es el resultado final común a las enfermedades cardiovasculares. Cerca de 23 millones de personas en todo el mundo se ven afectadas por esta patología. Como parte integral del tratamiento, los cuidados paliativos están indicados para la prevención y alivio del sufrimiento. En este escenario de múltiples interacciones, surgen desafíos que influyen en la planificación de la atención. Objetivos: comprender la percepción de los profesionales de la salud sobre los factores que intervienen en la integración de los cuidados paliativos en el proceso de planificación del cuidado del paciente / familia con insuficiencia cardíaca crónica, y discutir los límites y posibilidades de integrar los cuidados paliativos en este contexto. Método: estudio cualitativo, descriptivo y exploratorio, realizado con profesionales experimentados en la atención de pacientes con insuficiencia cardíaca en cuidados paliativos, en una institución federal de referencia para el tratamiento de enfermedades cardiovasculares en Rio de Janeiro, Brasil. Los datos se recopilaron entre julio de 2020 y julio de 2021. Se realizaron entrevistas semiestructuradas y se analizó el contenido mediante análisis de contenido temático. Resultados: desde la percepción de los profesionales, los mayores desafíos que experimentan las personas que necesitan este cuidado se encuentran en el ámbito social con repercusiones en otros ámbitos de la vida. En macropolítica se evidenció la necesidad de estructurar los servicios de atención domiciliaria especializados en atender este perfil de pacientes. Las debilidades en la formación de los profesionales en este tema, la alta rotación en la institución, sumada a la carga de trabajo, se percibieron como factores desafiantes para lograr la calidad de la atención. Consideraciones finales: La realidad identificada en este estudio puede ser la misma que enfrentan otras instituciones del país, señalando posibles necesidades de intervención a través del fortalecimiento de políticas públicas. Todavía es necesario invertir en la construcción de pautas más claras que unan los cuidados paliativos en cada fase de la insuficiencia cardíaca.

Reliability and validity of six-minute step test in patients with heart failure

Exercise intolerance is the hallmark consequence of advanced chronic heart failure (HF). The six-minute step test (6MST) has been considered an option for the six-minute walk test because it is safe, inexpensive, and can be applied in small places. However, its reliability and concurrent validity has still not been investigated in participants with HF with reduced ejection fraction (HFrEF). Clinically stable HFrEF participants were included. Reliability and error measurement were calculated by comparing the first with the second 6MST result. Forty-eight hours after participants underwent the 6MST, they were invited to perform a cardiopulmonary exercise test (CPET) on a cycle ergometer. Concurrent validity was assessed by correlation between number of steps and peak oxygen uptake (V̇O2 peak) at CPET. Twenty-seven participants with HFrEF (60±8 years old and left ventricle ejection fraction of 41±6%) undertook a mean of 94±30 steps in the 6MST. Intra-rater reliability was excellent for 6MST (ICC=0.9), with mean error of 4.85 steps and superior and inferior limits of agreement of 30.6 and -20.9 steps, respectively. In addition, strong correlations between number of steps and CPET workload (r=0.76, P<0.01) and peak V̇O2 (r=0.71, P<0.01) were observed. From simple linear regression the following predictive equations were obtained with 6MST results: V̇O2 peak (mL/min) = 350.22 + (7.333 × number of steps), with R2=0.51, and peak workload (W) = 4.044 + (0.772 × number of steps), with R2=0.58. The 6MST was a reliable and valid tool to assess functional capacity in HFrEF participants and may moderately predict peak workload and oxygen uptake of a CPET.

Cardiopatía en el paciente anciano / Cardiovascular disease in the elderly

Las enfermedades cardiovasculares son muy frecuentes en la población anciana (pacientes mayores de 75 años). El enfrentamiento y manejo de ellas es distinto al indicado en pacientes jóvenes. Son escasos los estudios que incluyen población mayor de 75 años, con evidencia acerca de las diferencias que existen en la respuesta terapéutica en comparación al paciente joven. El anciano tiene mayor fragilidad y múltiples comorbilidades, con reserva cardiaca disminuida, lo que obliga a un manejo integral y acucioso. Los cambios propios de la edad repercuten tanto en riñón, cerebro, hígado, musculatura y corazón, lo que los hace pacientes más proclives a presentar complicaciones de la terapia farmacológica o intervencional. El objetivo de este artículo es resumir las recomendaciones sobre el manejo de las cardiopatías más frecuentes en el anciano, incluyendo insuficiencia cardiaca crónica, cardiopatía coronaria, hipertensión arterial, estenosis aórtica valvular y fibrilación auricular no valvular.

Cardiovascular diseases are very common in the elderly population, and their management is different. There are few studies that include population older than 75 years, with little evidence about the differences in the therapeutic response compared to the young patient. The elderly have greater fragility and multiple comorbidities, with diminished cardiac reserve, which requires a comprehensive and careful management. Changes due to advanced age, in kidney, brain, liver and musculature (among others), make them more vulnerable to complications of the pharmacological or interventional treatment. The objective of this article is to summarize the recommendations on the management of the most frequent heart diseases in the elderly, including chronic heart failure, coronary heart disease, arterial hypertension, valvular aortic stenosis, and non-valvular atrial fibrillation.

La anamnesis como pronóstico de mortalidad en la neumonía adquirida en la comunidad / Anamnesis as mortality prognosis in the community acquired pneumonia

RESUMEN Introducción: La neumonía adquirida en la comunidad constituye un importante problema de salud a nivel global, en Cuba es la cuarta causa de muerte. Los índices pronósticos ayudan a detectar tempranamente los pacientes de alto riesgo, pero esto tiene baja sensibilidad y especificidad. Objetivo: determinar durante la anamnesis factores pronósticos de mortalidad en la neumonía adquirida en la comunidad. Materiales y métodos: estudio analítico longitudinal retrospectivo con un grupo donde se aplicaron pruebas no paramétricas y cálculo de riesgo relativo. Resultados: edad de 78 ± 10 años con 53 % femeninas. La mortalidad global de 57 % antecedentes de diabetes mellitus, 53 % enfermedad cerebro vascular anterior 34 %, el 42 % estaba encamados. El 38 % tenían más de cinco días enfermos y el 69 % estaba consumiendo antimicrobianos antes del ingreso. El 23 % padecían de insuficiencia cardiaca congestiva y el 73 % de enfermedad pulmonar obstructiva crónica. El síndrome confusional fue un buen predictor de mortalidad (x2=0,05) (RR=2,8). El encamamiento prolongado no predijo mortalidad a los cinco días (x2=0,43). El uso de antimicrobianos previos incremento el riesgo en (RR=0,8) con (x2=0,05). La insuficiencia cardiaca fue el mejor predictor (x2=0,006) (RR=1,2). La enfermedad pulmonar obstructiva crónica predijo con(x2=0,019) y (RR=1,47). Conclusiones: se considera como factores fuertemente predictivos el antecedente de insuficiencia cardiaca, de enfermedad pulmonar obstructiva crónica y el paciente que acude con síndrome confusional.

ABSTRACT Introduction: community acquired pneumonia is an important health problem around the world, and in Cuba it is the fourth cause of death. Prognostic indexes help to detect early the patients at high risk, but they have low sensibility and specificity. Objective: to determine the mortality prognostic factors in the community acquired pneumonia during the anamnesis. Material and methods: analytic, retrospective, longitudinal study in a group applying non-parametric tests and relative risk calculation. Results: age: 78 ± 10 years; 53 % of women. Global mortality of 57 %; 53 % had antecedents of diabetes mellitus; 34 % had previous cerebro-vascular disease, and 42 % were bedridden patients. 38 % was sick more than five days and 69 % took antimicrobials before being admitted. 23 % suffered congestive heart failure and 73 % chronic obstructive pulmonary disease. Confusional syndrome was a good predictor of mortality (x2=0.05) (RR=2.8). Long confinement to bed did not predict mortality at the fifth day (x2=0.43). The previous use of antimicrobials increased the risk (RR=0.8) con (x2=0.05). Heart failure was the best predictor (x2=0.006) (RR=1.2). Chronic obstructive pulmonary disease predicted with (x2=0.019) y (RR=1.47). Conclusions: antecedents of heart failure and chronic obstructive pulmonary disease, and the patient arriving with confusional syndrome are considered strongly predictive factors.

Adductor Pollicis Muscle Thickness as a Marker of Nutritional Status in Heart Failure

Malnutrition is associated with morbidity and mortality in patients with heart failure (HF). Thus, it is essential to apply reliable indicators to assess the nutritional status of these individuals. Objective: To evaluate the thickness of the adductor pollicis muscle (APM) in patients with HF as an indicator of somatic protein status and correlate the obtained values with conventionally used parameters and electrical bioimpedance (EBI) markers. Methods: Cross-sectional study with patients with HF undergoing regular outpatient treatment. APM thickness was measured in the dominant arm, and the values obtained were classified according to gender and age. The anthropometric parameters assessed included the body mass index (BMI) and specific parameters to assess the muscle (arm muscle circumference [AMC] and arm muscle area [AMA]). Values of phase angle (PA), standard PA (SPA), and lean mass were obtained by EBI. Statistical analyses were performed with the software Statistical Package for the Social Sciences, version 19, using unpaired Student's t, Mann-Whitney, or one-way analysis of variance (ANOVA) tests for comparisons between groups, as appropriate. The correlation between variables of interest was performed using Pearson's or Spearman's correlation coefficient, as adequate. The level of significance was set at 5%. Results: About 70% of the 74 patients evaluated were classified as malnourished according to the APM thickness. Values of AMC, AMA, and lean mass correlated positively with APM thickness (p < 0.005). The APM thickness also correlated positively with PA and SPA (r = 0.49, p < 0.001 and r = 0.31, p = 0.008, respectively). Conclusion: Patients with HF presented a high frequency of protein malnutrition when APM thickness was used as an indicator of nutritional status. APM thickness values correlated with conventional measures of somatic protein evaluation and may be related to the prognosis of these patients, since they correlated positively with PA and SPA

Determinats of the distamce covered during a six-minute walk test in patients with chronic heart failure / Determinantes da distância percorrida durante teste de caminhada de seis minutos em pacientes com insuficiência cardíaca crônica

Background: The evaluation of the functional capacity of patients with chronic heart failure (HF) by means of the distance covered in the six-minute walk test (6MWT) has assumed great importance, since the 6MWD is a predictor of mortality and hospitalization in this population, however the determinants of better distance traveled in patients with HF are little explored, especially in the Brazilian population. Objective: To evaluate the determinants of 6MWD in patients with chronic HF. Methods: A cross-sectional study was performed with 81 HF patients in outpatient treatment. 6MWD was used as the outcome variable and sociodemographic, clinical, physical-functional and emotional data were submitted to multiple regression analysis using the stepwise method with a significance level of 5%. Results: Mean age of participants was 56.71 years; the 6MWD showed a bivariate correlation with age (r = -0.27, p = 0.01), maximal inspiratory pressure (r = 0.42, p < 0.01), maximal expiratory pressure (r = 0.36, p < 0.01), handgrip strength (r = 0.38, p < 0.01), Borg scale (-0.22, p = 0.04), Charlson index (r = -0.25, p = 0.02) and modified Medical Research Council (mMRC) dyspnea scale (r = -0.42, p < 0.01). In the multivariate analysis, the variables gender (p = 0.001), age (0.004), forced vital capacity (FVC) (p = 0.016) and mMRC (p = 0.001) simultaneously explained 37% of variance in the 6MWD. Conclusion: Higher levels of dyspnea on daily life activities, female sex, older age and lower forced vital capacity are determinants of a shorter 6MWD in patients with chronic HF

The relation between echocardiographic epicardial fat thickness and cha2ds2-vasc score in patients with sinus rhythm

Abstract Objective: To evaluate the predictive value of epicardial fat thickness (EFT) in CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups. Methods: A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA2DS2-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score. Results: Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA2DS2-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA2DS2-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA2DS2-VASc score. Conclusion: Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Insuficiência cardíaca aguda (ICA) - como avaliar o perfil hemodinâmico e quando internar / Acute heart failure (AHF) - how to evaluate the hemodynamic profile and when to hospitalize

A Insuficiência cardíaca é uma síndrome clínica cuja prevalência vem aumentado nos últimos anos, sendo uma das principais causas de internação no Brasil e no mundo. A apresentação da insuficiência cardíaca aguda compreende dois espectros, quais sejam, insuficiência cardíaca crônica agudizada e insuficiência cardíaca nova e ambas estão associadas a alta morbidade e mortalidade. A primeira abordagem desses pacientes deve ser realizada de maneira sistemática para estabelecer o diagnóstico, classificação hemodinâmica e estratificação de risco para orientar adequadamente as condutas iniciais. A decisão terapêutica imediata é essencial para otimizar o manejo desses pacientes, visando a melhor evolução prognóstica intra e extra-hospitalar

Heart failure is a clinical syndrome that has been increasing over the last few years and is currently one of the main causes of hospitalization in Brazil and in the world. Acute heart failure has two forms of presentation - chronic acute decompensated heart failure and new heart failure, both conditions being associated with high morbidity and mortality. The first approach to these patients should be conducted systematically in order to establish the diagnosis, the hemodynamic classification, and the risk stratification in order to adequately guide the initial conducts. An immediate therapeutic decision is essential to optimize the intra- and extra-hospital management of these patients for better prognostic evolution

Características clínico epidemiológicas de la insuficiencia cardíaca aguda en un hospital terciario de lima, Perú / Epidemiological Clinical Characteristics of Acute Cardiac Insufficiency in a Tertiary Hospital in Lima, Peru

RESUMEN Con el objetivo de describir las características clínicas y epidemiológicas de la insuficiencia cardiaca aguda (ICA), se realizó un estudio descriptivo en 1075 pacientes de un hospital de Lima. La edad promedio fue 74 años y el 55% fueron de sexo masculino. El 39% tuvo ICA con fracción de eyección reducida, el 15% con fracción de eyección de rango medio y el 46% con fracción de eyección preservada. Las comorbilidades más frecuentes fueron la hipertensión arterial (52,6%) y la enfermedad coronaria (51%). El 29,2% de los pacientes tuvo hospitalizaciones previas por ICA. La mediana de la estancia hospitalaria fue de 3 días. La mortalidad intrahospitalaria por todas las causas fue 7,2%. La hospitalización ocurre, predominantemente, en pacientes de edad avanzada y con múltiples comorbilidades. El bajo uso de fármacos recomendados, conjuntamente con la alta frecuencia de hospitalizaciones previas, probablemente, inciden en la alta tasa de mortalidad registrada en el presente estudio.

ABSTRACT The objective of this study was to describe the clinical and epidemiological characteristics of acute heart failure (AHF) in 1,075 patients from a hospital in Lima, Peru. The average patient age was 74 years and 55% of study subjects were men. Moreover, 39% of patients in the sample had AHF with low ejection fraction, 15% had intermediate ejection fraction, and 46% had preserved ejection fraction. The most common comorbidities were hypertension (52.6%) and coronary disease (51%). Moreover, 29.2% of patients had previous hospitalizations due to AHF. The median hospital stay was 3 days. The rate of in- hospital mortality from all causes was 7.2%. Hospitalization was more common in elderly patients with multiple comorbidities. The low use of prescription drugs together with the high rate of previous hospitalizations may explain the high mortality rate reported in this study.

Importancia de las co-morbilidades en la insuficiencia cardiaca / Importance of the co morbidities in the heart failure

La insuficiencia cardíaca afecta aproximadamente a 5.1 millones de adultos en los Estados Unidos de América, con expectativas de alcanzar a casi 8 millones de adultos para 2030. Los pacientes portadores de insuficiencia cardiaca están en mayor riesgo de sufrir una mayor morbilidad y mortalidad que la población en general; además, existen co-morbilidades que pueden complicar el cuidado de estos pacientes. La diabetes mellitus, el dolor crónico y la depresión son diagnósticos que muy a menudo coexisten con la insuficiencia cardiaca. Los medicamentos con que normalmente se tratan estas co-morbilidades pueden inducir o empeorar los síntomas de la insuficiencia cardiaca, así que determinar la terapia apropiada es de vital importancia. Los médicos deben entender la relación que existe entre estas medicaciones y la insuficiencia cardiaca para mejorar la asistencia, aumentar la seguridad del paciente y reducir la morbilidad y mortalidad. Este trabajo analiza la asociación entre ciertos medicamentos usados para el tratamiento de estas co-morbilidades y su relación con la insuficiencia cardiaca. El propósito de este artículo es proporcionar una orientación farmacológica donde las opciones de tratamiento tengan especial consideración con un aumento de la supervisión médica, para evitar la descompensación o aparición de la insuficiencia cardiaca en los pacientes portadores de diabetes mellitus, dolor crónico y depresión (AU).

Heart failure affects approximately 5.1 million adults in the USA, with expectations of a rise to nearly 8 million adults by 2030. Patients with heart failure are at increased risk for morbidity/mortality, and co-morbidities can further complicate care for these patients. Diabetes mellitus, chronic pain, and depression are diagnoses that often coexist with heart failure. Medications commonly used to treat these co-morbidities may induce or worsen heart failure symptoms, so determining appropriate drug therapy is important. Healthcare providers must understand the relationship between these medications and heart failure in order to improve prescribing practices to increase patient safety and reduce morbidity and mortality. This manuscript discusses the association between certain medications used to treat the aforementioned diagnoses and their relationship to heart failure. The purpose of this article is to provide guidance on which pharmacologic options require special consideration, increased monitoring, or complete avoidance in heart failure patients with diabetes mellitus, chronic pain, and/or depression (AU).

Quando a ressonância magnética importa para a avaliação das cardiopatias / When Magnetic resonance imaging matters for the evaluation of cardiopathies

A ressonância magnética cardíaca (RMC) é uma modalidade de imagem não invasiva capaz de fornecer informações precisas e, muitas vezes, únicas na investigação de cardiopatias em geral e, em especial, nas cardiomiopatias. A capacidade de caracterizar precisamente o miocárdio do ponto de vista de sua contratilidade e suas características teciduais, diferenciando precisamente o miocárdio normal da fibrose miocárdica e identificando o edema miocárdio nas situações de agressão aguda ou recente do miocárdio, tornam a RMC indispensável hoje em qualquer serviço terciário e avançado de cardiologia do mundo. Neste artigo revisamos as aplicações clássicas e mais recentes da RMC em cardiopatias não isquêmicas, dividindo o uso das técnicas de RMC em dois grandes grupos: investigação da insuficiência cardíaca e das arritmias ventriculares. Dentro destes dois grupos pontuamos as etiologias mais importantes e frequentemente envolvidas. Na síndrome da insuficiência cardíaca destacam-se a cardiomiopatia dilatada com a fibrose mesocárdica linear septal e a miocardite viral com a manifestação de fibrose multifocal e mesoepicárdica. Uma proporção das cardiomiopatias dilatadas pode ter origem em uma miocardite viral prévia. A sarcoidose cardíaca pode apresentar uma variedade de tipos de realce tardio de padrão não isquêmico e isquêmico, e ser associada tanto ao quadro clínico de IC como de arritmia. A presença de sarcoidose pulmonar ou sistêmica pode ou não estar presente. A amiloidose cardíaca é o protótipo da cardiomiopatia restritiva e pode ser identificada pela RMC pelo padrão de realce tardio miocárdico global circunferencial (tipo AL) ou difuso, poupando o ápex do ventrículo esquerdo (tipo transtirretina). Finalmente, uma entidade ainda pouco entendida, a não compactação do ventrículo esquerdo (VE), em geral não apresenta realce tardio, mas tem fenótipo de trabeculação ventricular típico. No grupo das síndromes arrítmicas revisamos várias etiologias frequentemente associadas a esta apresentação clínica. Na hemossiderose cardíaca os valores de T2* abaixo de 20 ms indicam precisamente sobrecarga significativa de ferro miocárdico e associação com disfunção ventricular e arritmia ventricular. Na cardiomiopatia hipertrófica, a hipertrofia assimétrica e a fibrose miocárdica difusa, heterogênea e que acomete focalmente as inserções ventriculares, constituem o padrão clássico. Quantidade de fibrose acima de 15% da massa ventricular esquerda indica risco duas vezes maior de morte súbita. Na cardiomiopatia/displasia arritmogênica do ventrículo direito (VD), os volumes e a função ventricular direita global e segmentar pela RMC são partes fundamentais dos critérios diagnósticos da displasia pelo consenso atual. A cardiomiopatia chagásica tem mostrado intensa fibrose miocárdica desde as fases iniciais, mais intensa em homens que mulheres e frequentemente associada à edema miocárdico, marcador de provável inflamação crônica. A endomiocardiofibrose apresenta imagem patognomônica no realce tardio, o sinal do duplo V, caracterizando a fibrose miocárdica e trombo/calcificação preenchendo o ápex do VE e/ou VD. Nas valvopatias, além da detecção de fibrose miocárdica, que tem valor prognóstico, a RMC é precisa em quantificar as regurgitações, sendo indicada sua realização na insuficiência mitral antes da decisão de procedimento cirúrgico de troca ou correção valvar, eliminado um número significativo de casos em que a insuficiência mitral é superestimada pela ecocardiografia. Com esta revisão, cobrimos uma vasta gama de cardiopatias para as quais as técnicas de RMC realmente importam no diagnóstico e na estratificação prognóstica

Cardiovascular magnetic resonance (CMR) imaging is a noninvasive form of imaging capable of providing accurate and often unique information in the investigation of heart disease in general, and especially in cardiomyopathies. The ability to accurately characterize the myocardium in terms of its contractility and tissue characteristics, precisely differentiating normal myocardium from myocardial fibrosis and identifying myocardial edema in situations of acute or recent myocardial injury, has made CMR indispensable in any tertiary and advanced cardiology service around the World. In this paper, we review the classical and more recent applications of CMR in non-ischemic heart diseases, dividing the use of CMR techniques into two main groups: heart failure (HF) and ventricular arrhythmia investigations. Within these two groups, we highlight the most important and frequently involved etiologies. In heart failure syndrome, we focused on dilated cardiomyopathy with septal linear mesocardial fibrosis and viral myocarditis with the manifestation of multifocal and mesoepicardiac fibrosis. A proportion of dilated cardiomyopathies may have originated with an ancient viral myocarditis. Cardiac sarcoidosis may present a variety of late enhancement types of non-ischemic and ischemic patterns, and is associated with clinical signs of both HF and arrhythmia. The presence of pulmonary or systemic sarcoidosis may or may not be present. Cardiac amyloidosis is the prototype of restrictive cardiomyopathy, and can be identified in CMR by the global circumferential subendocardial (AL type) or diffuse myocardial enhancement pattern sparing the left ventricle (LV) apex (transthyretin type). Finally, a poorly understood entity, LV non-compaction generally does not present late enhancement, but has a typical ventricular trabeculation phenotype. In the group of arrhythmic syndromes, we reviewed several etiologies frequently associated with this clinical presentation. In cardiac siderosis, values of T2* below 20 ms accurately indicate a significant overload of myocardial iron and association with ventricular dysfunction and ventricular arrhythmia. In hypertrophic cardiomyopathy, asymmetric hypertrophy and diffuse myocardial fibrosis, which is heterogeneous and focally affects the ventricular insertions, constitute the classic pattern. An amount of fibrosis above 15% of the left ventricular mass indicates a two-fold increased risk of sudden death. In arrhythmogenic right ventricle (RV) cardiomyopathy/dysplasia, global and segmental right ventricular function and volumes by CMR are fundamental parts of the diagnostic criteria of dysplasia, according to current consensus. Chagasic cardiomyopathy has shown intense myocardial fibrosis since the early stages, which is more intense in men than women, and is frequently associated with myocardial edema, a marker of probable chronic inflammation. Endomyocardial fibrosis presents a pathognomonic image in late enhancement, the double V sign, characterizing myocardial fibrosis and thrombus/calcification filling the LV and/or RV apex. In valve diseases, in addition to the detection of myocardial fibrosis that has prognostic value, CMR is precise in quantifying regurgitations, and is indicated in mitral regurgitation prior to the decision for surgical valve replacement/correction, eliminating a significant number of cases in which mitral insufficiency is overestimated by the echocardiogram. This review covers a wide range of cardiopathies in which CMR techniques are extremely important in the diagnosis and prognostic stratification

Enfermedad de Chagas. Amenaza en sombras para los corazones de la América Latina / Chagas disease. A threat unknown for the hearts of Latin Americ

Introducción: la enfermedad de Chagas es de etiología parasitaria generalmente crónica. Es una de las enfermedades más desatendidas del mundo. Constituye un problema de salud, social y económico en muchos países latinoamericanos. Objetivo: se revisaron 35 bibliografías con el objetivo de describir las características clínicas, diagnósticas y terapéuticas de la Enfermedad de Chagas. Desarrollo: esta entidad, generalmente afecta el tracto gastrointestinal o al corazón. La cardiopatía chagásica crónica es la forma más grave de la enfermedad y se asocia a una alta mortalidad. Los principales elementos para el diagnóstico de la enfermedad son el antecedente epidemiológico compatible y demostrar la presencia del parásito. El tratamiento médico en la fase crónica es el correspondiente a una miocardiopatía dilatada, no se recomenda el tratamiento antiparasitario en la fase crónica de la enfermedad. Conclusiones: es una causa frecuente de insuficiencia cardiaca en Latinoamérica. Afecta fundamentalmente a jóvenes y no tiene un tratamiento específico que mejore la supervivencia(AU)

Introduction: Chagas disease has generally chronic parasitic etiology. It is one of the most neglected diseases worldwide. It is a health, social and economic concern in many Latin American countries. Objective: 35 bibliographies were reviewed with the aim at describing the clinical, diagnostic and therapeutic characteristics of Chagas disease. Development: This entity usually affects the gastrointestinal tract or the heart. Chronic Chagas' heart disease is the disease's most severe form and is associated with high mortality. The main elements for the diagnosis of the disease are the compatible epidemiological antecedent and demonstration of the parasite presence. The medical treatment in the chronic phase corresponds to a dilated cardiomyopathy, without the recommended antiparasitic treatment in the chronic phase of the disease. Conclusions: Tt is a frequent cause of heart failure in Latin America. It affects mainly young people and does not have a specific treatment that improves survival(AU)

Associação das condições sociais e clínicas à qualidade de vida de pacientes com insuficiência cardíaca / Asociación de condiciones social y clínicas para calidad de vida del paciente con insuficiencia cardiaca / Association of social and clinical conditions to the quality of life of patients with heart failure

RESUMO Objetivo Analisar a associação entre as condições sociodemográficas e clínicas com a qualidade de vida relacionada à saúde de pacientes com insuficiência cardíaca. Método Estudo transversal, com amostra não probabilística de 84 pacientes com insuficiência cardíaca, em seguimento ambulatorial, realizado no município de João Pessoa, PB, Brasil, no período de janeiro a julho de 2015. Utilizou-se o questionário Minnesota Living with Heart Failure Questionnaire. Na análise dos dados, foram aplicados os testes: t-Student, ANOVA e Correlação de Pearson, com nível de significância de 5%. Resultados Os escores médios do Minnesota Living with Heart Failure Questionnaire revelaram boa qualidade de vida do grupo pesquisado. Houve associação negativa significante entre qualidade de vida e idade: portanto, quanto menor a idade, pior a qualidade de vida. Conclusão Fazem-se necessárias ações de promoção à saúde para melhorar a capacidade de enfretamento dessa doença, em especial, para os pacientes mais jovens.

RESUMEN Objetivo Analizar la asociación entre las condiciones sociodemográficas y clínicas con la calidad de vida relacionada con la salud de los pacientes con insuficiencia cardiaca. Método Estudio transversal con una muestra no probabilística de 84 pacientes ambulatorios con insuficiencia cardiaca, realizados en la ciudad de João Pessoa, PB, Brasil, de enero a julio de 2015. Se utilizó el cuestionario de Minnesota Living with Heart Failure. En el análisis de los datos, se aplicaron las pruebas: la t de Student, ANOVA y correlación de Pearson, con un nivel de significación del 5%. Resultados Las puntuaciones promedio de los Minnesota Living with Heart Failure Cuestionario mostraron una buena calidad de vida del grupo estudiado. Hubo una asociación negativa significativa entre la calidad de vida y la edad: por lo tanto cuanto más joven peor es la calidad de vida. Conclusión son acciones de promoción de la salud necesarias para mejorar la capacidad de control de esta enfermedad, especialmente para los pacientes más jóvenes.

ABSTRACT Objective To analyze the association between sociodemographic and clinical conditions with the quality of life related to health of heart failure patients Method Cross-sectional study with a non-random sample of 84 outpatients with heart failure, performed in the city of João Pessoa, PB, Brazil, in the period from January to July 2015. The questionnaire by name Minnesota Living with Heart Questionnaire was used The following tests were applied in data analysis: t-Student, ANOVA and Pearson's Correlation, com a 5% significance level. Results The average scores of the Minnesota Living with Heart Failure Questionnaire showed a good quality of life in the group under study. There was a significant negative association between quality of life and age: thus the lower the age, the worse the quality of life. Conclusion Health promotion actions become necessary to improve the coping capacity of this disease, especially for younger patients.

Acute Heart Failure Registry: Risk Assessment Model in Decompensated Heart Failure / Registro de Insuficiência Cardíaca Aguda: Modelo de Avaliação de Risco na Insuficiência Cardíaca Descompensada

Abstract Background: Heart failure (HF) is a highly prevalent syndrome. Although the long-term prognostic factors have been identified in chronic HF, this information is scarcer with respect to patients with acute HF. despite available data in the literature on long-term prognostic factors in chronic HF, data on acute HF patients are more scarce. Objectives: To develop a predictor of unfavorable prognostic events in patients hospitalized for acute HF syndromes, and to characterize a group at higher risk regarding their clinical characteristics, treatment and outcomes. Methods: cohort study of 600 patients admitted for acute HF, defined according to the European Society of Cardiology criteria. Primary endpoint for score derivation was defined as all-cause mortality and / or rehospitalization for HF at 12 months. For score validation, the following endpoints were used: all-cause mortality and / or readmission for HF at 6, 12 and 24 months. The exclusion criteria were: high output HF; patients with acute myocardial infraction, acute myocarditis, infectious endocarditis, pulmonary infection, pulmonary artery hypertension and severe mitral stenosis. Results: 505 patients were included, and prognostic predicting factors at 12 months were identified. One or two points were assigned according to the odds ratio (OR) obtained (p < 0.05). After the total score value was determined, a 4-point cut-off was determined for each ROC curve at 12 months. Two groups were formed according to the number of points, group A < 4 points, and group B = 4 points. Group B was composed of older patients, with higher number of comorbidities and predictors of the combined endpoint at 6, 12 and 24 months, as linearly represented in the survival curves (Log rank). Conclusions: This risk score enabled the identification of a group with worse prognosis at 12 months.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome de elevada prevalência. Apesar de existir na literatura informação relativa aos fatores prognósticos a longo prazo na IC crônica, esta é mais escassa no que diz respeito aos pacientes com IC aguda. Objetivos: Desenvolver um score preditor de eventos prognósticos desfavoráveis em doentes admitidos com síndromes de IC aguda e caracterizar um grupo de maior risco quanto às suas características clínicas, terapêutica e resultados. Métodos: Estudo de coorte de 600 doentes internados com IC aguda, definida de acordo com os critérios da Sociedade Europeia de Cardiologia. O endpoint primário para a derivação do score foi definido como mortalidade de qualquer causa e/ou reinternação por IC aos 12 meses. Para a validação do score, foram utilizados como endpoints: mortalidade de qualquer causa e/ou reinternação por IC aos 6, 12 e 24 meses. Os critérios de exclusão foram: IC de alto débito, pacientes com infarto agudo do miocárdio, miocardite aguda, endocardite infeciosa, infeção pulmonar, hipertensão arterial pulmonar e estenose mitral grave. Resultados: Foram incluídos 505 doentes e identificados preditores prognósticos aos 12 meses. Atribuíram-se 1 ou 2 pontos (p.) de acordo com os odds ratio (OR) obtidos (p < 0,05). Após a determinação do valor de score total, foi estabelecido um cut-off de 4 pontos por curva ROC. Constituíram-se 2 grupos de acordo com a pontuação, grupo A < 4 p. versus grupo B = 4 p. O grupo B era constituído por idosos, com maior número de comorbidades e preditor de endpoint combinado aos 6, 12 e 24 meses traduzido linearmente nas curvas de sobrevida (Log rank). Conclusões: Este score de risco permitiu identificar um grupo com pior prognóstico aos 12 meses.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation / Teste Cardiopulmonar de Exercício: Fundamentos, Aplicabilidade e Interpretação

ABSTRACT Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

RESUMO O teste cardiopulmonar de exercício (TCPE) vem ganhando importância crescente como método de avaliação funcional tanto no Brasil quanto no Mundo. Nas suas aplicações mais frequentes, o teste consiste em submeter o indivíduo a um exercício de intensidade gradativamente crescente até a exaustão ou o surgimento de sintomas e/ou sinais limitantes. Neste exame se mensura a ventilação (VE), o consumo de oxigênio (VO2), a produção de gás carbônico (VCO2) e as demais variáveis de um teste de exercício convencional. Adicionalmente, podem ser verificadas, em situações específicas, a oximetria de pulso e as alças fluxo-volume antes, durante e após o esforço. A análise integrada dos dados permite a completa avaliação dos sistemas cardiovascular, respiratório, muscular e metabólico no esforço, sendo considerado padrão-ouro na avaliação funcional cardiorrespiratória.1-6 O TCPE permite definir mecanismos relacionados à baixa capacidade funcional, os quais podem ser causadores de sintomas como a dispneia, correlacionando-os com alterações dos sistemas cardiovascular, pulmonar e musculoesquelético. Também pode ser de grande aplicabilidade na avaliação prognóstica em cardiopatas, pneumopatas e em pré-operatório, além de auxiliar na prescrição mais criteriosa do exercício em sujeitos normais, em atletas, em cardiopatas e em pneumopatas. Assim como ocorre com o uso clínico, a pesquisa nesse campo também cresce e várias contribuições científicas de pesquisadores nacionais são publicadas em periódicos de alto fator de impacto. Sendo assim, o objetivo deste documento é fornecer uma revisão ampla da aplicabilidade do TCPE nas diferentes situações clínicas, bem como servir como guia prático na interpretação desse teste propedêutico.

Clasificación según nivel de morbilidad e intensidad del uso de recursos de una población con patologías crónicas en Atención Primaria de Salud utilizando “Adjusted Clinical Groups” (ACG) / Adjusted Clinical Groups Method (ACG) to allocate resources according to the disease burden of each health center

Background: Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. Aim: To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. Material and Methods: We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. Results: The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. Conclusions: This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center.