Geriatric nutritional risk index as a nutritional and survival risk assessment tool in stable outpatients with systolic heart failure.

BACKGROUND AND AIMS: Malnutrition is frequent in heart failure (HF). However, the best tool for evaluating malnutrition in geriatric patients with HF with reduced ejection fraction (HFrEF) is unknown. This study aimed to evaluate the incremental prognostic value of the geriatric nutritional risk index (GNRI) in stable geriatric outpatients with HFrEF compared with a clinical/laboratory prognostic model. METHODS AND RESULTS: A total of 143 outpatients with HFrEF, aged >65 years, a LVEF <40%, and who were stable and on optimal therapy were studied. Follow-up lasted 3 years. The outcome was all-cause death. The GNRI was calculated as follows: [(1.489 × serum albumin (g/L)) + (41.7 × (current body weight/ideal weight)]. The 3-year death rate was 36.4% and 16 (11.2%) patients were at risk of malnutrition (GNRI ≤98). Deceased patients had a lower GNRI (113.6 ± 9.1 vs. 105.6 ± 9.2; p < 0.001) than did survivors. Greater values of the GNRI (hazard ratio = 0.93, 95% confidence interval [CI] = 0.90-0.95; p < 0.001) and GNRI >98 (hazard ratio = 0.29, 95% CI 0.15-0.57; p < 0.001) were associated with better survival. These factors remained significant after adjustment of significant confounders. The GNRI was a better discriminator of death than weight and albumin. Adding the GNRI to the clinical/laboratory predictor survival model significantly increased the c-statistics from 0.93 to 0.95 (p < 0.001) and the chi-square likelihood ratio test from 106.15 to 119.9. CONCLUSION: The risk of malnutrition, as assessed by the GNRI, in stable geriatric outpatients with HFrEF is a strong independent predictor of survival. The GNRI adds significant prognostic information to the clinical/laboratory model.

Hemorheological effects of sodium fluorescein in rats.

Sodium fluorescein is widely used in clinical practice for the study of the retinal circulation by angiography. It has been reported several hemorheological and microvascular abnormalities induced by this compound. The aim of this work was to analyse the hemorheological effects of intravenous sodium fluorescein in an animal model. Twenty male 10-16 weeks-old Wistar rats were used, under systemic anaesthesia. The animals were divided in 2 groups of 10 each: (1) intravenous injection of sodium fluorescein (14 mg/kg of body weight)--Group NaF, (2) controls (injection of NaCl 0.9%)--Group CTRL. A blood sample was drawn by aortic puncture after 60 minutes and hemorheological parameters determined: hematocrit, hemoglobin, metahemoglobin, carboxyhemoglobin, plasma viscosity, erythrocyte deformability, membrane fluidity and acetylcholinesterase activity. In the Group NaF there was a 20% reduction of the AChE activity (p<0.05) and an increase in PV (p<0.05). Concerning hemoglobin status, a three-fold increase in COHb (p<0.001) was shown. In conclusion, the NaF injection in the animal model produces hemorheological abnormalities similar to those reported in the human.

The effect of sodium fluorescein angiography on erythrocyte properties.

Sodium fluorescein angiography is a widely used routine ophthalmological diagnostic procedure which enables the study of chorioretinal microcirculation and consists of the injection of sodium fluorescein into the systemic bloodstream. The aim of the present study was to evaluate whether or not fluorescein interferes with erythrocyte properties during the angiographic procedure. In a group of 37 patients, 26 with non-insulin-dependent diabetes mellitus (DM) with and without retinopathy, and 11 without diabetes mellitus (non-DM) although affected by other ophthalmological diseases, all undergoing routine angiography, blood samples were drawn before (T0) and 30 min (T30) after fluorescein injection. The erythrocyte aggregation index (EAI), membrane lipid fluidity and erythrocyte acetylcholinesterase activity were determined in both groups. After fluorescein injection there was no statistical change in EAI and erythrocyte membrane fluidity in either group. Erythrocyte acetylcholinesterase activity, a marker of membrane protein integrity, decreased significantly (p < 0.01) in the DM group. Membrane lipid fluidity did not change with fluorescein injection, however (i) in the DM group erythrocyte membranes became more rigid than in the non-DM (DPH: p < 0.01); (ii) EAI and membrane lipid fluidity became significantly correlated (r = 0.6263, p < 0.05) in non-DM patients at T30. In conclusion, fluorescein administration for angiographic procedures seems to interact with erythrocyte membrane, namely, in diabetic patients, which may interfere with the blood flow in the microcirculation.

Sodium fluorescein influence on the hemorheological profile of non-insulin dependent diabetes mellitus patients.

Sodium fluorescein angiography is a widely used technology in ophthalmology, which allows us to visualise the chorioretinal microcirculation. Previous reports showed a prolongation of the retinal circulation time along with erythrocyte hyperaggregation and a decrease of erythrocyte acetylcholinesterase activity and a possible interference with the erythrocyte's membrane fluidity. The aim of the present work is to investigate the influence of sodium fluorescein on the hemorheological profile of a group of 23 non-insulin dependent diabetes mellitus (NIDDM) patients undergoing routine retinal angiography. Thirty minutes after the endovenous administration of the fluorescein there was: (I) an increase of whole blood viscosity (p = 0.015), erythrocyte elongation index (EEI, p < 0.05), whole blood pH (p < 0.001), methemoglobin (p < 0.001) and carboxyhemoglobin (p < 0.001) concentrations; (II) no variation of plasma osmolality and erythrocyte aggregation index (EAI); (III) a decrease of the erythrocyte acetylcholinesterase activity, p < 001; (IV) no variation in membrane lipid fluidity, although 1,6-diphenyl-1,3,5-hexatriene (DPH) correlated directly with the EEI, while 1,4-trimethyl-phenyl-1,3,5-hexatriene (TMA-DPH) and EAI correlated inversely, suggesting that the decreasing EEI (lower erythrocyte deformablity) might be associated with an increased rigidity of the external polar region and fluidification of the hydrophobic region of the erythrocyte membrane, with an increasing EAI. In conclusion, the endovenous administration of sodium fluorescein in NIDDM patients during the retinal angiography procedure interferes with the erythrocyte membrane and possibly with the microcirculatory blood flow.

Impairment of the erythrocyte membrane fluidity in survivors of acute myocardial infarction. A prospective study.

Erythrocytes have to constantly adapt themselves to the varying circulatory system shear stress forces and capillaries diameter. Membrane lipid and protein content have an important role in determining the erythrocyte shape and are main determinants of the membrane solid and fluid behaviour which enables the erythrocyte to respond to the outer environment modifications. Membrane fluidity is an inverse index of membrane microviscosity. The aim of the present work is to evaluate prospectively in three periods of time (discharge, after 6 months and one year later) in survivors of an acute myocardial infarction (AMI) the erythrocyte membrane fluidity (outer and inner bilayer) and establish a relation with the cardiovascular events or need of coronary revascularization during a two year clinical follow up. Sixty survivors of acute myocardial infarction were recruited during 1994-96 and were prospectively studied in three periods (discharge, 6 months and after one year), and were compared with a control group (n = 36). Membrane lipid fluidity was determined by means of fluorescence polarisation with two probes: 1,6-diphenyl-1,2,5-hexatriene (DPH) and 1,4-trimethylamine 6-phenyl hexa-1,3,5-triene (TMA-DPH), for the characterisation of the hydrophobic and external polar region, respectively. The hydrophobic region was more rigidified (p < 0.01) in the erythrocytes from AMI patients, in relation to the control group. During the time of the study there was a progressive erythrocyte membrane rigidification (DPH p < 0.001; TMA-DPH p < 0.001). We found no relation between erythrocyte membrane fluidity and the coronary risk factors, cardiovascular events or the need of coronary revascularization during the clinical follow-up. In conclusion, after the myocardial infarction erythrocyte membrane of AMI survivors becomes more rigid with time, which could contribute to the decreased erythrocyte deformability and the increased blood viscosity previously described in this group of patients.

Ethanol and erythrocyte membrane interaction: a hemorheologic perspective.

Previous studies have documented structural and functional changes induced by ethanol-erythrocyte membrane interaction. In order to perform an in vitro study on the effect of different ethanol concentrations on erythrocyte hemorheologic properties, blood samples were collected from 21 male donors at the Hospital of Santa Maria. Whole blood aliquots were incubated with ethanol solutions of rising concentrations. The following parameters were measured: erythrocyte aggregation, haemoglobin, carboxyhaemoglobin and methaemoglobin concentrations, hematocrit, plasma osmolality and erythrocyte membrane fluidity (fluorescence polarisation probes TMA-DPH and DPH). With ethanol blood concentrations of 45 mM a rise in plasma osmolality (0.352 Osm/kg H2O vs 0.310 Osm/kg H2O; p < 0.001) was verified. With 67 mM concentration a decrease of erythrocyte aggregation (11.03 vs 12.81; p < 0.05) and an increase in plasma osmolality (0.380 Osm/kg H2O vs 0.310 Osm/kg H2O; p < 0.001) were obtained. In conclusion, ethanol only changes erythrocyte aggregation for a concentration of 67 mM. These data could lead to future changes in therapeutic approaches to situations such as alcoholic coma.

[Prognosis of postoperative aortic dissection. Assessment with magnetic resonance]. / Prognóstico da dissecção da aorta após cirurgia. Avaliação por ressonância magnética.

OBJECTIVE: To evaluate operated type A aortic dissection by Magnetic Resonance Imaging (MRI), in order to detect long-term complications and identify prognostic indexes of evolution. DESIGN: Prospective study with a three-year period of follow-up. Prognosis evaluation. SETTINGS: Outpatient Clinic at Hospital de Santa Maria and Magnetic Resonance Imaging Center at Hospital da Cruz Vermelha. PATIENTS: A sample of 37 patients submitted to type A aortic dissection surgery, included sequentially, after exclusion of those with contraindication to MRI. METHODS: Initial evaluation (clinical and MRI study) at 3 to 4 months and at 1, 2 and 3 years after surgery. The mean follow-up time was 39.3 +/- 2.9 months. We evaluated the following complications over the aorta (aortic graft and five segments of residual aorta) and the aortic valve: aneurysm, pseudoaneurysm, rupture, re-dissection, progressive aortic valve regurgitation, reoperation and death. The prognostic indexes analysed were: presence of residual flap; false lumen patency; presence of re-entry points; false lumen to aorta dimension ratio; initial aortic dimension; increase of aortic dimension. RESULTS: All patients, with the exception of three that died, remained asymptomatic. COMPLICATIONS: Aneurysm was detected in 45.9% of patients, located in one or more segments; rupture occurred in three patients, preceded by aneurysm and pseudoaneurysm development; moderate or severe aortic regurgitation was detected in 47.8% of patients. Prognostic indexes: 1. Aneurysm development in each segment yeilded a significant association with: presence of residual flap in the same and other segments; higher initial dimension of the same and other segments, with the exception of the abdominal segment; higher increase in dimension of the same and other segments, with the exception of the abdominal segment; 2. Moderate or severe aortic regurgitation development showed a tendency to association with higher increase in dimension of proximal ascending aorta. 3. No association was found between aneurysm and aortic regurgitation development. CONCLUSIONS: Patients operated for type A aortic dissection had a high incidence of late complications which lead to reoperation and in some cases death. The presence of a residual flap, increased aortic dimensions and higher increase rate of aortic dimensions were associated with a complicated evolution. MRI was a very useful technique for long-term monitoring and to identify prognostic indexes of evolution.

[The effect of angiography with disodium fluorescein on the hemorheologic parameters of diabetics]. / Estudo da influência da angiografia com fluoresceína bissódica nos parâmetros hemorreológicos de doentes com diabetes mellitus.

Chorioretinal angiography with fluorescein is an auxiliary method widely used in Ophthalmology which enables us to study the blood/humour and blood/retina/choroid interface. The presence of a strange compound in circulation may interfere with blood flow homeostasis. With the aim of studying fluorescein influence in blood rheology, blood samples were drawn before, immediately after and 30 minutes after fluorescein bolus injection; from 10 patients with diabetes mellitus, with or without retinopathy, blood fluidity (hematocrit, erythrocyte aggregation and whole blood viscosity) and erythrocyte membrane functional properties were determined. After fluorescein injection there was erythrocyte hyperaggregation (37.7%, p = 0.004), was detected, hemoglobin concentration (p = 0.039) and hematocrit (p = 0.013) decrease, and a double time increase of methemoglobin concentration (p < 0.001) the erythrocyte membrane hydrophobic region became more rigid (p = 0.016). All these abnormalities normalized after 30 minutes. In conclusion, fluorescein angiography interferes acutely with the hemorheological parameters of patients with diabetes mellitus, with erythrocyte hyperaggregation which could interfere with the microcirculation of these patients.

Nutritional status of geriatric outpatients with systolic heart failure and its prognostic value regarding death or hospitalization, biomarkers and quality of life.

INTRODUCTION: The prevalence of malnutrition in ambulatory patients with heart failure is difficult to determine, depending on the timing and methodology. OBJECTIVE: To determine the nutritional status of outpatients with systolic heart failure with the Mini Nutritional Assessment (MNA) full and short-form versions, and evaluate its relationship with the short-term prognosis, biomarkers and quality of life. METHODS: Fifty consecutive (70% male), geriatric (74.3+ 6.2years old) stable outpatient with heart failure (NYHA class II 68%, III 32%) and left ventricular ejection fraction of 26.7 +11.5% were included and followed during 12 months. At a routine visit to the heart failure clinic, the MNA, the Minnesota Living with Heart Failure questionnaire (MLHFQ) were applied. According to the MNA screening score the nutritional status was classified using the MNA full (MNA-F) and the short-form (MNA-F) versions of the questionnaire. The recorded events were death and hospitalization. STATISTICS: The survival and hospitalizations curves were evaluated with the Log-Rank test and Cox Regression analysis. The association between parameters was analyzed with the Pearson and Spearmann correlation coefficient. RESULTS: (1) The mortality and hospitalization rates were 12% and 42%, respectively. (2) With the MNA-SF 7.6% of the patients had malnutrition and 20% were at risk of malnutrition. There was a good agreement (90%) between the MNA-SF and the MNA-F classifications. (3) There was a significant relationship between the MNA screening score and the MLHFQ (rs= -0.592 p<0.001), Nt-ProBNP (rs= -0.49 p<0.001) and total plasma protein (r= 0.672 p=0.006); (3) The MNA-SF nutritional classification was associated with the 12 months survival (Log-Rank p=0.044) and hospitalization (Log-Rank p=0.005) curves. (4) Those patients with malnutrition by the MNA-SF were at greater risk of death (HR= 8.0 p=0.059) and hospitalization (HR 8.1 p=0.008). CONCLUSION: The MNA is useful for the evaluation of the nutritional status of elderly outpatients with systolic heart failure. It is a good predictor of the short-term outcome and is also associated with the quality of life and Nt-ProBNP.