Impact of Gender in Predictive Value for Heart Transplantation Listing

BACKGROUND: Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. METHODS: Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. RESULTS: A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. CONCLUSION: Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.publishersversionpublishe

Still a Powerful Tool?

Background: New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). Methods: Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. Results: CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. Conclusion: ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.publishersversionpublishe

Insights from CardioMEMS™

Publisher Copyright: © 2024 Sociedade Portuguesa de CardiologiaIntroduction and objectives: Left ventricular global longitudinal strain (LVGLS) is an indicator of myocardial function in patients with heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Nevertheless, it is not clear whether LVGLS correlates with filling pressures and cardiac output (CO) in an ambulatory setting. We aimed to assess whether LVGLS is associated with invasive pulmonary artery pressures (PAP) and CO in outpatients using the invasive remote monitoring CardioMEMS™ system. Methods: This single-center, prospective observational study included patients with HFrEF undergoing remote monitoring using the CardioMEMS™ system, between January 2020 and December 2022. Repeated transthoracic echocardiography (TTE) studies were performed in each patient and invasive hemodynamic data were obtained during the TTE studies using the CardioMEMS™ system. Univariate and multivariate models were used to assess the potential association between LVGLS and invasive PAP and CO. Results: Twelve patients were included and 46 TTE studies were analyzed. LVGLS was correlated with diastolic (d) PAP (r=0.403, p=0.041) and CO (r=−0.426, p=0.039) in the univariate analysis. In multivariate models, LVGLS was an independent predictor of dPAP and CO, but not mean PAP or systolic PAP. The variation of LVGLS between TTE studies was correlated with the variation of dPAP during follow-up (r=0.60, p=0.017). Conclusions: In a cohort of HFrEF patients under invasive hemodynamic remote monitoring, LVGLS was independently associated with invasive filling pressures and CO, in an outpatient setting. These findings reinforce the value of LVGLS for the management of outpatients with HFrEF.proofepub_ahead_of_prin

Hipotiroidismo no idoso

Trabalho final de mestrado integrado em Medicina (Geriatria), apresentado á Faculdade de Medicina da Universidade de CoimbraIntrodução: As doenças da tiroide são muito prevalentes, ocorrendo mais frequentemente em mulheres idosas. Como os sintomas associados à disfunção tiroideia são semelhantes aos que ocorrem no envelhecimento, bons métodos de diagnóstico para o hipotiroidismo clínico e subclínico são cruciais em idosos. Enquanto a evidência científica é clara na indicação para tratamento no hipotiroidismo clínico, a indicação para tratamento no hipotiroidismo subclínico deve ser revista, especialmente na população geriátrica. Objetivo: O objetivo desta revisão científica é analisar se o hipotiroidismo tem sido abordado de acordo com a evidência científica atual para a população geriátrica. Como a maioria das dúvidas se prendem com o benefício em tratar o hipotiroidismo subclínico, foi efetuada uma extensa revisão de associações entre o hipotiroidismo subclínico e mortalidade, qualidade de vida, reversão sintomática, doença cardiovascular, mobilidade funcional, função cognitiva, depressão, entre outras. Resultados: A terapêutica hormonal substitutiva recomendada no hipotiroidismo é a levotiroxina sódica. A dose inicial de substituição deve ser inferior na suspeita de doença cardíaca concomitante. O maior risco da terapêutica com levotiroxina sódica é a sobredosagem, havendo como efeitos adversos possíveis a ansiedade, fraqueza muscular, osteoporose e fibrilhação auricular. Os resultados para a associação na população geriátrica entre o hipotiroidismo subclínico e mortalidade total, progressão para hipotiroidismo clínico, doença cardiovascular, dislipidémia, mobilidade funcional, função cognitiva, depressão e qualidade de vida são variáveis entre vários estudos. Esta variação nos resultados pode refletir diferenças nos participantes – idade, sexo, valores de TSH ou doença cardiovascular pré-existente. Contudo, os resultados sugeriram que o hipotiroidismo subclínico não parece associado com alterações metabólicas e neuropsiquiátricas nos indivíduos mais idosos dos 6 idosos, não dando suporte científico a uma diminuição do limite superior de referência da normalidade do TSH ou a uma diminuição do valor ótimo a atingir de TSH com a terapêutica hormonal de substituição, como guidelines anteriores recomendaram. Apenas um estudo recente indicou que o rastreio do hipotiroidismo pode ser útil, com aproximadamente 1% dos indivíduos rastreados a obterem uma melhoria na qualidade de vida. No entanto, o hipotiroidismo subclínico foi associado a um aumento do risco de eventos coronários e de mortalidade por causas cardiovasculares nos indivíduos com valores superiores de TSH, particularmente quando a concentração de TSH era superior a 10mU/L. Conclusão: Em doentes com um elevado risco de progressão para hipotiroidismo clínico, uma monitorização apertada da função tiroideia pode ser a melhor opção, sendo razoável não recomendar o rastreio da doença tiroideia em indivíduos idosos assintomáticosIntroduction: Thyroid disorders are highly prevalent, occurring most frequently in aging women. Thyroid-associated symptoms are very similar to symptoms of the aging process; thus, improved methods for diagnosing overt and subclinical hypothyroidism in elderly people are crucial. There is no doubt about the indication for treatment of overt hypothyroidism, but indications for treatment of subclinical disease should be revised, especially in old people. 7 Objective: The aim of this study was to analyze how the hypothyroidism is being managed in elderly people. Since there are more doubts in the treatment of subclinical hypothyroidism, I performed an extended revision of the associations between subclinical hypothyroidism and mortality, life satisfaction, symptoms, cardiovascular disease, lipid abnormalities, functional mobility, cognitive function, depression and others. Results: The recommended and appropriate replacement therapy for hypothyroidism is levothyroxine sodium. The initial replacement dose should be low if heart disease is suspected. The major risk of levothyroxine sodium therapy is over-replacement, with anxiety, muscle wasting, osteoporosis and atrial fibrillation as adverse effects. Data regarding the association in old people between subclinical hypothyroidism and total mortality, progression to overt hypothyroidism, cardiovascular disease, abnormalities in serum cholesterol or triglyceride levels, functional mobility, cognitive function, depression and quality of life were conflicting among large prospective cohort studies. This might reflect differences in participants – age, sex, thyroid-stimulating hormone levels, or preexisting cardiovascular disease. However, the findings may suggest that subclinical hypothyroidism does not appear to be associated with metabolic and neuropsychiatric derangement in the oldest old subjects, giving no support to decrease the upper reference limit for TSH or to lower the optimal TSH target in levothyroxine treatment in older adults, as recommended in previous guidelines. Only one recent study indicated that screening for hypothyroidism would be worthwhile with approximately 1% of people screened with an improvement in quality of life. Nonetheless, subclinical hypothyroidism is associated with an increased risk of coronary heart disease events and coronary heart mortality in those with higher TSH levels, particularly in those with a TSH concentration of 10mU/L or greater. 8 Conclusion: In patients with a high risk of progression to overt disease, close monitoring of thyroid function could be the best option and it is reasonable to recommend against screening for thyroid disease in asymptomatic elderly individual

Hipotiroidismo no idoso

Trabalho final de mestrado integrado em Medicina (Geriatria), apresentado á Faculdade de Medicina da Universidade de CoimbraIntrodução: As doenças da tiroide são muito prevalentes, ocorrendo mais frequentemente em mulheres idosas. Como os sintomas associados à disfunção tiroideia são semelhantes aos que ocorrem no envelhecimento, bons métodos de diagnóstico para o hipotiroidismo clínico e subclínico são cruciais em idosos. Enquanto a evidência científica é clara na indicação para tratamento no hipotiroidismo clínico, a indicação para tratamento no hipotiroidismo subclínico deve ser revista, especialmente na população geriátrica. Objetivo: O objetivo desta revisão científica é analisar se o hipotiroidismo tem sido abordado de acordo com a evidência científica atual para a população geriátrica. Como a maioria das dúvidas se prendem com o benefício em tratar o hipotiroidismo subclínico, foi efetuada uma extensa revisão de associações entre o hipotiroidismo subclínico e mortalidade, qualidade de vida, reversão sintomática, doença cardiovascular, mobilidade funcional, função cognitiva, depressão, entre outras. Resultados: A terapêutica hormonal substitutiva recomendada no hipotiroidismo é a levotiroxina sódica. A dose inicial de substituição deve ser inferior na suspeita de doença cardíaca concomitante. O maior risco da terapêutica com levotiroxina sódica é a sobredosagem, havendo como efeitos adversos possíveis a ansiedade, fraqueza muscular, osteoporose e fibrilhação auricular. Os resultados para a associação na população geriátrica entre o hipotiroidismo subclínico e mortalidade total, progressão para hipotiroidismo clínico, doença cardiovascular, dislipidémia, mobilidade funcional, função cognitiva, depressão e qualidade de vida são variáveis entre vários estudos. Esta variação nos resultados pode refletir diferenças nos participantes – idade, sexo, valores de TSH ou doença cardiovascular pré-existente. Contudo, os resultados sugeriram que o hipotiroidismo subclínico não parece associado com alterações metabólicas e neuropsiquiátricas nos indivíduos mais idosos dos 6 idosos, não dando suporte científico a uma diminuição do limite superior de referência da normalidade do TSH ou a uma diminuição do valor ótimo a atingir de TSH com a terapêutica hormonal de substituição, como guidelines anteriores recomendaram. Apenas um estudo recente indicou que o rastreio do hipotiroidismo pode ser útil, com aproximadamente 1% dos indivíduos rastreados a obterem uma melhoria na qualidade de vida. No entanto, o hipotiroidismo subclínico foi associado a um aumento do risco de eventos coronários e de mortalidade por causas cardiovasculares nos indivíduos com valores superiores de TSH, particularmente quando a concentração de TSH era superior a 10mU/L. Conclusão: Em doentes com um elevado risco de progressão para hipotiroidismo clínico, uma monitorização apertada da função tiroideia pode ser a melhor opção, sendo razoável não recomendar o rastreio da doença tiroideia em indivíduos idosos assintomáticosIntroduction: Thyroid disorders are highly prevalent, occurring most frequently in aging women. Thyroid-associated symptoms are very similar to symptoms of the aging process; thus, improved methods for diagnosing overt and subclinical hypothyroidism in elderly people are crucial. There is no doubt about the indication for treatment of overt hypothyroidism, but indications for treatment of subclinical disease should be revised, especially in old people. 7 Objective: The aim of this study was to analyze how the hypothyroidism is being managed in elderly people. Since there are more doubts in the treatment of subclinical hypothyroidism, I performed an extended revision of the associations between subclinical hypothyroidism and mortality, life satisfaction, symptoms, cardiovascular disease, lipid abnormalities, functional mobility, cognitive function, depression and others. Results: The recommended and appropriate replacement therapy for hypothyroidism is levothyroxine sodium. The initial replacement dose should be low if heart disease is suspected. The major risk of levothyroxine sodium therapy is over-replacement, with anxiety, muscle wasting, osteoporosis and atrial fibrillation as adverse effects. Data regarding the association in old people between subclinical hypothyroidism and total mortality, progression to overt hypothyroidism, cardiovascular disease, abnormalities in serum cholesterol or triglyceride levels, functional mobility, cognitive function, depression and quality of life were conflicting among large prospective cohort studies. This might reflect differences in participants – age, sex, thyroid-stimulating hormone levels, or preexisting cardiovascular disease. However, the findings may suggest that subclinical hypothyroidism does not appear to be associated with metabolic and neuropsychiatric derangement in the oldest old subjects, giving no support to decrease the upper reference limit for TSH or to lower the optimal TSH target in levothyroxine treatment in older adults, as recommended in previous guidelines. Only one recent study indicated that screening for hypothyroidism would be worthwhile with approximately 1% of people screened with an improvement in quality of life. Nonetheless, subclinical hypothyroidism is associated with an increased risk of coronary heart disease events and coronary heart mortality in those with higher TSH levels, particularly in those with a TSH concentration of 10mU/L or greater. 8 Conclusion: In patients with a high risk of progression to overt disease, close monitoring of thyroid function could be the best option and it is reasonable to recommend against screening for thyroid disease in asymptomatic elderly individual

Myocardial work is associated with significant left ventricular myocardial fibrosis in patients with hypertrophic cardiomyopathy

Copyright © 2021, The Author(s), under exclusive licence to Springer Nature B.V. part of Springer NatureLate gadolinium enhancement on cardiac magnetic resonance adds prognostic information in patients with hypertrophic cardiomyopathy. Whether Myocardial work, a new parameter on transthoracic echocardiographic, can be associated with significant fibrosis in hypertrophic cardiomyopathy patients is unknown. In a single-centre prospective evaluation of hypertrophic cardiomyopathy patients in whom transthoracic echocardiographic and cardiac magnetic resonance were performed, Myocardial work and related indices were calculated from global longitudinal strain and from estimated left ventricular pressure curves. The extent of late gadolinium enhancement was quantitatively assessed. Late gadolinium enhancement ≥ 15% was chosen to define significant fibrosis. Logistic regression analysis was used to find the variables associated with late gadolinium enhancement ≥ 15% and cut-off values were determined. Among the forty-six patients analysed mean age was 56 ± 15 years, 28 (61%) were male patients and the mean left ventricular ejection fraction by transthoracic echocardiographic was 67 ± 8%. Global constructive work and global work index were significantly related to late gadolinium enhancement ≥ 15%, while global longitudinal strain nearly reached statistical significance. A cut-off ≤ 1550 mmHg% of global constructive work was associated with significant fibrosis with a sensitivity of 91% and a specificity of 84%, while the best cut-off for global longitudinal strain (> - 15%) had a sensitivity of 67% and a specificity of 76%. In our study cohort, global constructive work was associated with significant left ventricular myocardial fibrosis in cardiac magnetic resonance, suggesting its utility in patients who may not be able to have a cardiac magnetic resonance study.info:eu-repo/semantics/publishedVersio

Dapagliflozin Impact on the Exercise Capacity of Non-Diabetic Heart Failure with Reduced Ejection Fraction Patients

Background: Dapagliflozin has been shown to reduce morbidity and mortality in Heart Failure with reduced Ejection Fraction (HFrEF), but its impact on exercise capacity of non-diabetic HF outpatients is unknown. Methods: Adult non-diabetic HF patients with a left ventricular ejection fraction (LVEF) 2) variation. Results: A total of 40 patients were included (mean age 61 ± 13 years, 82.5% male, mean LVEF 34 ± 5%), half being randomized to dapagliflozin, with no significant baseline differences between groups. The reported drug compliance was 100%, with no major safety events. No statistically significant difference in HF events was found (p = 0.609). There was a 24% reduction in the number of patients in New York Heart Association (NYHA) class III in the treatment group as opposed to a 15.8% increase in the control group (p = 0.004). Patients under dapagliflozin had a greater improvement in pVO2 (3.1 vs. 0.1 mL/kg/min, p = 0.030) and a greater reduction in NT-proBNP levels (−217.6 vs. 650.3 pg/mL, p = 0.007). Conclusion: Dapagliflozin was associated with a significant improvement in cardiopulmonary fitness at 6 months follow-up in non-diabetic HFrEF patients

Capacidade Preditiva dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca em Terapia de Ressincronização Cardíaca

Resumo Fundamento Há evidências sugerindo que um corte do pico de consumo de oxigênio (pVO2) de 10ml/kg/min fornece uma estratificação de risco mais precisa em pacientes com Terapia de Ressincronização Cardíaca (TRC). Objetivo Comparar o poder prognóstico de vários parâmetros do teste cardiopulmonar de exercício (TCPE) nesta população e avaliar a capacidade discriminativa dos valores de corte de pVO2 recomendados pelas diretrizes. Métodos Avaliação prospectiva de uma série consecutiva de pacientes com insuficiência cardíaca (IC) com fração de ejeção do ventrículo esquerdo ≤40%. O desfecho primário foi um composto de morte cardíaca e transplante cardíaco urgente (TC) nos primeiros 24 meses de acompanhamento, e foi analisado por vários parâmetros do TCPE para a maior área sob a curva (AUC) no grupo TRC. Uma análise de sobrevida foi realizada para avaliar a estratificação de risco fornecida por vários pontos de corte diferentes. Valores de p < 0,05 foram considerados significativos. Resultados Um total de 450 pacientes com IC, dos quais 114 possuíam aparelho de TRC. Esses pacientes apresentaram um perfil de risco basal mais alto, mas não houve diferença em relação ao desfecho primário (13,2% vs 11,6%, p = 0,660). A pressão expiratória de dióxido de carbono no limiar anaeróbico (PETCO2AT) teve o maior valor de AUC, que foi significativamente maior do que o de pVO2 no grupo TRC (0,951 vs 0,778, p = 0,046). O valor de corte de pVO2 atualmente recomendado forneceu uma estratificação de risco precisa nesse cenário (p <0,001), e o valor de corte sugerido de 10 ml/min/kg não melhorou a discriminação de risco em pacientes com dispositivos (p = 0,772). Conclusão A PETCO2AT pode superar o poder prognóstico do pVO2 para eventos adversos em pacientes com TRC. O ponto de corte de pVO2 recomendado pelas diretrizes atuais pode estratificar precisamente o risco dessa população

Levosimendan in outpatients with advanced heart failure: Single-center experience of 200 intermittent perfusions

Introduction: Patients with advanced heart failure (HF) have high morbidity and mortality, with only a small proportion being eligible for advanced therapies. Intermittent outpatient levosimendan infusion has been shown to provide symptomatic relief and reduce the rate of HF events. Our aim was to assess the safety and efficacy of outpatient levosimendan administration in an advanced HF population. Methods: This is a report of a single-center experience of consecutive advanced HF patients referred for intermittent intravenous outpatient administration of levosimendan, between January 2018 and March 2021. Baseline and follow-up evaluation included clinical assessment, laboratory tests, transthoracic echocardiography and cardiopulmonary exercise testing. Baseline and clinical follow-up data were compared using the Wilcoxon signed-rank test. Results: A total of 24 patients (60.8 years, 83% male, mean left ventricular ejection fraction [LVEF] 24%), with a median of 1.5 HF hospitalizations in the previous six months, were referred for outpatient levosimendan pulses, the majority as a bridge to transplantation or due to clinical deterioration. At six-month follow-up there was a significant reduction in HF hospitalizations to 0.4±0.7 (p<0.001). NYHA class IV (52.2% to 12.5%, p=0.025) and NT-proBNP (8812.5 to 3807.4 pg/ml, p=0.038) were also significantly reduced. Exercise capacity was significantly improved, including peak oxygen uptake (p=0.043) and VE/VCO2 slope (p=0.040). LVEF improved from 24.0% to 29.7% (p=0.008). No serious adverse events were reported. Conclusion: Repeated levosimendan administration in advanced HF patients is a safe procedure and was associated with a reduction in HF hospitalizations, functional and LVEF improvement, and reduction in NT-proBNP levels during follow-up. Resumo: Introdução: Doentes com insuficiência cardíaca avançada (ICA) apresentam uma elevada morbimortalidade, sendo apenas uma pequena proporção elegível para terapêuticas avançadas. A administração intermitente de levosimendan em hospital de dia demonstrou proporcionar alívio sintomático e reduzir a taxa de eventos de IC. O nosso objetivo foi avaliar a segurança e eficácia da administração intermitente de levosimendan em contexto de ambulatório. Métodos: Trata-se do relato de uma experiência unicêntrica de doentes com ICA consecutivamente referenciados para administração intermitente de levosimendan em ambulatório, entre janeiro de 2018 e março de 2021. A avaliação inicial e de follow-up incluiu uma avaliação clínica, laboratorial e ecocardiográfica, bem como a realização, de prova de esforço cardiorrespiratória. Os dados iniciais e de follow-up foram comparados com recurso ao Wilcoxon signed-rank test. Resultados: Foram referenciados 24 doentes (60,8 anos, 83% do sexo masculino, fração de ejeção ventricular esquerda média [FEVE] de 24%), com uma média de 1,7 hospitalizações por IC nos seis meses anteriores, para pulsos de levosimendan em ambulatório, a maioria como ponte para transplante ou devido a agravamento clínico. Aos seis meses de follow-up, verificou-se uma redução significativa de hospitalizações por IC para 0,4±0,7, p<0,001. Verificou-se igualmente uma redução significativa de doentes em classe NYHA IV (52,2% para 12,5%, p=0,025) e dos níveis de NT-proBNP (de 8.812,5 para 3.807,4 pg/mL, p=0,038). A capacidade funcional melhorou de forma significativa, nomeadamente o consumo máximo de oxigénio (p=0,043) e o declive VE/VCO2 (p=0,040). Houve uma melhoria da FEVE de 24,0% para 29,7%, p=0,008. Não se registaram eventos adversos significativos. Conclusão: A administração de levosimendan em contexto de ambulatório em pacientes com ICA é um procedimento seguro e conduziu a uma redução das hospitalizações por IC, melhoria da classe funcional e da FEVE e redução dos níveis de NT-proBNP durante o follow-up

Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction

Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients