Análise Crítica e Limitações do Diagnóstico de Insuficiência Cardíaca com Fração de Ejeção Preservada (ICFEp)

Com o aumento da expectativa de vida da população e a maior frequência de fatores de risco como obesidade, hipertensão arterial e diabetes, espera-se um aumento na prevalência de insuficiência cardíaca com fração de ejeção preservada (ICFEp). Entretanto, no momento, o diagnóstico e o tratamento de pacientes com ICFEp permanecem desafiadores. O diagnóstico sindrômico de ICFEp inclui diversas etiologias e doenças com tratamentos específicos, mas que apresentam pontos em comum em relação à apresentação clínica e à avaliação laboratorial no que diz respeito aos biomarcadores como BNP e NT-ProBNP, à avaliação ecocardiográfica do remodelamento cardíaco e às pressões de enchimento diastólico ventricular esquerdo. Extensos ensaios clínicos randomizados envolvendo a terapia nesta síndrome falharam na demonstração de benefícios para o paciente, fazendo-se necessária uma reflexão acerca do diagnóstico, dos mecanismos de morbidade, da taxa de mortalidade e da reversibilidade. Na revisão, serão abordados os conceitos atuais, as controvérsias e, especialmente, os desafios no diagnóstico da ICFEp através de uma análise crítica do escore da European Heart Failure Association.

Infection in Patients with Decompensated Heart Failure: In-Hospital Mortality and Outcome

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.

Reverse Cardiac Remodeling: A Marker of Better Prognosis in Heart Failure

In heart failure syndrome, myocardial dysfunction causes an increase in neurohormonal activity, which is an adaptive and compensatory mechanism in response to the reduction in cardiac output. Neurohormonal activity is initially stimulated in an attempt to maintain compensation; however, when it remains increased, it contributes to the intensification of clinical manifestations and myocardial damage. Cardiac remodeling comprises changes in ventricular volume as well as the thickness and shape of the myocardial wall. With optimized treatment, such remodeling can be reversed, causing gradual improvement in cardiac function and consequently improved prognosis.

Temporal variation in the prognosis and treatment of advanced heart failure - before and after 2000

Background

The treatment of heart failure has evolved in recent decades suggesting that survival is increasing.

Objective

To verify whether there has been improvement in the survival of patients with advanced heart failure.

Methods

We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis.

Results

The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7).

Conclusions

Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.

Predictors of low cardiac output in decompensated severe heart failure

OBJECTIVE

To identify predictors of low cardiac output and mortality in decompensated heart failure.

INTRODUCTION

Introduction: Patients with decompensated heart failure have a high mortality rate, especially those patients with low cardiac output. However, this clinical presentation is uncommon, and its management is controversial.

METHODS

We studied a cohort of 452 patients hospitalized with decompensated heart failure with an ejection fraction of <0.45. Patients underwent clinical-hemodynamic assessment and Chagas disease immunoenzymatic assay. Low cardiac output was defined according to L and C clinical-hemodynamic profiles. Multivariate analyses assessed clinical outcomes. P<0.05 was considered significant.

RESULTS

The mean age was 60.1 years; 245 (54.2%) patients were >60 years, and 64.6% were men. Low cardiac output was present in 281 (63%) patients on admission. Chagas disease was the cause of heart failure in 92 (20.4%) patients who had higher B type natriuretic peptide levels (1,978.38 vs. 1,697.64 pg/mL; P = 0.015). Predictors of low cardiac output were Chagas disease (RR: 3.655, P<0.001), lower ejection fraction (RR: 2.414, P<0.001), hyponatremia (RR: 1.618, P = 0.036), and renal dysfunction (RR: 1.916, P = 0.007). Elderly patients were inversely associated with low cardiac output (RR: 0.436, P = 0.001). Predictors of mortality were Chagas disease (RR: 2.286, P<0.001), ischemic etiology (RR: 1.449, P = 0.035), and low cardiac output (RR: 1.419, P = 0.047).

CONCLUSIONS

In severe decompensated heart failure, predictors of low cardiac output are Chagas disease, lower ejection fraction, hyponatremia, and renal dysfunction. Additionally, Chagas disease patients have higher B type natriuretic peptide levels and a worse prognosis independent of lower ejection fraction.

Constrictive pericarditis with extensive calcification

A patient with signs and symptoms of right heart failure of unknown etiology was referred to a referral hospital in the eastern area of the city of São Paulo with a diagnosis of calcified constrictive pericarditis and was treated by surgery. This pathology is characterized by an irreversible process of pericardium calcification, and surgery is the only alternative to control the symptoms and improve patients' quality of life. This case drew special attention due to the extensive calcification involving the interventricular septum. The unusual aspect of the images has made the diagnosis difficult and raised doubts about the existence of an associated disease.

[Is it necessary to suspend betablockers in decompensated heart failure with low output?]

BACKGROUND

there is evidence that the suspension of betablockers (BB) in decompensated heart failure may increase mortality. Dobutamine (dobuta) is the most commonly used inotrope in decompensation, however, BB and dobuta act with the same receptor with antagonist actions, and concurrent use of both drugs could hinder compensation.

OBJECTIVE

to evaluate whether the maintenance of BB associated with dobuta difficults cardiac compensation.

METHODS

we studied 44 patients with LVEF < 45% and the need for inotropics. Divided into three groups according to the use of BB. Group A (n=8): those who were not using BB at baseline; Group B (n=25): those who used BB, but was suspended to start dobuta; Group C (n = 11): those who used BB concomitant to dobuta. To compare groups, we used the Student t, Fisher exact and chi-square tests. Considered significant if p < 0.05.

RESULTS

mean LVEF 23.8 ± 6.6%. The average use of dobuta use was similar in all groups (p = 0.35), and concomitant use of dobutamine with BB did not increase the length of stay (BB 20.36 ± 11.04 days vs without BB 28.37 ± 12.76 days, p = NS). In the high dose, BB was higher in patients whose medication was not suspended (35.8 ± 16.8 mg/day vs 23.0 ± 16.7 mg/day, p = 0.004).

CONCLUSION

maintaining BB associated with dobutamine did not increase the length of hospitalization and was not associated with the worst outcome. Patients who did not suspend BB were discharged with higher doses of the drug.

Microneurography and venous occlusion plethysmography in heart failure: correlation with prognosis

BACKGROUND

Microneurography and venous occlusion plethysmography can be considered methods of assessment of the sympathetic activity.

OBJECTIVE

To evaluate the intensity of the sympathetic activity through microneurography and venous occlusion plethysmography in patients with heart failure (HF) and correlate this intensity with prognosis.

METHODS

52 patients with HF (ejection fraction < 45% at the echocardiogram): 12 with FCII and 40 with FCIV. After compensation, the muscular sympathetic nervous activity (MSNA) in the peroneal nerve (microneurography) and the muscular blood flow (MBF) in the forearm were evaluated (venous occlusion plethysmography). After an 18-month follow-up, the patients were divided in 3 groups: 12 with FCII, 19 with FCIV that did not die and 21 with FCIV that died. The intensity of the sympathetic activity was compared in the three different groups.

RESULTS

Patients with FCII presented lower MSNA (p=0.026) and higher MBF (p=0.045) than the ones with FCIV that did not die. The patients with FCIV that died presented higher MSNA (p<0.001) and lower MBF (p=0.002) than the patients with FCIV that did not die. ROC curve: cutoff >53.5 impulses/min for MSNA (S=90.55. E=73.68%) and < 1.81 ml/min/100gr for MBF (S=90.4%. E=73.7%). Kaplan-Meier curve: higher survival with MSNA < 53.5 impulses/min (p<0.001), and/or MBF >1.81 ml/min/100gr (P<0.001). Logistic regression analysis: the higher the MSNA and the lower the MBF, the higher is the probability of death.

CONCLUSION

The intensity of the MSNA and the MBF can be considered prognostic markers in advanced HF.

Hyperkalemia during spironolactone use in patients with decompensated heart failure

BACKGROUND

The incidence of hyperkalemia related to spironolactone use is low in stable heart failure; however, it has not been studied during decompensation.

OBJECTIVE

To evaluate the influence of spironolactone on serum potassium in decompensated heart failure (HF).

METHODS

In a cohort study, patients that had been hospitalized due to decompensated HF, with left ventricular ejection fraction (LVEF) < 0.45 and serum potassium between 3.5 and 5.5 mEq/l were selected. The patients were divided according to spironolactone use (Group S) or no use (Group C). The outcome was potassium increase (> 6.0 mEq/l) and the use of calcium polystyrene. A multivariate analysis through logistic regression was carried out and values of p < 0.05 were considered significant.

RESULTS

A total of 186 patients (group S: 56; group C: 130) were studied; LVEF of 0.25, aged 55.5 years and 65.2% of them males. The incidence of hyperkalemia was 10.7% in group S and 5.4% in group C (p = 0.862). The multivariate analysis showed that serum urea > 60.5 mg/dl during the hospitalization presents a relative risk of 9.6 (95%CI 8.03 - 11.20; p = 0.005) for the occurrence of hyperkalemia.

CONCLUSION

The incidence of hyperkalemia was two-fold higher with spironolactone use, but it was not statistically significant. The increase in urea levels was associated to the hyperkalemia. Randomized studies are necessary to clarify this issue.

[Eikenella corrodens infective endocarditis]

The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) account for 3% of the cases of endocarditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of upper respiratory tract and oropharynx. The following characteristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings; difficult diagnosis due to the fastidious nature of the microorganisms; and negative cultures. The Eikenella corrodens endocarditis was first described in 1972. That microorganism continues to be a rare etiological agent. We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.

Atmospheric BTX and polyaromatic hydrocarbons in Rio de Janeiro, Brazil

Polycyclic aromatic and monoaromatic (benzene, toluene and xylene, or BTX) hydrocarbons were monitored in Rio de Janeiro, Brazil, during the summer of 1998/1999. The levels of these aromatic chemicals decreased with distance from main roads, indicating mobile sources are the main pollutant emitters in this Latin American city. Benzo[ghi]perylene/indeno[1,2,3-cd]pyrene and benzene/toluene ratios corroborate this idea. However, higher benzene/toluene ratios at one of the major access routes into the city suggest pollutant inputs from a nearby refinery. Literature data were reviewed in order to outline differences and similarities among sources and levels of aromatic pollutants in large urban agglomerations worldwide. Concentrations of benzo[a]pyrene and benzene, which are well-known carcinogenic chemicals, were relatively low in Rio de Janeiro. This fact was attributed to specific atmospheric conditions during the tropical summer and differences in vehicle fuel composition.

Further lipophilic flavonols in Vellozia graminifolia (Velloziaceae) by high temperature gas chromatography: quick detection of new compounds

Further lipophilic flavonols present in Vellozia graminifolia have been determined by high temperature high resolution gas chromatography (HTHRGC) and by HTHRGC coupled to mass spectrometry (MS). These methods resulted in the detection, isolation and characterisation of a monoisoprenylated flavonol 3,5,4'-trimethoxy-3'-hydroxy-6,7-(2"-isopropenyldihydrofurano)flavone from the ethyl acetate extract of the whole plant. The structural elucidation was accomplished using spectral data, including two-dimensional NMR, and on chemical transformations. Both HTHRGC and HTHRGC-MS were shown to be alternative and extremely valuable methods for the quick screening of flavonoid aglycones and other chemical metabolites of the Velloziaceae.

Rapid screening of polar compounds in Brazilian propolis by high-temperature high-resolution gas chromatography-mass spectrometry

Methanol extracts of propolis from six different places, five in Rio de Janeiro state and one in São Paulo state, both in the Southeast of Brazil, were investigated using high-temperature high-resolution gas chromatography (HT-HRGC) and HT-HRGC-mass spectometry. The main purpose of the study was to establish the applicability of HT-HRGC as an analytical method for systematic studies of polar propolis fractions. Several compounds, including carbohydrates, phenolic acid derivatives, and high molecular weight compounds (e.g., wax esters of long chain fatty alcohols) could be readily characterized in the crude extracts by HT-HRGC-MS. HT-HRGC and HT-HRGC-MS were shown to be quick and informative tools for rapid analysis of crude polar extracts without cleanup.

Rapid screening of natural products by high-resolution high-temperature gas chromatography

The crude ethanol extracts from the leaves of three Croton hemiargyrus hemiargyreus plants are fractionated by thin-layer chromatography, yielding five fractions. The fractions and the crude extract are analyzed by high-temperature high-resolution gas chromatography coupled with mass spectrometry (HT-HRGC-MS). Several natural products, including thermolabile components, can be characterized directly in the samples, such as alkaloids, terpenes, flavonoids, acids, alcohols, etc. The cold on-column technique proves to be appropriate for the injection of these thermolabile compounds. HT-HRGC-MS is shown to be a valuable tool and an alternative technique to classical phytochemical procedures for the simple and fast routine analysis of natural products in crude extracts.

Atmospheric carcinogens in Rio de Janeiro during the summer of 1998/99: benzo[a]pyrene and benzene

Rio de Janeiro, the second largest city in Brazil, is affected by severe pollution episodes and presents a high respiratory cancer incidence in comparison with the rest of the country. To monitor atmospheric pollution during the summer of 1998/1999 and to estimate the impact of organic pollution on public health, we determined the levels of two carcinogenic organic chemicals, benzo[a]pyrene and benzene, in four distinct sites throughout the city. A review of the levels recorded in other urban areas worldwide during the last ten years indicates that the benzo[a]pyrene (< or = 0.70 ng/m3) and benzene (< or = 11 micrograms/m3) concentrations found in Rio are relatively low. The highest levels were generally recorded in developing Asian countries, whereas the lowest values were found in North America. Unlike urban areas in temperate zones, pollution derived from domestic heating is minor in Rio de Janeiro, where most of the benzo[a]pyrene and benzene pollution originates from vehicular traffic. The quite distinct fuels used in light-duty vehicles in Brazil, combined with strong light incidence and increased rainfall during the summer, also contribute to diminish the levels of such pollutants.

Sedimentary 4-desmethyl sterols and n-alkanols in an eutrophic urban estuary, Capibaribe River, Brazil

Sterols, n-alkanols, organic carbon (OC), C/N ratios and carbon isotope data (delta 13C) were investigated in sediments of the urban Capibaribe River estuary, NE Brazil, in order to assess allochthonous and autochthonous sources of organic matter (OM). Sedimentary OC values are high, but C/N ratios and delta 13C data generally fall within the range of values reported in other riverine systems, and suggest mixed inputs from aquatic and terrestrial matter. Mean values for total 4-desmethyl sterols and high molecular weight (HMW) n-alkanols are 11.0 micrograms/g and 2.8 micrograms/g, respectively. Sterols are found at highest levels in areas of enhanced urban outfalls. They can be related to major planktonic species growing in riverine waters. Stanol/stenol ratios suggest a high degree of alteration of the autochthonous OM as a result of elevated temperatures and microbiological proliferation. Even though sterols suggest the importance of autochthonous inputs to the river, HMW n-alkanols indicate major terrigenous accumulation at the mouth and 10 km upriver. Coprostanol and epicoprostanol levels are comparable to other sewage contaminated hydrosystems, but not as high as expected given the importance of sewage outfalls and low riverine water discharge. However, high (coprostanol)/(coprostanol + cholestanol) ratio values indicate that fecal contamination is significant.

Development and validation of a screening method for DES, zeranol, and beta-zearalanol in bovine urine by HRGC-MS and evaluation of robustness for routine survey of the Brazilian herd

A method and evaluated for screening and confirmation of diethylstilbestrol (DES), alpha- and beta-zearalanol in bovine urine was developed. The residues were extracted from urine by C18 cartridges and purified on alumina columns. For screening and confirmation purposes, the anabolic derivatives were analyzed by gas chromatography-mass spectrometry after derivatization with BSTFA + 1% TMCS or a solution of PFPA/acetone (1:2, v/v), respectively. The recovery of most analytes for the whole procedure was higher than 96%, with a detection limit of 0.5 ppb. This procedure is being routinely applied to the Brazilian National Program for the Control of Residues in Meat (PNCRBC).

Nutritional deficiencies in chronic alcoholics: relation to dietary intake and alcohol consumption

OBJECTIVES

Relationships of nutritional status with ethanol consumption and diet were studied in 33 chronic alcoholics with no clinical or laboratory evidence of liver disease.

METHODS

Nutritional assessment included subjective global assessment, weight-height index, body mass index, and serum albumin measurements. Dietary intake included estimates of daily intake of substrates, folic acid, vitamins B1, B5, B6, and B12. Circulating concentrations of folate, pyridoxal-phosphate and vitamin B12 were evaluated as well.

RESULTS

Only 18.1% of patients were considered malnourished, with body mass indices lower than those with an average or good nutritional status (p < 0.0001). Body weight was under 90% of the ideal in 8/33 (24%) patients. Serum albumin values were within normal range in all patients. In terms of calories provided by nonalcoholic substrates, protein, or vitamin intake, we observed no differences between well and poorly nourished individuals. However, malnourished alcoholics consumed significantly more ethanol (p = 0.01) and an inverse correlation was found between ethanol intake and weight-height index (r = -0.35; p = 0.03). Low circulating concentrations of pyridoxal-phosphate and red blood cell folate were found in 51.5% and 60.6% of alcoholics, respectively. These were not correlated with vitamin dietary intake or ethanol consumption, but there was a trend toward malnourished patients to present lower concentrations of red blood cell folate (p = 0.13).

CONCLUSIONS

Although over malnutrition is infrequent in this group of chronic alcoholics, specific vitamin deficiencies are present in a substantial proportion of patients and are more likely related to alcohol consumption.

Hyperhomocysteinemia in chronic alcoholism: correlation with folate, vitamin B-12, and vitamin B-6 status

Serum homocysteine concentrations have been shown to be a sensitive functional indicator of intracellular folate, vitamin B-12, and vitamin B-6 status. Chronic alcoholism is known to interfere with one-carbon metabolism, for which the above vitamins serve as coenzymes. In the present study, these vitamins were assessed in 32 chronic alcoholics and 31 healthy volunteers by measuring blood vitamin concentrations as well as serum homocysteine concentrations. In chronic alcoholics, serum pyridoxal 5'-phosphate and red blood cell folate concentrations were significantly lower than in the control subjects (P < 0.001 and P = 0.008, respectively). Mean serum homocysteine was twice as high in chronic alcoholics than in nondrinkers (P < 0.001). Beer consumers had significantly lower concentrations of homocysteine compared with drinkers of wine or spirits (P = 0.05). These results suggest that by interfering with folate or vitamin B-6 metabolism, chronic alcohol intake may impair the disposal of homocysteine through the transmethylation or transsulfuration pathways.