Non-introduction or withdrawal of prognostic-modifying drugs in HF with reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction

HF-FER has pharmacological strategies that allow better outcomes for patients, but the introduction of prognostic-modifying drugs or maximum dose titration is conditioned by the patient's performance, adverse effects, comorbidities and therapeutic inertia from physicians.

Objective

To evaluate the profile of patients admitted with a diagnosis of HF-FER in the Internal Medicine (IM) ward in 2019.

Methods

Retrospective analysis of hospitalized patients with HF-FER, evaluating the use of prognostic-modifying drugs, and adverse effects of drugs identified throughout the disease.

Results

We evaluated 130 patients (203 episodes) in 2019 with a diagnosis of HF-FER. 65.3% of patients (n:85) were on ACE inhibitors or ARBs. In 15.2% (n:13) the drug was introduced in 2019 and in 32.9% (n:28) the maximum dose of the drug was prescribed. We identified 30 patients (23%) with class withdrawal: 5 cases due to hypotension; 4 cases for renal dysfunction, 1 case for terminal HF and 20 cases not specified. In 19 patients (22%) on ACE inhibitors/ARBs, sacubitril/valsartan was introduced. As for beta-blockers, 81.5% of patients (n:106) had a prescription and in 20.7% of cases (n:22) the drug was initiated in 2019. This class was suspended in 9.2% of patients (n:22), with 5 cases for bradycardia, 2 cases for terminal HF and in 15 cases for unspecified reasons. As for the most recent prognostic modifying drugs, 17.7% of patients were on sacubitril/valsartan (n:23) with 86.9% (n:20) of patients starting it in 2019. The same was suspended in 7 patients : 2 cases for hypotension, 1 for hyperkalemia, 1 for renal dysfunction, 1 for economic insufficiency and in 2 cases not described. 17 patients (13.1%) were under iSGLT2, in which 88.2% of cases were introduced in 2019, with no drug suspension.

In cases where drugs were suspended, they were not reintroduced.

Among elderly patients (>65 years), we identified 112 patients (179 episodes) with 51.7% (n:58) aged 85 years or older. 50% of patients in class III (n:56) and 40.2% in class IV (n:45) of the NYHA. 89.2% of the patients they remained oriented at the time of hospital discharge (n:100) or in the 2 days prior to the fatal event and 96% (n:108) of the patients maintained the ability to verbally express related symptoms. 66.9% of patients (n:75) were on ACE inhibitors or ARBs; 80.3% (n:90) under beta blocker; 30.3% (n:34) under aldosterone receptor inhibitor; 13.3% (n:15) under iSGLT2; 17.8% (n:20) under sacubitril-valsartan.

Conclusion

The impact of prognostic-modifying drugs on HF-FER should lead physicians to reflect on reasons for their suspension or non-introduction, emphasizing the importance of keeping in clinical records the limitations for their use. Withdrawal of drugs should prompt management of the identified adverse effect so that it can be reintroduced as soon as possible. Therapeutic inertia should be avoided, especially in individuals who may benefit from these drugs in the evolution of HF.

Health-related quality of life and disability in adults with juvenile idiopathic arthritis: comparison with adult-onset rheumatic diseases

Objective

To compare physical disability, mental health, fatigue and health-related quality of life (HRQoL) across juvenile idiopathic arthritis (JIA) categories in adulthood and between JIA and adult-onset rheumatic diseases.

Methods

Cross-sectional analysis nested in a cohort of adult patients with JIA registered in the Rheumatic Diseases Portuguese Register (Reuma.pt). Physical disability (Health Assessment Questionnaire—Disability Index), mental health symptoms (Hospital Anxiety and Depression Scale), fatigue (Functional Assessment of Chronic Illness Therapy—Fatigue Scale (FACIT-F)) and HRQoL (EuroQol-5D (EQ5D) and Short Form (SF-36)) were compared across JIA categories. Patients with polyarticular JIA and enthesis-related arthritis (ERA) JIA were compared respectively to patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA), matched for gender and age, adjusted for disease duration and activity.

Results

585 adult patients with JIA were included. Comparison across JIA categories showed that persistent oligoarthritis and patients with ERA reported a higher score in EQ5D and SF-36 physical component when compared with other JIA categories.

Polyarticular JIA reported less disability and fatigue than patients with RA (median Health Assessment Questionnaire of 0.25 vs 0.63; p<0.001 and median FACIT-F score 42 vs 40; p=0.041). Polyarticular JIA had also better scores on EQ5D and all domains of SF-36, than patients with RA. Patients with ERA reported less depression and anxiety symptoms (0% vs 14.8%; p=0.003% and 9% vs 21.3%; p=0.002) and less fatigue symptoms (45 vs 41; p=0.01) than patients with SpA.

Conclusion

Persistent oligoarticular JIA and ERA are the JIA categories in adulthood with better HRQoL. Overall, adult polyarticular and patients with ERA JIA have lower functional impairment and better quality-of-life than patients with RA and SpA.

HIV-associated oral plasmablastic lymphoma and role of adherence to highly active antiretroviral therapy

Plasmablastic lymphoma (PBL) is an HIV-associated non-Hodgkin's lymphoma that primarily affects the oral cavity. We describe the case of an HIV patient with a lesion in the maxilla that lasted four months. He was diagnosed with PBL and received highly active antiretroviral therapy as well as chemotherapy and local radiotherapy. The lesion regressed after the third cycle of chemotherapy. The patient interrupted antiretroviral treatment and the lesion recurred. The immune reconstitution secondary to the use of antiretroviral therapy seems to participate in the regression of PBL and maintains the remission of the tumour, but it might not be enough to prevent the development of PBL.

The impact of the weight status on subjective symptomatology of the Polycystic Ovary Syndrome: a cross-cultural comparison between Brazilian and Austrian women

Group differences in symptomatology and symptom perception of young women ageing between 18 and 32 years suffering from polycystic ovarian syndrome (PCOS) were tested according to cultural background and weight status. In detail 31 Austrian women, living in Carinthia, Austria, and 102 Brazilian women, living in São Paulo, Brazil, were enrolled in the present study. All participants suffered from diagnosed PCOS. The prevalence of hirsutism, infertility, menstrual disturbances and overweight/obesity and their individual impact on health related quality of life were analysed. Furthermore the impact of weight status (BMI) on symptom perception was tested. It turned out, that the Brazilian sample exhibited higher prevalence of PCOS symptoms and these symptoms had a more negative impact on quality of life. The only exception was body weight. Although significantly leaner, the Austrian women showed a higher Cronin score of body weight than their Brazilian counterparts. The results of the present study may indicate that in western industrialized societies the fear of overweight is much more prevalent than in a developing country such as Brazil and thus it has more influence on the quality of life than all the other symptoms.

Survival of tubercle bacilli in heat-fixed and stained sputum smears

We used a slide culture technique to detect tubercle bacilli surviving in sputum smears (n=46) after conventional heat fixation and Ziehl-Neelsen staining. In all heat-fixed sputum smears, tubercle bacilli survived after time 0 (n=22), 24 h (n=7), 48 h (n=7), 72 h (n=4), and seven days (n=6). None of the stained sputum smears showed growth on slide cultures. Viable tubercle bacilli remaining in heat-fixed sputum smears for at least seven days may present an infection risk to laboratory staff. Thus, sputum smears should be stained immediately by the Ziehl-Neelsen method or stored in a safe container to avoid transmission of tuberculosis.

[Implantation of mechanical prosthetic valves in the pediatric age group. Review of the last ten years]

Our aim is to evaluate the outcome of 13 patients, under the age of 18, who underwent 15 valve replacements with mechanical prostheses, from January 1985 through December 1995, in our Hospital. The mean age was 11.7 +/- 5.0 years (from eight months to 18 years); six patients were male. The follow-up was five months to 9.5 years. All of them were initially in NYHA classes III or IV, under medical therapy. Indication for valve replacement was rheumatic valve disease in five and congenital in eight. The mitral valve was replaced in eight patients, the aortic in three and both valves in two patients. Two patients (15%) died in the early post operative period. After the procedure there was a remarkable hemodynamic improvement of the remaining patients; the echocardiographic evaluation showed good left ventricular function in all patients and a reduction in systolic pressure of the pulmonary artery and dimensions of the right chambers of the heart. Two patients had perivalvular leaks. Nine patients were NYHA functional class I, one in class II and one in class III. All patients received warfarin anticoagulation and antibiotic prophylaxis for infective endocarditis. There was no incidence of anticoagulant related haemorrhage or thromboembolic or infectious events. One patient (7.6%) underwent valve replacement as the first procedure; the others underwent valvuloplasty before replacement of the valve. Although valve replacement in this population should only take place when conventional forms of therapy fail, in our group we observed low mortality and morbidity rates.

[The percutaneous closure of the ductus arteriosus in adults]

From May 1990 to June 1998, 116 patients were submitted to percutaneous closure of patent ductus arteriosus. There were 18 adult patients, aged 18 to 61 years. Two patients had residual ductus after an attempted surgical ligation and two other patients had a calcified ductus. A device was not implanted in three patients, two of whom because of pulmonary hypertension being considered irreversible. Another patient, with a very large duct, underwent attempted occlusion, but the device embolized to the pulmonary artery and was retrieved percutaneously in the same session. This patient was operated later. Complete duct occlusion, confirmed by color Doppler echocardiography, was achieved in 14 of the remaining 15 patients (93%; 95% CL: 81-100). This was performed with a single catheterization in 12 cases, with implantation of one or more detachable coils in 8 patients; with a Rashkind device in 3, and a combination of a Rashkind device and coils in 1. In two cases complete duct occlusion required a second catheterization for implantation of additional detachable coils, including one patient with intravascular hemolysis in whom resolution of this problem was achieved with additional coils. In recent years, we have preferentially used detachable coils implanted through 5 Fr catheters, with a controlled release mechanism. This is a safer and less expensive device. Patients with pulmonary hypertension can be submitted to a trial occlusion of the duct with a balloon catheter to evaluate the response of pulmonary artery pressures. Percutaneous closure of the patent ductus arteriosus can be performed with excellent results in adults. Complete occlusion was achieved in 14 of the 15 patients (93%) without pulmonary hypertension or extremely large ductus. This is similar to our results in the pediatric population.

Papillary fibroelastoma of the mitral valve in a 3-year-old child: case report

A 3.5-year-old boy with stroke secondary to embolization of a primary cardiac tumor is presented. The diagnosis was made by two-dimensional echocardiography and confirmed intraoperatively. A papillary fibroelastoma was identified histologically. It is a rare condition and a diagnostic challenge, as patients are asymptomatic before embolization. In view of the severe consequences, prompt surgery is recommended.

[Holter electrocardiography en pediatric cardiology: preliminary experience]

PURPOSE

Evaluation of the diagnostic value of continuous electrocardiographic recording (Holter monitoring) in Paediatric Cardiology.

STUDY DESIGN

Retrospective study based on the data records of the Arrhythmia Department regarding patients with less than 20 years of age with Holter monitoring performed between January 1983 and February 1995 (374 recordings).

PATIENTS

277 patients were studied, 163 were male and 114 female with a mean age of 12 +/- 5 years. Heart organic anomalies were present in 155 patients and 92 patients had previous cardiac surgery with cardiopulmonary bypass. Clinical indications for Holter recording were the evaluation of symptoms related to arrhythmias (38%), documented dysrhythmia (23%), arrhythmia detected on physical examination (18%) and evaluation of risk in patients without symptoms of arrhythmia (17%).

METHODS

Holter recordings were performed during 24 hours with two channels (modified V1 and V5).

RESULTS

Significant rhythm and conduction disturbances were found in 122 patients. These were ventricular premature complexes > or = 10/hour (27 patients), AV block (25 patients) and supraventricular premature complexes > or = 10/hour (22 patients). Holter recording revealed significant dysrhythmias in 52% of patients with previously documented dysrhythmia, in 43% of patients referred for assessment of risk without symptoms of arrhythmia, provided insight in 48% of requests due to arrhythmia detected on physical examination and 24% of requests for symptoms related to arrhythmias. In 13 patients the results of Holter recording led to therapeutic or diagnostic measures.

CONCLUSIONS

Holter recording showed an overall sensitivity of 44% in the detection of significant arrhythmias and led to therapeutic and additional diagnostic measures in 11% of these patients. Holter recording seems to provide important information in the evaluation of arrhythmias in the paediatric age group.

[How to make a surgical curriculum]

Discussion on curriculum vitae is a highly valorized parameter in the final exam to obtain the degree of medical specialist in Portugal. However, the lack of guidelines for making up a curriculum causes difficulties for everyone involved: residents, juries and institutions which govern the equity of the process. This paper presents guidelines for a curriculum which can be applied to any surgical speciality. The proposal is based on the regulations which govern post-graduate medical training. A broad debate on this issue is also suggested in this article.

[Percutaneous closure of patent ductus arteriosus with the Rashkind device]

PURPOSE

To assess the efficacy and safety of the percutaneous closure of the persistent ductus arteriosus with the Rashkind device.

DESIGN

Clinical, angiographic and echocardiographic assessment of the patency of the ductus arteriosus at the time of the implantation of the first or second Rashkind device, followed by clinical and echocardiographic control at one, three and six months and yearly thereafter.

PATIENTS

Thirty two patients with patent ductus arteriosus. Twenty seven were female and five male. Their ages ranged between 10 months and 33 years (6.8 +/- 7.7 years) and their weights between 7.3 and 52 (20.1 +/- 12.4) kg. Two patients were excluded due to a ductal diameter greater than 8 mm. Thirty patients had successful device implantation.

METHODS

Implantation at cardiac catheterization of the Rashkind double umbrella occluder device in the narrowest portion of the patent ductus arteriosus. Twenty one patients had one device implanted and five had the implantation of a second device four to 12 months later, due to persistent patency of the ductus.

RESULTS

Total closure was achieved in 26 out of 30 patients. In 21 patients the occlusion was obtained with a single device and in five patients with two devices. Among the remaining four patients, one is awaiting the implantation of a second device and the other three are under follow-up as their first devices were implanted recently. There were no complications.

CONCLUSIONS

Percutaneous closure of the ductus arteriosus with the Rashkind device represents an efficient and safe alternative to surgery in most patients.

[Permanent pacing in childhood: a review of 11 years of experience]

STUDY OBJECTIVE

To review our eleven year experience in the implantation and follow-up of permanent Pacemakers in the paediatric age group.

DESIGN

Retrospective study.

SETTING

Children submitted to permanent cardiac Pacing implantation and accompanied in the Pacing Center of the Hospital de Santa Maria.

PATIENTS

Children from both sexes, aged from neonate to 14 years old, with brady-dysrhythmia and indication for permanent cardiac Pacing implantation.

MATERIAL AND METHODS

From November 1980 to September 1991, 16 children had permanent Pacemaker implantation. We describe the clinical and electrocardiographic characteristics of the population, mode of Pacing used, technical data from the implantation and evolution.

RESULTS

One children died due to associated cardiac defect not related to the Pacemaker. The other 15 children remain in follow-up with normofunctioning Pacemakers and free of symptoms. We had to perform 11 reinterventions in 8 children due to generator or electrode problems (28,2 months reintervention interval).

CONCLUSIONS

Improvements in Pacemaker technology and a careful technique of implantation can significantly reduce the morbidity associated to permanent pacemaker implantation in this age group.

[Lymphangioma of the mediastinum as a cause of chylopericardium]

Chylopericardium is a rare from of pericardial effusion. A case of a ten-year-old female patient with a chylopericardium incidentally detected during a mild respiratory infection through cardiac enlargement at the chest X ray is reported. The techniques used to achieve this diagnosis are described, a special emphasis being put on the CT-scan and lymphangiography, which have not been used in such cases so far. These techniques provided very useful data which were determinant for the success of the proposed therapy. This and other cases reported in the paper indicate that the most common cause of primary chylopericardium is a mediastinal lymphangioma.

[Aortic valve stenosis without apparent "gradient". Demonstration and treatment in heart catheterization]

The case of a six years-old girl with Ductus Arterious, Pulmonary Hypertension, Aortic Stenosis and poor left ventricular function is presented. No aortic valvular gradient could be found on a simple aortic and left ventricular pressure measurement, but it could be recorded when transvalvular aortic flow was increased while the Ductus Arteriosus was occluded with a balloon. This manoeuver forced an increase in pulmonary blood flow by avoiding right-to-left ductal shunting, thus increasing the venous return to the left heart and across the aortic valve. The aortic valve stenosis was subsequently relieved by percutaneous balloon valvuloplasty performed in two separate instances. This was thought to be particularly indicated in this case, considering the high risks of open-heart surgery.

Pattern of energy storage in the liver and muscle of rats submitted to total parenteral nutrition

TPN was administered to young male rats for 10 days at a low (270 kcal/kg/day) and a high (250 kcal/kg/day) energy level, with an isonitrogenous supply (0.9 g N/kg/day). The non-protein calories were divided into three energy substrate ratios: 0% Fat 100% Glucose , 6% Fat 94% Glucose , and 60% Fat 40% Glucose . Glycogen, acylglycerols and enzyme activities of the heart and some skeletal muscles (tib. anterior, ext. dig. longus and soleus) were unaffected by the various intravenous regimens. The glycogen content of the liver was significantly higher in both low fat groups. There was also a clear tendency in all groups to lower values of glycogen as the energy level of the TPN increased. The opposite trend was seen with acylglycerols, which were highest in the high glucose and high fat groups. The highest acylglycerol content was found in the high fat group at the high energy level. This study demonstrates that unbalanced intravenous regimens, without fat or with a fat overload (20 g/kg/day), seem to alter the storage pattern of glycogen and fat in the liver, particularly when hypercaloric regimens are given. The heart and skeletal muscles seemed to be protected from this effect.

Metabolic response of simultaneous versus sequential intravenous administration of amino acids and energy substrates to rats

Three groups of rats were maintained on total intravenous nutrition for ten days. Group SA and SB were infused sequentially (2 X 12 h periods per day), SA received amino acids (AA) during the night and carbohydrates (CHO) + FAT during the day. The SB group received nutrients in the opposite order. A control group received a mixed solution simultaneously for 24 h/day. The sequentially fed groups showed a lower weight gain (2.4 +/- 0.4, 2.6 +/- 0.2 vs 4.9 +/- 0.3 g/day), nitrogen balance (95 +/- 7, 95 +/- 6 vs 139 +/- 7 mg/day) and nitrogen utilization (69 +/- 3, 67 +/- 3 vs 87 +/- 3%) compared with the control group. Administration of energy substrate in the SA and SB was a stronger denominator for O2 consumption and changes in RQ than the periods of physical activity. Control animals did not show any diurnal variations in O2 and RQ. Glucose, FFA and insulin were higher with CHO + FAT administration compared to AA infusion or simultaneous AA/CHO/FAT administration. In conclusion, the results suggest that simultaneous administration of a mixture of AA/CHO/FAT is preferable for whole body nitrogen economy during TPN.

Total parenteral nutrition with different ratios of fat/carbohydrate at two energy levels: an animal study

Different regimens of total parenteral nutrition were evaluated in 64 growing rats, during a 10-day period. Thirty-two rats were kept at a low energy regimen (270 kcal/kg body weight per day), and the remaining rats were infused with a high energy solution (350 kcal/kg/day). At each energy level, four fat/carbohydrate (CHO) nonprotein energy ratios were tested: 0% fat/100% CHO (no fat); 6% fat/94% CHO (low fat); 30% fat/70% CHO (medium fat); 60% fat/40% CHO (high fat). A daily supply of 0.9 g nitrogen/kg of a well balanced amino acid solution was administered to all rats. Growth, nitrogen balance, net nitrogen utilization, and blood status were evaluated. Carcass, liver, and muscle composition were investigated with respect to protein, fat, and water content. Liver and body composition was similar between groups at the same energy level. At the higher energy level the fat deposition was increased. At the low energy level, rats from no fat and low fat groups lost weight during the first 3 days of the experimental period. The medium fat groups showed the highest weight gain at each energy level. This suggests the importance of the presence of fat in total parenteral nutrition programs. During the last days of the experimental period, all rats gained weight, and showed a positive nitrogen balance. All groups given 350 kcal/kg/day gained weight more rapidly and showed a better nitrogen balance and utilization than the corresponding group given 270 kcal/kg/day. This study emphasizes that a well-balanced proportion of energy and substrates is important.

Serum lipids and fatty acids composition of tissues in rats on total parenteral nutrition (TPN)

The modulating effect of energy and exogenous triglyceride supply on serum lipids and fatty acid composition of liver, tibialis anterior muscle, subcutaneous and peri-epididymal fat was assessed in rats using Total Parenteral Nutrition (TPN). Nutrients were infused continuously for 10 days through a central vein catheter. Four levels of fat were tested: No fat, Low fat (6% non-protein calories), Medium fat (30%) and High fat (60%), at 2 energy levels (270 kcal and 350 kcal/kg X day). An isonitrogenous supply was given to all groups as 0.9 g N/kg X day. At the highest level of fat intake (20.4 g/kg) at the high energy level triglycerides, cholesterol and phospholipids of serum were elevated. Biochemical signs of essential fatty acid (EFA) deficiency were observed as rising levels of eicosatrienoic acid and lowered concentrations of linoleic and arachidonic acid, mostly in the liver and the muscle in the No fat groups. EFA levels were reduced significantly in the No fat and Low fat groups and more pronounced at the high energy level. In conclusion, our study suggests that when energy intake is increased the EFA status becomes more critical. It seems evident that more EFA is required in absolute values when hypercaloric diets are given.

Successful management of cor triatriatum associated with anomalous pulmonary/systemic venous connection in an infant

Diagnosis and successful surgical repair of cor triatriatum, associated with anomalous pulmonary/systemic venous connection in a 6-month-old infant, is described. Follow-up at 2 years revealed no abnormalities. The clinical findings, hemodynamics, and surgical treatment are discussed, together with a review of the literature. This is a rare, life-threatening situation presenting significant diagnostic difficulties in infancy. It is, however, amenable to surgery provided that an early diagnosis is achieved.