estado da arte na abordagem da insuficiência cardíaca

The prevalence of heart failure has increased over the past decades and is a major social and economic burden on healthcare services. Patient quality of life is severely impaired and heart failure is one of the main causes of death in Portugal. The functional organization of multidisciplinary teams engaged in the treatment of these patients is essential to improve health care provision and outcomes, specifically reducing mortality, hospital admissions, and improving quality of life. We describe current approaches to heart failure management and discuss the organization of heart failure units and cooperation among these units and also with other healthcare professionals.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

Endarterectomia vs. angioplastia na estenose carotídea

Trabalho final de mestrado integrado em Medicina, área científica de Cirurgia Vascular, apresentada á Faculdade de Medicina da Universidade de CoimbraIntrodução: A estenose carotídea está implicada em cerca 30% dos acidentes vasculares cerebrais isquémicos. A endarterectomia carotídea constitui o tratamento padrão para a aterosclerose da artéria carotídea, visando sobretudo a profilaxia das suas complicações tromboembólicas, embora a angioplastia com stent tenha vindo a emergir como uma possível alternativa menos invasiva. Deste modo, têm sido realizados diversos ensaios clínicos que comparam as duas abordagens em diferentes classes de pacientes. Objectivos: Rever os princípios clínicos da endarterectomia e da angioplastia carotídea com stent e comparar as duas abordagens terapêuticas como profilaxia do acidente vascular cerebral. Desenvolvimento: Em pacientes com estenose carotídea sintomática, a angioplastia carotídea com stent está associada a um maior risco de acidente vascular cerebral e morte perioperatórias, assim como de bradicardia ou hipotensão. Por outro lado, apesar de ambas as abordagens apresentarem baixo risco, a endarterectomia tem uma taxa maior de enfarte agudo do miocárdio, lesão de nervos cranianos e hematoma no local de acesso. A médio prazo, a reestenose é mais frequente com a angioplastia, mas isso não se traduz num aumento da taxa de acidente vascular cerebral ipsilateral. Em pacientes assintomáticos, ainda não existem dados publicados suficientes. Em pacientes com elevado risco cirúrgico, a angioplastia com stent conseguiu provar a sua não inferioridade. Contudo, esta abordagem endovascular tem um custo mais elevado que a terapia convencional. Conclusões: A evidência actual parece indicar que a angioplastia carotídea com stent, ainda, não constitui um tratamento equivalente à endarterectomia na profilaxia do acidente vascular cerebral, mantendo-se esta como a intervenção padrão com este objectivo.Introduction: Carotid stenosis is implicated in about 30% of ischemic strokes. Carotid endarterectomy has been the standard treatment for carotid atherosclerosis, aiming at prophylaxis of ischemic episodes, but carotid angioplasty and stenting have emerged as a less-invasive treatment alternative. Therefore, there have been several randomized trials that compare the two interventions in different classes of patients. Objectives: To review the clinical principles of endarterectomy and carotid angioplasty with stenting and to compare the two therapeutic approaches for stroke prophylaxis. Development: In patients with symptomatic carotid stenosis, carotid angioplasty with stenting is associated with an increased risk of periprocedural stroke and death, as well as bradycardia or hypotension. On the other hand, although both approaches have a low risk, endarterectomy has a higher rate of myocardial infarction, cranial nerve injury and surgical site haematoma. During medium-term follow-up, restenosis is more frequently associated with carotid angioplasty and stenting, but this has not resulted in an increase rate of ipsilateral stroke. In asymptomatic patients, there is not enough published data. In patients at high surgical risk, carotid angioplasty and stenting was able to prove its noninferiority. However, endovascular treatment costs more than endarterectomy. Conclusions: Current evidence seems to indicate that carotid angioplasty and stenting isn’t yet an equivalent tratment to endarterectomy for stroke prophylaxis, and so the surgical procedure remains the standard approach

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

Perceção da cardiologia, preferências profissionais e impacto na escolha de carreira entre cardiologistas portugueses: resultados do questionário da Task Force Mulheres na Cardiologia da Sociedade Portuguesa de Cardiologia

© 2023 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)Introduction and objectives: Cardiology has not been seen as an attractive specialty, and women have avoided it for many years. Some surveys have been performed in other countries, but in Portugal, the situation is largely unknown. Methods: An online survey on perceptions of cardiology and professional preferences was sent to 1371 members of the Portuguese Society of Cardiology, of whom 18.2% completed the survey. Results: We included 219 cardiologists or cardiology trainees, of whom 50.2% were female, with decreasing proportions from younger to older age groups, in which males still predominate. Women are less often married and more frequently childless, particularly those working in an invasive subspecialty, where they represent only 16% of all respondents working in these areas. Men's perception is that women do not choose these areas due to family reasons, radiation concerns and difficult working conditions, but from the female perspective, male dominance, lack of female role models and restricted access are the main barriers. Women consider it is difficult for them to obtain a leadership role, but men do not think the same (75.5% vs. 27.5%). Conclusion: In Portugal, females predominate in younger age groups, suggesting a paradigm change. Women are less frequently married and more frequently childless, particularly women working in invasive subspecialties. Women consider that it is more difficult for them to obtain a leadership role. Moreover, the barriers reported by women are substantially different from men regarding the reasons for not choosing an invasive subspecialty.info:eu-repo/semantics/publishedVersio

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

Outcomes in Pregnant Women with Valvular Heart Disease from Portuguese-Speaking African Countries Treated in Portugal through an International Agreement of Health Cooperation

Aims: We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during a twenty-year period, through a memorandum of agreement of international cooperation. Methods and results: A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22–29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048). Conclusion: In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy