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Rohde LE, Rover MM, Hoffmann Filho CR, Rabelo-Silva ER, Silvestre OM, Martins SM, Passos LCS, de Figueiredo Neto JA, Danzmann LC, Silveira FS, Mesas CE, Hernandes ME, Moura LZ, Simões MV, Ritt LEF, Nishijuka FA, Bertoldi EG, Dall Orto FTC, Magedanz EH, Mourilhe-Rocha R, Fernandes-Silva MM, Ferraz AS, Schwartzmann P, de Castilho FM, Pereira Barretto AC, dos Santos Júnior EG, Nogueira PR, Canesin M, Beck-da-Silva L, de Carvalho Silva M, Adolfi Júnior MS, Santos RHN, Ferreira A, Pereira D, López Pedraza L, Kojima FCS, Campos V, de Barros e Silva PGM, Blacher M, Cavalcanti AB, Ramires F. Multifaceted Strategy Based on Automated Text Messaging After a Recent Heart Failure Admission: The MESSAGE-HF Randomized Clinical Trial. JAMA Cardiol 2024; 9:105-113. [PMID: 38055237 PMCID: PMC10701668 DOI: 10.1001/jamacardio.2023.4501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/27/2023] [Indexed: 12/07/2023]
Abstract
Importance Readmissions after an index heart failure (HF) hospitalization are a major contemporary health care problem. Objective To evaluate the feasibility and efficacy of an intensive telemonitoring strategy in the vulnerable period after an HF hospitalization. Design, Setting, and Participants This randomized clinical trial was conducted in 30 HF clinics in Brazil. Patients with left ventricular ejection fraction less than 40% and access to mobile phones were enrolled up to 30 days after an HF admission. Data were collected from July 2019 to July 2022. Intervention Participants were randomly assigned to a telemonitoring strategy or standard care. The telemonitoring group received 4 daily short message service text messages to optimize self-care, active engagement, and early intervention. Red flags based on feedback messages triggered automatic diuretic adjustment and/or a telephone call from the health care team. Main Outcomes and Measures The primary end point was change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 180 days. A hierarchical win-ratio analysis incorporating blindly adjudicated clinical events (cardiovascular deaths and HF hospitalization) and variation in NT-proBNP was also performed. Results Of 699 included patients, 460 (65.8%) were male, and the mean (SD) age was 61.2 (14.5) years. A total of 352 patients were randomly assigned to the telemonitoring strategy and 347 to standard care. Satisfaction with the telemonitoring strategy was excellent (net promoting score at 180 days, 78.5). HF self-care increased significantly in the telemonitoring group compared with the standard care group (score difference at 30 days, -2.21; 95% CI, -3.67 to -0.74; P = .001; score difference at 180 days, -2.08; 95% CI, -3.59 to -0.57; P = .004). Variation of NT-proBNP was similar in the telemonitoring group compared with the standard care group (telemonitoring: baseline, 2593 pg/mL; 95% CI, 2314-2923; 180 days, 1313 pg/mL; 95% CI, 1117-1543; standard care: baseline, 2396 pg/mL; 95% CI, 2122-2721; 180 days, 1319 pg/mL; 95% CI, 1114-1564; ratio of change, 0.92; 95% CI, 0.77-1.11; P = .39). Hierarchical analysis of the composite outcome demonstrated a similar number of wins in both groups (telemonitoring, 49 883 of 122 144 comparisons [40.8%]; standard care, 48 034 of 122 144 comparisons [39.3%]; win ratio, 1.04; 95% CI, 0.86-1.26). Conclusions and Relevance An intensive telemonitoring strategy applied in the vulnerable period after an HF admission was feasible, well-accepted, and increased scores of HF self-care but did not translate to reductions in NT-proBNP levels nor improvement in a composite hierarchical clinical outcome. Trial Registration ClinicalTrials.gov Identifier: NCT04062461.
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Affiliation(s)
- Luis E. Rohde
- Cardiovascular Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | | | | | | | | | | | | | - Luiz C. Danzmann
- Hospital Universitário de Canoas e Universidade Luterana do Brasil, Canoas, Brazil
| | | | | | | | | | - Marcus V. Simões
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Luiz E. F. Ritt
- Instituto D’Or de Pesquisa e Ensino, Hospital Cárdio Pulmonar, Salvador, Brazil
| | | | | | | | | | - Ricardo Mourilhe-Rocha
- Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Pedro Schwartzmann
- Centro Avançado de Pesquisa e Ensino e Hospital Unimed de Ribeirão Preto, Ribeirão Preto, Brazil
| | - Fábio M. de Castilho
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | - Manoel Canesin
- Hospital Universitário Regional do Norte do Paraná, Londrina, Brazil
| | - Luis Beck-da-Silva
- Cardiovascular Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | | | | | - Amanda Ferreira
- Cardiovascular Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Danielle Pereira
- Cardiovascular Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | | | | | | | | | - Mariana Blacher
- Cardiovascular Division, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Rohde LE, Hoffmann Filho CR, Rover MM, Rabelo-Silva ER, Lopez L, Passos LCS, Silvestre OM, Martins SM, de Figueiredo Neto JA, Silveira FS, Canesin MF, Simões MV, Akio Nishijuka F, Bertoldi EG, Danzmann LC, Mourilhe-Rocha R, Magedanz EH, Esteves M, de Castilho FM, Fernandes-Silva MM, Ritt LEF, Blacher M, Soares RM, Cavalcanti AB, Ramirez F. Design of a multifaceted strategy based on automated text messaging in patients with recent heart failure admission. ESC Heart Fail 2021; 8:5523-5530. [PMID: 34535979 PMCID: PMC8712788 DOI: 10.1002/ehf2.13516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/30/2021] [Accepted: 07/05/2021] [Indexed: 11/20/2022] Open
Abstract
Aims To evaluate a telemonitoring strategy based on automated text messaging and telephone support after heart failure (HF) hospitalization. Methods and results The MESSAGE‐HF study is a prospective multicentre, randomized, nationwide trial enrolling patients from 30 clinics in all regions of Brazil. HF patients with reduced left ventricular ejection fraction (<40%) and access to mobile phones are eligible after an acute decompensated HF hospitalization. Patients meeting eligibility criteria undergo an initial feasibility text messaging assessment and are randomized to usual care or telemonitoring intervention. All patients receive a HF booklet with basic information and recommendations about self‐care. Patients in the intervention group receive four daily short text messages (educational and feedback) during the first 30 days of the protocol to optimize self‐care; the feedback text messages from patients could trigger diuretic adjustments or a telephone call from the healthcare team. After 30 days, the frequency of text messages can be adjusted. Patients are followed up after 30, 90, and 180 days, with final status ascertained at 365 days by telephone. Our primary endpoint is the change in N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) levels after 180 days. Secondary endpoints include changes in NT‐proBNP after 30 days; health‐related quality of life, HF self‐care, and knowledge scales after 30 and 180 days; and a composite outcome of HF hospitalization and cardiovascular death, adjudicated by a blinded and independent committee. Conclusions The MESSAGE‐HF trial is evaluating an educational and self‐care promotion strategy involving a simple, intensive, and tailored telemonitoring system. If proven effective, it could be applied to a broader population worldwide.
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Affiliation(s)
- Luis E Rohde
- Serviço de Cardiologia, Hospital Moinhos de Vento, R. Ramiro Barcelos, 910 - Moinhos de Vento, Porto Alegre, 90035-000, Brazil.,Heart Failure Clinic, Hospital de Clinicas de Porto Alegre and Nursing School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Marciane M Rover
- Instituto de Cardiologia/ Fundação Universitária de Cardiologia- Porto Alegre/RS., Porto Alegre, Brazil
| | - Eneida Rejane Rabelo-Silva
- Heart Failure Clinic, Hospital de Clinicas de Porto Alegre and Nursing School, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | - Silvia M Martins
- Pronto-Socorro Cardiológico Universitário de Pernambuco - Prof. Luiz Tavares, Recife, Brazil
| | | | | | - Manoel F Canesin
- Hospital Universitário da Universidade Estadual de Londrina, Londrina, Brazil
| | - Marcus V Simões
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | - Luiz C Danzmann
- Hospital Universitário de Canoas da Universidade Luterana do Brasil, Canoas, Brazil
| | - Ricardo Mourilhe-Rocha
- Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Fábio M de Castilho
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Luiz E F Ritt
- Instituto D'or de Pesquisa e Ensino (IDOR) and Hospital Cárdio Pulmonar, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Mariana Blacher
- Serviço de Cardiologia, Hospital Moinhos de Vento, R. Ramiro Barcelos, 910 - Moinhos de Vento, Porto Alegre, 90035-000, Brazil
| | - Rafael M Soares
- HCor Research Institute, R. Des. Eliseu Guilherme, 147 - Paraíso, São Paulo, 04004-030, Brazil
| | - Alexandre B Cavalcanti
- HCor Research Institute, R. Des. Eliseu Guilherme, 147 - Paraíso, São Paulo, 04004-030, Brazil
| | - Felix Ramirez
- HCor Research Institute, R. Des. Eliseu Guilherme, 147 - Paraíso, São Paulo, 04004-030, Brazil
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de Castilho FM, Ribeiro ALP, Nobre V, Barros G, de Sousa MR. Heart rate variability as predictor of mortality in sepsis: A systematic review. PLoS One 2018; 13:e0203487. [PMID: 30204803 PMCID: PMC6133362 DOI: 10.1371/journal.pone.0203487] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/21/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Autonomic dysregulation is one of the recognized pathophysiological mechanisms in sepsis, generating the hypothesis that heart rate variability (HRV) can be used to predict mortality in sepsis. METHODS This was a systematic review of studies evaluating HRV as a predictor of death in patients with sepsis. The search was performed by independent researchers in PubMed, LILACS and Cochrane, including papers in English, Portuguese or Spanish, indexed until August 20th, 2017 with at least 10 patients. Study quality was assessed by Newcastle-Ottawa Scale. To analyze the results, we divided the articles between those who measured HRV for short-term recordings (≤ 1 hour), and those who did long-term recordings (≥ 24 hours). RESULTS Nine studies were included with a total of 536 patients. All of them were observational studies. Studies quality varied from 4 to 7 stars in Newcastle-Ottawa Scale. The mortality rate in the studies ranged from 8 to 61%. Seven studies performed HRV analysis in short-term recordings. With the exception of one study that did not explain which group had the lowest results, all other studies showed reduction of several HRV parameters in the non-survivors in relation to the surviving septic patients. SDNN (Standard deviation of the Normal to Normal interval), TP (Total Power), VLF (Very Low Frequency Power), LF (Low Frequency Power), LF/HF (Low Frequency Power / High Frequency Power), nLF (Normalized Low Frequency Power), α1/α2 (short-term and long-term fractal scaling coefficients from DFA) and r-MSSD (Square root of the squared mean of the difference of successive NN-intervals) of the non-survivor group were reduced in relation to the survivors in at least one study. Two studies found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors. Three studies performed HRV analysis using long-term recordings. Only one of these studies found difference between surviving and non-surviving groups, and even so, in only one HRV parameter: LogHF. CONCLUSIONS Several HRV parameters are reduced in nonsurviving septic patients in short-term recording. Two studies have found that SDNN is associated with mortality in sepsis, even after adjusting for possible confounding factors.
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Affiliation(s)
- Fábio M. de Castilho
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Antonio Luiz P. Ribeiro
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Vandack Nobre
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Núcleo Interdisciplinar de Investigação em Medicina Intensiva (NIIMI), UFMG, Belo Horizonte, Brazil
| | - Guilherme Barros
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Marcos R. de Sousa
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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de Castilho FM, Ribeiro ALP, da Silva JLP, Nobre V, de Sousa MR. Heart rate variability as predictor of mortality in sepsis: A prospective cohort study. PLoS One 2017; 12:e0180060. [PMID: 28654692 PMCID: PMC5487061 DOI: 10.1371/journal.pone.0180060] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/08/2017] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a serious medical condition with increasing prevalence and high mortality. The role of the autonomic nervous system in pathophysiology of sepsis has been increasingly researched. The objective of this study is to evaluate the Heart rate variability (HRV) as a predictor of mortality in septic patients. Methods This was a prospective cohort of patients diagnosed with sepsis. Patient recruitment was carried out at ICU in tertiary university hospital between March 2012 and February 2014. Clinical data and laboratory exams were collected at admission. Each patient underwent a 20-minute Holter and a 24-hour Holter on the first day of enrollment. The primary outcome was the 28-day all-cause mortality. Results A total of 63 patients were included. Patients were categorized into nonsurvivor group (n = 16) or survivor group (n = 47) depending on this endpoint. Survivors were younger (48.6 years vs. 63.0 years), had better renal function and lower values in severity scores (APACHE II and SOFA) compared to nonsurvivors. In the 20-minute Holter, SDNN, Total Power, VLF Power, LF Power and LF/HF of nonsurvivors were significantly lower than those of survivors (p = <0.001, p = 0.003, p = 0.002, p = 0.006, p = 0.009 respectively). ROC curve of SDNN was built, showing area under the curve of 0.772 (0.638–0.906) for mortality. The value of 17ms was chosen as best SDNN cutoff to discriminate survivors and nonsurvivors. In the Cox proportional regression, adjusted for SOFA score and for APACHE II, a SDNN ≤ 17ms was associated with a greater risk of death, with hazard ratios of 6.3 (1.4–28.0; p = 0.015) and 5.5 (1,2–24,8; p = 0.027), respectively. The addition of the dichotomized SDNN to the SOFA model reduced AIC and increased the concordance statistic and the R2, indicating that predictive power of the SDNN + SOFA model is better than predictive power of SOFA only. Conclusions Several HRV parameters are reduced in nonsurviving septic patients. SDNN ≤17 is a risk factor for death in septic patients, even after adjusting for severity scores.
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Affiliation(s)
- Fábio M. de Castilho
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- * E-mail:
| | - Antonio Luiz P. Ribeiro
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - José Luiz P. da Silva
- Department of Statistics, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Vandack Nobre
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
- Núcleo Interdisciplinar de Investigação em Medicina Intensiva (NIIMI), UFMG, Belo Horizonte, Brazil
| | - Marcos R. de Sousa
- Hospital das Clínicas and School of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
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