Valor Prognóstico dos Níveis Plasmáticos de NT-proBNP em Pacientes Hospitalizados com Mais de 80 Anos de Idade em um Hospital em Pequim,China

BackgroundDespite growing evidence that N-terminal pro-brain natriuretic peptide (NT-proBNP) has an important prognostic value in older adults, there is limited data on its prognostic predictive value.ObjectivesThe aim of this study is to evaluate the clinical significance of NT-proBNP in hospitalized patients older than 80 years of age in Beijing, China.MethodsThis prospective, observational study was conducted in 724 very elderly patients in a geriatric ward (age ≥80 years, range, 80100 years, mean, 86.6 3.0 years). Multivariate linear regression analysis was used to screen for factors independently associated with NT-proBNP, and the Cox proportional hazard regression model was used to screen for relationships between NT-proBNP levels and major endpoints. The major endpoints assessed were all-cause death and MACEs. P values < 0.05 were considered statistically significant.ResultsThe prevalence rates of coronary heart disease, hypertension, and diabetes mellitus were 81.4%, 75.1%, and 41.2%, respectively. The mean NT-proBNP level was 770 ± 818 pg/mL. Using multivariate linear regression analyses, correlations were found between plasma NT-proBNP and body mass index, atrial fibrillation, estimated glomerular filtration rate, left atrial diameter, left ventricular ejection fraction, use of betablocker, levels of hemoglobin, plasma albumin, triglycerides, serum creatinine, and blood urea nitrogen. The risk of all-cause death (HR, 1.63; 95% CI, 1.0052.642; P = 0.04) and major adverse cardiovascular events (MACE; HR, 1.77; 95% CI, 1.2893.531; P = 0.04) in the group with the highest NT-proBNP level was significantly higher than that in the group with the lowest level, according to Cox regression models after adjusting for multiple factors. As expected, echocardiography parameters adjusted the prognostic value of NT-proBNP in the model.ConclusionsNT-proBNP was identified as an independent predictor of all-cause death and MACE in hospitalized patients older than 80 years of age.     

Relação entre Velocidade de Onda de Pulso e Biomarcadores Cardiovasculares em Pacientes com Fatores de Risco

BackgroundThe relationship between pulse wave velocity (PWV) and biomarkers of structural changes of the left ventricle and carotid arteries remains poorly understood.ObjectiveTo investigate the relationship between PWV and these biomarkers.MethodsThis was an analytical, retrospective, cross-sectional study. Medical records of patients with diabetes mellitus, dyslipidemia, and pre-hypertension or hypertension, who underwent central blood pressure (CBP) measurement using Mobil-O-Graph®, and carotid doppler or echocardiography three months before and after the CBPM were analyzed. Statistical analysis was performed using Pearson or Spearman correlation, linear bivariate and multiple regression analysis, and the t test (independent) or Mann-Whitney test. A p <0.05 indicated statistical significance.ResultsMedical records of 355 patients were analyzed, mean age 56.1 (±14.8) years, 51% male. PWV was correlated with intima-media thickness (IMT) of carotids (r=0.310) and left ventricular septal thickness (r=0.191), left ventricular posterior wall thickness (r=0.215), and left atrial diameter (r=0.181). IMT was associated with PWV adjusted by age and peripheral systolic pressure (p=0.0004); IMT greater than 1 mm increased the chance of having PWV above 10 m/s by 3.94 times. PWV was significantly higher in individuals with left ventricular hypertrophy (p=0.0001), IMT > 1 mm (p=0.006), carotid plaque (p=0.0001), stenosis ≥ 50% (p=0.003), and target-organ damage (p=0.0001).ConclusionPWV was correlated with IMT and echocardiographic parameters, and independently associated with IMT. This association was stronger in individuals with left ventricular hypertrophy, increased IMT, carotid plaque, stenosis ≥ 50%, and target organ damage. (Arq Bras Cardiol. 2020; 115(6):1125-1132)     

Resultados Precoces do Procedimento de Norwood em um Centro de Referência no Brasil

BackgroundOnly two papers have addressed the early outcomes of patients with hypoplastic left heart syndrome (HLHS) undergoing the Norwood operation, in Brazil.ObjectivesWe evaluated patients with HLHS undergoing the first-stage Norwood operation in order to identify the predictive factors for early (within the first 30 days after surgery) and intermediate (from early survival up to the Glenn procedure) mortality.MethodsPatients with HLHS undergoing the stage I Norwood procedure from January 2016 through April 2019, in our service, were enrolled. Demographic, anatomical, and surgical data were analyzed. Endpoints were early mortality (within the first 30 days after surgery), intermediate mortality (from early survival up to the Glenn procedure) and the need for postoperative ECMO support. Univariate and multivariate analyses were performed, and odds ratios, with 95% confidence intervals, were calculated. A p-value <0.05 was considered statistically significant.ResultsA total of 80 patients with HLHS underwent the stage I Norwood procedure. The 30-day survival rate was 91.3% and the intermediate survival rate 81.3%. Fourteen patients (17.5%) required ECMO support. Lower weight (p=0.033), aortic stenosis (vs aortic atresia; p=0.036), and the need for postoperative ECMO support (p=0.009) were independent predictive factors for 30-day mortality. Mitral valve stenosis (vs mitral valve atresia; p=0.041) was an independent predictive factor for intermediate mortality.ConclusionThe present study includes the largest Brazilian cohort of patients with HLHS undergoing the stage I Norwood procedure in the recent era. Our survival rates were comparable to the highest survival rates reported globally. Low body weight, aortic valve stenosis, and the need for postoperative ECMO support were independent predictors for 30-day mortality. Mitral valve stenosis was the only independent predictive factor for intermediate mortality.     

Fatores que Impactam a Decisão de Realizar Ventriculografia Esquerda em Doença Arterial Coronariana

BackgroundLeft ventriculography is an invasive method for assessment of left ventricular systolic function. Since the advent of noninvasive methods, its use has been questioned, as it carries some risk to the patient.ObjectiveTo assess which factors are independently associated with the decision to perform ventriculography in patients with coronary artery disease.MethodsAnalytical, retrospective, database review study of electronic medical records comparing 21 predefined variables of interest among patients undergoing coronary angiography. P-values <0.05 were considered significant.ResultsWe evaluated 600 consecutive patients undergoing coronary angiography. Left ventriculography was performed in the majority of cases (54%). After multivariate analysis, patients with chronic coronary syndrome (OR 1.72; 95% CI: 1.20–2.46; p < 0.01) were more likely to undergo the procedure. Patients with known ventricular function (OR 0.58; 95% CI: 0.40–0.85; p < 0.01); those with a history of CABG (OR 0.31; 95% CI: 0.14–0.69; p < 0.01) or hypertension (OR 0.58; 95% CI: 0.36–0.94; p = 0.02); and those with higher creatinine levels (OR 0.42; 95% CI: 0.26–0.69; p < 0.01) had greater odds of not undergoing ventriculography.ConclusionsIn patients undergoing coronary angiography, a diagnosis of chronic coronary syndrome was independently associated with greater likelihood of left ventriculography, while having previously determined ventricular function, a history of hypertension or CABG, and higher creatinine levels were associated with a decreased likelihood of undergoing this procedure.     

Intensidade de Exercício durante o Teste de Caminhada de 6 Minutos em Pacientes com Doença Arterial Periférica

Background Non-supervised ground walking has been recommended for patients with symptomatic peripheral artery disease (PAD). However, the magnitude of the effort required by this activity and the characteristics of patients whose ground walking is more intense are unclear.Objectives To determine whether ground walking exceeds the ventilatory threshold (VT), a recognized marker of exercise intensity, in patients with symptomatic PAD.Methods Seventy patients (61.4% male and aged 40 to 85 years old) with symptomatic PAD were recruited. Patients performed a graded treadmill test for VT determination. Then, they were submitted to a 6-minute walk test so the achievement of VT during ground ambulation could be identified. Multiple logistic regression was conducted to identify predictors of VT achievement during the 6-minute walk test. The significance level was set at p < 0.05 for all analyses.Results Sixty percent of patients achieved VT during the 6-minute walk test. Women (OR = 0.18 and 95%CI = 0.05 to 0.64) and patients with higher cardiorespiratory fitness (OR = 0.56 and 95%CI = 0.40 to 0.77) were less likely to achieve VT during ground walking compared to men and patients with lower cardiorespiratory fitness, respectively.Conclusion More than half of patients with symptomatic PAD achieved VT during the 6-minute walk test. Women and patients with higher cardiorespiratory fitness are less likely to achieve VT during the 6-minute walk test, which indicates that ground walking may be more intense for this group. This should be considered when prescribing ground walking exercise for these patients. (Arq Bras Cardiol. 2020; 114(3):486-492)     

Análise de Escores de Risco para Predição de Mortalidade em Pacientes Submetidos à Cirurgia Cardíaca por Endocardite

Background Risk scores are available for use in daily clinical practice, but knowing which one to choose is still fraught with uncertainty.Objectives To assess the logistic EuroSCORE, EuroSCORE II, and the infective endocarditis (IE)-specific scores STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E, as predictors of hospital mortality in patients undergoing cardiac surgery for active IE at a tertiary teaching hospital in Southern Brazil.MethodsRetrospective cohort study including all patients aged ≥ 18 years who underwent cardiac surgery for active IE at the study facility from 2007-2016. The scores were assessed by calibration evaluation (observed/expected [O/E] mortality ratio) and discrimination (area under the ROC curve [AUC]). Comparison of AUC was performed by the DeLong test. A p < 0.05 was considered statistically significant.Results A total of 107 patients were included. Overall hospital mortality was 29.0% (95%CI: 20.4-37.6%). The best O/E mortality ratio was achieved by the PALSUSE score (1.01, 95%CI: 0.70-1.42), followed by the logistic EuroSCORE (1.3, 95%CI: 0.92-1.87). The logistic EuroSCORE had the highest discriminatory power (AUC 0.77), which was significantly superior to EuroSCORE II (p = 0.03), STS-IE (p = 0.03), PALSUSE (p = 0.03), AEPEI (p = 0.03), and RISK-E (p = 0.02).Conclusions Despite the availability of recent IE-specific scores, and considering the trade-off between the indexes, the logistic EuroSCORE seemed to be the best predictor of mortality risk in our cohort, taking calibration (O/E mortality ratio: 1.3) and discrimination (AUC 0.77) into account. Local validation of IE-specific scores is needed to better assess preoperative surgical risk. (Arq Bras Cardiol. 2020; 114(3):518-524)     

Sinais de Injúria Cardíaca em Pacientes Pediátricos com COVID-19 Gravemente Enfermos: Uma Experiência de Centro Único no Brasil

BackgroundSome patients with COVID-19 present myocardial injury.ObjectiveTo detect myocardial injury in critically ill paediatric patients, and to compare cardiac involvement between children with severe acute respiratory syndrome (SARS) and children with multisystemic inflammatory syndrome (MIS-C).MethodsAll COVID-19 children admitted to a referral intensive care unit were prospectively enrolled and had a two-dimensional echocardiogram (2D-TTE) and a cardiac troponin I (cTnI) assay within the first 72 hours. For statistical analysis, two-sided p < 0.05 was considered significant.ResultsThirty-three patients were included, of which 51.5% presented elevated cTnI and/or abnormal 2D-TTE and 36.4% needed cardiovascular support, which was more frequent in patients with both raised cTnI and 2D-TTE abnormalities than in patients with normal exams (83.3% and 33.3%, respectively; p 0.006, 95% CI = 0.15-0.73). The most common 2D-TTE findings were pericardial effusion (15.2%) and mitral/tricuspid regurgitation (15.2%). Signs of cardiac involvement were more common in MIS-C than in SARS. MIS-C patients also presented a higher rate of the need for cardiovascular support (66.7% vs 25%, p 0.03, 95% CI = -0.7 to -0.04) and a more frequent rate of raised cTnI (77.8% vs 20.8%; p 0.002, 95% CI = 0.19 to 0.79). The negative predictive values of cTnI for the detection of 2D-TTE abnormalities were 100% for MIS-C patients and 73.7% for SARS patients.Conclusionsigns of cardiac injury were common, mainly in MIS-C patients. 2D-TTE abnormalities were subtle. To perform a cTnI assay upon admission might help providers to discriminate those patients with a more urgent need for a 2D-TTE.     

Risco de Morte em Idosos com Sonolência Excessiva Diurna,Insônia e Depressão: Estudo de Coorte Prospectiva em População Urbana no Nordeste Brasileiro

BackgroundThe close relationship between sleep regulation and cardiovascular events is one of the main focuses of research in contemporary medicine. Sleep habits and characteristics interfere with the cardiac rhythm and also with life expectancy, especially in the elderly.ObjectiveTo estimate the risk of death and cardiovascular events in community-dwelling elderly individuals complaining of insomnia and excessive daytime sleepiness over eight years of follow-up.MethodA prospective cohort was designed with 160 elderly, with the first wave occurring in 2009 and the second in 2017. Follow-up groups were determined by exposure or not to complaints of primary insomnia and excessive daytime sleepiness with or without snoring. The covariates gender, marital status, depression, hypertension and diabetes were controlled. The primary outcome was death and the secondary outcome was cardio-cerebrovascular events (CCV). Outcome risks were estimated by relative risk (RR) through Poisson regression, adopting α≤0.05.ResultsThere were 40 (25.97%: 19.04-32.89) deaths over the period and 48 (30.76%: 23.52-38.01) CCV. Men had a higher risk (RR = 1.88; 1.01-3.50) of death. Depression (RR = 2.04; 1.06-3.89), insomnia severity (RR = 2.39; 1.52-4.56) and sleep latency between 16-30 minutes (RR = 3, 54; 1.26-9.94) and 31-60 minutes (RR = 2.23; 1.12-4.47) increased the risk of death independently in community-dwelling elderly. CCV were predicted only in the hypertensive and / or diabetic elderly (RR = 8.30; 1.98-34.82).ConclusionMortality in the elderly is influenced by the emotional state and difficulty in falling asleep, unlike CCVs, which are conditioned only by arterial and metabolic blood pressure conditions.     

Impacto do Alto Risco Cardiovascular na Mortalidade Hospitalar em Pacientes Internados em Terapia Intensiva por COVID-19

BackgroundSome studies have shown a higher prevalence of deaths in patients with cardiovascular risk factors (CRF) during hospitalization for COVID-19.ObjectivesTo assess the impact of high cardiovascular risk in patients hospitalized in intensive care for COVID-19MethodsRetrospective study with patients admitted to an intensive care unit, with a diagnosis of COVID-19 confirmed by RT-PCR, and with at least one troponin measurement during hospitalization. The criteria for defining high cardiovascular risk (HCR) patients were: history of established cardiovascular disease (myocardial infarction, stroke, or peripheral arterial disease), diabetes, chronic kidney disease with clearance < 60ml/min, or presence of 3 CRFs (hypertension, smoking, dyslipidemia, or age > 65 years). The primary outcome of this study is all-cause in-hospital mortality. P<0.05 was considered significant.ResultsThis study included 236 patients, mean age = 61.14±16.2 years, with 63.1% men, 55.5% hypertensive, and 33.1% diabetic; 47.4% of the patients also presented HCR. A significant increase in mortality was observed as the number of risk factors increased (0 FRC: 5.9%; 1 FRC: 17.5%; 2 FRC: 32.2% and ≥3 FRC: 41.2%; p=0.001). In the logistic regression adjusted for severity (SAPS3 score), the HCR and myocardial injury group had a higher occurrence of in-hospital mortality (OR 40.38; 95% CI 11.78-138.39). Patients without HCR but with myocardial injury also exhibited a significant association with the primary outcome (OR 16.7; 95% CI 4.45-62.74).ConclusionIn patients hospitalized in intensive care for COVID-19, HCR impacts in-hospital mortality only in patients with myocardial injury.     

Treino de Força Reduz Stress Oxidativo Cardíaco e Renal em Ratos com Hipertensão Renovascular

BackgroundStrength training has beneficial effects on kidney disease, in addition to helping improve antioxidant defenses in healthy animals.ObjectiveTo verify if strength training reduces oxidative damage to the heart and contralateral kidney caused by the renovascular hypertension induction surgery, as well as to evaluate alterations in the activity of superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) endogenous antioxidant enzymes.MethodsEighteen male rats were divided into three groups (n=6/group): sham, hypertensive, and trained hypertensive. The animals were induced to renovascular hypertension through left renal artery ligation. Strength training was initiated four weeks after the induction of renovascular hypertension, continued for a 12-weeks period, and was performed at 70% of 1RM. After the training period, the animals were euthanized and the right kidney and heart were removed for quantitation of hydroperoxides, malondialdehyde and sulfhydryl groups, which are markers of oxidative damage. In addition, the activity of SOD, CAT, and GPx antioxidant enzymes was also measured. The adopted significance level was 5% (p < 0.05).ResultsAfter strength training, a reduction in oxidative damage to lipids and proteins was observed, as could be seen by reducing hydroperoxides and total sulfhydryl levels, respectively. Furthermore, an increased activity of superoxide dismutase, catalase, and glutathione peroxidase antioxidant enzymes was observed.ConclusionStrength training is able to potentially reduce oxidative damage by increasing the activity of antioxidant enzymes. (Arq Bras Cardiol. 2021; 116(1):4-11)     

Capacidade Preditiva dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca em Terapia de Ressincronização Cardíaca

BackgroundThere is evidence suggesting that a peak oxygen uptake (pVO₂) cut-off of 10ml/kg/min provides a more precise risk stratification in cardiac resynchronization therapy (CRT) patients.ObjectiveTo compare the prognostic power of several cardiopulmonary exercise testing (CPET) parameters in this population and assess the discriminative ability of the guideline-recommended pVO₂cut-off values.MethodsProspective evaluation of consecutive heart failure (HF) patients with left ventricular ejection fraction ≤40%. The primary endpoint was a composite of cardiac death and urgent heart transplantation (HT) in the first 24 follow-up months, and was analysed by several CPET parameters for the highest area under the curve (AUC) in the CRT group. A survival analysis was performed to evaluate the risk stratification provided by several different cut-offs. p values <0.05 were considered significant.ResultsA total of 450 HF patients, of which 114 had a CRT device. These patients had a higher baseline risk profile, but there was no difference regarding the primary outcome (13.2% vs 11.6%, p =0.660). End-tidal carbon dioxide pressure at anaerobic threshold (P_ETCO_2AT)had the highest AUC value, which was significantly higher than that of pVO₂in the CRT group (0.951 vs 0.778, p =0.046). The currently recommended pVO₂cut-off provided accurate risk stratification in this setting (p <0.001), and the suggested cut-off value of 10 ml/min/kg did not improve risk discrimination in device patients (p =0.772).ConclusionP_ETCO_2ATmay outperform pVO₂’s prognostic power for adverse events in CRT patients. The current guideline-recommended pVO2 cut-off can precisely risk-stratify this population.