Diretriz da Sociedade Brasileira de Cardiologia sobre Diagnóstico e Tratamento de Pacientes com Cardiomiopatia da Doença de Chagas

This guideline aimed to update the concepts and formulate the standards of conduct and scientific evidence that support them, regarding the diagnosis and treatment of the Cardiomyopathy of Chagas disease, with special emphasis on the rationality base that supported it.  Chagas disease in the 21st century maintains an epidemiological pattern of endemicity in 21 Latin American countries. Researchers and managers from endemic and non-endemic countries point to the need to adopt comprehensive public health policies to effectively control the interhuman transmission of T. cruzi infection, and to obtain an optimized level of care for already infected individuals, focusing on diagnostic and therapeutic opportunistic opportunities.   Pathogenic and pathophysiological mechanisms of the Cardiomyopathy of Chagas disease were revisited after in-depth updating and the notion that necrosis and fibrosis are stimulated by tissue parasitic persistence and adverse immune reaction, as fundamental mechanisms, assisted by autonomic and microvascular disorders, was well established. Some of them have recently formed potential targets of therapies.  The natural history of the acute and chronic phases was reviewed, with enhancement for oral transmission, indeterminate form and chronic syndromes. Recent meta-analyses of observational studies have estimated the risk of evolution from acute and indeterminate forms and mortality after chronic cardiomyopathy. Therapeutic approaches applicable to individuals with Indeterminate form of Chagas disease were specifically addressed. All methods to detect structural and/or functional alterations with various cardiac imaging techniques were also reviewed, with recommendations for use in various clinical scenarios. Mortality risk stratification based on the Rassi score, with recent studies of its application, was complemented by methods that detect myocardial fibrosis.  The current methodology for etiological diagnosis and the consequent implications of trypanonomic treatment deserved a comprehensive and in-depth approach. Also the treatment of patients at risk or with heart failure, arrhythmias and thromboembolic events, based on pharmacological and complementary resources, received special attention. Additional chapters supported the conducts applicable to several special contexts, including t. cruzi/HIV co-infection, risk during surgeries, in pregnant women, in the reactivation of infection after heart transplantation, and others.     Finally, two chapters of great social significance, addressing the structuring of specialized services to care for individuals with the Cardiomyopathy of Chagas disease, and reviewing the concepts of severe heart disease and its medical-labor implications completed this guideline.Esta diretriz teve como objetivo principal atualizar os conceitos e formular as normas de conduta e evidências científicas que as suportam, quanto ao diagnóstico e tratamento da CDC, com especial ênfase na base de racionalidade que a embasou. A DC no século XXI mantém padrão epidemiológico de endemicidade em 21 países da América Latina. Investigadores e gestores de países endêmicos e não endêmicos indigitam a necessidade de se adotarem políticas abrangentes, de saúde pública, para controle eficaz da transmissão inter-humanos da infecção pelo T. cruzi, e obter-se nível otimizado de atendimento aos indivíduos já infectados, com foco em oportunização diagnóstica e terapêutica. Mecanismos patogênicos e fisiopatológicos da CDC foram revisitados após atualização aprofundada e ficou bem consolidada a noção de que necrose e fibrose sejam estimuladas pela persistência parasitária tissular e reação imune adversa, como mecanismos fundamentais, coadjuvados por distúrbios autonômicos e microvasculares. Alguns deles recentemente constituíram alvos potenciais de terapêuticas. A história natural das fases aguda e crônica foi revista, com realce para a transmissão oral, a forma indeterminada e as síndromes crônicas. Metanálises recentes de estudos observacionais estimaram o risco de evolução a partir das formas aguda e indeterminada e de mortalidade após instalação da cardiomiopatia crônica. Condutas terapêuticas aplicáveis aos indivíduos com a FIDC foram abordadas especificamente. Todos os métodos para detectar alterações estruturais e/ou funcionais com variadas técnicas de imageamento cardíaco também foram revisados, com recomendações de uso nos vários cenários clínicos. Estratificação de risco de mortalidade fundamentada no escore de Rassi, com estudos recentes de sua aplicação, foi complementada por métodos que detectam fibrose miocárdica. A metodologia atual para diagnóstico etiológico e as consequentes implicações do tratamento tripanossomicida mereceram enfoque abrangente e aprofundado. Também o tratamento de pacientes em risco ou com insuficiência cardíaca, arritmias e eventos tromboembólicos, baseado em recursos farmacológicos e complementares, recebeu especial atenção. Capítulos suplementares subsidiaram as condutas aplicáveis a diversos contextos especiais, entre eles o da co-infecção por T. cruzi/HIV, risco durante cirurgias, em grávidas, na reativação da infecção após transplante cardíacos, e outros.    Por fim, dois capítulos de grande significado social, abordando a estruturação de serviços especializados para atendimento aos indivíduos com a CDC, e revisando os conceitos de cardiopatia grave e suas implicações médico-trabalhistas completaram esta diretriz.&nbsp

Expansion Pulmonary Therapy in Blood Oxygenation and Lactate Serum Level in Postoperative Cardiac Surgery

<div><p>Abstract Background: Cardiovascular and pulmonary complications often occur in the immediate post- surgery period and may be prevented and/or treated with lung expansion techniques. Objective: To evaluate the efficacy of lung expansion techniques in serum arterial lactate levels and oxygenation in patients in this surgical recovery phase. Method: A prospective and analytical study was carried out in postoperative cardiac surgery patients, hemodynamically stable. Measurements of artery lactate levels and partial pressure of oxygen were obtained from arterial blood samples drawn before and after lung expansion techniques, including alveolar recruiting maneuver and intermittent positive pressure breathing. Results: 40 patients with average age of 51.1 ± 14.9 years, 55% female, were included. It is possible to observe the statistically significant difference (p < 0.05) in the comparison between values of baseline and post-operative arterial lactate, oxygen level, oxygen saturation/fraction of inspired oxygen in both procedures. In relation to the outcome of oxygen blood pressure, only the group on intermittent positive pressure breathing achieved significant improvement. Conclusion: The lung expansion techniques used have contributed with the reduction of lactate level, improvement in oxygenation and oxygen saturation in this population, but did not alter intensive care unit length of stay.</p></div

Influência do gênero no valor prognóstico da troponina I após angioplastia coronariana eletiva Influence of gender on the prognostic value of troponin I after elective percutaneous coronary interventions

OBJETIVO: Avaliar a associação entre níveis de troponina I (TnI) em pacientes submetidos, eletivamente, a intervenções coronárias percutâneas (ICP) com ocorrência de eventos cardíacos adversos (ECA) no seguimento de 6 meses. MÉTODOS: No período de um ano, foram selecionados consecutivamente 111 pacientes submetidos a ICP eletiva, com angina estável (AE), instável (AI) ou isquemia silenciosa (IS), assintomáticos por mais de 72 horas antes do procedimento. As dosagens de TnI foram realizadas entre 8 e 24 horas após a ICP. Cada paciente foi contatado por telefone, após seis meses, e questionado quanto à ocorrência de ECA, definidos como morte, infarto do miocárdio, nova revascularização e recorrência de isquemia. RESULTADOS: Ocorreu elevação de TnI em 24 (21,6%) pacientes após a ICP, independente de características clínicas e complicações do procedimento. O surgimento de eventos foi mais freqüente em quem apresentou elevação de TnI: 66,7 vs. 42,5% (RR=1,57; IC95%=1,08-2,28). Este risco parece ser maior nos subgrupos de gênero feminino e naqueles com diagnóstico prévio de AI. Após análise multivariada, apenas gênero se confirmou como co-variável modificadora de efeito com risco de ECA maior em mulheres com elevação de TnI (OR=7,22. IC95%=1,4 -36,9) e similar em homens (OR=1,26. IC95%=0,35-4,55). CONCLUSÃO: Elevação de TnI foi freqüentemente encontrada após ICP e é um fator associado ao surgimento de ECA a médio prazo. Entretanto, quando ajustada para outras variáveis, este efeito só se manteve em pacientes do gênero feminino.<br>OBJECTIVE: To evaluate the association between troponin I concentrations (TnI) in patients submitted to elective percutaneous coronary interventions (PCI) and adverse coronary events (ACE) during a six month follow-up period. METHODS: One hundred and eleven patients who had been submitted to an elective PCI were consecutively selected during a one year timeframe. The patients had stable angina (SA), unstable angina (UA) or silent ischemia (SI) and were asymptomatic for at least 72 hours before the procedure. TnI concentrations were measured between 8 and 24 hours after the PCI. Each patient was contacted by telephone six months later and interviewed regarding ACE which were defined as death, myocardial infarction, new revascularization and recurrent ischemia. RESULTS: Twenty-four patients showed elevated concentrations of TnI (21.6%) after the PCI regardless of clinical characteristics or procedure complications. Those who presented elevated TnI concentrations had higher event rates: 66.7 vs. 42.5% (RR=1.57; CI 95%=1.08-2.28). This risk seems to be higher in the subgroups of females and patients with a previous diagnosis of unstable angina. Multivariate analysis confirmed that gender was the only effect modifying co-variable associated with ACE risk, which is higher for females with elevated TnI concentrations (OR=7.22; CI 95%=1.4 -36.9) and unaltered for males (OR=1.26; CI 95%=0.35-4.55). CONCLUSION: Elevated TnI concentrations were a common occurrence after PCI and is a factor related to the development of ACE in the mid term. However, when adjusted for other variables, this effect is only maintained in female patients

Cardiovascular risk in carotid disease: assessment of doppler sonography and biomarker results Risco cardiovascular e doença carotídea: avaliação de resultados de doppler e biomarcadores

INTRODUCTION: Atherosclerosis and correlated cardiovascular problems, whose mechanical and physiological disorders cause thickening and hardening of blood vessels, are among the main causes of death worldwide. OBJECTIVE: To assess plasma concentrations of biomarkers from the lipid metabolism and carotid doppler sonography results by correlating them with atherogenic carotid disease. METHODS: the study comprised 66 patients aged 57.5 ± 15.5 years (20-77), from which 63% were female. Serum markers and doppler sonography images were used to evaluate the association with atherogenic carotid disease (ACD). RESULTS: There was a higher prevalence of ACD among females (33% vs. 15%), age range 56-65, showing a relative risk (RR) of 1.56 among females (p 40 mg/dl and 19% had HDL-C &#8805; 40 mg/dl. The prevalence of HDL-C > 40 mg/dl at levels II, III and IV was considerable. There was no difference in HDL-C among the groups (p = 0.4910; unpaired t test). Furthermore, there was no difference in paraoxonase (PON1) activity when stratified to HDL-C > and 0.05). CONCLUSION: The female group displayed higher ACD prevalence at 56-65 age range, with RR of 1.56 times higher. These findings substantiate the importance of analyzing this group and age range carefully, inasmuch as the absence of hormonal protection may increase ACD risk and ultimately influence HDL antioxidant activity due to its direct action on PON1. Triglycerides (TG)/HDL-C ratio indicates cardiovascular risk and impaired reverse cholesterol transport.INTRODUÇÃO: Complicações da aterosclerose agregam as principais causas de morte no mundo por problemas cardiovasculares relativos a distúrbio da condição mecânica e fisiológica que promove espessamento e endurecimento nas artérias. OBJETIVO: Avaliar as concentrações plasmáticas de biomarcadores do metabolismo lipídico e os resultados de doppler de carótidas, relacionando-os com a doença aterogênica de carótidas. MÉTODOS: Foram acompanhados 66 pacientes, com a média de idade entre 57,5 ± 15,5 anos, (20 a 77), sendo 63% mulheres. Utilizaram-se biomarcadores séricos e imagens (doppler) para avaliar a associação com a doença aterogênica carotídea (DCA). RESULTADOS E DISCUSSÃO: A DCA foi mais prevalente no gênero feminino (33% vs. 15%) entre as idades de 56-65 anos, risco relativo (RR) 1,56 nas mulheres (p 40 mg/dl em comparação com 19% que tinham concentração de HDL-C &#8805; 40 mg/dl. A prevalência de HDL-C > 40 mg/dl nos graus II, III e IV foi significativa. Não houve diferença de HDL-C entre os grupos (p = 0,4910, teste t não pareado). Não foi observada diferença entre as atividades de paraoxonase (PON1) quando estratificada para HDL-C > e 0,05). CONCLUSÃO: O gênero feminino teve maior prevalência de DCA entre 56-65 anos, RR 1,56 vezes maior. Esse achado revela a importância de atenção nesse gênero e nessa faixa etária, uma vez que a ausência de proteção hormonal agrava o risco de DCA, podendo influenciar na atividade antioxidante da HDL por atuar diretamente na PON1. A razão triglirecídeos (TG)/HDL-C aponta para risco cardiovascular e deficiências no transporte reverso do colesterol

Evaluation of variables responsible for hospital mortality in patients with rheumatic heart disease undergoing double valve replacement

Objective: To describe the hospital mortality and associated clinical and echocardiographic variables in patients with rheumatic disease who underwent double valve replacement surgery. Methods: This is a cross sectional descriptive study of mortality, performed in a referral hospital in Salvador, Bahia. Records from patients with rheumatic disease who underwent double valve replacement surgery during the years 2007-2011 were analyzed. Results: The studied sample comprises 104 patients and 60 (57.7%) were male. The mean age was 38.04±14.45. Sixty five bioprostheses and 38 mechanical prostheses were used in these patients at the time of surgery. There were statistically significant differences between the two groups, when we analyzed the following variables: the mean age (36.30±13.03 vs. 45.35±17.8 years-old, P=0.011), mean hemoglobin (11.10±2.19 vs. 9.22±2.26 g/dL, P=0.002), mean hematocrit (34.22±5.86 vs. 28.44±6.62%, P<0.001). New York Heart Association functional class III and IV (NYHA) (P=0.022) was statistically associated with mortality. Conclusion: We concluded that the mean hemoglobin/hematocrit level and the NYHA functional class was the major variables associated to the mortality among these patients. Based on these data one may concern about the patient best moment for surgery and the patient hemoglobin level

Effects of neuromuscular electrostimulation in patients with heart failure admitted to ward

Abstract Background Neuromuscular electrostimulation has become a promising issue in cardiovascular rehabilitation. However there are few articles published in the literature regarding neuromuscular electrostimulation in patients with heart failure during hospital stay. Methods This is a randomized controlled pilot trial that aimed to investigate the effect of neuromuscular electrostimulation in the walked distance by the six-minute walking test in 30 patients admitted to ward for heart failure treatment in a tertiary cardiology hospital. Patients in the intervention group performed a conventional rehabilitation and neuromuscular electrostimulation. Patients underwent 60 minutes of electrostimulation (wave frequency was 20 Hz, pulse duration of 20 us) two times a day for consecutive days until hospital discharge. Results The walked distance in the six-minute walking test improved 75% in the electrostimulation group (from 379.7 ± 43.5 to 372.9 ± 46.9 meters to controls and from 372.9 ± 62.4 to 500 ± 68 meters to electrostimulation, p Conclusion The neuromuscular electrostimulation group showed greater improvement in the walked distance in the six-minute walking test in patients admitted to ward for compensation of heart failure.</p