Prognostic Prediction of Cardiopulmonary Exercise Test Parameters in Heart Failure Patients with Atrial Fibrillation / Previsão Prognóstica dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca e Fibrilação Atrial

Abstract Background: Atrial fibrillation (AF) is associated with increased mortality in heart failure (HF) patients. Objective: To evaluate whether the risk of AF patients can be precisely stratified by relation with cardiopulmonary exercise test (CPET) cut-offs for heart transplantation (HT) selection. Methods: Prospective evaluation of 274 consecutive HF patients with left ventricular ejection fraction ≤ 40%. The primary endpoint was a composite of cardiac death or urgent HT in 1-year follow-up. The primary endpoint was analysed by several CPET parameters for the highest area under the curve and for positive (PPV) and negative predictive value (NPV) in AF and sinus rhythm (SR) patients to detect if the current cut-offs for HT selection can precisely stratify the AF group. Statistical differences with a p-value <0.05 were considered significant. Results: There were 51 patients in the AF group and 223 in the SR group. The primary outcome was higher in the AF group (17.6% vs 8.1%, p = 0.038). The cut-off value of pVO2 for HT selection showed a PPV of 100% and an NPV of 95.5% for the primary outcome in the AF group, with a PPV of 38.5% and an NPV of 94.3% in the SR group. The cut-off value of VE/VCO2 slope showed lower values of PPV (33.3%) and similar NPV (92.3%) to pVO2 results in the AF group. Conclusion: Despite the fact that AF carries a worse prognosis for HF patients, the current cut-off of pVO2 for HT selection can precisely stratify this high-risk group.

Resumo Fundamento: A fibrilação atrial (FA) está associada ao aumento da mortalidade em pacientes com insuficiência cardíaca (IC). Objetivo: Avaliar se o risco de pacientes com FA pode ser estratificado com precisão em relação aos pontos de corte do teste de esforço cardiopulmonar (TECP) para seleção do transplante cardíaco (TC). Métodos: Avaliação prospectiva de 274 pacientes consecutivos com IC com fração de ejeção do ventrículo esquerdo ≤ 40%. O endpoint primário foi um composto de morte cardíaca ou TC urgente no seguimento de 1 ano. O endpoint primário foi analisado através de vários parâmetros do TECP para a maior área sob a curva e para o valor preditivo positivo (VPP) e negativo (VPN) em pacientes com FA e ritmo sinusal (RS) para detectar se os atuais pontos de corte para a seleção de TC podem estratificar com precisão o grupo com FA. Diferenças estatísticas com valor de p < 0,05 foram consideradas significativas. Resultados: Havia 51 pacientes no grupo de FA e 223 no grupo RS. O endpoint primário foi maior no grupo FA (17,6% vs. 8,1%, p = 0,038). O valor de corte de pVO2 para a seleção do TC mostrou um VPP de 100% e um VPN de 95,5% para o endpoint primário no grupo FA, com um VPP de 38,5% e um VPN de 94,3% no grupo RS. O valor de corte da inclinação VE/VCO2 apresentou valores mais baixos de VPP (33,3%) e valor semelhante de VPN (92,3%) aos resultados de pVO2 no grupo FA. Conclusões: Apesar do fato de a FA apresentar um pior prognóstico para os pacientes com IC, o atual ponto de corte de pVO2 para a seleção de TC pode estratificar com precisão esse grupo de alto risco.

Left Ventricular Remodeling Patterns in Primary Healthcare / Padrões de Remodelamento Ventricular Esquerdo na Atenção Primária à Saúde

Abstract Background: Left ventricular remodeling (LVR) is related to both non-fatal and fatal outcomes. Objective: To describe the geometric patterns of the LV and their associations. Methods: A total of 636 individuals between the ages of 45 and 99 years in Rio de Janeiro, Brazil, were submitted to clinical evaluation, laboratory tests, electrocardiogram, and tissue Doppler echocardiography (TDE). The difference between categories was tested with Kruskall-Wallis with post hoc tests, once all variables studied are non-normally distributed and Pearson's Qui-square (categorical variables). Gross and adjusted ORs were estimated by logistic regression. The level of significance was 5% for all tests. Subjects had LVR characterized as: normal geometry (NG), concentric remodeling (CR), concentric hypertrophy (CH), and eccentric hypertrophy (EH). Results: The prevalence of altered patterns was 33%. Subjects presented NG (n = 423; 67%); EH (n = 186; 29%); CH (n = 14; 2%); and CR (n = 13; 2%). The variables of gender, age, level of education and albumin/creatinine ratio (A/C), showed a relationship with the chance of EH even after adjustment. Conclusion: Approximately one third of the studied individuals had LVR and were at risk for developing heart failure. Altered A/C in urine was associated with EH, indicating an early relationship between cardiac and renal dysfunction.

Resumo Fundamento: O remodelamento ventricular esquerdo (RVE) está relacionado a desfechos não fatais e fatais. Objetivo: Descrever os padrões geométricos do VE e suas associações. Métodos: Um total de 636 indivíduos entre 45 e 99 anos no Rio de Janeiro, Brasil, foi submetido a avaliação clínica, exames laboratoriais, eletrocardiograma e ecocardiograma com Doppler tecidual (EDT). A diferença entre as categorias foi testada com Kruskall-Wallis com testes post hoc, uma vez que todas as variáveis estudadas não são normalmente distribuídas e o qui-quadrado de Pearson (variáveis categóricas). As ORs brutas e ajustadas foram estimadas por regressão logística. O nível de significância foi de 5% para todos os testes. Os indivíduos tinham RVE caracterizada como: geometria normal (GN), remodelamento concêntrico (RC), hipertrofia concêntrica (HC) e hipertrofia excêntrica (HE). Resultados: A prevalência de padrões alterados foi de 33%. Os sujeitos apresentaram GN (n = 423; 67%); HE (n = 186; 29%); HC (n = 14; 2%); e RC (n = 13; 2%). As variáveis sexo, idade, escolaridade e razão albumina/creatinina (A/C) mostraram relação com a chance de HE, mesmo após o ajuste. Conclusão: Aproximadamente um terço dos indivíduos estudados apresentavam RVE e corriam risco de desenvolver insuficiência cardíaca. A/C alterada na urina foi associada à HE, indicando uma relação precoce entre disfunção cardíaca e renal.

B-type natriuretic peptide levels and diagnostic accuracy: excess fluid volume / Niveles del péptido natriurético tipo B y precisión diagnóstica: volumen de líquidos excesivo / Níveis do peptídeo natriurético tipo B e acurácia diagnóstica: volume de líquidos excessivo

ABSTRACT Aim: To analyze the behavior of B-type natriuretic peptide (BNP) in the presence of defining characteristics (DCs) of the nursing diagnosis Excess fluid volume (00026) in patients hospitalized for acute decompensated heart failure. Methods: Cohort study of patients admitted with acute decompensated heart failure (September 2015 to September 2016) defined by Boston Criteria. Patients hospitalized for up to 36 h with BNP values ≥ 100 pg/ml were included; BNP values at baseline-final assessment were compared by Wilcoxon test, the number of DCs at baseline-final assessment was compared by paired t-test. Results: Sixty-four patients were included; there was a significant positive correlation between delta of BNP and the number of DCs present at initial clinical assessment. Conclusions: The behavior of BNP was correlated to the DCs indicating congestion. With clinical compensation, DCs and BNP decreased. The use of this biomarker may provide additional precision to the nursing assessment.

RESUMEN Objetivo: Analizar el comportamiento del péptido natriurético tipo B (BNP) en presencia de características definitorias (CD) del diagnóstico de enfermería Exceso de volumen de líquidos (00026) en pacientes hospitalizados por insuficiencia cardíaca aguda descompensada (ICAD). Métodos: Estudio de cohorte de pacientes ingresados ​​con ICAD (septiembre/2015 a septiembre/2016).Se incluyeron pacientes hospitalizados hasta 36 h con valores de BNP ≥ 100 pg / ml; Los valores de BNP en la evaluación inicial basal se compararon mediante la prueba de Wilcoxon, el número de CD en la evaluación inicial basal se comparó mediante el Test-T apareado. Resultados: Se incluyeron 64 pacientes; hubo una correlación positiva significativa entre el delta del BNP y las CD presentes en la evaluación clínica inicial. Conclusiones: El comportamiento del BNP se correlacionó con las CD que indican congestión. Con compensación clínica, las CD y el BNP disminuyeron. El uso del BNP puede proporcionar precisión adicional a la evaluación de enfermería.

RESUMO Objetivo: Analisar o comportamento do peptídeo natriurético tipo B (BNP) na presença de características definidoras (CDs) do diagnóstico de enfermagem Excesso de volume de líquidos (00026) em pacientes hospitalizados por insuficiência cardíaca descompensada. Métodos: Estudo de coorte com pacientes internados com insuficiência cardíaca descompensada (setembro-2015 a setembro-2016), definida pelos Critérios de Boston. Pacientes hospitalizados por mais de 36 horas, valor de BNP ≥ 100 pg/ml foram incluídos; valores de BNP basal-final foram comparados pelo teste Wilcoxon; as CDs no basal-final foram comparadas pelo teste t pareado. Resultados: Sessenta e quatro pacientes foram incluídos; houve correlação positiva significativa entre o delta de BNP com o número de CDs presentes na avaliação clínica inicial. Conclusões: O comportamento do BNP foi correlacionado com as CDs, indicando congestão. Com a compensação clínica, as CDs e a concentração de BNP diminuíram. O uso deste biomarcador pode fornecer precisão adicional à avaliação de enfermagem.

Recomendaciones para la atención de pacientes con insuficiencia cardiaca y COVID-19 / Recommendations for the care of patients with heart failure and COVID-19

Resumen La pandemia por COVID-19 decretada por la Organización Mundial de la Salud (OMS) desde el 12 de marzo de 2020 está produciendo estragos a nivel mundial y es un verdadero reto económico, social y sanitario. Aunque las manifestaciones clínicas del COVID-19 son síntomas respiratorios, algunos pacientes también tienen síntomas cardiológicos. Dentro de los pacientes con afecciones cardiológicas2 suponen un grupo de mayor riesgo y que de hecho son un grupo especialmente vulnerable, por su mayor riesgo de contagio y mayor gravedad en caso de adquirir la enfermedad1 aquellos con insuficiencia cardiaca (IC), incluyendo al trasplante cardiaco (TC) y las asistencias ventriculares, así como los pacientes con hipertensión arterial pulmonar (HAP). La IC es la principal patología cardiovascular crónica y los pacientes en este grupo son los más vulnerables para el desarrollo de cuadros clínicos más graves tras sufrir la infección, y en mayor medida los casos con IC avanzada3. De hecho, la IC es unas de las complicaciones más frecuentes en los pacientes con COVID-194. De igual forma, los pacientes trasplantados que requieren de los inmunosupresores para evitar el rechazo del injerto, constituyen una población especialmente susceptible a la infección y a desarrollar procesos más graves. Esta situación ha hecho que la Asociación Nacional de Cardiólogos de México (ANCAM) y la Sociedad Mexicana de Cardiología (SMC) junto con sus respectivos capítulos, hayan elaborado las siguientes recomendaciones para el personal médico, que participa en la atención de este grupo especial de pacientes en los diferentes escenarios clínicos, que padezcan o no, COVID-19.

Abstract The COVID-19 pandemic decreed by the World Health Organization (WHO) since March 12, 2020 is wreaking havoc globally and it is a true economic, social and health challenge. Although the clinical manifestations of COVID-19 are respiratory symptoms, some patients also have cardiological symptoms. Among patients with cardiological conditions2 they represent a group of higher risk and, in fact, they are a particularly vulnerable group, due to their higher risk of contagion and greater severity in case of acquiring the disease1 those with heart failure (HF), including heart transplant (CT) and ventricular assists, as well as patients with pulmonary arterial hypertension (PAH). HF is the main chronic cardiovascular disease and patients in this group are the most vulnerable for the development of more serious clinical symptoms after suffering the infection, and to a greater extent cases with advanced HF3. In fact, HF is one of the most frequent complications in patients with COVID-194. Likewise, transplant patients who require immunosuppressants to avoid graft rejection, constitute a population especially susceptible to infection and to develop more serious processes. This situation has made the National Association of Cardiologists of Mexico (ANCAM) and the Mexican Society of Cardiology (SMC) together with their respective chapters, have prepared the following recommendations for medical personnel, who participate in the care of this special group of patients in the different clinical settings, who suffer or not, of COVID-19.

Heart Failure: An Overview of Morbidity and Mortality in Rio Grande do Sul

Abstract Background: Heart failure (HF) is the final pathway of most cardiac diseases. Although the prevalence of HF has increased, due to the ageing of the population, more comprehensive data have shown a reduction in the percentage of HF hospital admissions over the last years. Objective: Assess the morbidity and mortality of HF patients in Brazil, Rio Grande do Sul and Porto Alegre. Method: The study is a retrospective analysis of data from the Brazilian Unified Health System's (Sistema Único de Saúde [SUS]) Department of Informatics (DataSUS). We evaluated the incidence of HF hospital admissions, the average length of stay, hospital costs and sex ratio, during a ten-year period (2007 to 2016). Due to availability of the system, mortality rate and age range, the total duration of the study was nine years. Results: Within this period, the percentage of hospitalizations for HF decreased. On the other hand, the length of stay increased in all regions studied. Mortality rates were in decline in all regions. Hospital costs showed an increase of 110.8%. HF was more prevalent in patients between the seventh and eighth decades of life, with men being more affected than women, except in Rio Grande do Sul. Conclusion: We conclude that, in spite of the high costs of HF to healthcare providers, hospitalizations and mortality rates have shown a significant decline over the last years, which results from the advances in the treatment of this disease, through initiatives to improve patient education, engagement and planning in health care and self-care.

Clinimetric analysis of heart failure in Mexican patients / Análisis clinimétrico de la insuficiencia cardiaca en pacientes mexicanos

Abstract Heart failure (HF) is a syndrome characterized basically by a circulatory deficit to cover the metabolic and energetic demands of the body. This condition has a broad spectrum in its clinical presentation, affects the quality of life significantly, impacts the family/social environment, and generates a great demand for health services. The purpose of this research is to report the situational diagnose of patients with HF in Mexico. We evaluated 292 patients, 70.2% were men. Average age was 56.7 +- 14.3 years. Ischemic heart disease is the main etiology (98 patients, 33.9%) followed by hypertensive (22.6%) and idiopathic (23.3%) heart disease. The associated clinical background was obesity (31.1%), systemic hypertension (36.7%), myocardial infarction (26.4%), and dyslipidemia (15.1%). The most common symptom was stress dyspnea (41.4%) and jugular vein engorgement at physical examination (32.5%). Anemia was observed in 1% of patients. The average left ventricular ejection fraction was 29.2 +- 10.6%. Sinus rhythm was the most frequently detected in 84.9%. 19.9% of patients had an implantable cardioverter-defibrillator or cardiac resynchronization therapy. 13.7% of patients with QRS > 130 ms. In our population, the meta-analysis global group in chronic heart failure risk score calculated was 16.8 +- 5.7 and for EMPHASIS 3.3 +- 1.5. We observed that age at presentation in HF in this analysis is at least 10 years younger than in other reports. The grade of obesity takes relevance in our group. The association of anemia and HF in Mexico is rare.

Resumen La insuficiencia cardiaca es un síndrome caracterizado fundamentalmente por un déficit circulatorio para cubrir las demandas metabólicas y energéticas del organismo. Esta entidad tiene un amplio espectro en su presentación clínica, afecta de manera significativa la calidad de vida, impacta en el entorno familiar/social y genera una gran demanda de los servicios de salud. El propósito de esta investigación es reportar el diagnóstico situacional de pacientes con insuficiencia cardiaca (IC) en México. Evaluamos 292 enfermos, 70.2% eran hombres. Con edad promedio 56.7 +- 14.3 años. La principal etiología es la cardiopatía isquémica (33.9%), seguida de la hipertensiva (22.6%) e idiopática (23.3%). Los antecedentes clínicos asociados fueron: obesidad (31.1%), hipertensión arterial sistémica (36.7%), infarto al miocardio (26.4%) y dislipidemia (15.1%). El síntoma con mayor presentación fue la disnea de esfuerzos (41.4%) y a la exploración física la ingurgitación yugular (32.5%). Se observó anemia en 1% de los enfermos. La fracción de expulsión del ventrículo izquierdo (FEVI) promedio fue de 29.2 + 10.6%. El ritmo sinusal fue el más frecuentemente detectado en 84.9%. El 19.9% de los pacientes tenían instalado un desfibrilador automático implantable (DAI) o tratamiento de resincronización cardiaca (TRC). El 13.7% de los enfermos con QRS mayor de 130 ms. El riesgo (MAGGIC) calculado en nuestro grupo poblacional fue de 16.8 +- 5.7 y para EMPHASIS 3.3 +- 1.5. Observamos que la edad de presentación de la IC en el presente análisis es menor por 10 años en comparación con otros reportes. El grado de obesidad toma relevancia en nuestro grupo. La asociación de anemia e IC en México es poco frecuente.

The association between CHA2DS2-VASc score and erectile dysfunction: a cross-sectional study

ABSTRACT Purpose: This study aims to assess the association between CHA2DS2-VASc score and erectile dysfunction in patients who were admitted to cardiology outpatient clinics. Materials and methods: One hundred and two male patients who were admitted to the cardiology outpatient clinic were included to the study. Erectile dysfunction was evaluated in the urology outpatient clinic in the same hospital and scored using Turkish Version of The International Index of Erectile Function. CHA2DS2-VASc score was calculated for every patient using the current associated guidelines. Results: There was a negative correlation between The International Index of Erectile Function score and CHA2DS2-VASc score, age, hypertension, heart failure, diabetes mellitus, stroke respectively. Smoking and dislipidemia were not correlated with The International Index of Erectile Function score (p>0.05). Conclusion: CHA2DS2-VASc score can be used to detect Erectile dysfunction in patients who are admitted to the cardiology outpatient clinics.

Physical Exercise in the Management of Erectile Dysfunction in Patients with Heart Failure

Erectile dysfunction (ED) is a highly prevalent problem that affects the quality of life, prognosis and survival of patients with heart failure (HF). In the management of ED, physical exercise is a therapeutic strategy that reduces disease-related symptoms and optimizes drug use. However, the repercussions of physical exercise on ED in individuals with HF still need to be elucidated. In this sense, the objective of this study was to evaluate the effects of physical exercise on erectile function (EF) in HF patients. This was a systematic review conducted according to PRISMA guidelines. Patients with HF, male and ejection fraction ≤ 45% were submitted to physical exercise of different modalities. The search for scientific articles was conducted in the electronic databases (PubMed, LILACS, Cochrane-Library, Science Direct) from the inception until October 2018, according to the MeSH dictionary descriptors, which were suitable for all databases. Results: Three studies were analyzed, includinng 99 male subjects, age ranging from 53 years (± 7.48) to 58 years (± 12). Seventy subjects were submitted to a physical exercise program and 29 were in the control group. In all studies, physical exercise showed positive results in the management of ED regardless of erectile dysfunction (ED) classification status and intensity of exercise used. It was concluded that physical exercise of different intensities was considered an effective therapeutic intervention to improve EF in individuals with HF and ED

Impact of Coronary Artery Bypass Grafting on Muscle Mass Reduction on the 7th Postoperative Day

Ischemic heart failure is a chronic and degenerative disease with high morbidity and mortality in the world. Coronary artery bypass grafting is indicated as elective treatment and may cause a catabolic state that depletes energy reserves. Data on body composition evaluation in the postoperative period of major cardiac surgery are limited. Objective: To evaluate the influence of elective coronary artery bypass grafting on body composition on the seventh postoperative day of patients with ischemic heart failure. Methods: A cross-sectional study was carried out in which eighteen volunteers with New York Heart Association Class II and III heart failure underwent coronary artery bypass grafting. The energy and protein reserves of the participants were evaluated by anthropometry in the preoperative and on the seventh postoperative day. Paired t-Test or Mann-Whitney test was used if applicable. A significance level was considered at p value < 0.05. Results: A significant loss of muscle mass was observed through the reduction of arm muscle circumference after surgery (4.2%, p 0.007). Major surgery causes hypermetabolic state and systemic inflammatory stimulus, due to the release of hormones and cytokines that may justify the observed loss of muscle mass. Conclusion: Coronary artery bypass grafting had an impact on muscle mass reduction seven days after surgery in patients with ischemic heart failure

Sympatho-Vagal Imbalance is Associated with Sarcopenia in Male Patients with Heart Failure / Desequilíbrio Simpático-Vagal está Associado com Sarcopenia em Pacientes do Sexo Masculino com Insuficiência Cardíaca

Abstract Background: Resting sympathetic hyperactivity and impaired parasympathetic reactivation after exercise have been described in patients with heart failure (HF). However, the association of these autonomic changes in patients with HF and sarcopenia is unknown. Objective: The aim of this study was to evaluate the impact of autonomic modulation on sarcopenia in male patients with HF. Methods: We enrolled 116 male patients with HF and left ventricular ejection fraction < 40%. All patients underwent a maximal cardiopulmonary exercise testing. Maximal heart rate was recorded and delta heart rate recovery (∆HRR) was assessed at 1st and 2nd minutes after exercise. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography. Dual-energy X-ray absorptiometry was used to measure body composition and sarcopenia was defined by the sum of appendicular lean muscle mass (ALM) divided by height in meters squared and handgrip strength. Results: Sarcopenia was identified in 33 patients (28%). Patients with sarcopenia had higher MSNA than those without (47 [41-52] vs. 40 [34-48] bursts/min, p = 0.028). Sarcopenic patients showed lower ∆HRR at 1st (15 [10-21] vs. 22 [16-30] beats/min, p < 0.001) and 2nd min (25 [19-39] vs. 35 [24-48] beats/min, p = 0.017) than non-sarcopenic. There was a positive correlation between ALM and ∆HRR at 1st (r = 0.26, p = 0.008) and 2nd min (r = 0.25, p = 0.012). We observed a negative correlation between ALM and MSNA (r = -0.29, p = 0.003). Conclusion: Sympatho-vagal imbalance seems to be associated with sarcopenia in male patients with HF. These results highlight the importance of a therapeutic approach in patients with muscle wasting and increased peripheral sympathetic outflow.

Resumo Fundamento: Hiperatividade simpática de repouso e uma reativação parassimpática diminuída pós-exercício têm sido descritas em pacientes com insuficiência cardíaca (IC). No entanto, a associação dessas alterações autonômicas em pacientes com IC sarcopênicos ainda não são conhecidas. Objetivo: O objetivo deste estudo foi avaliar o impacto da modulação autonômica sobre sarcopenia em pacientes com IC do sexo masculino. Métodos: Foram estudados 116 pacientes com IC e fração de ejeção ventricular esquerda inferior a 40%. Todos os pacientes foram submetidos ao teste de exercício cardiopulmonar máximo. A frequência cardíaca máxima foi registrada, e o delta de recuperação da frequência cardíaca (∆RFC) foi avaliado no primeiro e no segundo minuto após o exercício. A atividade nervosa simpática muscular (ANSM) foi registrada por microneurografia. A Absorciometria Radiológica de Dupla Energia foi usada para medir composição cpororal, e a sarcopenia definida como a soma da massa muscular apendicular (MMA) dividida pela altura em metros ao quadrado e força da mão. Resultados: A sarcopenia foi identificada em 33 pacientes (28%). Os pacientes com sarcopenia apresentaram maior ANSM que aqueles sem sarcopenia - 47 (41-52) vs. 40 (34-48) impulsos (bursts)/min, p = 0,028). Pacientes sarcopênicos apresentaram ∆RFC mais baixo no primeiro [15 (10-21) vs. 22 (16-30) batimentos/min, p < 0,001) e no segundo [25 (19-39) vs. 35 (24-48) batimentos/min, p = 0,017) minuto que pacientes não sarcopênicos. Observou-se uma correlação positiva entre a MMA e a ANSM (r = -0,29; p = 0,003). Conclusão: Um desequilíbrio simpático-vagal parece estar associado com sarcopenia em pacientes com IC do sexo masculino. Esses resultados destacam a importância de uma abordagem terapêutica em pacientes com perda muscular e fluxo simpático periférico aumentado.

Efficacy, Safety, and Performance of Isolated Left vs. Right Ventricular Pacing in Patients with Bradyarrhythmias: A Randomized Controlled Trial / Eficácia, Segurança e Desempenho da Estimulação Ventricular Esquerda versus Direita em Pacientes com Bradiarritmias: Ensaio Clínico Randomizado

Abstract Background: Considering the potential deleterious effects of right ventricular (RV) pacing, the hypothesis of this study is that isolated left ventricular (LV) pacing through the coronary sinus is safe and may provide better clinical and echocardiographic benefits to patients with bradyarrhythmias and normal ventricular function requiring heart rate correction alone. Objective: To assess the safety, efficacy, and effects of LV pacing using an active-fixation coronary sinus lead in comparison with RV pacing, in patients eligible for conventional pacemaker (PM) implantation. Methods: Randomized, controlled, and single-blinded clinical trial in adult patients submitted to PM implantation due to bradyarrhythmias and systolic ventricular function ≥ 0.40. Randomization (RV vs. LV) occurred before PM implantation. The main results of the study were procedural success, safety, and efficacy. Secondary results were clinical and echocardiographic changes. Chi-squared test, Fisher's exact test and Student's t-test were used, considering a significance level of 5%. Results: From June 2012 to January 2014, 91 patients were included, 36 in the RV Group and 55 in the LV Group. Baseline characteristics of patients in both groups were similar. PM implantation was performed successfully and without any complications in all patients in the RV group. Of the 55 patients initially allocated into the LV group, active-fixation coronary sinus lead implantation was not possible in 20 (36.4%) patients. The most frequent complication was phrenic nerve stimulation, detected in 9 (25.7%) patients in the LV group. During the follow-up period, there were no hospitalizations due to heart failure. Reductions of more than 10% in left ventricular ejection fraction were observed in 23.5% of patients in the RV group and 20.6% of those in the LV group (p = 0.767). Tissue Doppler analysis showed that 91.2% of subjects in the RV group and 68.8% of those in the LV group had interventricular dyssynchrony (p = 0.022). Conclusion: The procedural success rate of LV implant was low, and the safety of the procedure was influenced mainly by the high rate of phrenic nerve stimulation in the postoperative period.

Resumo Fundamento: Considerando-se os potenciais efeitos deletérios da estimulação do ventrículo direito (VD), a hipótese desse estudo é que a estimulação unifocal ventricular esquerda pelo seio coronário é segura e pode proporcionar melhores benefícios clínicos e ecocardiográficos aos pacientes com bradiarritmias que apresentam função ventricular normal, necessitando apenas da correção da frequência cardíaca. Objetivos: Avaliar a segurança, a eficácia e os efeitos da estimulação do ventrículo esquerdo (VE), utilizando um cabo-eletrodo com fixação ativa, em comparação à estimulação do VD. Métodos: Estudo clínico, randomizado, simples-cego em pacientes adultos com indicação de marca-passo (MP) devido a bradiarritmias e função ventricular sistólica ≥ 0,40. A randomização aleatória (VD vs VE) ocorreu antes do procedimento. Os desfechos primários do estudo foram: o sucesso, a segurança e a eficácia do procedimento proposto. Os desfechos secundários foram: a evolução clínica e alterações ecocardiográficas. Empregou-se os testes Qui-quadrado, Exato de Fisher e t de Student, com nível de significância de 5%. Resultados: De junho de 2012 a janeiro de 2014 foram incluídos 91 pacientes, sendo 36 no grupo VD e 55 no grupo VE. As características basais dos pacientes dos dois grupos foram similares. O implante de MP foi realizado com sucesso e sem nenhuma intercorrência em todos os pacientes do grupo VD. Dos 55 pacientes inicialmente alocados para o grupo VE, o implante do cabo-eletrodo em veias coronárias não foi possível em 20 (36,4%) pacientes. Dentre os 35 pacientes que permaneceram com o cabo-eletrodo no VE, a estimulação frênica foi a complicação mais frequente e foi detectada em 9 (25,7%) pacientes. Na fase de seguimento clínico, não houve hospitalizações por insuficiência cardíaca. Reduções superiores a 10% na fração de ejeção do VE foram observadas em 23,5% dos pacientes do grupo VD e em 20,6% dos pacientes do grupo VE (p = 0,767). A análise feita pelo Doppler tecidual mostrou que 91,2% dos indivíduos do grupo VD e 68,8% dos do grupo VE apresentaram dissincronia interventricular (p = 0,022). Conclusões: A taxa de sucesso do implante no VE foi baixa e a segurança do procedimento foi influenciada, principalmente, pela alta taxa de estimulação frênica no pós-operatório.

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

Correlation between myocardial velocity measured using tissue doppler imaging in the left ventricular lead-implanted segment and response to cardiac resynchronization therapy

OBJECTIVES: This study investigated whether tissue Doppler imaging parameters, especially the peak systolic velocity of the left ventricular lead-implanted segment (Ss), affect cardiac resynchronization therapy response. METHODS: In this case-control study, 110 enrolled patients were divided into cases (responder group, n=65) and controls (nonresponder group, n=45) based on whether their left ventricular end-systolic volume was reduced by ≥15% at 6 months after surgery. Preoperative clinical and echocardiographic data were collected. Multivariate logistic regression models were used to analyze the factors affecting the response to cardiac resynchronization therapy, and receiver operating characteristic curves were plotted to evaluate their diagnostic values. RESULTS: The proportion of patients with left bundle branch block in the case group was higher than that in the control group. The control group showed a higher left atrial volume index, E/A ratio and E/Em ratio but lower Ss than that of the case group. A multivariate regression analysis showed that left bundle branch block, Ss, and an E/Em ratio>14 were independent risk factors affecting the response to cardiac resynchronization therapy. Ss=4.1 cm/s was the best diagnostic threshold according to the receiver operating characteristic curve. CONCLUSIONS: Ss is an important factor affecting the response to cardiac resynchronization therapy. Patients with heart failure associated with Ss<4.1 cm/s have a higher risk of nonresponse.

Prevalence of peripheral arterial disease in patients with heart failure with preserved ejection fraction

OBJECTIVES: To describe the prevalence of the reduced ankle-brachial index (ABI) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) attended at a HF clinic in the metropolitan region of Porto Alegre, and to compar the patients to those with reduced ejection fraction (HFrEF). METHODS: A descriptive observational study, included patients referred to the heart failure clinic in HU-Ulbra with HFpEF or HFrEF and diastolic dysfunction, and measurements of ABIs using vascular Doppler equipment were performed in both groups. RESULTS: The sample consisted of 106 patients with HF, 53.9% of the patients had HFpEF, and 19.4% had a diagnosis of peripheral arterial disease (PAD) (ABI less than 0.9). PAD was identified in 24.1% of the patients with HFpEF, while15.8% of patients in the HFrEF group were diagnosed with PAD. CONCLUSION: Our results did not identify a significantly different prevalence of altered and compatible PAD values in patients with HFpEF. However, we showed a prevalence of 19.4%, a high value if we consider similar populations.

Efecto de la terapia de resincronización ventricular en los parámetros de disfunción endotelial y función sistólica izquierda en pacientes con insuficiencia cardíaca crónica y bloqueo completo de rama izquierda / Endothelial dysfunction, left ventricular function, and chronic heart failure with complete left bundle branch block: effect of resynchronization therapy

Resumen: Introducción: La insuficiencia cardíaca crónica (ICC) es una condición compleja asociada a inflamación sistémica y a disfunción endotelial (DE) cuya patogénesis no es bien comprendida. Objetivo: Evaluar una posible relación entre marcadores de DE periférica con la respuesta a terapia de resincronización ventricular (TRV). Método: 20 pacientes con ICC, QRS ≥120ms y fracción de eyección ventricular izquierda (FEVI) ≤35% se estudiaron pre y 6 meses post-TRV con: Minnesota Living with Heart Failure Questionnaire (MLHFQ); test de marcha (TM-6min); Ecocardiografía-2D y SPECT de perfusión gatillado en reposo; proteína C-reactiva ultra sensible (us-PCR); péptido natriurético cerebral (pro-BNP); células endoteliales circulantes (CEC); moléculas de adhesión soluble vascular (sVCAM) e intercelular (sICAM); interleukina-6 (IL-6) y Factor von Willebrand (FvW). Se clasificaron como respondedores o no a TRV según criterios preestablecidos. Resultados: Promedios basales: pro-BNP 5.290pg/ml; us-PCR 1,7ug/mL; MLHFQ 72; TM-6min 391 metros. Las CEC y sICAM estaban sobre límites normales. Post-TRV, el 50% fue respondedor: 11/20 mejoraron ≥1 clase NYHA y ≥10% del TM-6min; ML-HFQ disminuyó (p<0.0001); FEVI mejoró (p=0.003); volumen final sistólico disminuyó (p=0.008) y también pro-BNP (p=0.03). En los respondedores, las CEC disminuyeron, persistiendo elevadas, sobre lo normal. Existieron correlaciones entre cambios de pro-BNP con TM-6min y entre us-PCR con MLHFQ y FvW (p≤0.004 en todas). Conclusiones: En ICC existe evidencia de significativa DE, expresada por sICAM y CEC, biomarcador periférico sensible. Estas disminuyeron 6 meses post-TRV, persistiendo sobre el límite normal. Otros parámetros funcionales e inflamatorios se correlacionaron en el grupo total, sin diferencias entre grupos respondedores y no respondedores.

Abstract: Introduction: Chronic heart failure (CHF) is a complex condition associated with systemic inflammation and endothelial dysfunction (ED) whose pathogenesis is not well understood. Objective: to evaluate a possible relationship between peripheral ED markers and response to cardiac resynchronization therapy (CRT). Method: 20 patients with CHF, QRS ≥120ms and left ventricular ejection fraction (LVEF) ≤35% were studied before and 6 months post-CRT. Minnesota Living with Heart Failure Questionnaire (MLHFQ); walking test (6min-WT); 2D-echocardiography and gated perfusion SPECT at rest; ultra-sensitive C-reactive protein (us-CRP); brain natriuretic peptide (pro-BNP); circulating endothelial cells (CEC); vascular soluble adhesion (sVCAM) and intercellular adhesion molecules (sICAM); interleukin-6 (IL-6) and von Willebrand Factor (vWF) were measured in all subjects. They were classified as responders or not to CRT, according to pre-established criteria. Results: Basal means: pro-BNP 5,290 pg / ml; us-CRP 1.7 ug/mL; MLHFQ 72; 6min-WT 391 meters. The CEC and IL-6 were above normal limits. Post-CRT, 50% were responders: 11/20 improved ≥1 NYHA class and ≥10% increase in 6min-WT; MLHFQ decreased (p <0.0001); LVEF improved (p = 0.003); final systolic volume decreased (p = 0.008) and also pro-BNP (p= 0.03). In responders CEC decreased, persisting over normal limits. There were correlations between changes of pro-BNP with TM-6min and between us-PCR with MLHFQ and vWF (p≤0.004 in all). Conclusions: In CHF there is evidence of significant ED, expressed by sICAM and CEC, a sensitive peripheral biomarker that decreased 6 months post-CRT although persisting above normal limits. Other functional and inflammatory parameters were correlated in the total group, without differences between responders and non-responders.

Phenotype mapping of heart failure with preserved ejection fraction / Mapeamento fenotípico da insuficiência cardíaca com fração de ejeção preservada

Heart failure with preserved ejection fraction (HFPEF) has become the main phenotypic model of heart failure (HF) in community and referral patients in Brazil and in the world. Despite advances in the development of new drugs for HF treatment, there has been no significant improvement in mortality of this condition. According to many studies, this can be explained by the heterogeneous nature of HF physiopathology, whose basic mechanisms may result in different clinical presentations, culminating in the emerging of different phenogroups in this syndrome. In this context, phenotype mapping of HFPEF has emerged as a possible solution, since it enables the development of clinical trials that establish specific therapeutic strategies for each phenotypic profile. New technologies in the field of artificial intelligence have enabled the assessment of a large volume of data and infer intrinsic patterns and different outcomes. Thereby, it is possible to obtain mutually exclusive categories of HFPEF, with a phenotype mapping of the syndrome and grouping of patients according to their phenotypic features. Besides, other diseases can have the same clinical phenotype but different pathophysiological basis, the so called "phenocopies". These tools enable the analysis and categorization of the wide spectrum of heart failure, contributing to solve the dilemmas of the treatment of this syndrome

Vasodilation and Reduction of Systolic Blood Pressure after One Session of High-Intensity Interval Training in Patients With Heart Failure with Preserved Ejection Fraction / Vasodilatação e Redução da Pressão Arterial Sistólica após uma Sessão de Treinamento Intervalado de Alta Intensidade em Pacientes com Insuficiência Cardíaca com Fração de Ejeção Preservada

Abstract Background: Heart failure with preserved ejection fraction (HFpEF) is a multifactorial syndrome characterized by a limited exercising capacity. High-intensity interval training (HIIT) is an emerging strategy for exercise rehabilitation in different settings. In patients with HFpEF, HIIT subacute effects on endothelial function and blood pressure are still unknown. Objective: To evaluate the subacute effect of one HIIT session on endothelial function and blood pressure in patients with HFpEF. Methods: Sixteen patients with HFpEF underwent a 36-minute session of HIIT on a treadmill, alternating four minutes of high-intensity intervals with three minutes of active recovery. Brachial artery diameter, flow-mediated dilation, and blood pressure were assessed immediately before and 30 minutes after the HIIT session. In all analyses, p <0.05 was considered statistically significant. Results: There was an increase in brachial artery diameter (pre-exercise: 3.96 ± 0.57 mm; post-exercise: 4.33 ± 0.69 mm; p < 0.01) and a decrease in systolic blood pressure (pre-exercise: 138 ± 21 mmHg; post-exercise: 125 ± 20 mmHg; p < 0.01). Flow-mediated dilation (pre-exercise: 5.91 ± 5.20%; post-exercise: 3.55 ± 6.59%; p = 0.162) and diastolic blood pressure (pre-exercise: 81 ± 11 mmHg; post-exercise: 77 ± 8 mmHg; p = 1.000) did not change significantly. There were no adverse events throughout the experiment. Conclusions: One single HIIT session promoted an increase in brachial artery diameter and reduction in systolic blood pressure, but it did not change flow-mediated dilation and diastolic blood pressure.

Resumo Fundamento: Insuficiência cardíaca com fração de ejeção preservada (ICFEP) é uma síndrome multifatorial caracterizada por limitação ao exercício. O treinamento intervalado de alta intensidade (HIIT) é uma estratégia emergente para a reabilitação do exercício em diferentes contextos. Em pacientes com ICFEP, os efeitos subagudos do HIIT sobre a função endotelial e a pressão arterial ainda são desconhecidos. Objetivo: Avaliar o efeito subagudo de uma única sessão do HIIT sobre a função endotelial e a pressão arterial em pacientes com ICFEP. Métodos: Dezesseis pacientes com ICFEP foram submetidos a uma sessão de 36 minutos de HIIT em esteira rolante, alternando quatro minutos de intervalos de alta intensidade com três minutos de recuperação ativa. O diâmetro da artéria braquial, a dilatação mediada pelo fluxo e a pressão arterial foram avaliados imediatamente antes e 30 minutos após a sessão de HIIT. Em todas as análises, p <0,05 foi considerado estatisticamente significativo. Resultados: Houve aumento do diâmetro da artéria braquial (pré-exercício: 3,96 ± 0,57 mm; pós-exercício: 4,33 ± 0,69 mm; p < 0,01), e diminuição da pressão arterial sistólica (pré-exercício: 138 ± 21 mmHg; pós-exercício: 125 ± 20 mmHg; p < 0,01). A dilatação mediada por fluxo (pré-exercício: 5,91 ± 5,20%; pós-exercício: 3,55 ± 6,59%; p = 0,162) e pressão arterial diastólica (pré-exercício: 81 ± 11 mmHg; pós-exercício: 77 ± 8 mmHg; p = 1,000) não se alteraram significativamente. Não houve eventos adversos durante o experimento. Conclusões: Uma única sessão do HIIT promoveu aumento do diâmetro da artéria braquial e redução da pressão arterial sistólica, mas não alterou a dilatação mediada pelo fluxo e a pressão arterial diastólica.

Relationship of Electromechanical Dyssynchrony in Patients Submitted to CRT With LV Lead Implantation Guided by Gated Myocardial Perfusion Spect / Relação entre Dissincronismo Elétrico e Mecânico em Pacientes Submetidos a TRC com Implante do Eletrodo de VE Orientado pela Cintilografia GATED SPECT

Abstract Background: Heart failure (HF) affects more than 5 million individuals in the United States, with more than 1 million hospital admissions per year. Cardiac resynchronization therapy (CRT) can benefit patients with advanced HF and prolonged QRS. A significant percentage of patients, however, does not respond to CRT. Electrical dyssynchrony isolated might not be a good predictor of response, and the last left ventricular (LV) segment to contract can influence the response. Objectives: To assess electromechanical dyssynchrony in CRT with LV lead implantation guided by GATED SPECT. Methods: This study included 15 patients with functional class II-IV HF and clinically optimized, ejection fraction of 35%, sinus rhythm, left bundle-branch block, and QRS ≥ 120 ms. The patients underwent electrocardiography, answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and underwent gated myocardial perfusion SPECT up to 4 weeks before CRT, being reassessed 6 months later. The primary analysis aimed at determining the proportion of patients with a reduction in QRS duration and favorable response to CRT, depending on concordance of the LV lead position, using chi-square test. The pre- and post-CRT variables were analyzed by use of Student t test, adopting the significance level of 5%. Results: We implanted 15 CRT devices, and 2 patients died during follow-up. The durations of the QRS (212 ms vs 136 ms) and the PR interval (179 ms vs 126 ms) were significantly reduced (p < 0.001). In 54% of the patients, the lead position was concordant with the maximal delay site. In the responder group, the lateral position was prevalent. The MLHFQ showed a significant improvement in quality of life (p < 0.0002). Conclusion: CRT determines improvement in the quality of life and in electrical synchronism. Electromechanical synchronism relates to response to CRT. Positioning the LV lead in the maximal delay site has limitations.

Resumo Fundamento: A insuficiência cardíaca (IC) afeta mais de 5 milhões de pessoas nos Estados Unidos, com mais de 1 milhão de internações/ano. A terapia de ressincronização (TRC) pode beneficiar pacientes com IC avançada e QRS alargado; entretanto, percentual significativo de pacientes não respondem à TRC. O dissincronismo elétrico isolado pode não representar um bom preditor de resposta, e o local da última ativação do ventrículo esquerdo (VE) pode influenciar na resposta. Objetivos: Avaliar o dissincronismo eletromecânico na TRC com o implante do eletrodo do VE orientado por GATED SPECT. Métodos: Incluídos 15 pacientes com IC classe funcional II-IV, otimizados clinicamente, com fração de ejeção de 35%, ritmo sinusal, bloqueio de ramo esquerdo, QRS ≥ 120 ms. Realizaram eletrocardiograma, Questionário Minnesota Vivendo com Insuficiência Cardíaca (MLHFQ) e cintilografia GATED SPECT até 4 semanas antes do implante. Reavaliados 6 meses após. Análise primária visou determinar a proporção de pacientes com redução da duração do QRS e resposta favorável à TRC dependendo da concordância ou não na posição do eletrodo, utilizando teste Qui-Quadrado. Análise das variáveis pré e pós TRC foi feita através do teste t de Student, assumindo significância de 5%. Resultados: Realizamos 15 implantes com 2 óbitos no seguimento. As reduções das durações do QRS (212 ms vs 136 ms) e do IPR (179 ms vs 126 ms) foram significativas (p < 0,001). Em 54%, o eletrodo foi concordante com o local de maior atraso. No grupo respondedor, a posição lateral foi prevalente. O MLHFQ mostrou melhora significativa da qualidade de vida (p < 0,0002). Conclusão: A TRC determina melhora da qualidade de vida e do sincronismo elétrico. O sincronismo eletromecânico relaciona-se com a resposta à TRC. O posicionamento do eletrodo de VE no sítio de maior retardo tem limitações.