Impact of an Exercise-Based Cardiac Rehabilitation Program on Cardiopulmonary Test Parameters.

INTRODUCTION: Exercise-based cardiac rehabilitation programs (CRPs) represent a multidisciplinary therapeutic approach tailored to improve cardiorespiratory fitness and overall health-related quality of life, while reducing cardiovascular hospitalizations and mortality. Our aim was to determine changes in exercise capacity and cardiac events according to the left ventricular ejection fraction (LVEF) following a CRP. METHODS: This single-center cohort study included 131 patients who completed a center-based CRP from 2015 to 2022. Cardiopulmonary exercise testing (CPET), transthoracic echocardiography, and laboratory analysis were performed before and after program completion. RESULTS: Of 232 enrolled patients, 131 were included in our cohort analysis, with 36.6% having a reduced LVEF. These patients exhibited higher rates of atrial fibrillation (p = 0.019) and NT-proBNP values (p < 0.001). Patients with reduced LVEF had lower peak VO2 (pVO2) (p = 0.046), percentage of predicted oxygen consumption (ppVO2) (p < 0.001), and VO2 at anaerobic threshold (p = 0.015) during baseline CPET. Completion of the CRP led to comparable improvements in exercise performance between groups, assessed through Δ pVO2 (p = 0.990), Δ ppVO2 (p = 0.610), and Δ VE/VCO2 slope (p = 0.200). In the study population, male gender and hypertension independently predicted variation in VE/VCO2 slope (p = 0.017) and oxygen uptake efficiency slope (p = 0.048), respectively, post-CRP. During follow-up, 9.2% of all patients had hospital admissions for cardiac events, and 3.8% died, with no significant differences between groups. CONCLUSION: Patients with reduced LVEF admitted to our CRP showed lower functional status based on specific CPET parameters. After CRP, both reduced and preserved LVEF groups experienced similar functional improvements. Therefore, strategies to increase participation of patients with reduced LVEF in such programs are warranted.

Cultural Translation and Validation of the Bariatric Quality of Life Index to European Portuguese.

INTRODUCTION: Obesity is a chronic noncommunicable disease, defined by a body mass index over 30 kg/m2. Its impact is not restricted to its association with higher risks of mortality and morbidity from other noncommunicable diseases, but also with a decrease in quality of life (QoL). There are several tools to assess QoL, from generic health-related tools to obesity-related specific ones. However, to assess QoL in patients undergoing bariatric surgery, only the Bariatric Analysis and Reporting Outcome System was available, which presented some significant problems. Therefore, the Bariatric Quality of Life (BQL) Index was developed. The aim of this study was the validation and cultural adaptation of the BQL Index for European Portuguese. METHODS: A cross-sectional study was conducted, with the presentation of two questionnaires to the participants: BQL Index and EQ-5D-3L (European Quality of Life 5 Dimensions and 3 Level) Index. Direct translation followed reviewing, back-translation, comparison, and pilot testing were performed. Retest was done six months after the baseline. The following psychometric properties were assessed: convergent validity using the Spearman r correlation coefficient between BQL Index and EQ-5D-3L Index; internal consistency based on Cronbach alpha coefficient; and reproducibility between test and retest through Spearman r correlation coefficient and intraclass correlation coefficient (ICC). RESULTS: A total of 260 participants were included, the mean age was 45 ± 10 years old, the mean body mass index was 44 ± 6.5 kg/m2 and 78% were females. The most frequent obesity-related comorbidities were osteoarticular disease (69%), anxiety/depression (60%), and hypertension (54%). The most common eating patterns were volume eater (67%) and sweet eater (62%). Quality of Life scores were 41.3 ± 9.3 for the BQL Index, 0.35 ± 0.19 for the EQ-5D-3L Index and 55.7 ± 19.8 for the EQ-5D-3L VAS. The translation yielded good convergent validity (r = 0.62), good internal consistency (alpha = 0.94), and good reproducibility (r = 0.62 and ICC = 0.79). CONCLUSION: Our translation exhibited good parametric properties, with validity within the original BQL values, higher internal consistency, and good reproducibility.

Diagnostic and prognostic contribution of DPD scintigraphy in transthyretin V30M cardiac amyloidosis.

BACKGROUND: Early diagnosis and prognostic stratification of cardiac transthyretin amyloidosis are crucial. Although 99mTc 3,3-diphosphono-1,2-propanedicarboxylic acid (DPD) scintigraphy is the preferred method for the non-invasive diagnosis, its accuracy appears to be limited in transthyretin amyloidosis protein (ATTR) V30M mutation. Furthermore, its prognostic value in this mutation is unknown. This study investigated the diagnostic value of DPD scintigraphy to detect ATTR cardiomyopathy in V30M mutation and explored its prognostic value regarding mortality. METHODS: A total of 288 ATTR V30M mutation carriers (median age: 46 years; 49% males) without myocardial thickening (defined as septal thickness ≥13mm) attributable to other causes and who underwent DPD scintigraphy were enrolled. ATTR cardiomyopathy was defined by septal thickness ≥13mm and at least one of the criteria: late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) uptake ratio <1.60; electrical heart disease or biopsy-documented amyloidosis. RESULTS: ATTR cardiomyopathy was identified in 41 (14.2%) patients and cardiac DPD uptake in 34 (11.8%). During a mean follow-up of 33.6 ± 1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with ATTR cardiomyopathy, 13 times higher in those with DPD uptake and 10 times higher in those with late H/M MIBG <1.60. The combined assessment of septal thickness and cardiac DPD uptake improved risk stratification: patients without septal thickening and without DPD retention had an excellent prognosis while those who presented either or both of them had a significantly worse prognosis, with 5-year mortality rates ranging from 39.9 to 53.3%. CONCLUSIONS: DPD scintigraphy is useful for prognostic stratification of ATTR V30M mutation carriers. Patients without septal thickening and no DPD uptake present the best prognosis compared to those with any signs of cardiac involvement.

Brugada Phenocopy Caused by Intracranial Hemorrhage.

Brugada syndrome (BrS) is a congenital channelopathy associated with an increased risk of malignant ventricular arrhythmias and sudden cardiac death in individuals without any structural cardiopathy. Brugada phenocopies (BrPs) are clinical entities that present electrocardiographic patterns similar to those of BrS that are elicited only under transitory pathophysiological conditions, with normalization of the ECG pattern after the resolution of those conditions. We present a rare case of BrP due to intracranial hemorrhage. We also present and discuss the diagnostic criteria for BrPs and their application to this case.

The value of multiparametric prediction scores in heart failure varies with the type of follow-up after discharge: a comparative analysis.

AIMS: Multiple prediction score models have been validated to predict major adverse events in patients with heart failure. However, these scores do not include variables related to the type of follow-up. This study aimed to evaluate the impact of a protocol-based follow-up programme of patients with heart failure regarding scores accuracy for predicting hospitalizations and mortality occurring during the first year after hospital discharge. METHODS AND RESULTS: Data from two heart failure populations were collected: one composed of patients included in a protocol-based follow-up programme after an index hospitalization for acute heart failure and a second one-the control group-composed of patients not included in a multidisciplinary HF management programme after discharge. For each patient, the risk of hospitalization and/or mortality within a period of 12 months after discharge was calculated using four different scores: BCN Bio-HF Calculator, COACH Risk Engine, MAGGIC Risk Calculator, and Seattle Heart Failure Model. The accuracy of each score was established using the area under the receiver operating characteristic curve (AUC), calibration graphs, and discordance calculation. AUC comparison was established by the DeLong method. The protocol-based follow-up programme group included 56 patients, and the control group, 106 patients, with no significant differences between groups (median age: 67 years vs. 68.4 years; male sex: 58% vs. 55%; median ejection fraction: 28.2% vs. 30.5%; functional class II: 60.7% vs. 56.2%, I: 30.4% vs. 31.9%; P = not significant). Hospitalization and mortality rates were significantly lower in the protocol-based follow-up programme group (21.4% vs. 54.7%; P < 0.001 and 5.4% vs. 17.9%; P < 0.001, respectively). When applied to the control group, COACH Risk Engine and BCN Bio-HF Calculator had, respectively, good (AUC: 0.835) and reasonable (AUC: 0.712) accuracy to predict hospitalization. There was a significant reduction of COACH Risk Engine accuracy (AUC: 0.572; P = 0.011) and a non-significant accuracy reduction of BCN Bio-HF Calculator (AUC: 0.536; P = 0.1) when applied to the protocol-based follow-up programme group. All scores showed good accuracy to predict 1 year mortality (AUC: 0.863, 0.87, 0.818, and 0.82, respectively) when applied to the control group. However, when applied to the protocol-based follow-up programme group, a significant predictive accuracy reduction of COACH Risk Engine, BCN Bio-HF Calculator, and MAGGIC Risk Calculator (AUC: 0.366, 0.642, and 0.277, P < 0.001, 0.002, and <0.001, respectively) was observed. Seattle Heart Failure Model had non-significant reduction in its acuity (AUC: 0.597; P = 0.24). CONCLUSIONS: The accuracy of the aforementioned scores to predict major events in patients with heart failure is significantly reduced when they are applied to patients included in a multidisciplinary heart failure management programme.

Association between the number of altered late potential criteria and increased arrhythmic risk in Brugada syndrome patients.

BACKGROUND: Brugada syndrome (BrS) is associated with abnormal electrophysiological properties at right ventricular epicardium, consisting of fragmented electrograms extending well beyond QRS termination. We aimed to evaluate the utility of signal-averaged electrocardiogram (SA-ECG) for the noninvasive assessment of late potentials (LP) and risk stratification of BrS patients. METHODS: A prospective, observational, single-center study of BrS patients is submitted to SA-ECG with the determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40 ms terminal portion of the QRS (RMS40), and duration of the low-amplitude electric potential component of the terminal portion of the QRS (LAS40). LP were considered positive when above standard cut-offs: fQRS > 114 ms, RMS40 < 20 µV, and LAS40 > 38 ms. The rates of malignant arrhythmic events (MAEs), defined as sudden death or appropriate shocks, were compared in relation to clinical characteristics and SA-ECG findings. RESULTS: A total of 106 BrS patients (mean age, 48 ± 12 years, 67.9% male) were studied, 49% with type-1 spontaneous pattern and 81% asymptomatic. During a median follow up of 4.7 years, 10 patients (7.1%) suffered MAEs, including 4 sudden deaths. The presence of LP was significantly associated with the arrhythmic risk, which increased with the number of altered LP criteria. In comparison to the patients who had none or 1 altered LP criterium, MAE risk was 4.7 times higher in those with 2 altered criteria and 9.4 times higher in those with 3 altered LP criteria. CONCLUSIONS: SA-ECG may be a useful tool for risk stratification in BrS. The presence of 2 or 3 abnormal LP criteria could identify a subset of asymptomatic patients at high risk of arrhythmic events.

Quality of Life in Obese Patients from a Multidisciplinary Bariatric Consultation: A Cross-Sectional Study Comparing to a Non-Bariatric Population and to the General Population.

Obesity is a chronic disease defined by a body mass index of ≥30 kg/m2, which can result in a decrease in quality of life (QoL). Our study aim was to assess the QoL of an obese population of bariatric surgery (BS) candidates, and to compare it to both that of a non-bariatric obese population (C) and that of the general population. This was a cross-sectional study using: (1) the EQ-5D-3L instrument: comparing BS with the C population and with the Portuguese general population; and (2) the Bariatric Quality of Life (BQL) Index: comparing the two groups of obese patients. We included 228 BS and 68 C obese patients. BS patients had higher BMI (44 ± 6 kg/m2 vs. 41 ± 6.5 kg/m2; p < 0.001), higher waist circumference (130 ± 13 cm vs. 123 ± 17 cm; p = 0.03), and higher total body fat mass (49.9 ± 6.7% vs. 45 ± 6.7%; p < 0.001). QoL as evaluated by EQ-5D-3L was similar, but the BQL index showed lower QoL in BS patients (40.9 ± 8.9 vs. 44.2 ± 11.2; p = 0.01). Compared to the Portuguese general population, BS patients had lower QoL (VAS: 55 ± 19 vs. 74.9; p < 0.001; index: 0.33 ± 0.2 vs. 0.76; p < 0.001). Despite higher adiposity in the BS group, QoL was similar between the groups by EQ-5D-3L. Nevertheless, there was a decrease in the QoL for the BS patients as determined using the BQL, a tool with higher sensitivity to bariatric patients.

Liraglutide Effectiveness in Type 2 Diabetes: Insights from a Real-World Cohort of Portuguese Patients.

Liraglutide is a long-acting glucagon-like peptide-1 receptor agonist prescribed to diabetic patients for glycaemic control. To understand the impact of liraglutide in the real-world setting, this study analysed its effects in a Portuguese cohort of Type 2 diabetes patients. This was an observational, multicentric, and retrospective study that included 191 liraglutide-treated patients with at least 12 months of treatment. Patients' data were collected and analysed during a 24-month follow-up period. Overall, liraglutide treatment effectively reduced HbA1c levels from 8.3% to around 7.5%, after 6, 12, and 24 months (p < 0.001). In fact, 38.2%, 37.2%, and 44.8% of patients at 6, 12, and 24 months, respectively, experienced an HbA1c reduction of at least 1%. Moreover, a persistent reduction in anthropometric features was also observed, with 44.0%, 47.6%, and 54.4% of patients achieving a weight reduction of at least 3% at 6, 12, and 24 months, respectively. Finally, significant improvements were observed in the HDL-c and LDL-c levels. Our results demonstrate that liraglutide effectively promoted the reduction of HbA1c values during routine clinical practice, which was sustained throughout the study. In addition, there were significant improvements in anthropometric parameters and other cardiovascular risk factors.

Digital home-based multidisciplinary cardiac rehabilitation: How to counteract physical inactivity during the COVID-19 pandemic.

Introduction and Objectives: Center-based cardiac rehabilitation (CR) programs have been forced to close due to COVID-19. Alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be considered. The aim of this study was to assess physical activity (PA) levels after completing a home-based digital CR program. Methods: A total of 116 cardiovascular disease (CVD) patients (62.6±8.9 years, 95 male) who had been attending a face-to-face CR program were recruited and assessed (baseline and at three months) on the following parameters: PA, sedentary behavior, adherence, cardiovascular and non-cardiovascular symptoms, feelings toward the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted of a multidisciplinary digital CR program, including regular patient assessment, and exercise, educational and psychological group sessions. Results: Ninety-eight CVD patients successfully completed all the online assessments (15.5% drop-out rate). A favorable main effect of time was an increase in moderate to vigorous PA and a decrease in sedentary time at three months. Almost half of the participants completed at least one online exercise training session per week and attended at least one of the online educational sessions. No major adverse events were reported and only one minor event occurred. Conclusion: During the pandemic, levels of moderate to vigorous PA improved after three months of home-based CR in CVD patients with previous experience in a face-to-face CR model. Diversified CR programs with a greater variety of content tailored to individual preferences are needed to meet the motivational and clinical requirements of CVD patients.

Introdução e objetivos: Os programas convencionais de reabilitação cardíaca (RC) foram forçados a encerrar devido à Covid-19. Modelos alternativos para que os doentes tenham acesso a um programa de RC evitando a inatividade física devem ser considerados. O objetivo deste estudo foi avaliar os níveis de atividade física (AF) de um programa digital de RC em casa. Métodos: Foram recrutados e avaliados (inicialmente e aos três meses) 116 doentes cardiovasculares (CV) (62,6±8,9 anos, 95 homens) que frequentavam um programa presencial de RC, nos seguintes parâmetros: AF, comportamento sedentário, adesão, sintomas CV e não CV, sentimentos face à pandemia, hábitos alimentares, fatores de risco, segurança e eventos adversos. A intervenção consistiu num programa digital multidisciplinar de RC, inclusive acompanhamento regular, sessões de exercício, de ensino e de psicologia em grupo. Resultados: Completaram com sucesso todas as avaliações online (15,5% drop-out) 98 pessoas com doença CV. Houve um efeito favorável no aumento da AF moderada a vigorosa e diminuição do tempo sedentário aos três meses. Quase metade da amostra fez, pelo menos, mais de uma sessão de exercício físico online por semana e assistiu a pelo menos uma das sessões educacionais online. Não se verificaram eventos major e registou-se apenas um minor. Conclusão: Em tempo de pandemia, os níveis de AF moderada a vigorosa melhoraram após três meses em doentes CV que frequentavam previamente um modelo presencial de RC. São necessários mais programas de RC com maior variedade de conteúdos adaptados à preferência individual para dar resposta às necessidades motivacionais e clínicas dos doentes CV.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes.

BACKGROUND: Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood. OBJECTIVES: To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact. METHODS: Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6th and 12th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death. RESULTS: 43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA. CONCLUSIONS: Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Reversal of Roux-en-Y Gastric Bypass Fails to Facilitate the Management of Recalcitrant Hypocalcaemia Caused by Primary Hypoparathyroidism.

Roux-en-Y gastric bypass (RYGB) is thought to reduce calcium absorption from the gut. Here, we report the case of a patient with a RYGB, who developed primary hypoparathyroidism after a total thyroidectomy, leading to recalcitrant hypocalcaemia. Despite aggressive oral calcium and calcitriol supplementation, she remained hypocalcaemic and required intravenous (IV) calcium supplementation to control her symptoms, and to keep calcium serum levels within an acceptable range. Teriparatide treatment improved calcium levels marginally. This treatment, however, was poorly tolerated and ultimately stopped by the patient. As a last resort, reversal of RYGB was performed to improve calcium absorption from the gut. Unfortunately, IV calcium supplementation remained necessary. This case illustrates that the reversal of RYGB is not always a guarantee for success in managing recalcitrant hypocalcaemia.

Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers and the risk of COVID-19 infection or severe disease: Systematic review and meta-analysis.

OBJECTIVE: Animal studies suggested that angiotensin-converting enzyme inhibitors (ACEi) and angiotensin-receptor blockers (ARB) facilitate the inoculation of potentially leading to a higher risk of infection and/or disease severity. We aimed to systematically evaluate the risk of COVID-19 infection and the risk of severe COVID-19 disease associated with previous exposure to (ACEi) and/or ARB). METHODS: MEDLINE, CENTRAL, PsycINFO, Web of Science Core Collection were searched in June 2020 for controlled studies. Eligible studies were included and random-effects meta-analyses were performed. The estimates were expressed as odds ratios (OR) and 95% confidence intervals (95%CI). Heterogeneity was assessed with I2 test. The confidence in the pooled evidence was appraised using the GRADE framework. RESULTS: Twenty-seven studies were included in the review. ACEi/ARB exposure did not increase the risk of having a positive test for COVID-19 infection (OR 0.99, 95%CI 0.89-1.11; I2 = 36%; 5 studies, GRADE confidence moderate). The exposure to ACEi/ARB did not increase the risk of all-cause mortality among patients with COVID-19 (OR 0.91, 95%CI 0.74-1.11; I2 = 20%; 17 studies; GRADE confidence low) nor severe/critical COVID-19 disease (OR 0.90, 95%CI 0.74-1.11; I2 = 55%; 17 studies; GRADE confidence very low). Exploratory analyses in studies enrolling hypertensive patients showed a association of ACEi/ARB with a significant decrease of mortality risk. CONCLUSIONS: ACEi/ARB exposure does not seem to increase the risk of having the SARS-CoV-2 infection or developing severe stages of the disease including mortality. The potential benefits observed in mortality of hypertensive patients reassure safety, but robust studies are required to increase the confidence in the results.

Non-invasive telemonitoring improves outcomes in heart failure with reduced ejection fraction: a study in high-risk patients.

AIMS: Non-invasive telemonitoring (TM) in patients with heart failure (HF) and reduced left ventricular ejection fraction (HFrEF) may be useful in the early diagnosis of HF decompensation, allowing therapeutic optimization and avoiding re-hospitalization. We describe a TM programme in this population and evaluate its effectiveness during a 12 month period. METHODS AND RESULTS: We conducted a single-centre study of patients discharged from hospital after decompensated HF, allocated into three groups: prospective TM programme, prospective HF protocol follow-up programme (PFP) with no TM facilities, and retrospective propensity-matched usual care (UC). TM effectiveness was assessed by all-cause hospitalizations and mortality; HF-related hospitalization (HFH), days lost to unplanned hospital admissions/death, functional capacity and quality of life (New York Heart Association, Kansas City Cardiomyopathy Questionnaire, 6 min walk test, and plasma N-terminal pro-brain natriuretic peptide) were also evaluated. A total of 125 patients were included [65.9 ± 11.9 years, 32% female, left ventricular ejection fraction 27% (21-32)]. TM was similar to PFP regarding effectiveness; TM reduced all-cause hospitalization and mortality (HR 0.27; 95% CI 0.11-0.71; P < 0.01) and HFH (HR 0.29; 95% CI 0.10-0.89; P < 0.05) as compared with UC. TM reduced the average number of days lost due to unplanned hospital admissions or all-cause death as compared with PFP (5.6 vs. 12.4 days, P < 0.05) and UC (5.6 vs. 48.8 days, P < 0.01). Impact on quality of life was similar between TM and PFP (P = 0.36). CONCLUSIONS: In patients with HFrEF and recent HF hospitalization, non-invasive TM reduced 12 month all-cause hospitalization/mortality and HFH as compared with usual care. TM also reduced the number of days lost due to unplanned hospital admission/death as compared with either an optimized protocol-based follow-up programme or usual care.

The CTo-aBCDE score: A new predictor of success in chronic total occlusions.

INTRODUCTION: Patient selection for percutaneous coronary intervention (PCI) in chronic total occlusions (CTOs) is crucial to procedural success. Our aim was to identify independent predictors of success in CTO PCI in order to create an accurate score. METHODS: In a single-center observational registry of CTO PCI, demographic and clinical data and anatomical characteristics of coronary lesions were recorded. Linear and logistic regression analysis were used to identify predictors of success. A score to predict success was created and its accuracy was measured by receiver operating curve analysis. RESULTS: A total of 377 interventions were performed (334 patients, age 68±11 years, 75% male). The success rate was 65% per patient and 60% per procedure. Predictors of success in univariate analysis were absence of active smoking (OR 2.02, 95% CI 1.243-3.29; p=0.005), presence of tapered stump (OR 5.2, 95% CI 2.7-10.2; p<0.001), absence of tortuosity (OR 6.44; 95% CI 3.02-13.75; p<0.001), absence of bifurcation (OR 1.95; 95% CI 1.08-3.51; p=0.026), absence of calcification (OR 3.1; 95% CI 3.10-5.41; p<0.001), LAD as target vessel (OR 1.9, 95% CI 1.0-3.5; p=0.048), and CTO length <20 mm (OR 3.00, 95% CI 1.69-5.3; p<0.001). Only anatomical factors were independent predictors of success, and an anatomical score (0-11 points) with high accuracy (area under the curve 0.831) was subsequently created. A score <3 was associated with low probability of success (15%), 3-8 with intermediate probability (55%), and >8 with high probability (95%). CONCLUSION: In our sample only anatomical characteristics were predictors of success. The creation of a score to predict success, with good accuracy, may enable selection of cases that can be treated by any operator, those in which a dedicated operator will be desirable, and those with an extremely low probability of success, which should be considered individually for conservative management, surgical revascularization or PCI by a team experienced in CTO.

Challenging diagnosis of resistance to thyroid hormone in a patient with pituitary adenoma.

The elevation of thyroid hormone with a normal or elevated thyroid-stimulation hormone (TSH) occurs uncommonly. This set a diagnosis challenge between TSH-secreting pituitary adenoma and resistance to thyroid hormone (RTH). We report a case of a young female patient with palpitations, with elevated thyroid hormone and non-suppressed TSH. TSH receptor antibody was undetectable. Thyroid ultrasound revealed mild heterogeneous goitre, and MRI revealed a microadenoma with 7.5 mm length in pituitary's left lobe. Pituitary hormones were within normal ranges. The thyrotropin-releasing hormone stimulation test showed normal TSH elevation, consistent with RTH. The genetic test revealed a mutation in heterozygosity in THRB gene (G344R) confirming RTH-beta. No pituitary surgery or thyroidectomy was performed nor were prescribed any antithyroid drugs. Inappropriate secretion of TSH requires a high level of clinical suspicion and the proper laboratory, genetic and radiological studies to conduct a correct diagnosis and prevent unnecessary and potential harmful therapies.

Interleukin-6 Producing Pheochromocytoma: A Rare Cause of Systemic Inflammatory Response Syndrome.

Systemic inflammatory response syndrome (SIRS) can be a rare manifestation of pheochromocytoma, since this adrenal tumor may produce cytokines and other hormones or neuropeptides besides catecholamines. We report the case of a 53-year-old female patient with a pheochromocytoma that presented with fever and weight loss of 5% in one month along with normocytic anemia, thrombocytosis, leukocytosis, and elevated C-reactive protein. In this setting, interleukin-6 (IL-6) was requested and was elevated [26.7ng/L (<7.0)]. She also presented biochemical evidence of ACTH-independent cortisol production without overt Cushing syndrome. After adrenalectomy, the inflammatory syndrome resolved and all biochemical parameters normalized, including IL-6 and ACTH. To our knowledge, this is the first case report of IL6-producing pheochromocytoma along with autonomous cortisol production.

Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life.

INTRODUCTION: Heart failure is associated with high rates of readmission and mortality, and there is a need for measures to improve outcomes. This study aims to assess the impact of the implementation of a protocol-based follow-up program for heart failure patients on readmission and mortality rates and quality of life. METHODS: A quasi-experimental study was performed, with a prospective registry of 50 consecutive patients discharged after hospitalization for acute heart failure. The study group was followed by a cardiologist at days 7-10 and the first, third, sixth and 12th month after discharge, with predefined procedures. The control group consisted of patients hospitalized for heart failure prior to implementation of the program and followed on a routine basis. RESULTS: No significant differences were observed between the two groups regarding mean age (67.1±11.2 vs. 65.8±13.4 years, p=0.5), NYHA functional class (p=0.37), or median left ventricular ejection fraction (27% [19.8-35.3] vs. 29% [23.5-40]; p=0.23) at discharge. Mean follow-up after discharge was similar (11±5.3 vs. 10.9±5.5 months, p=0.81). The protocol-based follow-up program was associated with a significant reduction in all-cause readmission (26% vs. 60%, p=0.003), heart failure readmission (16% vs. 36%, p=0.032), and mortality (4% vs. 20%, p=0.044). In the study group there was a significant improvement in all quality of life measures (p<0.001). CONCLUSION: A protocol-based follow-up program for patients with heart failure led to a significant reduction in readmission and mortality rates, and was associated with better quality of life.

Proton pump inhibitors and the risk of severe adverse events - A cardiovascular bombshell? / Inibidores da bomba de protões e o risco de eventos adversos graves ­ uma bomba cardiovascular?

Proton pump inhibitors are currently one of the most prescribed pharmacological classes in developed countries, given their effectiveness and safety profile, which has until now been considered favorable. However, in recent years, several papers have been published that associate prolonged use of these drugs with a wide range of adverse effects, posing doubts about their safety. Among the adverse effects described is an increased risk of cardiovascular events. This relationship was first described in subjects after acute coronary syndrome due to the interference of proton pump inhibitors in the cytochrome P450 2C19 and the conversion of clopidogrel to its active metabolite. More recent studies have also reported this relationship with the use of antiplatelet agents that do not depend on cytochrome P450 2C19 activation. The proposed mechanism is inhibition of dimethylarginine dimethylaminohydrolase, a physiological inhibitor of asymmetric dimethylarginine, which increases plasma concentrations of the latter enzyme, leading to lower levels of nitric oxide. By reviewing in this article the relationship between the use of proton pump inhibitors and increased risk of cardiovascular and cerebrovascular events, the authors aim to alert the medical community to the potentially harmful effects of these drugs, and recommend the setting of a moratorium on their prolonged use.

A Celiac Crisis in an Adult: Raising Awareness of a Life-threatening Condition.

OBJECTIVES: The Authors report the case of a 56-year-old man with celiac disease, who after ingesting a food containing gluten and experiencing a flu-like syndrome, developed severe diarrhea, vomiting, weight loss (15 kg), hypotension, renal dysfunction, hypokalemia and metabolic acidosis. MATERIALS AND METHODS: Admission to the Intensive Care Unit and exclusion of an infectious cause was determined. RESULTS: After receiving noradrenaline, methylprednisolone and correction of ionic disturbances, the patient recovered rapidly and had no further complication. CONCLUSION: The authors intend to increase awareness of celiac crisis, because despite being extremely rare in adults, it is potentially fatal and an quick diagnosis and treatment are crucial. LEARNING POINTS: Celiac crisis is an acute, life-threatening presentation of celiac disease.Its clinical presentation consists of severe diarrhea, metabolic disturbances (namely hypokalemia, hyponatremia, hypomagnesemia, hypocalcemia and metabolic acidosis), hypoproteinemia and dehydration.Hospitalization and correction of metabolic imbalance with intravenous fluids are required, with corticotherapy being necessary in some cases.