Search

AIMS: Chronic obstructive pulmonary disease (COPD) is a frequent comorbidity in patients with heart failure (HF). We assessed the influence of COPD on circulating levels and prognostic value of three HF biomarkers: N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin T (hs-TnT), and soluble suppression of tumorigenesis-2 (sST2).METHODS: Individual data from patients with chronic HF, known COPD status, NT-proBNP and hs-TnT values (n = 8088) were analysed. A subgroup (n = 3414) had also sST2 values.RESULTS: Patients had a median age of 66 years (interquartile interval 57-74), 77% were men and 82% had HF with reduced ejection fraction. NT-proBNP, hs-TnT and sST2 were 1207 ng/l (487-2725), 17 ng/l (9-31) and 30 ng/ml (22-44), respectively. Patients with COPD (n = 1249, 15%) had higher NT-proBNP (P = 0.042) and hs-TnT (P CONCLUSIONS: Among patients with HF, those with COPD have higher NT-proBNP and hs-TnT, but not sST2. All these biomarkers yield prognostic significance regardless of the COPD status.

Resumo Fundamento: A classificação da insuficiência cardíaca (IC) por fenótipos possui grande relevância na prática clínica. Objetivo: O estudo visou analisar a prevalência, as características clínicas e os desfechos entre os fenótipos de IC no contexto da atenção primária. Métodos: Trata-se de uma análise de um estudo de coorte que incluiu 560 indivíduos, com idade ≥ 45 anos, que foram selecionados aleatoriamente em um programa de atenção primária. Todos os participantes foram submetidos a avaliações clínicas, dosagem do peptídeo natriurético tipo B (BNP), eletrocardiograma e ecocardiografia em um único dia. A IC com fração de ejeção do ventrículo esquerdo (FEVE) < 40% foi classificado como IC com fração de ejeção reduzida (ICFEr), FEVE de 40% a 49% como IC com fração de ejeção intermediária (ICFEi) e FEVE ≥ 50% como IC com fração de ejeção preservada (ICFEp). Após 5 anos, os pacientes foram reavaliados quanto à ocorrência do desfecho composto de óbito por qualquer causa ou internação por doença cardiovascular. Resultados: Dos 560 pacientes incluídos, 51 pacientes tinham IC (9,1%), 11 dos quais tinham ICFEr (21,6%), 10 tinham ICFEi (19,6%) e 30 tinham ICFEp (58,8%). A ICFEi foi semelhante à ICFEp nos níveis de BNP (p < 0,001), índice de massa do ventrículo esquerdo (p = 0,037) e índice de volume do átrio esquerdo (p < 0,001). O fenótipo de ICFEi foi semelhante ao de ICFEr em relação à doença arterial coronariana (p = 0,009). Após 5 anos, os pacientes com ICFEi apresentaram melhor prognóstico quando comparados aos pacientes com ICFEp e ICFEr (p < 0,001). Conclusão: A prevalência de ICFEI foi semelhante ao observado em estudos anteriores. A ICFEI apresentou características semelhantes a ICFEP neste estudo. Nossos dados mostram que a ICFEi teve melhor prognóstico em comparação com os outros dois fenótipos. Abstract Background: The classification of heart failure (HF) by phenotypes has a great relevance in clinical practice. Objective: The study aimed to analyze the prevalence, clinical characteristics, and outcomes between HF phenotypes in the primary care setting. Methods: This is an analysis of a cohort study including 560 individuals, aged ≥ 45 years, who were randomly selected in a primary care program. All participants underwent clinical evaluations, b-type natriuretic peptide (BNP) measurements, electrocardiogram, and echocardiography in a single day. HF with left ventricular ejection fraction (LVEF) < 40% was classified as HF with reduced ejection fraction (HFrEF), LVEF 40% to 49% as HF with mid-range ejection fraction (HFmrEF) and LVEF ≥ 50% as HF with preserved ejection fraction (HFpEF). After 5 years, the patients were reassessed as to the occurrence of the composite outcome of death from any cause or hospitalization for cardiovascular disease. Results: Of the 560 patients included, 51 patients had HF (9.1%), 11 of whom had HFrEF (21.6%), 10 had HFmrEF (19.6%) and 30 had HFpEF (58.8%). HFmrEF was similar to HFpEF in BNP levels (p < 0.001), left ventricular mass index (p = 0.037), and left atrial volume index (p < 0.001). The HFmrEF phenotype was similar to HFrEF regarding coronary artery disease (p = 0.009). After 5 years, patients with HFmrEF had a better prognosis when compared to patients with HFpEF and HFrEF (p < 0.001). Conclusion: The prevalence of ICFEI was similar to that observed in previous studies. ICFEI presented characteristics similar to ICFEP in this study. Our data show that ICFEi had a better prognosis compared to the other two phenotypes.

Resumo Fundamento: A fração de ejeção (FE) tem sido utilizada em análises fenotípicas e na tomada de decisões sobre o tratamento de insuficiência cardíaca (IC). Assim, a FE tornou-se parte fundamental da prática clínica diária. Objetivo: Este estudo tem como objetivo investigar características, preditores e desfechos associados a alterações da FE em pacientes com diferentes tipos de IC grave. Métodos: Foram incluídos neste estudo 626 pacientes com IC grave e classe III–IV da New York Heart Association (NYHA). Os pacientes foram classificados em três grupos de acordo com as alterações da FE, ou seja, FE aumentada (FE-A), definida como aumento da FE ≥10%, FE diminuída (FE-D), definida como diminuição da FE ≥10%, e FE estável (FE-E), definida como alteração da FE

Introduction: There is a lack of consensus on the definition of response to cardiac resynchronization therapy (CRT), and it is not clear which response criteria have most influence on cardiac event-free survival. Objectives: To assess the predictive value of various response criteria in patients undergoing CRT and the agreement between them. Methods: We performed a secondary analysis of the BETTER-HF trial. Patient response was classified at six months after CRT according to eleven criteria used in previous trials. The predictive value of response criteria for survival free from mortality, cardiac transplantation and heart failure hospitalization was assessed by Cox regression analysis. Agreement between the different response criteria was assessed using Cohen's kappa (κ). Results: A total of 115 patients were followed for a mean of 25 months. During follow-up, 15 deaths occurred (13%) and 29 patients had at least one adverse cardiac event (25%). Only five of the eleven response criteria were predictors of event-free survival. The most powerful isolated clinical and echocardiographic predictors were a reduction of ≥1 NYHA functional class (HR 0.39 for responders; 95% CI 0.18-0.83, p=0.014) and an increase of at least 15% in left ventricular ejection fraction (HR 0.43, 95% CI 0.20-0.90, p=0.024), respectively. Agreement between the different response criteria was poor. Conclusions: Most currently used response criteria do not predict clinical outcomes and have poor agreement. It is essential to establish a consensus on the definition of CRT response in order to standardize studies. Resumo: Introdução: Não existe consenso na definição de respondedor à ressincronização cardíaca (TRC), e desconhece-se qual o critério de resposta que poderá ter maior influência na sobrevida livre de eventos cardíacos. Objectivos: Avaliar o valor preditivo de vários critérios de resposta em doentes submetidos à TRC, e analisar a concordância entre eles. Métodos: Subanálise do ensaio BETTER-HF. Os doentes foram classificados aos seis meses após TRC em respondedores, de acordo com onze critérios utilizados na literatura. O valor preditivo dos diferentes critérios de resposta para uma sobrevida livre de morte, transplante cardíaco e hospitalização por insuficiência cardíaca foi avaliado usando a regressão de Cox. A concordância entre os diferentes critérios foi avaliada usando o coeficiente k de Cohen. Resultados: 115 doentes foram seguidos durante um período médio de 25 meses. Durante o follow-up ocorreram 15 mortes (13%) e 29 doentes tiveram, pelo menos, um evento cardíaco adverso (25%). Apenas cinco dos onze critérios de resposta foram preditores de sobrevida livre de eventos. Os preditores clínicos e ecocardiográficos isolados mais poderosos foram a redução de, pelo menos, uma classe funcional de NYHA (HR 0,39; IC 95% 0,18-0,83, p=0,014) e um aumento de, pelo menos, 15% na fração de ejeção ventricular esquerda (FEVE) (HR 0,43; IC 95% 0,20-0,90, p=0,024), respetivamente. A concordância entre os diferentes critérios de resposta foi fraca. Conclusão: A maioria dos critérios de resposta utilizados não prevê outcomes clínicos e têm fraca concordância. É essencial criar um consenso na definição de resposta à TRC de forma a uniformizar os estudos. Keywords: Cardiac resynchronization therapy, Heart failure, Predictors of events, Response criteria, Palavras-chave: Terapia de ressincronização cardíaca, Insuficiência cardíaca, Preditores de eventos, Critérios de resposta

Heart Failure with mid-range Ejection Fraction (HFmEF) was recently described by European and Brazilian guidelines on Heart Failure (HF). The ejection fraction (EF) is an important parameter to guide therapy and prognosis. Studies have shown conflicting results without representative data from developing countries.To analyze and compare survival rate in patients with HFmEF, HF patients with reduced EF (HFrEF), and HF patients with preserved EF (HFpEF), and to evaluate the clinical characteristics of these patients.A cohort study that included adult patients with acute HF admitted through the emergency department to a tertiary hospital, reference in cardiology, in south Brazil from 2009 to 2011. The sample was divided into three groups according to EF: reduced, mid-range and preserved. A Kaplan-Meier curve was analyzed according to the EF, and a logistic regression analysis was done. Statistical significance was established as p0.05.A total of 380 patients were analyzed. Most patients had HFpEF (51%), followed by patients with HFrEF (32%) and HFmEF (17%). Patients with HFmEF showed intermediate characteristics related to age, blood pressure and ventricular diameters, and most patients were of ischemic etiology. Median follow-up time was 4.0 years. There was no statistical difference in overall survival or cardiovascular mortality (p=.0031) between the EF groups (reduced EF: 40.5% mortality; mid-range EF 39.7% and preserved EF 26%). Hospital mortality was 7.6%.There was no difference in overall survival rate between the EF groups. Patients with HFmEF showed higher mortality from cardiovascular diseases in comparison with HFpEF patients. (Arq Bras Cardiol. 2021; 116(1):14-23).A insuficiência cardíaca (IC) com fração de ejeção na faixa média ou intermediária (ICFEI) (em inglês, “mid-range ejection fraction) foi recentemente descrita em diretrizes europeia e brasileira recentes sobre o manejo da insuficiência cardíaca (IC). A fração de ejeção (FE) é um parâmetro importante para direcionar terapia e prognóstico. Estudos têm mostrado resultados conflitantes sem dados representativos de países em desenvolvimento.Analisar e comparar a taxa de sobrevida em pacientes com ICFEI com pacientes com IC e FE reduzida (ICFEr), e pacientes com IC e FE preservada, e avaliar as características clínicas desses pacientes.Estudo coorte que incluiu pacientes com IC aguda admitidos no departamento de emergência de um hospital terciário, referência em cardiologia, localizado no sul do Brasil, entre 2009 e 2011. A amostra foi dividida em três grupos de acordo com a FE: reduzida, intermediária e preservada. Curva de Kaplan-Meier foi analisada de acordo com a FE, e uma análise de regressão logística foi realizada. A significância estatística foi estabelecida em p0,05.Um total de 380 pacientes foram analisados. A maioria dos pacientes apresentaram ICFEp (515), seguido de ICFEr (32%) e ICFEI (17%). Os pacientes com ICFEI apresentaram características intermediárias em relação à idade, pressão arterial, e diâmetros ventriculares, e a maioria era de etiologia isquêmica. O período mediano de acompanhamento foi de 4 anos. Não se observou diferença na sobrevida geral ou na mortalidade cardiovascular (p=0,03) entre os grupos de FE (FE reduzida: mortalidade de 40,5%; FE intermediária: 39,7%, e FE preservada 26%). A mortalidade hospitalar foi 7,6%.Não houve diferença na taxa de sobrevida entre os grupos de FE diferentes. Os pacientes com ICFEI apresentaram maior mortalidade por doenças cardiovasculares em comparação a pacientes com ICFEp. (Arq Bras Cardiol. 2021; 116(1):14-23).

Resumo Fundamento O papel do polimorfismo genético do receptor beta1-adrenérgico Ser49Gly (PG-Rβ1-Ser49Gly) como preditor de eventos na insuficiência cardíaca (IC) não está definido para a população brasileira. Objetivos Avaliar a relação entre PG-Rβ1-Ser49Gly e desfechos clínicos em indivíduos com IC com fração de ejeção reduzida. Métodos Análise secundária de prontuários de 178 pacientes e identificação das variantes do PG-Rβ1-Ser49Gly, classificadas como Ser-Ser, Ser-Gly e Gly-Gly. Avaliar sua relação com evolução clínica. Foi adotado nível de significância de 5%. Resultados As médias da coorte foram: seguimento clínico, 6,7 anos; idade, 64,4 anos; 63,5% de homens e 55,1% brancos. A etiologia da IC foi predominantemente isquêmica (31,5%), idiopática (23,6%) e hipertensiva (15,7%). O perfil genético teve a seguinte distribuição: 122 Ser-Ser (68,5%), 52 Ser-Gly (28,7%), e 5 Gly-Gly (2,8%). Houve relação significativa entre esses genótipos e a classe funcional da New York Heart Association (NYHA) ao final do acompanhamento (p = 0,014) com o Gly-Gly associado a NYHA menos avançada. Com relação aos desfechos clínicos, houve associação significativa (p = 0,026) entre mortalidade e PG-Rβ1-Ser49Gly: o número de óbitos em pacientes com Ser-Gly (12) ou Gly-Gly (1) foi menor que com Ser-Ser (54). O alelo Gly teve um efeito protetor independente mantido após análise multivariada e foi associado à redução na chance de óbito de 63% (p = 0,03; odds ratio 0,37 – IC 0,15 a 0,91). Conclusão A presença do PG-Rβ1 Gly-Gly associou-se a melhor evolução clínica avaliada pela classe funcional da NYHA e foi preditor de menor risco de mortalidade, independentemente de outros fatores, em seguimento de 6,7 anos. (Arq Bras Cardiol. 2020; 114(4):616-624) Abstract Background The role of Ser49Gly beta1-adrenergic receptor genetic polymorphism (ADBR1-GP-Ser49Gly) as a predictor of death in heart failure (HF) is not established for the Brazilian population. Objectives To evaluate the association between ADBR1-GP-Ser49Gly and clinical outcomes in individuals with HF with reduced ejection fraction. Methods Secondary analysis of medical records of 178 patients and genotypes of GPRβ1-Ser49Gly variants, classified as Ser-Ser, Ser-Gly and Gly-Gly. To evaluate their association with clinical outcome. A significance level of 5% was adopted. Results Cohort means were: clinical follow-up 6.7 years, age 63.5 years, 64.6% of men and 55.1% of whites. HF etiologies were predominantly ischemic (31.5%), idiopathic (23.6%) and hypertensive (15.7%). The genetic profile was distributed as follows: 122 Ser-Ser (68.5%), 52 Ser-Gly (28.7%) and 5 Gly-Gly (2.8%). There was a significant association between these genotypes and mean NYHA functional class at the end of follow-up (p = 0.014) with Gly-Gly being associated with less advanced NYHA. In relation to the clinical outcomes, there was a significant association (p = 0.026) between mortality and GPRβ1-Ser49Gly: the number of deaths in patients with Ser-Gly (12) or Gly-Gly (1) was lower than in those with Ser-Ser (54). The Gly allele had an independent protective effect maintained after multivariate analysis and was associated with a reduction of 63% in the risk of death (p = 0.03; Odds Ratio 0.37 – CI 0.15–0.91). Conclusion The presence of β1-AR-GP Gly-Gly was associated with better clinical outcome evaluated by NYHA functional class and was a predictor of lower risk of mortality, regardless of other factors, in a 6.7-year of follow-up. (Arq Bras Cardiol. 2020; 114(4):613-615)

Background: Hepatic congestion is a frequent finding in patients with heart failure (HF). Physical examination has limitations in quantifying systemic congestion and requires correlation with echocardiographic and laboratory data (usually B-type natriuretic peptide, BNP, or N-terminal pro-B type natriuretic peptide, NT-proBNP). Hepatic elastography evaluates liver stiffness using a transducer that transmits low-frequency vibrations (50 Hz), and the speed of shear waves propagating through the tissues is measured by ultrasound. The faster the vibrations propagate in the hepatic parenchyma, the stiffer the liver, which, in case of HF, can be correlated with hepatic congestion. Objective: In this systematic review, case-controls, cohort studies, and randomized clinical trials were searched in MEDLINE, LILACS and Cochrane Database of Systematic Review, to evaluate the use of elastography in the detection of hepatic congestion in patients with HF. Methods: From the 49 articles retrieved, seven were selected for review, according to the inclusion and exclusion criteria. The most used methods for the diagnosis and evaluation of HF were echocardiography combined with BNP and NT-proBNP measurements. Results: Elastography performed at bedside was able to establish a significant correlation between increased liver stiffness and increased venous capillary pressure. In addition, liver elastography performed at hospital discharge was able to predict rehospitalization and mortality. Conclusion: Liver elastography is a non-invasive method that can be useful in predicting prognosis and mortality of individuals with HF, contributing to the clinical management of these patients.

Ejection fraction (EF) has been used in phenotype analyses and to make treatment decisions regarding heart failure (HF). Thus, EF has become a fundamental part of daily clinical practice.This study aims to investigate the characteristics, predictors, and outcomes associated with EF changes in patients with different types of severe HF.A total of 626 severe HF patients with New York Heart Association (NYHA) class III-IV were enrolled in this study. The patients were classified into three groups according to EF changes, namely, increased EF (EF-I), defined as an EF increase ≥10%, decreased EF (EF-D), defined as an EF decrease ≥10%, and stable EF (EF-S), defined as an EF change10%. A p-value lower than 0.05 was considered significant.Out of 377 severe HF patients, 23.3% presented EF-I, 59.5% presented EF-S, and 17.2% presented EF-D. The results further showed 68.2% of heart failure with reduced ejection fraction (HFrEF) in the EF-I group and 64.6% of heart failure with preserved ejection fraction (HFpEF) in the EF-D group. The predictors of EF-I included younger age, absence of diabetes, and lower left ventricular ejection fraction (LVEF). The predictors of EF-D were absence of atrial fibrillation, lower uric acid level, and higher LVEF. Within a median follow-up of 40 months, 44.8% of patients suffered from all-cause death.In severe HF, HFrEF presented the highest percentage in the EF-I group, and HFpEF was most common in the EF-D group.A fração de ejeção (FE) tem sido utilizada em análises fenotípicas e na tomada de decisões sobre o tratamento de insuficiência cardíaca (IC). Assim, a FE tornou-se parte fundamental da prática clínica diária.Este estudo tem como objetivo investigar características, preditores e desfechos associados a alterações da FE em pacientes com diferentes tipos de IC grave.Foram incluídos neste estudo 626 pacientes com IC grave e classe III–IV da New York Heart Association (NYHA). Os pacientes foram classificados em três grupos de acordo com as alterações da FE, ou seja, FE aumentada (FE-A), definida como aumento da FE ≥10%, FE diminuída (FE-D), definida como diminuição da FE ≥10%, e FE estável (FE-E), definida como alteração da FE10%. Valores p inferiores a 0,05 foram considerados significativos.Dos 377 pacientes com IC grave, 23,3% apresentaram FE-A, 59,5% apresentaram FE-E e 17,2% apresentaram FE-D. Os resultados mostraram ainda 68,2% de insuficiência cardíaca com fração de ejeção reduzida (ICFEr) no grupo FE-A e 64,6% de insuficiência cardíaca com fração de ejeção preservada (ICFEp) no grupo FE-D. Os preditores de FE-A identificados foram faixa etária mais jovem, ausência de diabetes e fração de ejeção do ventrículo esquerdo (FEVE) menor. Já os preditores de FE-D encontrados foram ausência de fibrilação atrial, baixos níveis de ácido úrico e maior FEVE. Em um seguimento mediano de 40 meses, 44,8% dos pacientes foram vítimas de morte por todas as causas.Na IC grave, a ICFEr apresentou maior percentual no grupo FE-A e a ICFEp foi mais comum no grupo FE-D.

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

BACKGROUND: An ischemic etiology of heart failure (HF) has been associated with reduced left ventricular reverse remodeling after cardiac resynchronization therapy (CRT). OBJECTIVE: The purpose of this study was to assess the relationship between the etiology of HF and reverse remodeling and outcome after CRT. METHODS: Consecutive patients undergoing CRT implantation between October 1, 2008 and August 14, 2015 were retrospectively evaluated. Coronary angiography classified ischemic vs nonischemic etiology. Reverse remodeling was defined as the changes in left ventricular ejection fraction (LVEF) after 6 months. Clinical outcome was assessed 1 year after implantation using a combined end point of all-cause mortality and HF readmission. RESULTS: A total of 685 patients were included (300/385 for ischemic/nonischemic etiology). Compared with patients with ischemic cardiomyopathy, patients with nonischemic cardiomyopathy exhibited a greater degree of improvement in LVEF (8.4% ± 10.4% vs 15.8% ± 12.3%; P < .001). After correcting for differences, an ischemic etiology of HF predicted less reverse remodeling (P < .001) and a higher rate of mortality or HF readmission (hazard ratio 1.63; 95% confidence interval [CI] 1.12-2.73; P = .011). Nevertheless, in comparison to a greater degree of improvement in LVEF, a lesser degree of improvement in LVEF (0%-5%) was associated with a higher risk of all-cause mortality and HF hospitalization in patients with nonischemic cardiomyopathy (odds ratio 9.78; 95% CI 1.95-49.04; P = .006) but not in patients with ischemic cardiomyopathy (odds ratio 3.58; 95% CI 0.85-15.18; P = .083). The most accurate cutoff for improvement in LVEF predicting good clinical outcome was 5.5% in ischemic cardiomyopathy vs 10.5% in nonischemic cardiomyopathy. CONCLUSION: CRT results in reverse remodeling in both patients with ischemic and nonischemic cardiomyopathy, but to a lesser extent in the former. Patients with an ischemic etiology are at an intrinsically higher risk of mortality and HF hospitalization, but derive benefit on outcome at a lesser degree of reverse remodeling.

International audience; Aims: Assessment of left ventricular (LV) volumes and ejection fraction (LVEF) with cardiac imaging is important in the selection of patients for cardiac resynchronization therapy (CRT). Several observational studies have explored the role of imaging-derived LV dyssynchrony parameters to predict the response to CRT, but have yielded inconsistent results, precluding the inclusion of imaging-derived LV dyssynchrony parameters in current guidelines for selection of patients for CRT. Methods: The EuroCRT is a large European multicentre prospective observational study led by the European Association of Cardiovascular Imaging. We aim to explore if combing the value of cardiac magnetic resonance (CMR) and echocardiography could be beneficial for selecting heart failure patients for CRT in terms of improvement in long-term survival, clinical symptoms, LV function, and volumes. Speckle tracking echocardiography will be used to assess LV dyssynchrony and wasted cardiac work whereas myocardial scar will be assessed with late gadolinium contrast enhanced CMR. All data will be measured in core laboratories. The study will be conducted in European centres with known expertise in both CRT and multimodality cardiac imaging.

Background: Cardiac resynchronization therapy (CRT) improves morbidity and mortality in heart failure with reduced ejection fraction (HFrEF) and electrical dyssynchrony. CRT patients in clinical practice are older compared with clinical trials. Objective: To investigate clinical response, reverse remodeling, outcome, and mode of death in octogenarians receiving CRT. Methods: Baseline characteristics, change in New York Heart Association (NYHA) functional class, reverse ventricular remodeling, heart failure readmissions, all-cause mortality, and mode of death were evaluated in CRT patients with comparison between octogenarians and nonoctogenarians. In addition, annual mortality rates of octogenarians undergoing CRT were compared with age-matched control subjects from the general population with the use of national actuarial tables. Results: A total of 686 patients, including 178 octogenarians (26%), were followed for 38 +/- 22 months. Octogenarians exhibited a similar change in NYHA functional class (P = .640), left ventricular ejection fraction increase (P = .796), and decrease in end-diastolic (P = .441) and end-systolic (P = .312) diameter compared with their younger counterparts undergoing CRT. Octogenarians had a higher all-cause mortality risk (P < .001), but heart failure readmission risk did not differ (hazard ratio 0.916, 95% confidence interval 0.638-1.313; P = .632). A higher proportion of noncardiac deaths was observed in octogenarians (74%) versus younger patients (50%; P = .022), with worsening heart failure rather than malignant tachyarrhythmia being the main cardiac cause of death. Compared with an age-matched sample from the general population, octogenarians receiving CRT had an equivalent annual mortality rate (log-rank test: P = .444). Conclusions: Octogenarians retain the ability to mount a significant symptomatic and ventricular remodeling response after CRT, resulting in survival similar to the general age-matched population. Pieter Martens, Petra Nijst, and Wilfried Mullens are researchers for the Limburg Clinical Research Program UHasselt-ZOL-Jessa, supported by the foundation Limburg Sterk Merk, Hasselt University, Ziekenhuis Oost-Limburg, and Jessa Hospital.

The heart is one of the most industrious organs in the human body. It starts beating in the first few weeks of embryonic life and keeps pumping blood till death. This organ can host a range of diseases as well. Some can hamper the vasculature, while others can affect its electrical activity, the heart valves, etc. All these conditions can lead to end-stage failure where it can no longer meet the requirements of the body's milieu. This imbalance between supply and demand leads to an array of symptoms. Medical management can reduce these clinical effects and possibly prolong the life expectancy in such patients. However, prescription medications can also have their own adverse effects. This necessitates that each line of treatment should be assessed on a risk vs benefit basis. The conventional approach has been to try and slow down the progression of heart failure (HF). However, the inception of stem cells in the management of HF has the potential for reversal of this pathology. Keeping this in view, many studies and trials are under process. To turn the clock back on the HF, before complications set in or get out of control, is the main focus of the time. This article attempts to evaluate various studies about stem cell therapy (SCT) and highlight the important aspects of this novel modality in changing patients' lives.

International audience; BACKGROUND:Analyses of country or regional differences in cardiovascular (CV) trials are based on geographical subgroup analyses. However, apart from map location and related racial, ethnic, and genetic variations, identified differences may also depend on social structure and provision and access to health care, for which country income and income inequality are indicators. The aim of the study was to examine the association between country per capita income and income inequality and prognosis in patients with heart failure or an acute coronary syndrome in 3 international trials (EMPHASIS-HF, EPHESUS, and EXAMINE).METHODS:Countries were classified into high income or low-middle income (LMICs) and into low, middle, or high inequality using the Gini index. The main outcome measures were all-cause and CV death.RESULTS:Patients from LMICs and countries with higher inequality were younger, were less often white, had fewer comorbid conditions, and were less often treated with guideline-recommended therapies, including devices. These patients had higher adjusted mortality rates (+15% to +70%) compared with patients from high-income countries and countries with less inequality. Patients from countries with the combination of greater inequality and low-middle income had particularly high mortality rates (+80% to +190%) compared with those that did not have both characteristics. Living in a country that is poor and has inequality had more impact on death rates than any comorbidity. These findings were reproduced in 3 trials.CONCLUSIONS:Patients from LMICs and countries with greater inequality had the highest mortality rates. The prognostic impact of income and inequality is substantial and should be considered when looking into subgroup differences in CV trials.Copyright © 2019 Elsevier Inc. All rights reserved.

Background: 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.

Aims To investigate the causes of death and the associated clinical factors in patients with atrial fibrillation (AF) in the contemporary clinical practice. Methods and results The Fushimi AF Registry is a community-based prospective survey of AF patients since March 2011 in Fushimi-ku, Kyoto. We investigated causes of death and the clinical indicators of cardiovascular (CV) and non-CV death in 4045 patients with available follow-up data by the end of November 2016. The mean age was 73.6 ± 10.9 years and the mean CHA 2 DS 2 -VASc score was 3.38 ± 1.69. Oral anticoagulants were prescribed in 55% of patients. During a median follow-up of 1105 days, there were 705 all-cause deaths (5.5%/year); 180 CV (26% of total deaths), 381 non-CV (54%), and 144 undetermined causes (20%). The most common causes of CV and non-CV death were heart failure (14.5%), malignancy (23.1%), and infection/sepsis (17.3%), while mortality due to stroke was only 6.5%. Mortality due to infection/sepsis and undetermined causes increased with aging. On multivariate analysis, the strongest indicator of CV death was pre-existing heart failure [hazard ratio (HR) 2.42, 95% confidence interval (CI) 1.66-3.54; P < 0.001] and that of non-CV death was anaemia (HR 2.84, 95% CI 2.22-3.65; P < 0.001). Conclusion In a Japanese community-based AF cohort, CV death was not mainly related to stroke but to heart failure. Non-CV death, mainly malignancy and infection, comprised more than a half of all deaths, which increased substantially in accordance with aging. Clinical factors that were associated with CV and non-CV death were distinct.

Aims To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs. Methods Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3 months were included — 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients). Results Compared to usual care, home-based CR improved VO 2max (mean difference: 1.6 ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (− 3.3, − 7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3). Conclusions Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.

Aims:\ud \ud To undertake an individual patient data (IPD) meta‐analysis to assess the impact of exercise‐based cardiac rehabilitation (ExCR) in patients with heart failure (HF) on mortality and hospitalisation, and differential effects of ExCR according to patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology, ejection fraction, and exercise capacity.\ud Methods and results:\ud \ud Randomised trials of exercise training for at least 3 weeks compared with no exercise control with 6‐month follow‐up or longer, providing IPD time to event on mortality or hospitalisation (all‐cause or HF‐specific). IPD were combined into a single dataset. We used Cox proportional hazards models to investigate the effect of ExCR and the interactions between ExCR and participant characteristics. We used both two‐stage random effects and one‐stage fixed effect models. IPD were obtained from 18 trials including 3912 patients with HF with reduced ejection fraction. Compared to control, there was no statistically significant difference in pooled time to event estimates in favour of ExCR although confidence intervals (CIs) were wide [all‐cause mortality: hazard ratio (HR) 0.83, 95% CI 0.67–1.04; HF‐specific mortality: HR 0.84, 95% CI 0.49–1.46; all‐cause hospitalisation: HR 0.90, 95% CI 0.76–1.06; and HF‐specific hospitalisation: HR 0.98, 95% CI 0.72–1.35]. No strong evidence was found of differential intervention effects across patient characteristics.\ud Conclusion:\ud \ud Exercise‐based cardiac rehabilitation did not have a significant effect on the risk of mortality and hospitalisation in HF with reduced ejection fraction. However, uncertainty around effect estimates precludes drawing definitive conclusions.

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.

AIMS: To assess the prognostic value of anti-apolipoprotein A-1 (anti-apoA-1) IgG after myocardial infarction (MI) and its association with major cardiovascular events (MACEs) at 12 months and to determine their association with resting heart rate (RHR), a well-established prognostic feature after MI. Anti-apoA-1 IgG have been reported in MI without autoimmune disease, but their clinical significance remains undetermined. METHODS AND RESULTS: A total of 221 consecutive patients with MI were prospectively included, and all completed a 12-month follow-up. Major cardiovascular events consisted in death, MI, stroke, or hospitalization either for an acute coronary syndrome or heart failure. Resting heart rate was obtained on Holter the day before discharge under the same medical treatment. Neonate rat ventricular cardiomyocytes (NRVC) were used in vitro to assess the direct anti-apoA-1 IgG effect on RHR. During follow-up, 13% of patients presented a MACE. Anti-apoA-1 IgG positivity was 9% and was associated with a higher RHR (P = 0.0005) and higher MACE rate (adjusted OR, 4.3; 95% CI, 1.46-12.6; P = 0.007). Survival models confirmed the significant nature of this association. Patients with MACE had higher median anti-apoA-1 IgG values at admission than patients without (P = 0.007). On NRVC, plasma from MI patients and monoclonal anti-apoA-1 IgG induced an aldosterone and dose-dependent positive chronotropic effect, abrogated by apoA-1 and therapeutic immunoglobulin (IVIG) pre-incubation. CONCLUSIONS: In MI patients, anti-apoA-1 IgG is independently associated with MACE at 1-year, interfering with a currently unknown aldosterone-dependent RHR determinant. Knowing whether anti-apoA-1 IgG assessment could be of interest to identify an MI patient subset susceptible to benefit from apoA-1/IVIG therapy remains to be demonstrated.

In the presence of aortic stenosis, the left ventricle (LV) faces a double challenge: a valvular load and an arterial load [(1)][1]. Transcatheter aortic valve replacement (TAVR) has now become a safe and effective alternative to surgery in patients with a contraindication or at high risk [(2)][2

Aims Cardiac resynchronization therapy (CRT) leads to reverse ventricular remodelling, improved functional capacity, and better clinical outcome in patients with advanced chronic heart failure, reduced ejection fraction, and evidence of ventricular conduction delay, who are under optimal medical therapy. This study investigated whether these benefits can be extrapolated to older patients, typically not included in randomized clinical trials. Methods and results Consecutive patients who received a CRT device between October 2008 and June 2011, including optimization afterwards in a dedicated clinic, were stratified into 3 pre-specified groups, according to age

Aims Device-based remote monitoring (RM) has been linked to improved clinical outcomes at short to medium-term follow-up. Whether this benefit extends to long-term follow-up is unknown. We sought to assess the effect of device-based RM on long-term clinical outcomes in recipients of implantable cardioverter-defibrillators (ICD). Methods We performed a retrospective cohort study of consecutive patients who underwent ICD implantation for primary prevention. RM was initiated with patient consent according to availability of RM hardware at implantation. Patients with concomitant cardiac resynchronization therapy were excluded. Data on hospitalizations, mortality and cause of death were systematically assessed using a nationwide healthcare platform. A Cox proportional hazards model was employed to estimate the effect of RM on mortality and a composite endpoint of cardiovascular mortality and hospital admission due to heart failure (HF). Results 312 patients were included with a median follow-up of 37.7months (range 1 to 146). 121 patients (38.2%) were under RM since the first outpatient visit post-ICD and 191 were in conventional follow-up. No differences were found regarding age, left ventricular ejection fraction, heart failure etiology or NYHA class at implantation. Patients under RM had higher long-term survival (hazard ratio [HR] 0.50, CI 0.27–0.93, p=0.029) and lower incidence of the composite outcome (HR 0.47, CI 0.27–0.82, p=0.008). After multivariate survival analysis, overall survival was independently associated with younger age, higher LVEF, NYHA class lower than 3 and RM. Conclusion RM was independently associated with increased long-term survival and a lower incidence of a composite endpoint of hospitalization for HF or cardiovascular mortality.

Background: Right-sided heart failure has high morbidity and mortality, and may be caused by pulmonary arterial hypertension. Fractal dimension is a differentiated and innovative method used in histological evaluations that allows the characterization of irregular and complex structures and the quantification of structural tissue changes. Objective: To assess the use of fractal dimension in cardiomyocytes of rats with monocrotaline-induced pulmonary arterial hypertension, in addition to providing histological and functional analysis. Methods: Male Wistar rats were divided into 2 groups: control (C; n = 8) and monocrotaline-induced pulmonary arterial hypertension (M; n = 8). Five weeks after pulmonary arterial hypertension induction with monocrotaline, echocardiography was performed and the animals were euthanized. The heart was dissected, the ventricles weighed to assess anatomical parameters, and histological slides were prepared and stained with hematoxylin/eosin for fractal dimension analysis, performed using box-counting method. Data normality was tested (Shapiro-Wilk test), and the groups were compared with non-paired Student t test or Mann Whitney test (p < 0.05). Results: Higher fractal dimension values were observed in group M as compared to group C (1.39 ± 0.05 vs. 1.37 ± 0.04; p < 0.05). Echocardiography showed lower pulmonary artery flow velocity, pulmonary acceleration time and ejection time values in group M, suggesting function worsening in those animals. Conclusion: The changes observed confirm pulmonary-arterial-hypertension-induced cardiac dysfunction, and point to fractal dimension as an effective method to evaluate cardiac morphological changes induced by ventricular dysfunction. Resumo Fundamento: Insuficiência cardíaca direita apresenta grande morbimortalidade e pode ser causada por hipertensão arterial pulmonar. Um método diferenciado e inovador utilizado em avaliações histológicas é a dimensão fractal, que permite a caracterização de estruturas irregulares e complexas e pode quantificar alterações estruturais dos tecidos. Objetivo: Avaliar a utilização do método da dimensão fractal nos cardiomiócitos de ratos com hipertensão arterial pulmonar induzida por monocrotalina, associada com análise histológica e funcional. Métodos: Ratos Wistar machos foram divididos em 2 grupos: controle (C; n = 8) e hipertensão arterial pulmonar induzida por monocrotalina (M; n = 8). Após 5 semanas da indução da hipertensão arterial pulmonar pela monocrotalina, foi realizado ecocardiograma. Os animais foram eutanasiados, o coração dissecado e os ventrículos pesados para avaliação dos parâmetros anatômicos. Lâminas histológicas foram confeccionadas, coradas com hematoxilina/eosina para análise da dimensão fractal, realizada pelo método box-counting . Inicialmente foi testada a normalidade dos dados (teste Shapiro Wilk) e a comparação entre os grupos foi por meio do teste t de Student não pareado ou teste de Mann Whitney (p < 0,05). Resultados: Maiores valores da dimensão fractal foram observados no grupo M em comparação ao C (1,43 ± 0,06 vs. 1,37 ± 0,04; p < 0,05). O ecocardiograma apontou menores valores no grupo M para velocidade máxima pulmonar, tempo de aceleração pulmonar e tempo de ejeção, sugerindo piora funcional nesses animais, que também apresentaram hipertrofia cardíaca. Conclusão: As alterações observadas comprovam a disfunção cardíaca induzida pela hipertensão arterial pulmonar e apontam que a dimensão fractal é um método eficaz para avaliar alterações morfológicas cardíacas induzidas pela disfunção ventricular.

Background: Heart failure (HF) and ischemic heart diseases (IHD) are important causes of death in Brazil. Objective: To assess proportional mortality (PM) due to HF and IHD as underlying causes stratified by sex and age groups in the Brazilian geoeconomic regions from 2004 to 2011. Methods: Data from death certificates were obtained in the DATASUS site under the following International Statistical Classification of Diseases and Related Health Problems codes, 10th Revision: 1) from chapter IX: I20 to I24 for acute IHD, I25 for chronic IHD, and I50 for HF; and 2) from chapter XVIII, for ill-defined causes (IDC). Results: Proportional mortality due to HF increased with age in both sexes and all regions, the highest percentages being found among elderly women. Among men, the highest percentages were observed in the West-Central region up to the ninth decade, but, among the eldest individuals, the highest percentages were identified in the Southern region. Among women, the regions did not differ up to the age group of 70-79 years, although the West-Central region took the lead from 50 to 79 years; however, from the age of 80 years on, the Southern region showed the highest PM due to HF. Proportional mortality due to acute IHD in all Brazilian regions and in both sexes increased up to the age group of 60-69 years, from which it decreased. Among men, the Southeastern region had the highest percentages in the age group of 50-59 years, while women had lower PM due to acute IHD than men in all regions. In both sexes, PM due to chronic IHD increased with age in the Southern and Southeastern regions, which did not happen in the others, while the Southern region had the highest rate of all regions for all age groups. Conclusions: Regional differences were more prominent at more advanced ages, especially when deaths due to IDC were excluded. Resumo Fundamento: Insuficiência cardíaca (IC) e doenças isquêmicas do coração (DIC) são importantes causas de morte no Brasil. Objetivo: Avaliar a mortalidade proporcional (MP) por IC e DIC, como causas básicas, estratificada por sexo e faixa etária nas regiões brasileiras de 2004 a 2011. Métodos: As informações das declarações de óbito foram obtidas no site do DATASUS, codificadas conforme a Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde, 10ª Revisão: 1) do Capítulo IX: I20 a I24 para DIC aguda, I25 para DIC crônica, e I50 para IC; e 2) do Capítulo XVIII, para causas mal definidas (CMD). Resultados: A MP por IC aumentou com a idade nos dois sexos e em todas as regiões, as mais altas porcentagens sendo encontradas entre as mulheres mais idosas. Entre os homens, as mais altas porcentagens foram observadas na região Centro-Oeste até a nona década; entre os mais idosos, porém, as mais altas porcentagens foram identificadas na região Sul. Entre as mulheres, as regiões não diferiram até a faixa etária de 70-79 anos, embora a região Centro-Oeste tenha liderado dos 50 aos 79 anos; entretanto, a partir dos 80 anos, a região Sul apresentou a mais alta MP por IC. Em todas as regiões brasileiras e nos dois sexos, a MP por DIC aguda aumentou até a faixa etária de 60-69 anos, a partir da qual diminuiu. Entre os homens, a região Sudeste apresentou as mais altas porcentagens na faixa etária de 50-59 anos, enquanto as mulheres tiveram menor MP por DIC aguda em comparação aos homens em todas as regiões. Nos dois sexos, a MP por DIC crônica aumentou com a idade nas regiões Sul e Sudeste, mas não nas demais, enquanto a região Sul apresentou a mais alta MP entre todas as regiões para todas as faixas etárias. Conclusões: Diferenças regionais foram mais marcantes nas idades mais avançadas, especialmente quando excluídas as mortes por CMD.

Made available in DSpace on 2018-12-11T17:04:25Z (GMT). No. of bitstreams: 0 Previous issue date: 2016-07-01. Added 1 bitstream(s) on 2019-10-09T18:30:31Z : No. of bitstreams: 1 S0066-782X2016004000033.pdf: 513463 bytes, checksum: d9ba48636cd68e1b4524c887cc0e4851 (MD5) Background: Right-sided heart failure has high morbidity and mortality, and may be caused by pulmonary arterial hypertension. Fractal dimension is a differentiated and innovative method used in histological evaluations that allows the characterization of irregular and complex structures and the quantification of structural tissue changes. Objective: To assess the use of fractal dimension in cardiomyocytes of rats with monocrotaline-induced pulmonary arterial hypertension, in addition to providing histological and functional analysis. Methods: Male Wistar rats were divided into 2 groups: control (C; n = 8) and monocrotaline-induced pulmonary arterial hypertension (M; n = 8). Five weeks after pulmonary arterial hypertension induction with monocrotaline, echocardiography was performed and the animals were euthanized. The heart was dissected, the ventricles weighed to assess anatomical parameters, and histological slides were prepared and stained with hematoxylin/eosin for fractal dimension analysis, performed using box-counting method. Data normality was tested (Shapiro-Wilk test), and the groups were compared with non-paired Student t test or Mann Whitney test (p < 0.05). Results: Higher fractal dimension values were observed in group M as compared to group C (1.39 ± 0.05 vs. 1.37 ± 0.04; p < 0.05). Echocardiography showed lower pulmonary artery flow velocity, pulmonary acceleration time and ejection time values in group M, suggesting function worsening in those animals. Conclusion: The changes observed confirm pulmonary-arterial-hypertension-induced cardiac dysfunction, and point to fractal dimension as an effective method to evaluate cardiac morphological changes induced by ventricular dysfunction. UNOESTE FCT/UNESP Departamento de Fisioterapia FCT/UNESP Departamento de Educação Física UNOESTE Departamento de Morfologia UNESP Faculdade de Medicina UNESP FCT/UNESP Departamento de Fisioterapia FCT/UNESP Departamento de Morfologia UNESP Faculdade de Medicina UNESP

Background:Heart failure (HF) is one of the leading causes of hospitalization in adults in Brazil. However, most of the available data is limited to unicenter registries. The BREATHE registry is the first to include a large sample of hospitalized patients with decompensated HF from different regions in Brazil.Objective:Describe the clinical characteristics, treatment and prognosis of hospitalized patients admitted with acute HF.Methods:Observational registry study with longitudinal follow-up. The eligibility criteria included patients older than 18 years with a definitive diagnosis of HF, admitted to public or private hospitals. Assessed outcomes included the causes of decompensation, use of medications, care quality indicators, hemodynamic profile and intrahospital events.Results:A total of 1,263 patients (64±16 years, 60% women) were included from 51 centers from different regions in Brazil. The most common comorbidities were hypertension (70.8%), dyslipidemia (36.7%) and diabetes (34%). Around 40% of the patients had normal left ventricular systolic function and most were admitted with a wet-warm clinical-hemodynamic profile. Vasodilators and intravenous inotropes were used in less than 15% of the studied cohort. Care quality indicators based on hospital discharge recommendations were reached in less than 65% of the patients. Intrahospital mortality affected 12.6% of all patients included.Conclusion:The BREATHE study demonstrated the high intrahospital mortality of patients admitted with acute HF in Brazil, in addition to the low rate of prescription of drugs based on evidence. Fundamento:A insuficiência cardíaca (IC) é uma das principais causas de hospitalização em adultos no Brasil, no entanto a maioria dos dados disponíveis é limitada a registros unicêntricos. O registro BREATHE é o primeiro a incluir uma ampla amostra de pacientes hospitalizados com IC descompensada de diferentes regiões do Brasil.Objetivo:Descrever as características clínicas, tratamento e prognóstico intra-hospitalar de pacientes admitidos com IC aguda.Métodos:Estudo observacional tipo registro, com seguimento longitudinal. Os critérios de elegibilidade incluíram pacientes acima de 18 anos com diagnóstico definitivo de IC, admitidos em hospitais públicos ou privados. Os desfechos avaliados incluíram causas de descompensação, uso de medicações, indicadores de qualidade assistencial, perfil hemodinâmico e eventos intra-hospitalares.Resultados:O total de 1.263 pacientes (64 ± 16 anos, 60% mulheres) foi incluído a partir de 51 centros de diferentes regiões do Brasil. As comorbidades mais comuns foram hipertensão arterial (70,8%), dislipidemia (36,7%) e diabetes (34%). Em torno de 40% dos pacientes apresentavam função sistólica do ventrículo esquerdo normal e a maioria foi admitida com perfil clínico-hemodinâmico quente-úmido. Vasodilatadores e inotrópicos endovenosos foram administrados a menos de 15% da amostra estudada. Indicadores de qualidade assistencial baseados nas orientações de alta hospitalar foram atingidos em menos de 65% dos pacientes. A mortalidade intra-hospitalar afetou 12,6% do total dos pacientes incluídos.Conclusão:O estudo BREATHE demonstrou a alta mortalidade intra-hospitalar dos pacientes admitidos com IC aguda no Brasil, somada à baixa taxa de prescrição de medicamentos baseados em evidências.

Objective To investigate whether time from onset of heart failure signs and/or symptoms (ie, progression to stage C/D heart failure) until implantation affects reverse remodelling and clinical outcome after cardiac resynchronisation therapy (CRT). Design Cohort study of consecutive CRT patients, implanted between 1 October 2008 and 30 April 2011. Setting Single tertiary care centre (Ziekenhuis Oost-Limburg, Genk, Belgium). Patients Consecutive CRT patients (n=172; 71±9 years), stratified into tertiles according to the time since first heart failure signs and/or symptoms at implantation. Main outcome measures Change in left ventricular dimensions, New York Heart Association (NYHA) functional class and freedom from all-cause mortality or heart failure admission. Results Baseline renal function was better in patients implanted earlier after emerging heart failure symptoms (estimated glomerular filtration rate=73±20 vs 63±23 vs 58±26 ml/min/1.73 m 2 for tertiles, respectively). After 6 months, decreases in left ventricular end-diastolic/systolic diameter and improvement in NYHA functional class were similar among tertiles. Freedom from all-cause mortality or heart failure admission was better in patients with early implantation (p value=0.042). However, this was not the case in patients with preserved renal function (p value=0.794). Death from progressive heart failure was significantly more frequent in patients implanted later in their disease course. Conclusions Reverse left ventricular remodelling after CRT is not affected by the duration of heart failure. However, clinical outcome is better in patients implanted earlier in their disease course, which probably relates to better renal preservation.

WOS: 000310542300010, PubMed ID: 22983154, Background: Depression has been found to be a predictor of rehospitalization and mortality in heart failure (HF). Parathyroid hormone (PTH) is a novel promising biomarker that can predict hospitalization, functional status and mortality in HF. Objective: We aimed to investigate the association of depression with serum PTH levels in patients with systolic HF. Methods: A total of consecutive 100 outpatients with systolic HF having left ventricular ejection fraction (LVEF) < 40%, were prospectively studied. All patients underwent laboratory tests, including brain natriuretic peptide (BNP) and PTH analyses. The patients were asked to complete the Beck Depression Inventory-II (BDI). Results: Fifty-one patients (51%) were shown to have poor BDI score (BDIS > 18). Patients with poor BDI score had significantly higher PTH levels compared to those with good BDIS (133 +/- 46 pg/ml vs. 71 +/- 26 pg/ml, p < 0.001). In multivariable logistic regression model, PTH level (Odds ratio (OR) = 1.035, p = 0.003), LVEF (OR = 0.854, p = 0.004), NYHA functional class III/IV (OR = 28.022, p = 0.005), C-reactive protein (CRP) (OR = 1.088, p = 0.020), and presence of pretibial edema (OR = 12.341, p = 0.033) were found to be independent predictors of moderate to severe depression after adjustment of other potential confounders. Conclusion: Systolic HF patients with moderate to severe depression had higher serum levels of PTH and CRP, poor functional status and lower LVEF. The association of depression with such parameters might explain the contribution of depression to hospitalization and mortality in HF. (Arq Bras Cardiol 2012;99(4):915-923)

Congestive heart failure (HF) remains one of the most important and challenging clinical problems in cardiovascular medicine in Brazil and worldwide. Evidence suggests that mortality in this setting has decreased in Brazil over recent years1, which may be related, at least partially, to a more intense and widespread use of neurohormonal blockade (with angiotensin-converting-enzyme inhibitors and beta-blockers) in patients with advanced HF2. To better evaluate the characteristics of end-stage heart disease in Brazil, the ongoing I Brazilian Registry of Heart Failure (BREATHE registry) will evaluate the profile of 1,200 patients admitted with decompensated HF to 60 hospitals representative of the different Brazilian regions3. Final results of the BREATHE registry are expected to be available within the next months. In spite of recent improvements in medical therapy, advanced HF continues to impose an ominous prognosis; in some subsets, mortality rates can reach up to 30% to 50% in the first year of disease, according to contemporary series of Brazilian centers4. In this context, therapeutic alternatives have been intensively investigated in an attempt to improve the outcomes of patients with HF.

Background Chronic heart failure (CHF) is an increasingly prevalent condition with high mortality and morbidity rates. This review examines the role of depression, anxiety, and social support on prognosis in CHF. Method and Results Prospective studies that examined mortality as an outcome, and assessed depression, anxiety, or social support as associates were included. Methodological qualities were evaluated. In total, 25 studies were identified. Concerning depression, 6 of 15 studies of inpatients, 10 of 11 studies of outpatients, and 1 study of a mixed sample found associations between depression and prognosis, with greater associations rendered by depressive symptomatology in outpatients. Anxiety was not associated with prognosis in one inpatient study and one outpatient study. There was a univariable trend in one outpatient study for anxiety to be associated with prognosis. In two of six studies of inpatients and in two of four studies of outpatients, social support was associated with prognosis. On the basis of methodological quality, studies on depression showed mixed results, no conclusions could be drawn for anxiety because this association was not investigated soundly, and the quality of the social network was not associated with outcome. Conclusion Evidence suggests that depressive symptoms and social support might be associated with prognosis in CHF outpatients, independently of biomedical risk factors. With respect to anxiety, no conclusions can be drawn. Future studies are warranted to disentangle associations with psychological factors.