Melhora no Consumo Máximo de Oxigênio e na Ventilação após Tratamento com Sacubitril-Valsartana

BackgroundSacubitril/valsartan had its prognosis benefit confirmed in the PARADIGM-HF trial. However, data on cardiopulmonary exercise testing (CPET) changes with sacubitril-valsartan therapy are scarce.ObjectiveThis study aimed to compare CPET parameters before and after sacubitril-valsartan therapy.MethodsProspective evaluation of chronic heart failure (HF) patients with left ventricular ejection fraction ≤40% despite optimized standard of care therapy, who started sacubitril-valsartan therapy, expecting no additional HF treatment. CPET data were gathered in the week before and 6 months after sacubitril-valsartan therapy. Statistical differences with a p-value <0.05 were considered significant.ResultsOut of 42 patients, 35 (83.3%) completed the 6-month follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment for adverse events. Mean age was 58.6±11.1 years. New York Heart Association class improved in 26 (74.3%) patients. Maximal oxygen uptake (VO₂max) (14.4 vs. 18.3 ml/kg/min, p<0.001), VE/VCO₂slope (36.7 vs. 31.1, p<0.001), and exercise duration (487.8 vs. 640.3 sec, p<0.001) also improved with sacubitril-valsartan. Benefit was maintained even with the 24/26 mg dose (13.5 vs. 19.2 ml/kg/min, p=0.018) of sacubitril-valsartan, as long as this was the highest tolerated dose.ConclusionsSacubitril-valsartan therapy is associated with marked CPET improvement in VO₂max, VE/VCO₂slope, and exercise duration. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)     

Resultados Clínicos e Hemodinâmicos de Longo Prazo após o Transplante de Coração em Pacientes Pré-Tratados com Sildenafil

Background Elevated pulmonary vascular resistance remains a major problem for heart transplant (HT) candidate selection.Objective This study sought at assess the effect of pre-HT sildenafil administration in patients with fixed pulmonary hypertension.Methods This retrospective, single-center study included 300 consecutive, HT candidates treated between 2003 and 2013, in which 95 patients had fixed PH, and of these, 30 patients were treated with sildenafil and eventually received a transplant, forming Group A. Group B included 205 patients without PH who underwent HT. Pulmonary hemodynamics were evaluated before HT, as well as 1 week after and 1 year after HT. Survival was compared between the groups. In this study, a p value < 0.05 was considered statistically significant.Results After treatment with sildenafil but before HT, PVR (-39%) and sPAP (-10%) decreased significantly. sPAP decreased after HT in both groups, but it remained significantly higher in group A vs. group B (40.3 ± 8.0 mmHg vs 36.5 ± 11.5 mmHg, p=0.022). One year after HT, sPAP was 32.4 ± 6.3 mmHg in group A vs 30.5 ± 8.2 mmHg in group B (p=0.274). The survival rate after HT at 30 days (97% in group A versus 96% in group B), at 6 months (87% versus 93%) and at one year (80% vs 91%) were not statistically significant (Log-rank p=0.063). After this first year, the attrition rate was similar among both groups (conditional survival after 1 year, Log-rank p=0.321).Conclusion In patients with severe PH pre-treated with sildenafil, early post-operative hemodynamics and prognosis are numerically worse than in patients without PH, but after 1 year, the medium to long-term mortality proved to be similar. (Arq Bras Cardiol. 2021; 116(2):219-226)     

Valor do Diâmetro do Átrio Esquerdo com Escore CHA2DS2-Vasc na Predição da Trombose Atrial Esquerda/Trombose de Apêndice Atrial Esquerdo na Fibrilação Atrial Não Valvar

BackgroundAtrial fibrillation is the most common persistent arrhythmia, and is the main factor that leads to thromboembolism.ObjectiveTo investigate the value of left atrial diameter combined with CHA2DS2-VASc score in predicting left atrial/left atrial appendage thrombosis in non-valvular atrial fibrillation.MethodsThis is a retrospective study. 238 patients with non-valvular atrial fibrillation were selected and divided into two groups: thrombosis and non-thrombosis. CHA2DS2-VASc score was determined. P<0.05 was considered statistically significant.ResultsMultivariate logistic regression analysis revealed that the history of stroke/transient ischemic attack, vascular disease, CHA2DS2-VASc score, left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) were independent risk factors for left atrial/left atrial appendage thrombosis (p<0.05). Receiver operating characteristic curve analysis revealed that the area under the curve for the CHA2DS2-VASc score in predicting left atrial/left atrial appendage thrombosis was 0.593 when the CHA2DS2-VASc score was ≥3 points, and sensitivity and specificity were 86.5% and 32.6%, respectively, while the area under the curve for LAD in predicting left atrial/left atrial appendage thrombosis was 0.786 when LAD was ≥44.17 mm, and sensitivity and specificity were 89.6% and 60.9%, respectively. Among the different CHA2DS2-VASc groups, the incidence rate of left atrial/left atrial appendage thrombosis in patients with LAD ≥44.17 mm was higher than patients with LAD <44.17 mm (p<0.05).ConclusionCHA2DS2-VASc score and LAD are correlated with left atrial/left atrial appendage thrombosis in non-valvular atrial fibrillation. For patients with a CHA2DS2-VASc score of 0 or 1, when LAD is ≥44.17 mm, the risk for left atrial/left atrial appendage thrombosis remained high. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)     

Mortalidade por Insuficiência Cardíaca com Fração de Ejeção Intermediária

Background The prognostic importance of the classification ‘heart failure (HF) with mid-range ejection fraction (EF)’ remains uncertain.Objective To analyze the clinical characteristics, comorbidities, complications, and in-hospital and late mortality of patients classified as having HF with mid-range EF (HFmrEF – EF: 40%-49%), and to compare them to those of patients with HF with preserved EF (HFpEF – EF > 50%) and with HF with reduced EF (HFrEF – EF < 40%) on admission for decompensated HF.Methods Ambispective cohort of patients admitted to the cardiac intensive care unit due to decompensated HF. Clinical characteristics, comorbidities, complications, and in-hospital and late mortality were assessed. The software R was used, with a 5% significance, for the tests chi-square, analysis of variance, Cox multivariate, and Kaplan-Meier survival curve, in addition to machine-learning techniques (Elastic Net and survival tree).Results 519 individuals were included between September 2011 and June 2019 (mean age, 74.87 ± 13.56 years; 57.6% were men). The frequencies of HFpEF, HFmrEF and HFrEF were 25.4%, 27% and 47.6%, respectively. Previous infarction was more frequent in HFmrEF. The mean follow-up time was 2.94 ± 2.55 years, with no statistical difference in mortality between the groups (53.8%, 52.1%, 57.9%). In the survival curve, there was difference between neither the HFpEF and HFmrEF groups, nor the HFpEF and HFrEF groups, but between the HFmrEF and HFrEF groups. Age over 77 years, previous HF, history of readmission, dementia and need for vasopressors were associated with higher late mortality in the survival tree.Conclusion The EF was not selected as a variable associated with mortality in patients with decompensated HF.     

Avaliação do Tempo de Condução Atrioventricular Dinâmica para Acoplamento ao Intervalo RR em Atletas e Indivíduos Sedentários

BackgroundAtrioventricular conduction time ( AVCT ) is influenced by autonomic input and subject to physiological remodeling.ObjectiveTo evaluate beat-by-beat AVCT and RR-interval variability in athletes and healthy sedentary subjects.MethodsTwenty adults, including 10 healthy sedentary (Controls) and 10 elite long-distance runners (Athletes), age, weight and height-adjusted, underwent maximal metabolic equivalent (MET) assessment, and 15-min supine resting ECG recording seven days later. The interval between P-wave and R-wave peaks defined the AVCT . Mean (M) and standard deviation (SD) of consecutive RR-intervals (RR) and coupled AVCT were calculated, as well as regression lines of RR vs. AVCT (RR-AVCT) . Concordant AV conduction was defined as positive RR-AVCT slope and discordant otherwise. A multivariate linear regression model was developed to explain MET based on AVCT and RR-interval variability parameters. Significance-level: 5 %.ResultsIn Athletes, M-RR and SD-RR values were higher than in Controls, whereas M-AVCT and SD-AVCT were not. RR-AVCT slopes were, respectively, 0.038 ± 0.022 and 0.0034 ± 0.017 (p < 0.05). Using a cut-off value of 0.0044 (AUC 0.92 ± 0.07; p < 0.001), RR-AVCT slope showed 100% specificity and 80% sensitivity. In a multivariate model, SD-RR and RR-AVCT slope were independent explanatory variables of MET (F-ratio: 17.2; p < 0.001), showing 100% specificity and 90% sensitivity (AUC 0.99 ± 0.02; p < 0.001).ConclusionIn elite runners, AVCT to RR -interval dynamic coupling shows spontaneous discordant AV conduction, characterized by negative AVCT vs. RR -interval regression line slope. RR -intervals standard deviation and AVCT vs. RR -interval regression line slope are independent explanatory variables of MET (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)     

Desnutrição e Caquexia na Insuficiência Cardíaca Descompensada e Cardiomiopatia Chagásica: Ocorrência e Associação com Desfechos Hospitalares

BackgroundNutritional disorders are common among patients with heart failure (HF) and associated with poor prognosis. Importantly, some populations of patients, like the ones with Chagas disease, are frequently excluded from most analyses.ObjectiveWe sought to study the occurrence of undernutrition and cachexia in patients with Chagas disease during episodes of decompensated HF (DHF) as compared to other etiologies, and to investigate the influence of these findings on hospital outcomes.MethodsWe performed a consecutive case series study with patients hospitalized with DHF. Patients underwent the Subjective Global Assessment of nutritional status (SGA), besides anthropometric and laboratorial measures, and were evaluated for the occurrence of cachexia, low muscle mass and strength. We studied the occurrence of death or urgent heart transplantation during hospitalization.ResultsAltogether, 131 patients were analyzed and 42 (32.1%) had Chagas disease. Patients with Chagas disease had lower Body Mass Index (BMI) (22.4 kg/m²[19.9-25.3] vs. 23.6 kg/m2 [20.8-27.3], p=0.03), higher frequency of undernutrition (76.2% vs 55.1%, p=0.015) and higher occurrence of death or transplant (83.3% vs. 41.6%, p<0.001). We found that, in patients with Chagas etiology, the occurrence of death or cardiac transplantation were associated with undernutrition (3 [42.9%] patients with hospital discharge vs 29 [82.9%] patients with death or heart transplant, p=0.043).ConclusionsTaken together, our results indicate that patients with Chagas disease hospitalized with DHF often present with nutritional disorders, especially undernutrition; importantly, this finding was associated with the occurrence of death and heart transplant during hospitalization.     

Risco Cardiovascular e Elegibilidade Para Estatina na Prevenção Primária: Comparação Entre a Diretriz Brasileira e a Diretriz da AHA/ACC

Background Differences between the updated versions of the Brazilian Guideline on Dyslipidemias and the American Heart Association (AHA)/American College of Cardiology (ACC) Cholesterol Guideline regarding cardiovascular risk stratification and statin eligibility are unknown.Objectives To compare cardiovascular risk categorization and statin eligibility based on the Brazilian guideline with those based on the AHA/ACC guideline in primary prevention patients.Methods We retrospectively analyzed individuals aged 40-74 years without high-risk conditions, with LDL-c 70 to < 190 mg/dL, not on lipid-lowering drugs, who underwent routine clinical assessment. Cardiovascular risk was stratified according to the Brazilian and the AHA/ACC guidelines. Subjects were considered eligible for statin therapy if LDL-c was at least 30 mg/dL above the target for the cardiovascular risk (Brazilian guideline) or the 10-year atherosclerotic cardiovascular disease risk was ≥7.5% (AHA/ACC guideline). A p-value < 0.05 was considered statistically significant.Results The study sample consisted of 18,525 subjects (69% male, age 48 ± 6 years). Among subjects considered at intermediate or high risk by the Brazilian guideline, over 80% would be in a lower risk category by the AHA/ACC guideline. Among men, 45% and 16% would be statin eligible by the Brazilian and the AHA/ACC guidelines criteria, respectively (p < 0.001). Among women, the respective proportions would be 16% and 1% (p < 0.001). Eighty-two percent of women and 57% of men eligible for statins based on the Brazilian guideline criterion would not be eligible according to the AHA/ACC guideline criterion.Conclusions Compared with the AHA/ACC guideline, the Brazilian guideline classifies a larger proportion of primary prevention patients into higher-risk categories and substantially increases statin eligibility. (Arq Bras Cardiol. 2020; 115(3):440-449)     

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)     

Efetividade e Segurança da Remoção de Cabos-Eletrodos Transvenosos de Marca-Passos e Desfibriladores Implantáveis no Cenário da Prática Clínica Real

BackgroundTransvenous lead extraction (TLE) of cardiac implantable electronic devices (CIED) is an uncommon procedure and requires specialized personnel and adequate facilities.ObjectivesTo evaluate the effectiveness and safety of the removal of CIED leads and to determine risk factors for surgical complications and mortality in 30 days.MethodsProspective study with data derived from clinical practice. From January 2014 to April 2020, we included 365 consecutive patients who underwent TLE, regardless of the indication and surgical technique used. The primary outcomes were: success rate of the procedure, combined rate of major complications and intraoperative death. Secondary outcomes were: risk factors for major intraoperative complications and death within 30 days. Univariate and multivariate analysis were used, with a significance level of 5%.ResultsProcedure success rate was 96.7%, with 90.1% of complete success and 6.6% of clinical success. Major intraoperative complications occurred in 15 (4.1%) patients. Predictors of major complications were: lead dwelling time ≥ 7 years (OR = 3.78, p = 0.046) and change in surgical strategy (OR = 5.30, p = 0.023). Functional class III-IV (OR = 6.98, p <0.001), renal failure (OR = 5.75, p = 0.001), CIED infection (OR = 13.30, p <0.001), number of procedures performed (OR = 77.32, p <0.001) and major intraoperative complications (OR = 38.84, p <0.001) were predictors of 30-day mortality.ConclusionsThe results of this study, which is the largest prospective registry of consecutive TLE procedures in Latin America, confirm the safety and effectiveness of this procedure in the context of real clinical practice. (Arq Bras Cardiol. 2020; 115(6):1114-1124)     

Controle da Pressão Arterial e Fatores Associados em um Serviço Multidisciplinar de Tratamento da Hipertensão

BackgroundAlthough team-based care is recommended for patients with hypertension, results of this intervention in a real-world setting are missing in the literature.ObjectiveTo report the results of a real-world long-term team-based care for hypertensive patients we conducted this study.MethodsData of hypertensive patients attending a multidisciplinary treatment center located in the Midwest region of Brazil in June 2017 with at least two follow-up visits were retrospectively assessed. Anthropometric, blood pressure (BP), follow-up time, pharmacological treatment, diabetes and lifestyle data were collected from the last visit to the service. BP values < 140 x 90 mmHg in non-diabetics and < 130 x 80 mmHg in diabetics were considered controlled. A logistic regression model was built to identify variables independently associated to BP control. Significance level adopted p < 0.05.ResultsA total of 1,548 patients were included, with a mean follow-up time of 7.6 ± 7.1 years. Most patients were female (73.6%; n=1,139) with a mean age of 61.8 ±12.8 years. BP control rates in all the sample, and in non-diabetics and diabetics were 68%, 79%, and 37.9%, respectively. Diabetes was inversely associated with BP control (OR 0.16; 95%CI 0.12-0.20; p<0.001) while age ≥ 60 years (OR 1.48; 95%CI 1.15-1.91; p=0.003) and female sex (OR 1.38; 95%CI 1.05-1.82; p=0.020) were directly associated.ConclusionsA BP control rate around 70% was found in patients attending a multidisciplinary team care center for hypertension. Focus on patients with diabetes, younger than 60 years and males should be given to further improve these results. (Arq Bras Cardiol. 2020; 115(2):174-181)     

Ablação Por Cateter Sem Uso de Fluoroscopia Para Tratamento de Fibrilação Atrial e Arritmias Atriais: Eficácia e Segurança

BackgroundThe use of ionizing radiation in medical procedures is associated with significant health risks for patients and the health care team.ObjectivesEvaluate the safety and acute efficacy of ablation for atrial fibrillation (AF) and supraventricular arrhythmias (SVTs) using an exclusively non-fluoroscopic approach guided by intracardiac echo (ICE) and 3D-mapping.Methods95 pts (mean age 60 ± 18 years, 61% male) scheduled for AF Ablation (69 pts, 45 paroxysmal AF and 24 persistent AF) or non-AF SVT (26 pts – 14 AV node reentry, 6 WPW, 5 right atrial (RA) flutters, 1 atrial tachycardia) underwent zero fluoro procedures. Nine patients (9.5%) had permanent pacemakers or defibrillator resynchronization (CRT-D) devices. Both CARTO (65%) and NAVx (35%) mapping systems were used, as well as Acunav and ViewFlex ICE catheters.ResultsPulmonary vein isolation (PVI), as well as all other targets that needed ablation in both atria were reached and adequately visualized. No pericardial effusions, thrombotic complications or other difficulties were seen in these series. Difficult transseptal puncture (19 patients - 20%) was managed without fluoroscopy in all cases. No backup fluoroscopy was used, and no lead apparel was needed. Pacemaker interrogations after the procedure did not show any lead damage, dislocation, or threshold changes.ConclusionsA radiation-free (fluoroless) catheter ablation strategy for AF and other atrial arrhythmias is acutely safe and effective when guided by adequate ICE and 3D-mapping utilization. Multiple different bi-atrial sites were reached and adequately ablated without the need for backup fluoroscopy. No complications were seen. (Arq Bras Cardiol. 2020; 114(6):1015-1026)     

Avaliação da Senescência de Células Sanguíneas Mononucleares Periféricas e na Disfunção Endotelial entre Adultos com Alto Risco Cardiovascular

BackgroundCardiovascular diseases (CVD) are one of the leading causes of mortality and morbidity worldwide. Biological aging has been associated with the occurrence of adverse cardiovascular outcomes; however, the underlying mechanism of this process remains unknown.ObjectivesThis study sought to evaluate if peripheral blood mononuclear cell (PBMC) senescence and endothelial biomarkers could influence cardiovascular (CV) risk and be suitable markers for the early detection of cardiovascular diseases in adults.MethodsIn this cross-sectional study patients free of CVD were classified as lower (n=32) and higher Interheart Risk (IHR) scores (n=28). PBMC senescence was assessed by estimating the telomerase activity (TA) and detecting the presence of senescent cells and endothelial dysfunction by estimating the concentration of nitrite and nitrate and of total antioxidant capacity (TAC). Statistical analysis was performed with SPSS version 16.0 (SPSS Inc., Chicago, IL). All p-values <0.05 were considered statistically significant.ResultsPBMC senescence 0.95 [p-value = 0.0001; 95% CI (0.874-1.026)] was a significant predictor of patients with higher IHR scores with a cut-off value of 21.65 with a sensitivity and specificity of 92% and 88% respectively. PBMC senescence, nitrite and nitrate and TA were found to be independently associated with high IHR scores.ConclusionPBMC senescence, TA and nitrite, and nitrate status are suitable measures to predict high cardiovascular risk in adults with CV risk. Nevertheless, long-term follow-up studies are needed to confirm these findings. (Arq Bras Cardiol. 2021; 116(1):37-47)