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.

A 10-Year Trend Analysis of Heart Failure in the Less Developed Brazil / Insuficiência Cardíaca no Brasil Subdesenvolvido: Análise de Tendência de Dez Anos

Abstract Background: Data on heart failure (HF) epidemiology in less developed areas of Brazil are scarce. Objective: Our aim was to determine the HF morbidity and mortality in Paraiba and Brazil and its 10-year trends. Methods: A retrospective search was conducted from 2008 to 2017 using the DATASUS database and included patients ≥ 15 years old with a primary diagnosis of HF. Data on in-hospital and population morbidity and mortality were collected and stratified by year, gender and age. Pearson correlation and linear-by-linear association test for trends were calculated, with a level of significance of 5%. Results: From 2008 to 2017, HF admissions decreased 62% (p = 0.004) in Paraiba and 34% (p = 0.004) in Brazil. The in-hospital mortality rate increased in Paraiba and Brazil [65.1% (p = 0.006) and 30.1% (p = 0.003), respectively], but the absolute in-hospital mortality had a significant decrease only in Paraiba [37.5% (p = 0.013)], which was maintained after age stratification, except for groups 15-19, 60-69 and > 80 years. It was observed an increase in the hospital stay [44% (p = 0.004) in Paraiba and 12.3% (p = 0.004) in Brazil]. From 2008 to 2015, mortality rate for HF in the population decreased 10.7% (p = 0.047) in Paraiba and 7.7% (p = 0.017) in Brazil. Conclusions: Although HF mortality rate has been decreasing in Paraiba and Brazil, an increase in the in-hospital mortality rate and length of stay for HF has been observed. Hospital-based clinical studies should be performed to identify the causes for these trends of increase.

Resumo Fundamento: Dados sobre a epidemiologia da insuficiência cardíaca (IC) em áreas pouco desenvolvidas são escassos. Objetivos: Nosso objetivo foi determinar a morbidade e a mortalidade por IC na Paraíba e no Brasil, e sua tendência em dez anos. Métodos: Realizou-se uma busca retrospectiva de 2008 a 2017 utilizando-se o banco de dados do DATASUS incluindo pacientes com idade ≥ 15 anos, com diagnóstico primário de IC. Os dados da morbimortalidade por IC foram coletados e estratificados por ano, sexo e idade. Foram realizados correlação de Pearson e teste para tendências de Mantel-Haenzsel. Um nível de 5% foi definido como estatisticamente significativo. Resultados: De 2008 a 2017, as internações por IC diminuíram 62% (p = 0,004) na Paraíba, e 34% (p = 0,004) no Brasil. A taxa de mortalidade hospitalar aumentou na Paraíba e no Brasil [65,1% (p = 0,006) e 30,1% (p = 0,003), respectivamente], mas a mortalidade hospitalar em números absolutos apresentou uma diminuição significativa somente na Paraíba [37,5% (p = 0,013)], o que foi mantido após a estratificação por idade, exceto para os grupos 15-19, 60-69 e > 80 anos. Observou-se um aumento no período de internação [44% (p = 0,004) na Paraíba e 12,3% (p = 0,004) no Brasil]. De 2008 a 2015, a taxa de mortalidade por IC na população diminuiu 10,7% na Paraíba (p = 0,047) e 7,7% (p = 0,017) no Brasil. Conclusões: Apesar de a taxa de mortalidade por IC estar diminuindo na Paraíba e no Brasil, observou-se um aumento na taxa de mortalidade hospitalar e na duração da internação por IC. Devem ser realizados estudos clínicos em hospitais para serem identificadas as causas dessa tendência de aumento.

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.

Caracterización clínica epidemiológica de la diabetes mellitus en dos áreas de salud. Municipio Cárdenas. 2017 / Clinico-epidemiological characterization of diabetes mellitus in two health areas. Municipality of Cardenas. 2017

RESUMEN Introducción: la diabetes mellitus es un trastorno metabólico caracterizado por hiperglucemia crónica con alteraciones en los carbohidratos, grasas y proteínas. Las tasas de morbimortalidad han aumentado al igual que la obesidad, constituye un problema de salud en el mundo, Cuba y la provincia de Matanzas. Objetivo: realizar una caracterización clínica epidemiológica de la diabetes mellitus tipo 2 en dos áreas de salud, conocer las variables e identificar las barreras para una posterior intervención. Materiales y métodos: se realizó un estudio epidemiológico descriptivo- transversal a 750 diabéticos tipo 2 mayores de 18 años en dos áreas de salud. Se realizaron encuestas, procesándose en el programa Epi-Info, obteniéndose la frecuencia de las variables, y las diferencias estadísticas significativas entre variables de las dos aéreas de salud, utilizándose el valor de p < 0,05 % y el Chi2. Resultados: el promedio de edad fue de 62,2 años, predominio del sexo femenino y color de la piel blanca. La hipertensión arterial y la obesidad fueron las enfermedades más asociadas, y el tabaquismo, la ingestión de bebidas alcohólicas y azucaradas, y la no realización de ejercicios físicos fueron los factores asociados más relevantes. Los medicamentos más utilizados fueron la glibenclamida y la metformina. Conclusiones: la diabetes mellitus es la primera causa de fracaso renal en el mundo occidental, siendo la insuficiencia renal una de las complicaciones crónicas más graves de esta enfermedad. Entre las principales causas de muerte de esta enfermedad son las complicaciones macrovasculares, manifestadas clínicamente como cardiopatía isquémica, insuficiencia cardíaca, la enfermedad vascular cerebral y la insuficiencia arterial periférica.

ABSTRACT Introduction: diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with alterations in carbohydrates, fats and proteins. Morbi-mortality rates have increased as have done obesity, being a health problem in the world, Cuba and the province of Matanzas. Objective: to carry out clinical-epidemiological characterization of type 2 diabetes mellitus in two health areas, knowing the variables and identifying the barriers for a subsequent intervention. Materials and methods: a cross-sectional descriptive study was carried out in 750 type-2 diabetic patients over 18 years in two health areas. Surveys were made and processed in Epi-Info program, showing significant statistic differences among variables of both health areas; p < 0,05 % value and Chi2 were used. Results: the average age was 62.2 years, predominating female sex and white skin color. The most commonly associated diseases were arterial hypertension and obesity; smoking and drinking alcoholic and sugar-sweetened beverages and sedentary life were the most relevant associated factors. The most commonly used medications were glibenclamide and metformin. Conclusions: diabetes is the first cause of renal failure in the Western world, being renal insufficiency one of the most serious chronic complications of this disease. The main causes of death of this disease are macro vascular complications clinically manifested as ischemic heart disease, heart failure, cerebra-vascular disease and peripheral arterial insufficiency.

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

Evaluation of the effect of hospitalization on mortality in patients with heart failure followed in primary care / Evaluación del efecto de las hospitalizaciones sobre mortalidad en pacientes con Insuficiencia cardíaca seguidos en atención primaria

Abstract Background: Heart failure (HF) is a serious health-care problem. The aim of this study is to evaluate the effect of the first acute episode of decompensated HF that requires a hospitalization on the survival of newly diagnosed cases of HF with follow-up for 5 years in primary care (PC). Methods: This was a longitudinal observational study of a retrospective cohort of patients with information extracted from electronic medical records of PC. Incident cases of HF from 2006 to 2010 or until death were studied through a survival analysis with Kaplan–Meier and Cox proportional hazards multivariate regression, after applying the propensity score matching technique (PSM). Results: A total of 3061 new cases of HF were identified. The PSM analysis was performed with 529 couples, with a total of 1058 patients. 5-year survival was 65% in no hospitalized and 53% in hospitalized patients. Factors with an increased risk of mortality were having prescribed nitrates (heart rate [HR] = 1.56; 1.08-2.24). Factors with protective effect were having received the annual influenza vaccine (HR = 0.04; 0.01-0.15) and having been indicated X-rays by PC physician (HR = 0.76; 0.67-0.88). Conclusions: The findings indicate that hospitalizations are associated with a significant increase in mortality in patients recently diagnosed with HF. It is important to reinforce the need for the prevention of acute decompensated HF and for strategies to improve post-discharge outcomes.

Resumen Antecedentes: La insuficiencia cardiaca (IC) es un serio problema de asistencia médica. El objetivo de este estudio es evaluar el efecto del primer episodio de IC aguda descompensada que requiere una hospitalización en la supervivencia de los casos de IC recientemente diagnosticados con un seguimiento de 5 años en Atención Primaria (AP). Métodos: Estudio observacional longitudinal de una cohorte retrospectiva de pacientes con información extraída de la historia clínica electrónica de AP. Se estudiaron los casos incidentes de IC desde 2006 a 2010 o hasta su fallecimiento con un análisis de supervivencia de Kaplan-Meier y un modelo de regresión de Cox, después de aplicar la técnica del Propensity Score Matching (PSM). Resultados: Se identificaron 3.061 casos nuevos de IC. El análisis PSM se realizó con 529 pareja, con un total de 1.058 pacientes. La supervivencia a los cinco años fue del 65% en pacientes no hospitalizados y del 53% en pacientes hospitalizados. Los factores con mayor riesgo de mortalidad fueron tener prescritos nitratos (HR = 1,56; 1,08-2,24). Los factores con efecto protector fueron haber recibido la vacuna anual de la gripe (HR = 0,04; 0,01-0,15) y haber sido indicadas radiografías por el médico de AP (HR = 0,76; 0,67-0,88). Conclusiones: Los hallazgos indican que las hospitalizaciones se asocian con un aumento significativo de la mortalidad en pacientes diagnosticados recientemente con IC. Es importante reforzar la necesidad de prevenir la IC descompensada aguda y las estrategias para mejorar los resultados posteriores al alta.

Redistribution of heart failure deaths using two methods: linkage of hospital records with death certificate data and multiple causes of death data / Redistribuição de óbitos por insuficiência cardíaca usando dois métodos: linkage de registros hospitalares com dados de atestados de óbito e de causas múltiplas de morte / Redistribución de las muertes por fallo cardíaco usando dos métodos: enlace a registros hospitalarios con datos del certificado de defunción y sobre causas múltiples de la muerte

Heart failure is considered a garbage code when assigned as the underlying cause of death. Reassigning garbage codes to plausible causes reduces bias and increases comparability of mortality data. Two redistribution methods were applied to Brazilian data, from 2008 to 2012, for decedents aged 55 years and older. In the multiple causes of death method, heart failure deaths were redistributed based on the proportion of underlying causes found in matched deaths that had heart failure listed as an intermediate cause. In the hospitalization data method, heart failure deaths were redistributed based on data from the decedents' corresponding hospitalization record. There were 123,269 (3.7%) heart failure deaths. The method with multiple causes of death redistributed 25.3% to hypertensive heart and kidney diseases, 22.6% to coronary heart diseases and 9.6% to diabetes. The total of 41,324 heart failure deaths were linked to hospitalization records. Heart failure was listed as the principal diagnosis in 45.8% of the corresponding hospitalization records. For those, no redistribution occurred. For the remaining ones, the hospitalization data method redistributed 21.2% to a group with other (non-cardiac) diseases, 6.5% to lower respiratory infections and 9.3% to other garbage codes. Heart failure is a frequently used garbage code in Brazil. We used two redistribution methods, which were straightforwardly applied but led to different results. These methods need to be validated, which can be done in the wake of a recent national study that will investigate a big sample of hospital deaths with garbage codes listed as underlying causes.

A insuficiência cardíaca, quando atribuída como a causa básica de morte, é considerada um código lixo. A reatribuição de códigos lixo a causas plausíveis tem por objetivo reduzir viés e aumentar a comparabilidade de dados sobre mortalidade. Dois modelos de redistribuição foram aplicados a dados brasileiros de 2008 a 2012, para pacientes falecidos de 55 anos de idade ou mais. No modelo de causas múltiplas de morte, óbitos por insuficiência cardíaca foram redistribuídos com base na proporção de causas básicas identificadas em óbitos pareados que tinham insuficiência cardíaca listada como causa intermediária. No método de dados hospitalares, óbitos por insuficiência cardíaca foram redistribuídos com base nos dados dos registros de hospitalização dos pacientes falecidos. Houve 123.269 (3,7%) óbitos por insuficiência cardíaca. O método de causas múltiplas de morte redistribuiu 25,3% para doenças cardíacas hipertensivas e doenças renais, 22,6% para doenças cardíacas coronarianas e 9,6% para diabetes. Houve 41.324 óbitos por insuficiência cardíaca relacionados com registros de hospitalização. A insuficiência cardíaca foi listada como o diagnóstico principal em 45,8% dos registros de hospitalização correspondentes. Para estes, não foi feita redistribuição. Para os óbitos remanescentes, o método de dados hospitalares redistribuiu 21,2% para outras doenças (não cardíacas), 6,5% para infecções das vias aéreas inferiores e 9,3% para outros códigos lixo. A insuficiência cardíaca é um código lixo frequentemente usado no Brasil. Nós usamos dois métodos de redistribuição, aplicados de forma simples, mas que levaram a resultados distintos. É importante que esses métodos sejam validados, o que pode ser feito a partir de um estudo nacional recente que investigará uma grande amostra de óbitos hospitalares com códigos lixo listados como causas básicas.

El fallo cardíaco, cuando es asignado como causa subyacente de la muerte está considerado como código basura. El objetivo de este estudio es reasignar códigos basura de fallecimiento, con el fin de reducir sesgos e incrementar la comparabilidad de los datos de mortalidad. Se aplicaron dos métodos de redistribución en los datos brasileños de 2008 a 2012, para fallecidos de 55 años y mayores. En el método de causas múltiples de muerte, las muertes por fallo cardiaco fueron redistribuidas basándose en la proporción de causas subyacentes encontradas en las muertes compatibles que contaban con un fallo cardiaco descrito como causa intermedia. En el método de datos de hospitalización, las muertes por fallo cardiaco fueron redistribuidas basándose en datos del historial de hospitalización de los fallecimientos. Hubo 123.269 (3,7%) muertes por fallo cardíaco. El método de múltiples causas de fallecimiento redistribuyó un 25,3% a problemas de hipertensión cardiaca y enfermedades de riñón, un 22,6% a enfermedades coronarias de corazón y un 9,6% a diabetes. Hubo 41.324 muertes por fallos cardiacos vinculadas a los registros de hospitalización. El fallo cardíaco fue listado como diagnóstico principal en un 45,8% de los registros de hospitalización correspondientes. Para estos últimos, no se produjo redistribución. En el caso de los restantes, el método de datos de hospitalización redistribuyó un 21,2% a un grupo con otras enfermedades (no-cardíacas), un 6,5% a infecciones en las vías respiratorias bajas y un 9,3% a otros códigos basura. El fallo cardíaco es frecuentemente usado en Brasil como código basura. Usamos dos métodos de redistribución, que fueron directamente aplicados, pero que condujeron a resultados diferentes. Es importante validar estos métodos, que como consecuencia de un estudio nacional recientemente iniciado es posible que se pueda hacer, además de investigar una gran muestra de muertes hospitalarias registradas con códigos basura procedentes de causas subyacentes.

Causes of hospital admissions and deaths among Brazilian elders between 2005 and 2015 / Causas de internación hospitalar y óbito en los adultos mayores brasileños entre 2005 y 2015 / Causas de internação hospitalar e óbito em idosos brasileiros entre 2005 e 2015

Abstract OBJECTIVE To analyze the ranking and percentage variation of the main causes of hospital admissions and death of Brazilian elders between 2005 and 2015, according to gender and age groups. METHOD Retrospective and temporal analysis study. The six main causes of hospitalization and death of elders were collected in DATASUS according to sex and age groups (60 ~ 79, ≥80) in 2017. RESULTS Heart Failure (2005) and pneumonia (2015) were the two main causes of hospital admissions in both sexes and age groups, except for the younger group. Acute Myocardial Infarction was the main cause of death in 2005 and 2015. The second cause in the overall ranking was the Stroke in 2005 and Pneumonia in 2015. CONCLUSION Circulatory and respiratory diseases were the main causes of hospital admissions and death among the elderly, highlighting the impotant increase in pneumonia as a cause of morbimortality.

Resumen OBJETIVO Analizar el ranking y la variación porcentual de las principales causas de internación y muerte de adultos mayores brasileños entre 2005 y 2015, de acuerdo con sexo y grupos de edad. MÉTODO Estudio retrospectivo, de análisis temporal. Las seis principales causas de internación y muerte de adultos mayores fueron recogidas en el DATASUS, según el sexo y grupos de edad (60 ~ 79; ≥80), en 2017. RESULTADOS La Insuficiencia Cardiaca (2005) y la neumonía (2015) fueron las dos las principales causas de hospitalizaciones en ambos sexos y grupos de edad, excepto en ancianos más jóvenes. El infarto agudo de miocardio fue la principal causa de muerte en 2005 y 2015. La segunda causa en el ranking general fue el accidente vascular cerebral en 2005 y la neumonía en 2015. CONCLUSIÓN Las enfermedades del aparato circulatorio y respiratorio fueron las principales causas de hospitalización y muerte entre los ancianos, destacándose el significativo aumento de la neumonía como causa de morbimortalidad.

Resumo OBJETIVO Analisar o ranking e a variação percentual das principais causas de internação e óbito de idosos brasileiros entre 2005 e 2015, de acordo com sexo e grupos etários. MÉTODO Estudo retrospectivo, de análise temporal. As seis principais causas de internação e óbito de idosos foram coletados no DATASUS, segundo o sexo e grupos etários (60~79; ≥80), em 2017. RESULTADOS A Insuficiência Cardíaca (2005) e a pneumonia (2015) foram as duas principais causas de hospitalizações em ambos os sexos e grupos etários, exceto em idosos mais jovens. O Infarto Agudo do Miocárdio foi a principal causa de óbito em 2005 e 2015. Já a segunda causa no ranking geral foi o Acidente Vascular Cerebral em 2005, e a Pneumonia em 2015. CONCLUSÃO As doenças do aparelho circulatório e respiratório foram as principais causas de hospitalização e óbito entre os idosos, destacando-se o significativo aumento da pneumonia como causa de morbimortalidade.

Insuficiência cardíaca na população geriátrica: dados de um registro unicêntrico / Heart failure in the older population: data from a single-center registry

OBJETIVO: Analisar o perfil e o seguimento clínico de pacientes com insuficiência cardíaca. MÉTODOS: Estudo prospectivo observacional de pacientes com insuficiência cardíaca, que comparou a população geriátrica (≥ 65 anos) com o restante da amostra (18 a 64 anos). Todos eram acompanhados ambulatorialmente em clínica especializada de um hospital-escola e foram incluídos consecutivamente entre abril e novembro de 2013, tendo sido acompanhados por 3 anos ou óbito. RESULTADOS: Da amostra total de 100 pacientes, 56% eram idosos. Na comparação entre idosos (média de 74±7 anos) e não idosos (média de 52±8 anos), houve diferença significativa quanto a peso corporal (72,6±16 kg vs. 80,8±19kg; p=0,02), índice de massa corporal (28,6±5,7kg/m2 vs. 32,6±5,9kg/m2; p=0,001), fibrilação atrial (35,7% vs. 11,3%; p=0,005) e doença renal crônica (28,5% vs. 13,6%; p=0,04). A prescrição de betabloqueadores e de inibidores da enzima conversora de angiotensina ou bloqueadores do receptor de angiotensina não diferiu entre os grupos, e nem os dados ecocardiográficos e a ocorrência de desfechos no seguimento clínico. CONCLUSÃO: Idosos foram a maioria dentre pacientes com insuficiência cardíaca e apresentaram maior prevalência de doença renal crônica e fibrilação atrial, além de menores peso e índice de massa corporal. Tais diferenças não resultaram em maior incidência de desfechos adversos na evolução de médio prazo. (AU)

OBJECTIVE: To assess the clinical profile and follow-up of patients with heart failure. METHODS: This is a prospective, observational study that compared the geriatric population (≥ 65 years old) with the remaining portion of the sample (18 to 64 years old). All of them were assisted in a specialized outpatient clinic of a university hospital, and were included consecutively from April to November 2013, being followed for three years or until death. RESULTS: From the sample of 100 patients, 56% were older people. In the comparison between older people (average 74 ± 7 years old) and non-older people (average 52 ± 8 years old), a significant difference was found for body weight (72.6 ± 16Kg vs. 80.8 ± 19Kg, p=0.02), body mass index (28.6 ± 5.7Kg/m2 vs. 32.6 ± 5.9 Kg/m2, p=0.001), atrial fibrillation (35.7% vs. 11.3%, p=0.005), and chronic kidney disease (28.5% vs. 13.6%, p=0.04). The prescription of beta-blockers and angiotensin converting enzyme inhibitors, or angiotensin receptor blockers did not differ between the groups, neither did the echocardiographic values and the occurrence of outcomes at clinical follow-up. CONCLUSION: Older people were the majority among patients with heart failure, and presented a higher prevalence of chronic kidney disease and atrial fibrillation, and lower body weight and body mass index. Those differences did not result in greater incidence of adverse outcomes at mid-term follow-up. (AU)

Número de internações hospitalares, custos hospitalares, média de permanência e mortalidade por insuficiência cardíaca nas regiões brasileiras, no ano de 2017 / Number of hospitalizations, hospital costs, average of permanence and mortality from heart failure in brazilian regions in the year 2017

A insuficiência cardíaca (IC) é, hoje, um dos principais problemas de saúde nos países desenvolvidos e provoca importante redução da qualidade de vida, sendo, ainda, uma importante causa de internação em todas as regiões brasileiras. Objetivos: descrever o número de internações por IC por regiões brasileiras no ano de 2017 e o impacto dessas internações nos custos hospitalares. Analisar o número de internações por regiões. Discutir a média de permanência de internações hospitalares por regiões. Comparar a média de permanência e a taxa de mortalidade por regiões. Avaliar o impacto dos custos hospitalares por internação, por regiões. Metodologia: pesquisa de natureza quantitativa, descritiva, realizada no ano de 2017, baseada em dados secundários, constituídos por informações de saúde coletadas no Departamento de Informática do Sistema Único de Saúde (DATASUS), a partir do Sistema de Informações Hospitalares (SIH/SUS). Resultados: no Brasil, no ano de 2017, foi verificado um total de internações por IC de 208.111, correspondente a um valor total de R$ 339.719.216,50 de custos hospitalares por IC, com uma média de permanência total de 7,5 dias de internamento por IC e uma taxa de mortalidade de 11%. Destaca-se uma forte correlação entre média de permanência e a taxa de mortalidade, tendo como resultado r = 0,871. Conclusão: as internações de indivíduos por IC correspondem a um alto risco, por ser esperada uma taxa de mortalidade elevada nesse perfil de pacientes. Melhoria na qualidade assistencial e maiores ações por parte do governo são necessárias para conscientizar a população sobre os meios de prevenção e o tratamento correto da a insuficiência cardíaca, responsável pela maior taxa de mortalidade no Brasil.

Heart Failure (HF) is today one of the main health problems in developed countries and causes substantial reduction of quality of life and is still an important cause of hospitalization in all Brazilian regions. Objectives: describe the number of hospitalizations by HF for Brazilian regions in the year 2017 and the impact of these of these hospitalization in hospital costs. Analyze the number of hospitalizations by region. Discuss the average stay of hospitalization by regions. Compare average permanence and mortality rate by region. Evaluate the impact of hospital costs for hospitalization by regions. Methodology: research of quantitative, descriptive nature, defined in secondary data in the period of 2017, based on health information, with data collected from National Health System Computer Department (DATASUS), from the Hospital Information System (SIH/SUS). Results: it was viewed in Brazil, in the year 2017, a total of 208,111 hospitalizations due to HF, a total amount of R$ 339.719.216,50 of hospital costs by HF, an average of 7.5 days total stay of hospitalization due to HF and a mortality rate of 11%. A strong correlation between average permanence and mortality rate, resulting in r = 0.87. Conclusion: the hospitalizations of individuals by HF represent a high risk group, therefore, a high mortality rate in this profile of hospitalization is expected. Healthcare quality improvement are needed and biggest actions on the part of the Government to educate the public about how to prevent the HF and how to treat correctly the appearance of this which is still responsible for greater mortality rate in Brazil, the heart failure.

Effectiveness of natriuretic peptide-guided treatmen of chronic heart failure. A meta-analysis / Efectividad del tratamiento guiado por el péptido natriurético para la insuficiencia cardiaca crónica. Meta-análisis

Abstract Objective: To evaluate the efficacy of natriuretic peptide (NP)-guided therapy compared to clinically-guided therapy in reducing mortality and hospital admissions in chronic heart failure (HF) patients. Methods: Randomised clinical trials (RCT) were selected through a systematic review. Four meta-analyses were conducted for the outcomes of overall mortality, HF-related mortality, overall hospital admissions, and HF-related hospital admissions. Heterogeneity between studies and publication bias were also assessed. Results: Nine RCTs were found with a total of 1914 patients. NP-guided therapy significantly reduced overall mortality and HF-related hospital admissions. No significant results were found for HF-related mortality and overall hospital admissions. Some clinical heterogeneity regarding interventions performed was found between studies. Publication bias was found for HF-related and overall hospital admissions. Conclusions: NP-guided therapy seems to improve outcomes compared to clinically-guided therapy. However, heterogeneity found between interventions might reduce the generalisation of these results. Specific interventions of the clinical trials should be examined when making recommendations regarding NP-guided therapy. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

Resumen Objetivo: Evaluar la eficacia de la terapia guiada por el péptido natriurético (PN) en comparación con la terapia guiada clínicamente para reducir la mortalidad y la hospitalización de la insuficiencia cardiaca (IC) crónica. Métodos: Los ensayos clínicos aleatorizados fueron seleccionados a través de una revisión sistemática. Cuatro metaanálisis se realizaron para los resultados de mortalidad general, mortalidad por IC, hospitalización general y la hospitalización por IC. Se evaluó la heterogeneidad entre los estudios y el sesgo de publicación. Resultados: Nueve ensayos clínicos aleatorizados se encontraron con un total de 1,914 pacientes. La terapia guiada con el PN reduce significativamente la mortalidad general y la hospitalización por IC. No se encontraron resultados significativos para la mortalidad por IC y la hospitalización general. El sesgo de publicación se encontró para las hospitalizaciones por IC y globales. Conclusiones: La terapia guiada por PN parece mejorar los resultados en comparación con la terapia guiada clínicamente. Sin embargo, la heterogeneidad encontrada entre las intervenciones podría reducir la generalización de estos resultados. Las intervenciones específicas de los ensayos clínicos deben ser analizadas al hacer recomendaciones con respecto a la terapia de guiada por PN. © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. Este es un artículo Open Access bajo la licencia CC BY-NC-ND (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome / Infecção em Pacientes com Insuficiência Cardíaca Descompensada: Mortalidade Hospitalar e Evolução

Abstract Background: Heart failure (HF) is a syndrome, whose advanced forms have a poor prognosis, which is aggravated by the presence of comorbidities. Objective: We assessed the impact of infection in patients with decompensated HF admitted to a tertiary university-affiliated hospital in the city of São Paulo. Methods: This study assessed 260 patients consecutively admitted to our unit because of decompensated HF. The presence of infection and other morbidities was assessed, as were in-hospital mortality and outcome after discharge. The chance of death was estimated by univariate logistic regression analysis of the variables studied. The significance level adopted was P < 0.05. Results: Of the patients studied, 54.2% were of the male sex, and the mean age ± SD was 66.1 ± 12.7 years. During hospitalization, 119 patients (45.8%) had infection: 88 (33.8%) being diagnosed with pulmonary infection and 39 patients (15.0%), with urinary infection. During hospitalization, 56 patients (21.5%) died, and, after discharge, 36 patients (17.6%). During hospitalization, 26.9% of the patients with infection died vs 17% of those without infection (p = 0.05). However, after discharge, mortality was lower in the group that had infection: 11.5% vs 22.2% (p = 0.046). Conclusions: Infection is a frequent morbidity among patients with HF admitted for compensation of the condition, and those with infection show higher in-hospital mortality. However, those patients who initially had infection and survived had a better outcome after discharge.

Resumo Fundamento: A insuficiência cardíaca (IC) é uma síndrome cujas formas avançadas têm mau prognóstico, que é mais agravado pela presença de comorbidades. Objetivo: Avaliamos o impacto da infecção em pacientes com IC descompensada que internaram em hospital universitário terciário de São Paulo. Métodos: Estudamos 260 pacientes consecutivos que internaram em nossa unidade com IC descompensada. Avaliamos a presença de infecção e de outras morbidades. Avaliaram-se mortalidade hospitalar e evolução após a alta. A chance de óbito foi estimada pela análise de regressão logística univariada para as variáveis estudadas. Considerou-se P < 0,05 significativo. Resultados: Dos pacientes estudados, 54,2% eram homens, sendo a idade média ± DP de 66,1 ± 12,7 anos. Durante a internação, 119 pacientes (45,8%) apresentaram infecção: 88 (33,8%) tiveram diagnóstico de infecção pulmonar e 39 (15%), de infecção urinária. A mortalidade hospitalar ocorreu em 56 pacientes (21,5%) e, após a alta, 36 pacientes (17,6%) morreram no seguimento. Durante a internação, 26,9% do grupo com infecção morreu vs 17% do grupo sem infecção (p = 0,05). Entretanto, após a alta, a mortalidade foi menor no grupo com infecção: 11,5% vs 22,2% (p = 0,046). Conclusões: Infecção é uma comorbidade frequente entre os pacientes com IC internados para compensação, causando um aumento da mortalidade durante a hospitalização. Entretanto, após a alta, os pacientes inicialmente com infecção apresentaram melhor evolução.

Insuficiencia cardíaca aguda: evaluación de la mortalidad posterior al egreso hospitalario / Acute Heart Failure: evaluation of mortality after hospital discharge

Evaluar la mortalidad intrahospitalaria, y post egreso a 30 y 90 días de pacientes con insuficiencia cardíaca (IC). Métodos: Estudio de casos, prospectivo, longitudinal y descriptivo en pacientes hospitalizados, durante el periodo Mayo 2016 ­ Junio 2017. Los contrastes entre variables nominales se hicieron con la prueba de Chi-cuadrado. En el caso de las variables continuas se aplicó la prueba "t de Student" para muestras independientes (dos grupos: fallecidos, vivos). Se modeló un análisis de regresión logística binario de la mortalidad. Resultados: Un total de 400 pacientes fue incluido en el estudio. La mortalidad general fue de 32,2 %, la hospitalaria de 9,5 %, a 30 días de seguimiento 18,2 % y de 22,7 % a los 90 días. La edad promedio fue de 65,07±15,8 años. El género femenino fue el predominante con 58,1 %. El nivel educativo bajo fue el más frecuente (p=0,002). La comorbilidad de miocardiopatía tóxica e idiopática tuvo relación estadística (p= 0,039). La clase funcional III-IV tuvo relación estadística (p=0,002). Se determinaron variables independientes asociadas con mortalidad: inotrópicos al ingreso (OR 5,47[IC 95 %; 1,46 ­ 6,14], p= 0,000), estancia hospitalaria > 5 días (OR 3 [IC 95% 1,46 ­ 6,14], p= 0,003), abandono de tratamiento (OR 2,70 [IC 95% 1,47 ­ 4,97], p= 0,001), clase funcional III-IV (1,45 [IC 95%; 0,02 ­ 0,22], p=0,378). Se evidenció que el uso de beta-bloqueador al ingreso fue un factor reductor de mortalidad (OR 0,48 IC 95 %; 0,26 ­ 0,89, p= 0,019). Conclusiones: La mortalidad hospitalaria y en control ambulatorio fue muy elevada. La insuficiencia cardíaca en la población de pacientes estudiados en este trabajo se presenta de forma más precoz con respecto a otros estudios. El beta-bloqueador indicado al ingreso fue un factor reductor de mortalidad(AU)

To evaluate hospital and ambulatory mortality at 30 and 90 days of follow-up in patients with heart failure. Methods: Case study, prospective, longitudinal and descriptive in patients who were treated in the hospital, during the period May 2016 - June 2017. The contrasts between nominal variables were measured with the Chi-square test. In the case of continuous variables, the T test was applied for independent samples (case:two groups: deceased, alive). A binary logistic regression analysis of mortality was performed. Results: A total of 400 patients were included in the study. The overall mortality was 32.2%; the hospital mortality was 9.5%, at 30 days of follow-up and 18.2%, at 90 days of follow-up 22.7%. The average age was 65.07 ± 15.8 years. The female gender was 58.1%. The low educational level was the most frequent variable (p = 0.002). The comorbidity of toxic and idiopathic cardiomyopathy had a statistical relationship (p = 0.039). Functional class III-IV had a statistical relationship (p = 0.002). Independent variables associated with mortality were determined: inotropic on admission (OR 5.47 [95% CI, 1.46-6.14], p = 0.000), hospitalstay> 5 days (OR 3 [95% CI 1.46] - 6,14], p = 0,003), abandonment of treatment (OR 2.70 [95% CI 1.47 - 4.97], p = 0.001); the use of a beta-blocker on admission was a mortality reducing factor (OR 0.48 IC 95%, 0.26-0.89, p = 0.019). Conclusions: The hospital and ambulatory mortality were very high. Heart failure in the population of patients studied in our hospital occured earlier than in other studies. The beta-blocker indicated at admission in this study was a mortality reducing factor(AU)

Heart failure complicating myocardial infarction. A report of the Peruvian Registry of ST-elevation myocardial infarction (PERSTEMI) / Insuficiencia cardiaca complicando el infarto de miocardio. Un reporte de Peruvian Registry of ST-elevation Myocardial Infarction (PERSTEMI)

Abstract Objectives: The aim of this study is to determine the incidence, associated factors, and 30-day mortality of patients with heart failure (HF) after ST elevation myocardial infarction (STEMI) in Peru. Methods: Observational, cohort, multicentre study was conducted at the national level on patients enrolled in the Peruvian registry of STEMI, excluding patients with a history of HF. A comparison was made with the epidemiological characteristics, treatment, and 30 day-outcome of patients with (Group 1) and without (Group 2) heart failure after infarction. Results: Of the 388 patients studied, 48.7% had symptoms of HF, or a left ventricular ejection fraction <40% after infarction (Group 1). Age > 75 years, anterior wall infarction, and the absence of electrocardiographic signs of reperfusion were the factors related to a higher incidence of HF. The hospital mortality in Group 1 was 20.6%, and the independent factors related to higher mortality were age > 75 years, and the absence of electrocardiographic signs of reperfusion. Conclusions: Heart failure complicates almost 50% of patients with STEMI, and is associated with higher hospital and 30-day mortality. Age greater than 75 years and the absence of negative T waves in the post-reperfusion ECG are independent factors for a higher incidence of HF and 30-day mortality.

Resumen Objetivos: Se desea saber la incidencia, los factores asociados y la mortalidad a 30 días de los pacientes con insuficiencia cardiaca (IC) postinfarto de miocardio con elevación del segmento ST (IMCEST) en Perú. Métodos: Estudio observacional, de cohortes, multicéntrico a nivel nacional, de pacientes enrolados en el registro peruano de IMCEST, excluyendo los pacientes con antecedente de IC. Se compararon las características epidemiológicas, tratamiento y evolución a 30 días de los pacientes con (grupo 1) y sin (grupo 2) IC postinfarto. Resultados: De 388 pacientes se encontró un 48.7% con síntomas de IC o fracción de eyección de ventrículo izquierdo < 40% postinfarto (grupo 1). La edad > 75 años, el infarto de pared anterior y la ausencia de signos electrocardiográficos de reperfusión fueron los factores relacionados a mayor incidencia de IC. La mortalidad intrahospitalaria en el grupo 1 fue del 20.6% y los factores independientes relacionados a mayor mortalidad fueron la edad > 75 años y la ausencia de signos electrocardiográficos de reperfusión. Conclusiones: La IC complica casi al 50% de pacientes con IMCEST y está asociada a mayor mortalidad intrahospitalaria y a 30 días. La edad > 75 años y la ausencia de ondas T negativas en el electrocardiograma posreperfusión son factores independientes de mayor incidencia de IC y de mortalidad a 30 días.

O NT-ProBNP da admissão versus da alta como preditor prognóstico na insuficiência cardíaca Agudamente Descompensada / NT-ProBNP at Admission Versus NT-ProBNP at discharge as a prognostic predictor in acute decompensated heart failure

Fundamento: Pacientes internados por insuficiência cardíaca (IC) descompensada recebem intensa terapia diurética e vasodilatadora nos primeiros dias, conduta normalmente bem-sucedida na compensação do quadro, permitindo alta hospitalar. No entanto, é comum a recorrência de agravamento nas primeiras semanas após a alta. Objetivo: Avaliar se o principal preditor de recorrência de desfechos em pacientes com IC é o grau de descompensação na admissão ou o estado volêmico obtido após controle clínico. Métodos: coorte prospectiva de pacientes admitidos entre janeiro de 2013 e outubro de 2014, com diagnóstico de IC agudamente descompensada, acompanhados até 60 dias após a alta hospitalar. O critério de inclusão foi aumento da dosagem plasmática do NT-proBNP (> 450 pg/mL para pacientes abaixo de 50 anos ou NT-proBNP > 900 pg/mL para pacientes acima de 50 anos). O desfecho primário foi a combinação de óbito cardiovascular após compensação e reinternação por IC descompensada em 60 dias. Resultados: Foram estudados 90 pacientes, com mediana do NT-proBNP da admissão 3947 pg/mL (IIQ = 2370 pg/mL a 7000 pg/mL), mediana da variação absoluta do NT-proBNP de -1533 pg/mL (IIQ = -3569 pg/mL a 747 pg/mL), e mediana do NT-proBNP da alta de 1946 pg/mL (IIQ = 1000 pg/mL a 3781 pg/mL). A incidência do desfecho combinado foi de 30%, sendo 12,2% de óbitos e 20% de readmissão. A curva ROC do NT-proBNP da admissão e eventos cardiovasculares em 60dias apresentou uma área sob a curva de 0,49 (p = 0,89; IC 95% = 0,36 ­ 0,62). A variação absoluta do NT-proBNP apresentou área sob a curva de 0,65 (p = 0,04; IC 95% =0,51 ­ 0,79) para eventos em 60 dias, e o NT-proBNP da alta apresentou área sob a curva de 0,69 (p = 0,03; IC 95% = 0,58 ­ 0,80). Em análise multivariada, NT-proBNP que precedeu a alta foi preditor do desfecho primário, independente do valor mensurado na admissão e de outros fatores de risco. Conclusão: Diferente do grau de descompensação que motivou a internação, o estado volêmico obtido após compensação da IC se associa a eventos recorrentes. Este achado sugere que, independentemente da gravidade inicial, é a resposta ao tratamento durante o internamento que determina a vulnerabilidade do paciente para nova descompensação

Background: Patients admitted for decompensated heart failure (HF) receive intensive diuretic and vasodilator therapy in the first days. Normally, this is a successful approach that leads to HF compensation and hospital discharge. However, recurrences within the first week of discharge are common. Objective: to evaluate whether the main predictor of recurrent outcomes in patients with HF is the severity of decompensation at admission or patient's blood volume after clinical management. Methods: Prospective, cohort study of patients admitted between January 2013 and October 2014, with diagnosis of acute decompensated HF, who were followed-up for 60 days after discharge. Inclusion criterion was increased plasma NT-proBNP (> 450 pg/mL for patients younger than 50 years or >900pg/mL for patients older than 50 years). Primary outcome was the combination of cardiovascular death with rehospitalization for decompensated HF in 60 days. Results: Ninety patients were studied, with median NT-proBNP at admission of 3,947pg/mL (IQR: 2,370 ­ 7,000 pg/mL), and median NT-proBNP at discharge of 1,946pg/mL (IQR: 1,000 ­ 3,781 pg/mL). The incidence of combined outcome was 30% (12.2% of deaths and 20% of rehospitalization). The area under the ROC curve for NT-proBNP at admission and 60-day cardiovascular events was 0.49 (p = 0.89; 95% CI = 0.36 ­ 0.62). The area under the curve of NT-proBNP absolute variation for 60 day-events was 0.65 (p = 0.04; 95%CI = 0.51 ­ 0.79), and the area under the curve for NT-BNP at discharge was 0.69 (p = 0.03; 95%CI = 0.58 ­ 0.80). In the multivariate analysis, pre-discharge NT-proBNP was a predictor of the primary outcome, independently of the NT-proBNP at admission and other risk factors. Conclusion: Different from the severity of decompensation at hospitalization, blood volume after compensation of HF is associated with recurrent event. This finding suggests that, regardless of initial severity, therapy response during hospitalization is determinant of the risk of recurrent decompensation

Causes and Predictors of In-Hospital Mortality in Patients Admitted with or for Heart Failure at a Tertiary Hospital in Brazil / Causas e Preditores de Mortalidade Intra-Hospitalar em Pacientes que Internam com ou por Insuficiência Cardíaca em Hospital Terciário no Brasil

Abstract Background: Although heart failure (HF) has high morbidity and mortality, studies in Latin America on causes and predictors of in-hospital mortality are scarce. We also do not know the evolution of patients with compensated HF hospitalized for other reasons. Objective: To identify causes and predictors of in-hospital mortality in patients hospitalized for acute decompensated HF (ADHF), compared to those with HF and admitted to the hospital for non-HF related causes (NDHF). Methods: Historical cohort of patients hospitalized in a public tertiary hospital in Brazil with a diagnosis of HF identified by the Charlson Comorbidity Index (CCI). Results: A total of 2056 patients hospitalized between January 2009 and December 2010 (51% men, median age of 71 years, length of stay of 15 days) were evaluated. There were 17.6% of deaths during hospitalization, of which 58.4% were non-cardiovascular (63.6% NDHF vs 47.4% ADHF, p = 0.004). Infectious causes were responsible for most of the deaths and only 21.6% of the deaths were attributed to HF. The independent predictors of in-hospital mortality were similar between the groups and included: age, length of stay, elevated potassium, clinical comorbidities, and CCI. Renal insufficiency was the most relevant predictor in both groups. Conclusion: Patients hospitalized with HF have high in-hospital mortality, regardless of the primary reason for hospitalization. Few deaths are directly attributed to HF; Age, renal function and levels of serum potassium, length of stay, comorbid burden and CCI were independent predictors of in-hospital death in a Brazilian tertiary hospital.

Resumo Fundamento: Apesar da insuficiência cardíaca (IC) apresentar elevada morbimortalidade, são escassos os estudos na América Latina sobre causas e preditores de mortalidade intra-hospitalar. Desconhece-se, também, a evolução de pacientes com IC compensada hospitalizados por outros motivos. Objetivo: Identificar causas e preditores de mortalidade intra-hospitalar em pacientes que internam por IC aguda descompensada (ICAD), comparativamente aqueles que possuem IC e internam por outras condições (ICND). Métodos: Coorte histórica de pacientes internados em um hospital público terciário no Brasil com diagnóstico de IC identificados pelo escore de comorbidade de Charlson (ECCharlson). Resultados: Foram avaliados 2056 pacientes que internaram entre janeiro de 2009 e dezembro de 2010 (51% homens; idade mediana de 71 anos; tempo de permanência de 15 dias). Ocorreram 17,6% de óbitos durante a internação, dos quais 58,4% por causa não cardiovascular (63,6% ICND versus 47,4% ICAD, p = 0,004). As causas infecciosas foram responsáveis pela maior parte dos óbitos e apenas 21.6% das mortes foram atribuídas à IC. Os preditores independentes de mortalidade intra-hospitalar foram semelhantes entre os grupos e incluíram: idade, tempo de permanência, potássio elevado, comorbidades clínicas e ECCharlson. A insuficiência renal foi o preditor de maior relevância em ambos grupos. Conclusão: Pacientes internados com IC apresentam elevada mortalidade intra-hospitalar, independentemente do motivo primário de internação. Poucos óbitos são diretamente atribuídos à IC; Idade, alteração na função renal e níveis séricos de potássio, tempo de permanência, comorbidades e ECCharlson foram preditores independentes de morte intra-hospitalar em hospital terciário brasileiro. (Arq Bras Cardiol. 2017; [online].ahead print, PP.0-0)

Un caso de amiloidosis AL / A case report of AL amyloidosis

Antecedentes: la amiloidosis es una enfermedad sistémica que resulta del depósito de proteínas mal plegadas; en la amiloidosis de cadena ligera de la inmunoglobulina (AL), las fibrillas están compuestas de fragmentos de cadenas ligeras monoclonales. En la Argentina, la densidad de incidencia de amiloidosis AL es 4,54 cada millón de personas/año. Caso: paciente femenina de 71 años que consulta por dolor neural localizado en miembro superior izquierdo, asociado a edemas en ambos miembros inferiores y disnea de esfuerzo, pérdida de peso, constipación y macroglosia. Al examen físico presenta tensión arterial de 100/60 mm Hg; está afebril, saturando 98% de aire ambiente; peso de 46 kg y un índice de masa corporal de 18,9. Se constatan cadenas livianas libres Kappa: 5,8 mg/L, Lambda: 430 mg/L y con relación K/L: 0,13 mg/L y un ProBNP de 1686 pg/mL. La biopsia de grasa abdominal informó depósitos de amiloide, tinción de rojo Congo positivo. Resonancia magnética (RM) de corazón con contraste (gadolinio), compatible con amiloidosis cardíaca. La tomografía computarizada (TC) de tórax demostró un área de consolidación en lóbulo superior del pulmón derecho, rojo Congo positivo focal. Ante el diagnóstico de amiloidosis AL se realiza tratamiento con CYBORD. Se consolidó el tratamiento con un trasplante autólogo de médula ósea. Discusión: la afectación cardíaca es la principal causa de morbilidad y mortalidad dentro de la amiloidosis. (AU)

Background: amyloidosis is a systemic disease resulting from the deposition of misfolding proteins, in immunoglobulin light chain amyloidosis (AL) fibrils are composed of fragments of monoclonal light chains. In Argentina the incidence density of AL amyloidosis is 4.54 per million people year. Case: a 71-year-old female patient who consults for neural pain located in the left upper limb, associated with edemas in both lower limbs and exertional dyspnea, weight loss, constipation and macroglossia. On physical examination she had blood pressure of 100/60 mmHg, afebrile, saturating 98% of ambient air, weight of 46 kg and body mass index of 18.9. The peripheral blood laboratory has Kappa free light chains: 5.8 mg/L, Lambda: 430 mg/L with K L ratio: 0.13 mg/L and a ProBNP of 1686 pg/mL. Abdominal fat biopsy reports positive Congo red staining. Cardiac magnetic resonance with contrast (gadolinium) has been performed and result compatible with cardiac amyloidosis. Chest CT showed an area of consolidation in the upper lobe of the right lung; positive congo red. With the diagnosis of AL amyloidosis she was treated with CYBORD. Autologous stem cell transplantation was performed. Discussion: cardiac involvement is the main cause of morbidity and mortality by amyloidosis. (AU)

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).

Incidencia y letalidad intrahospitalaria por insuficiencia cardiaca en Chile: ¿Existen diferencias por sexo? / Incidence and hospital mortality due to heart failure. Are there any differences by sex?

Background: Gender may influence the incidence, severity and hospital mortality due to heart failure (HF). Aim: To evaluate the influence of sex on the proportion of patients hospitalized due to heart failure, its incidence and hospital mortality. Methods: Analysis of the hospital discharge database of the Chilean Ministry of Health during 2014. All hospital admissions for HF were considered according to ICD-10 codes, including the discharge diagnosis of congestive HF (I500), left ventricular HF (I501) and non-specified HF (I509). Incidence rates, proportion of discharges due to HF and hospital mortality were calculated according to age and sex. Results: During 2014, there were 1,306,431 discharges from Chilean hospitals. Of these, 125,484 were for cardiovascular disease and 10% of these corresponded to HF (12,825). The incidence rate was slightly higher in men than in women (0.71 and 0.70 per 1,000 admissions respectively). Among patients aged 80 years or more, the prevalence of admissions for HF was higher in women (19.1 and 15.9% respectively, p < 0.01). Hospital mortality was also higher in women (9.7 and 8.6% respectively, p = 0.03). The factors associated with a higher hospital mortality were an age over 80 years (Odds Ratio (OR) 2.11; 95% confidence intervals (CI): 1.87-2.40; p < 0.01), a length of stay over seven days (OR 1.13; 95%CI: 1.01-1.29; p = 0.04), being admitted to high complexity facilities (OR 1.29; 95%CI: 1.12-1.50; p = 0.01) and being insured by the public national health fund (OR 1.94; 95%CI: 1.54-2.43; p < 0.01). Conclusions: The incidence of hospital admissions due to HF is similar in men and women. There is high hospital mortality, especially in women.