Search

1. Definicao do Problema […] 3a Diretriz de Avaliacao Cardiovascular Perioperatoria da Sociedade Brasileira de Cardiologia

Heart failure (HF) is a clinical condition that presents high morbidity and mortality and is one of the main reasons for hospital admissions all over the world. Although biochemical processes that occur in the body during heart failure are known, this syndrome is still associated to poor prognosis. Exhaled breath analysis has emerged as a promising noninvasive tool in different clinical conditions and, recently, it has been also tested in patients with HF. This review presents the main breath HF biomarkers, which reflect metabolic changes that occur in this complex syndrome. It also discusses the diagnostic and prognostic value of exhaled breath compounds for HF and makes a short description of the main technologies involved in this analysis. Some perspectives on the area are presented as well.

Heart failure (HF) is associated with poor prognosis, and the identification of biomarkers of its severity could help in its treatment. In a pilot study, we observed high levels of acetone in the exhaled breath of patients with HF. The present study was designed to evaluate exhaled acetone as a biomarker of HF diagnosis and HF severity.Of 235 patients with systolic dysfunction evaluated between May 2009 and September 2010, 89 patients (HF group) fulfilled inclusion criteria and were compared with sex- and age-matched healthy subjects (control group, n = 20). Patients with HF were grouped according to clinical stability (acute decompensated HF [ADHF], n = 59; chronic HF, n = 30) and submitted to exhaled breath collection. Identification of chemical species was done by gas chromatography-mass spectrometry and quantification by spectrophotometry. Patients with diabetes were excluded.The concentration of exhaled breath acetone (EBA) was higher in the HF group (median, 3.7 μg/L; interquartile range [IQR], 1.69-10.45 μg/L) than in the control group (median, 0.39 μg/L; IQR, 0.30-0.79 μg/L; P.001) and higher in the ADHF group (median, 7.8 μg/L; IQR, 3.6-15.2 μg/L) than in the chronic HF group (median, 1.22 μg/L; IQR, 0.68-2.19 μg/L; P.001). The accuracy and sensitivity of this method in the diagnosis of HF and ADHF were about 85%, a value similar to that obtained with B-type natriuretic peptide (BNP). EBA levels differed significantly as a function of severity of HF (New York Heart Association classification, P.001). There was a positive correlation between EBA and BNP (r = 0.772, P.001).EBA not only is a promising noninvasive diagnostic method of HF with an accuracy equivalent to BNP but also a new biomarker of HF severity.

Background The identification of new biomarkers of heart failure (HF) could help in its treatment. Previously, our group studied 89 patients with HF and showed that exhaled breath acetone (EBA) is a new noninvasive biomarker of HF diagnosis. However, there is no data about the relevance of EBA as a biomarker of prognosis. Objectives To evaluate whether EBA could give prognostic information in patients with heart failure with reduced ejection fraction (HFrEF). Methods After breath collection and analysis by gas chromatography-mass spectrometry and by spectrophotometry, the 89 patients referred before were followed by one year. Study physicians, blind to the results of cardiac biomarker testing, ascertained vital status of each study participant at 12 months. Results The composite endpoint death and heart transplantation (HT) were observed in 35 patients (39.3%): 29 patients (32.6%) died and 6 (6.7%) were submitted to HT within 12 months after study enrollment. High levels of EBA (≥3.7μg/L, 50th percentile) were associated with a progressively worse prognosis in 12-month follow-up (log-rank = 11.06, p = 0.001). Concentrations of EBA above 3.7μg/L increased the risk of death or HT in 3.26 times (HR = 3.26, 95%CI = 1.56–6.80, p = 0.002) within 12 months. In a multivariable cox regression model, the independent predictors of all-cause mortality were systolic blood pressure, respiratory rate and EBA levels. Conclusions High EBA levels could be associated to poor prognosis in HFrEF patients.

The cohort of long-term survivors of heart transplant is expanding, and the assessment of these patients requires specific knowledge of the surgical techniques employed to implant the donor heart, the physiology of the transplanted heart, complications of invasive tests routinely performed to detect graft rejection (GR), and the specific pathologies that may affect the transplanted heart. A joint EACVI/Brazilian cardiovascular imaging writing group committee has prepared these recommendations to provide a practical guide to echocardiographers involved in the follow-up of heart transplant patients and a framework for standardized and efficient use of cardiovascular imaging after heart transplant. Since the transplanted heart is smaller than the recipient's dilated heart, the former is usually located more medially in the mediastinum and tends to be rotated clockwise. Therefore, standard views with conventional two-dimensional (2D) echocardiography are often difficult to obtain generating a large variability from patient to patient. Therefore, in echocardiography laboratories equipped with three-dimensional echocardiography (3DE) scanners and specific expertise with the technique, 3DE may be a suitable alternative to conventional 2D echocardiography to assess the size and the function of cardiac chambers. 3DE measurement of left (LV) and right ventricular (RV) size and function are more accurate and reproducible than conventional 2D calculations. However, clinicians should be aware that cardiac chamber volumes obtained with 3DE cannot be compared with those obtained with 2D echocardiography. To assess cardiac chamber morphology and function during follow-up studies, it is recommended to obtain a comprehensive echocardiographic study at 6 months from the cardiac transplantation as a baseline and make a careful quantitation of cardiac chamber size, RV systolic function, both systolic and diastolic parameters of LV function, and pulmonary artery pressure. Subsequent echocardiographic studies should be interpreted in comparison with the data obtained from the 6-month study. An echocardiographic study, which shows no change from the baseline study, has a high negative predictive value for GR. There is no single systolic or diastolic parameter that can be reliably used to diagnose GR. However, in case several parameters are abnormal, the likelihood of GR increases. When an abnormality is detected, careful revision of images of the present and baseline study (side-by-side) is highly recommended. Global longitudinal strain (GLS) is a suitable parameter to diagnose subclinical allograft dysfunction, regardless of aetiology, by comparing the changes occurring during serial evaluations. Evaluation of GLS could be used in association with endomyocardial biopsy (EMB) to characterize and monitor an acute GR or global dysfunction episode. RV size and function at baseline should be assessed using several parameters, which do not exclusively evaluate longitudinal function. At follow-up echocardiogram, all these parameters should be compared with the baseline values. 3DE may provide a more accurate and comprehensive assessment of RV size and function. Moreover, due to the unpredictable shape of the atria in transplanted patients, atrial volume should be measured using the discs' summation algorithm (biplane algorithm for the left atrium) or 3DE. Tricuspid regurgitation should be looked for and properly assessed in all echocardiographic studies. In case of significant changes in severity of tricuspid regurgitation during follow-up, a 2D/3D and colour Doppler assessment of its severity and mechanisms should be performed. Aortic and mitral valves should be evaluated according to current recommendations. Pericardial effusion should be serially evaluated regarding extent, location, and haemodynamic impact. In case of newly detected pericardial effusion, GR should be considered taking into account the overall echocardiographic assessment and patient evaluation. Dobutamine stress echocardiography might be a suitable alternative to routine coronary angiography to assess cardiac allograft vasculopathy (CAV) at centres with adequate experience with the methodology. Coronary flow reserve and/or contrast infusion to assess myocardial perfusion might be combined with stress echocardiography to improve the accuracy of the test. In addition to its role in monitoring cardiac chamber function and in diagnosis the occurrence of GR and/or CAV, in experienced centres, echocardiography might be an alternative to fluoroscopy to guide EMB, particularly in children and young women, since echocardiography avoids repeated X-ray exposure, permits visualization of soft tissues and safer performance of biopsies of different RV regions. Finally, in addition to the indications about when and how to use echocardiography, the document also addresses the role of the other cardiovascular imaging modalities during follow-up of heart transplant patients. In patients with inadequate acoustic window and contraindication to contrast agents, pharmacological SPECT is an alternative imaging modality to detect CAV in heart transplant patients. However, in centres with adequate expertise, intravascular ultrasound (IVUS) in conjunction with coronary angiography with a baseline study at 4-6 weeks and at 1 year after heart transplant should be performed to exclude donor coronary artery disease, to detect rapidly progressive CAV, and to provide prognostic information. Despite the fact that coronary angiography is the current gold-standard method for the detection of CAV, the use of IVUS should also be considered when there is a discrepancy between non-invasive imaging tests and coronary angiography concerning the presence of CAV. In experienced centres, computerized tomography coronary angiography is a good alternative to coronary angiography to detect CAV. In patients with a persistently high heart rate, scanners that provide high temporal resolution, such as dual-source systems, provide better image quality. Finally, in patients with insufficient acoustic window, cardiac magnetic resonance is an alternative to echocardiography to assess cardiac chamber volumes and function and to exclude acute GR and CAV in a surveillance protocol.

Background Sudden death has been considered the main cause of death in patients with Chagas heart disease. Nevertheless, this information comes from a period before the introduction of drugs that changed the natural history of heart failure. We sought to study the mode of death of patients with heart failure caused by Chagas heart disease, comparing with non-Chagas cardiomyopathy. Methods and results We examined the REMADHE trial and grouped patients according to etiology (Chagas vs non-Chagas) and mode of death. The primary end-point was all-cause, heart failure and sudden death mortality; 342 patients were analyzed and 185 (54.1%) died. Death occurred in 56.4% Chagas patients and 53.7% non-Chagas patients. The cumulative incidence of all-cause mortality and heart failure mortality was significantly higher in Chagas patients compared to non-Chagas. There was no difference in the cumulative incidence of sudden death mortality between the two groups. In the Cox regression model, Chagas etiology (HR 2.76; CI 1.34–5.69; p = 0.006), LVEDD (left ventricular end diastolic diameter) (HR 1.07; CI 1.04–1.10; p, Author Summary Chagas disease remains a burden for public health systems in Latin American countries. Several authors believe that sudden death is the main cause of death in this population. So many efforts have been made to prevent sudden death in Chagas disease. In order to verify if sudden death is the leading cause of death in Chagasic heart failure, we performed a subanalysis of the REMADHE prospective trial, which included a population of outpatients in a tertiary referral center for heart failure. We grouped patients according to etiology (Chagas vs non-Chagas) and modes of death that were classified as progressive heart failure death, sudden death, other cardiovascular death, noncardiovascular death or unknown death. Our study showed that in this end of the spectrum of presentation of Chagas disease, with systolic heart dysfunction, progressive heart failure is the main mode of death. These data have implications for the development of new strategies for prevention of chagasic heart failure.

Background Renal dysfunction is associated with increased mortality in patients with decompensated heart failure. However, interventions targeted to prevention in this setting have been disappointing. We investigated the effects of hypertonic saline solution (HSS) for prevention of renal dysfunction in decompensated heart failure. Methods In a double-blind randomized trial, patients with decompensated heart failure were assigned to receive three-day course of 100mL HSS (NaCl 7.5%) twice daily or placebo. Primary end point was an increase in serum creatinine of 0.3mg/dL or more. Main secondary end point was change in biomarkers of renal function, including serum levels of creatinine, cystatin C, neutrophil gelatinase-associated lipocalin—NGAL and the urinary excretion of aquaporin 2 (AQP 2 ), urea transporter (UT-A 1 ), and sodium/hydrogen exchanger 3 (NHE 3 ). Results Twenty-two patients were assigned to HSS and 12 to placebo. Primary end point occurred in two (10%) patients in HSS group and six (50%) in placebo group (relative risk 0.3; 95% CI 0.09–0.98; P=0.01). Relative to baseline, serum creatinine and cystatin C levels were lower in HSS as compared to placebo (P=0.004 and 0.03, respectively). NGAL level was not statistically different between groups, however the urinary expression of AQP 2 , UT-A 1 and NHE 3 was significantly higher in HSS than in placebo. Conclusions HSS administration attenuated heart failure-induced kidney dysfunction as indicated by improvement in both glomerular and tubular defects, a finding with important clinical implications. HSS modulated the expression of tubular proteins involved in regulation of water and electrolyte homeostasis.

Renal failure is the most important comorbidity in patients with heart transplantation, it is associated with increased mortality. The major cause of renal dysfunction is the toxic effects of calcineurin inhibitors (CNI). Sirolimus, a proliferation signal inhibitor, is an imunossupressant recently introduced in cardiac transplantation. Its nonnephrotoxic properties make it an attractive immunosuppressive agent for patients with renal dysfunction. In this study, we evaluated the improvement in renal function after switching the CNI to sirolimus among patients with new-onset kidney dysfunction after heart transplantation.The study included orthotopic cardiac transplant (OHT) patients who required discontinuation of CNI due to worsening renal function (creatinine clearance50 mL/min). We excluded subjects who had another indication for initiation of sirolimus, that is, rejection, malignancy, or allograft vasculopathy. The patients were followed for 6 months. The creatinine clearance (CrCl) was estimated according to the Cockcroft-Gault equation using the baseline weight and the serum creatinine at the time of introduction of sirolimus and 6 months there after. Nine patients were included, 7 (78%) were males and the overall mean age was 60.1 +/- 12.3 years and time since transplantation 8.7 +/- 6.1 years. The allograft was beyond 1 year in all patients. There was a significant improvement in the serum creatinine (2.98 +/- 0.9 to 1.69 +/- 0.5 mg/dL, P = .01) and CrCl (24.9 +/- 6.5 to 45.7 +/- 17.2 mL/min, P = .005) at 6 months follow-up.The replacement of CNI by sirolimus for imunosuppressive therapy for patients with renal failure after OHT was associated with a significant improvement in renal function after 6 months.

Esta atualizacao da Diretriz de Insuficiencia Cardiaca Cronica (IC) - 2012 surge para reavaliar as recomendacoes atraves de uma avaliacao criteriosa das pesquisas (considerando-se a qualidade dos estudos), fundamental para que se atinja esse proposito. Para tanto, foi dada enfase ao efeito em desfechos de morte, a qualidade "CONSORT" (Consolidated Standards of Reporting Trials), a descricao qualitativa e quantitativa da otimizacao da medicacao, a populacao realmente incluida, as metanalises somente de estudos qualidade "CONSORT", a custo-efetividade, a existencia de efeito de classe, ao numero de pacientes incluidos e a analise de subgrupos apenas para gerar hipoteses. Na area da epidemiologia, as recentes abordagens das caracteristicas da IC com fracao de ejecao preservada (ICFEP) e da importância da IC como causa de morte no Brasil foram revisadas. Alem disso, este documento contempla a reavaliacao do valor dos biomarcadores no diagnostico e no seguimento da IC, o papel diagnostico da angiotomografia coronariana nos casos de risco intermediario ou baixo risco de doenca coronariana, a nao recomendacao de rotina do telemonitoramento; o surgimento da avaliacao familiar como recomendacao importante, e a reavaliacao da restricao da adicao de sal na dieta. As clinicas de IC e reabilitacao fisica, apesar de alguns resultados negativos ou controversos quanto a mortalidade, continuam com recomendacao importante. No campo do tratamento farmacologico, abrange-se a reavaliacao da indicacao do nebivolol, introduz-se a ivabradina como um novo paradigma no tratamento, os antagonistas da aldosterona nao tem efeito de classe reconhecido, o omega 3 passa a ser recomendado, o ferro administrado por via endovenosa e o sildenafil recebem indicacao em casos selecionados. Todas as recomendacoes para outras etiologias sao expandidas para a Doenca de Chagas. Na area da anticoagulacao, recomenda-se a utilizacao dos escores CHA2DS2VASC e o HAS-BLED na fibrilacao atrial, com introducao de inibidores da trombina e do fator Xa como alternativas na anticoagulacao. No tratamento cirurgico da IC, considerou-se que resultados neutros do estudo STICH influenciaram as recomendacoes, o transplante cardiaco continua a ser o tratamento indicado nas fases evolutivas tardias de IC, os dispositivos de assistencia circulatoria mecânica para terapia de destino passam a ter recomendacao, a duracao do QRS foi fundamental na indicacao de TRV-AV, e o CDI continua com recomendacao I para miocardiopatia isquemica. Entretanto, baseada em analise critica dos estudos considerando-se o custo-efetividade, o CDI nao atingiu recomendacao I para classes menos graves devido as limitacoes dos estudos. Tambem a importância da cardiotoxicidade por drogas para tratamento de neoplasias foi ressaltada, o tratamento da IC na gravidez e da miocardite foi revisado. Novos potenciais metodos de tratamento em fase de pesquisa sao apresentados e novos fluxogramas de diagnostico e tratamento da IC, reformulados, foram incluidos

Background Studies adopting electronic medical records and genomic information are becoming widespread. Through this new modality in research, it is possible to study how genetic variants influence susceptibility towards chronic conditions and can improve patient care. Our aim is to develop a biobank with 2,000 heart failure patients treated in a tertiary cardiology hospital containing electronic medical records data and biologic samples for performing genome-wide association studies for validation and development of medical decision routines aimed at helping the clinical management of patients. Methods/Design Patients between 18 and 80 years old with heart failure diagnosis of different etiologies and left ventricular ejection fraction ≤ 50% in the past 2 years will be eligible for enrollment on the cohort. After consent, patients will be submitted to clinical baseline, echocardiography, cardiograph impedance and biochemical evaluation. Study data will be collected and managed using Research Electronic Data Capture tools. The follow up will take place every 6 months to assess cardiovascular outcomes (all-cause mortality, cardiovascular mortality, hospitalization for worsening heart failure and current medication use). Initial analytical strategy will focus on the establishment of the accuracy of electronic medical records extraction protocols for main predictor factors of morbidity and mortality in heart failure. Discussion Building a biobank with biologic samples and clinical data of 2,000 heart failure patients we will perform genome-wide association studies. By this way, we pretend to study how genetic variants influence susceptibility towards chronic conditions. Besides, it will be created a working group focused on the development and implementation of algorithms for validation and application of medical routines using the electronic medical records of the Heart Institute (InCor - HCFMUSP). Trial registration Current Controlled Trials NTC02043431.

The latest Heart Failure Guidelines by the Department of Heart Failure of the Brazilian Society of Cardiology (DEIC/SBC) were finalized on March 2018. Since then, a significant number of therapeutic interventions and diagnostic approaches has arisen or consolidated their position in international clinical practice and in clinical research. In addition, the COVID-19 pandemic has taught us much about the pathophysiological model of myocardial damage and raised many questions about the continuity and safety of medication use in patients with chronic HF suffering from an acute manifestation of this new and complex clinical entity. In the last few months, we have been working quickly and collaboratively, and for the first time in 20 years, DEIC used digital platforms to discuss, deliberate, and draft this important document, opting for a focused update instead of a full-text guideline. We were inspired by the 2020 Canadian Heart Failure Guidelines,1 but had the benefit of observing the impact on clinical practice and the consolidation of this new knowledge, in addition to new results from clinical trials published over the last 12 months. In order to report on these developments, we hosted a pioneering scientific conference on September 19, 2020, the I Heart Failure Summit Brazil 2020 (digital), with approximately 900 participants, many of them DEIC associates. The leadership of the Science Board was key in organizing the various working groups and developing a secure and practical method for discussions and votes. With social distancing and the use of digital technology, the conference enabled wide-ranging debates from various perspectives, based on the best available scientific evidence. In this document, DEIC/SBC provides reviews and detailed updates to its Chronic Heart Failure Guidelines. The work started in July 2020, with the choice of the Editorial Board, which established priorities, divided the 52 participants into working groups, and developed a schedule of activities. These working groups, each consisting of five to seven participants, began intense online discussions that led to the elaboration of preliminary tables, widely circulated before their subsequent review by the 11-member Review Board. The final discussions took place during a virtual plenary session on December 4, 2020, with all collaborators, who had the opportunity to vote on the main recommendations. Decisions regarding classes of recommendation required a three-quarters supermajority vote. Class of Recommendation and Level of Evidence follow the same definitions used in the last guideline, as established by SBC/CONDir. See below. The therapeutic recommendations proposed in this document are based on the latest available scientific evidence, considering not only the aspects of clinical efficacy from large clinical trials. We have sought to summarize the primary recommendations in flowcharts and algorithms that are easy to understand and to apply in clinical practice, proposing approaches for the diagnosis and treatment of heart failure. Our commitment to the scientific community, linked to research and assistance to heart failure patients, public and private managers, and policy-makers, will certainly have the benefit of a document that sought to present scientific interventions in an accessible format, facilitating its implementation in the various spheres where heart failure patients receive care. Classes of Recommendation Class I Conditions for which there is conclusive evidence or, if not, there is general agreement that the procedure is safe and useful/effective. Class II Conditions for which there is conflicting evidence and/or divergence of opinion about the safety and usefulness/efficacy of the procedure. Class IIA Weight or evidence/opinion in favor of the intervention. Most approve. Class IIB Less well-established safety and usefulness/efficacy, without predominance. Class III Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective, and in some cases may be harmful. Levels of Evidence Level A Data derived from multiple consistent randomized controlled clinical trials, and/or a robust meta-analysis of randomized clinical trials. Level B Data derived from a less robust meta-analysis, one single randomized trial or non-randomized trials (observational). Level C Data derived from consensual expert opinion. Open in a separate window Dr. Evandro Tinoco Mesquita