Publications by authors named "Luís Beck-da-Silva"

50 Publications

Effect of adding hydrochlorothiazide to usual treatment of patients with acute decompensated heart failure: a randomized clinical trial.

Sci Rep 2021 Aug 13;11(1):16474. Epub 2021 Aug 13.

Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.

Acute decompensated heart failure (ADHF) is the leading cause of hospitalization in patients aged 65 years or older, and most of them present with congestion. The use of hydrochlorothiazide (HCTZ) may increase the response to loop diuretics. To evaluate the effect of adding HCTZ to furosemide on congestion and symptoms in patients with ADHF. This randomized clinical trial compared HCTZ 50 mg versus placebo for 3 days in patients with ADHF and signs of congestion. The primary outcome of the study was daily weight reduction. Secondary outcomes were change in creatinine, need for vasoactive drugs, change in natriuretic peptides, congestion score, dyspnea, thirst, and length of stay. Fifty-one patients were randomized-26 to the HCTZ group and 25 to the placebo group. There was an increment of 0.73 kg/day towards additional weight reduction in the HCTZ group (HCTZ: - 1.78 ± 1.08 kg/day vs placebo: - 1.05 ± 1.51 kg/day; p = 0.062). In post hoc analysis, the HCTZ group demonstrated significant weight reduction for every 40 mg of intravenous furosemide (HCTZ: - 0.74 ± 0.47 kg/40 mg vs placebo: - 0.33 ± 0.80 kg/40 mg; p = 0.032). There was a trend to increase in creatinine in the HCTZ group (HCTZ: 0.50 ± 0.37 vs placebo: 0.27 ± 0.40; p = 0.05) but no significant difference in onset of acute renal failure (HCTZ: 58% vs placebo: 41%; p = 0.38). No differences were found in the remaining outcomes. Adding hydrochlorothiazide to usual treatment of patients with acute decompensated heart failure did not cause significant difference in daily body weight reduction compared to placebo. In analysis adjusted to the dose of intravenous furosemide, adding HCTZ 50 mg to furosemide resulted in a significant synergistic effect on weight loss.Trial registration: The Brazilian Clinical Trials Registry (ReBEC), a publically accessible primary register that participates in the World Health Organization International Clinical Trial Registry Platform; number RBR-5qkn8h. Registered in 23/07/2019 (retrospectively), http://www.ensaiosclinicos.gov.br/rg/RBR-5qkn8h/ .
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http://dx.doi.org/10.1038/s41598-021-96002-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8363660PMC
August 2021

Acute necrotizing eosinophilic myocarditis possibly triggered by an antimigraine drug as an uncommon cause of acute heart failure: a case report.

Eur Heart J Case Rep 2021 Aug 9;5(8):ytab286. Epub 2021 Aug 9.

Internal Medicine Division, Hospital Moinhos de Vento, Porto Alegre, Brazil.

Background: Epigastric or chest pain with an abnormal electrocardiogram (ECG) in a young, otherwise healthy patient should trigger an investigation to rule out myocarditis. The myocarditis covers a wide spectrum of severity. The search for the aetiologic factor could be definitive for the success of therapy.

Case Summary: A previously healthy 29-year-old woman presented to the Emergency Room with epigastric pain, eosinophilia, and an abnormal ECG. A thorough evaluation including cardiac magnetic resonance and endomyocardial biopsy was undertaken. A diagnosis of acute necrotizing eosinophilic myocarditis was made.

Discussion: The case is particularly unique for its suspected predisposing trigger: an antimigraine drug. A possible systemic hypersensitivity reaction, reflected by the occurrence of concomitant severe serum eosinophilia, acute myocarditis, and central nervous system vasculitis, was successfully treated with steroids, further supporting the diagnosis.
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http://dx.doi.org/10.1093/ehjcr/ytab286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350354PMC
August 2021

Implications for Clinical Practice from a Multicenter Survey of Heart Failure Management Centers.

Clinics (Sao Paulo) 2021 20;76:e1991. Epub 2021 Jan 20.

Instituto de Moléstias Cardiovasculares Rio Preto Ltda.

Objectives: This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil.

Methods: The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment.

Results: Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment.

Conclusion: HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.
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http://dx.doi.org/10.6061/clinics/2021/e1991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798368PMC
April 2021

Revisiting heart failure assessment based on objective measures in NYHA functional classes I and II.

Heart 2021 Sep 23;107(18):1487-1492. Epub 2020 Dec 23.

Post-Graduate Program in Cardiology and Cardiovascular Sciences, Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

Objective: New York Heart Association (NYHA) functional class plays a central role in heart failure (HF) assessment but might be unreliable in mild presentations. We compared objective measures of HF functional evaluation between patients classified as NYHA I and II in the (ReBIC)-1 Trial.

Methods: The ReBIC-1 Trial included outpatients with stable HF with reduced ejection fraction. All patients had simultaneous protocol-defined assessment of NYHA class, 6 min walk test (6MWT), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and patient's self-perception of dyspnoea using a Visual Analogue Scale (VAS, range 0-100).

Results: Of 188 included patients with HF, 122 (65%) were classified as NYHA I and 66 (35%) as NYHA II at baseline. Although NYHA class I patients had lower dyspnoea VAS Scores (median 16 (IQR, 4-30) for class I vs 27.5 (11-49) for class II, p=0.001), overlap between classes was substantial (density overlap=60%). A similar profile was observed for NT-proBNP levels (620 pg/mL (248-1333) vs 778 (421-1737), p=0.015; overlap=78%) and for 6MWT distance (400 m (330-466) vs 351 m (286-408), p=0.028; overlap=64%). Among NYHA class I patients, 19%-34% had one marker of HF severity (VAS Score >30 points, 6MWT <300 m or NT-proBNP levels >1000 pg/mL) and 6%-10% had two of them. Temporal change in functional class was not accompanied by variation on dyspnoea VAS (p=0.14).

Conclusions: Most patients classified as NYHA classes I and II had similar self-perception of their limitation, objective physical capabilities and levels of natriuretic peptides. These results suggest the NYHA classification poorly discriminates patients with mild HF.
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http://dx.doi.org/10.1136/heartjnl-2020-317984DOI Listing
September 2021

Emerging Topics in Heart Failure: New Era of Pharmacological Treatment.

Arq Bras Cardiol 2020 11;115(5):956-960

Hospital das Clínicas da Universidade Federal de Goiás, Goiânia, GO - Brasil.

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http://dx.doi.org/10.36660/abc.20201106DOI Listing
November 2020

Admission NT-ProBNP in Myocardial Infarction: an Alert Sign?

Arq Bras Cardiol 2019 12;113(6):1138

Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS - Brazil.

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http://dx.doi.org/10.36660/abc.20190685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7021265PMC
December 2019

Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial.

Eur Heart J 2019 11;40(44):3605-3612

Hospital de Clínicas de Porto Alegre and Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, CEP, Porto Alegre, RS, Brazil.

Aims: Although loop diuretics are widely used to treat heart failure (HF), there is scarce contemporary data to guide diuretic adjustments in the outpatient setting.

Methods And Results: In a prospective, randomized and double-blind protocol, we tested the safety and tolerability of withdrawing low-dose furosemide in stable HF outpatients at 11 HF clinics in Brazil. The trial had two blindly adjudicated co-primary outcomes: (i) symptoms assessment quantified as the area under the curve (AUC) of a dyspnoea score on a visual-analogue scale evaluated at 4 time-points (baseline, Day 15, Day 45, and Day 90) and (ii) the proportion of patients maintained without diuretic reuse during follow-up. We enrolled 188 patients (25% females; 59 ± 13 years old; left ventricular ejection fraction = 32 ± 8%) that were randomized to furosemide withdrawal (n = 95) or maintenance (n = 93). For the first co-primary endpoint, no significant difference in patients' assessment of dyspnoea was observed in the comparison of furosemide withdrawal with continuous administration [median AUC 1875 (interquartile range, IQR 383-3360) and 1541 (IQR 474-3124), respectively; P = 0.94]. For the second co-primary endpoint, 70 patients (75.3%) in the withdrawal group and 77 patients (83.7%) in the maintenance group were free of furosemide reuse during follow-up (odds ratio for additional furosemide use with withdrawal 1.69, 95% confidence interval 0.82-3.49; P = 0.16). Heart failure-related events (hospitalizations, emergency room visits, and deaths) were infrequent and similar between groups (P = 1.0).

Conclusions: Diuretic withdrawal did not result in neither increased self-perception of dyspnoea nor increased need of furosemide reuse. Diuretic discontinuation may deserve consideration in stable outpatients with no signs of fluid retention receiving optimal medical therapy.

Clinicaltrials.gov Identifier: NCT02689180.
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http://dx.doi.org/10.1093/eurheartj/ehz554DOI Listing
November 2019

The Diuretic Effect of Sacubitril/Valsartan Might Be Clinically Relevant.

Arq Bras Cardiol 2019 07 15;112(6):791-792. Epub 2019 Jul 15.

Serviço de Cardiologia - Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brazil.

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http://dx.doi.org/10.5935/abc.20190080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6636368PMC
July 2019

Cardiopulmonary exercise testing may not predict appropriate implantable cardioverter defibrillator therapies in heart failure patients.

Acta Cardiol 2020 Oct 6;75(6):514-519. Epub 2019 Jun 6.

Cardiac Electrophysiology Group, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.

The prognostic value of cardiopulmonary exercise testing (CPET) variables for major cardiovascular events in patients with heart failure (HF) is widely established. However, the prognostic value of these variables as predictors of appropriate implantable cardioverter-defibrillator (ICD) therapies has not been sufficiently well addressed. This study aimed to evaluate CPET variables such as peak oxygen uptake (VO peak), relationship between change in minute ventilation (VE) and carbon dioxide output (VCO) during incremental exercise (VE/VCO slope) and exercise-related periodic breathing (EPB) as appropriate ICD therapy predictors in HF patients. We retrospectively assessed 61 HF patients who underwent CPET and had ICD implanted for primary prevention. Patients were followed for 767 ± 601 days. Primary outcome was appropriate ICD-delivered therapy, either anti-tachycardia pacing (ATP) or shock. The sample consisted mostly of male patients (65.6%), with severe ventricular dysfunction (mean left ventricular ejection fraction (LVEF) 27 ± 6%). The primary outcome occurred in 20 patients (32%). There were no significant differences in VO peak (17.7 ± 4.1 and 16.9 ± 4.5 mL/kg/min), VE/VCO slope (39.7 ± 8.4 and 39.6 ± 10.2) or EPB prevalence (20% and 19.5%) in patients with or without appropriate ICD therapy. According to Cox regression analysis, none of the CPET variables were significant predictors of appropriate ICD therapy. In this cohort study of HF patients, CPET variables did not predict appropriate ICD therapies. Further studies with large number of patients are warranted to address this issue.
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http://dx.doi.org/10.1080/00015385.2019.1625169DOI Listing
October 2020

Vaccinations in Heart Failure: An Expert-Opinion Based Recommendation That Deserves Randomized Validation.

JACC Heart Fail 2018 10 8;6(10):856-858. Epub 2018 Aug 8.

Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil.

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http://dx.doi.org/10.1016/j.jchf.2018.05.006DOI Listing
October 2018

Aggressive fluid and sodium restriction in decompensated heart failure with preserved ejection fraction: Results from a randomized clinical trial.

Nutrition 2018 10 21;54:111-117. Epub 2018 Mar 21.

Post Graduate Program in Health Sciences, Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Heart Failure and Transplant Group, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. Electronic address:

Objectives: Sodium and fluid restriction is commonly prescribed for heart failure patients. However, its role in the treatment of heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the effect of a diet with sodium and fluid restriction with an unrestricted diet in patients admitted for decompensated HFpEF.

Methods: Patients were randomized to a diet with sodium (0.8 g/d) and fluid (800 mL/d) restriction (intervention group [IG]) or an unrestricted diet (control group [CG]) and followed for 7 d or hospital discharge. The primary outcome was weight loss. Secondary outcomes included clinical stability, perception of thirst, neurohormonal activation, nutrient intake, readmission, and mortality rate after 30 d.

Results: Fifty-three patients were included (30, IG; 23, CG). The mean ejection fraction was 62% ± 8% for IG and 60% ± 7% for CG (P = 0.44). Weight loss was similar in both groups, being 1.6 ± 2.2 kg in the IG and 1.8 ± 2.1 kg in CG (P = 0.49) as well as the reduction in the congestion score (IG = 3.4 ± 3.5; CG = 3.8 ± 3.4; P = 0.70). The daily perception of thirst was higher in the IG (P = 0.03). Lower energy consumption was seen in the IG (P <0.001). No significant between-group differences at 30 d were found.

Conclusions: Aggressive sodium and fluid restriction does not provide symptomatic or prognosis benefits, but does produce greater perception of thirst, may impair the patient's food intake, and does not seem to have an important neurohormonal effect in patients admitted for decompensated HFpEF.
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http://dx.doi.org/10.1016/j.nut.2018.02.007DOI Listing
October 2018

Natriuretic Peptide and Clinical Evaluation in the Diagnosis of Heart Failure Hemodynamic Profile: Comparison with Tissue Doppler Echocardiography.

Arq Bras Cardiol 2018 Mar;110(3):270-277

Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Background: Physical examination and B-type natriuretic peptide (BNP) have been used to estimate hemodynamics and tailor therapy of acute decompensated heart failure (ADHF) patients. However, correlation between these parameters and left ventricular filling pressures is controversial.

Objective: This study was designed to evaluate the diagnostic accuracy of physical examination, chest radiography (CR) and BNP in estimating left atrial pressure (LAP) as assessed by tissue Doppler echocardiogram.

Methods: Patients admitted with ADHF were prospectively assessed. Diagnostic characteristics of physical signs of heart failure, CR and BNP in predicting elevation (> 15 mm Hg) of LAP, alone or combined, were calculated. Spearman test was used to analyze the correlation between non-normal distribution variables. The level of significance was 5%.

Results: Forty-three patients were included, with mean age of 69.9 ± 11.1years, left ventricular ejection fraction of 25 ± 8.0%, and BNP of 1057 ± 1024.21 pg/mL. Individually, all clinical, CR or BNP parameters had a poor performance in predicting LAP ≥ 15 mm Hg. A clinical score of congestion had the poorest performance [area under the receiver operating characteristic curve (AUC) 0.53], followed by clinical score + CR (AUC 0.60), clinical score + CR + BNP > 400 pg/mL (AUC 0.62), and clinical score + CR + BNP > 1000 pg/mL (AUC 0.66).

Conclusion: Physical examination, CR and BNP had a poor performance in predicting a LAP ≥ 15 mm Hg. Using these parameters alone or in combination may lead to inaccurate estimation of hemodynamics.
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http://dx.doi.org/10.5935/abc.20180046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5898778PMC
March 2018

Alcohol and the heart: the good, the bad and the worse in heart failure.

Heart 2018 10 5;104(20):1641-1642. Epub 2018 Apr 5.

Serviço de Cardiologia, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil.

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http://dx.doi.org/10.1136/heartjnl-2017-312924DOI Listing
October 2018

Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial.

Am Heart J 2017 Dec 24;194:125-131. Epub 2017 Aug 24.

Hospital de Clínicas de Porto Alegre e Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, (RS), Brazil.

Aims: Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC-1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals.

Methods: The ReBIC-1 trial is currently enrolling HF patients in NYHA functional class I-II, left ventricular ejection fraction ≤45%, without a HF-related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double-blinded protocol. The trial has two co-primary outcomes: (1) dyspnea assessment using a visual-analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow-up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre-defined sub-group analysis based on NT-proBNP levels at baseline is planned.

Perspective: Evidence-based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC-1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.
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http://dx.doi.org/10.1016/j.ahj.2017.08.012DOI Listing
December 2017

Effect of fluid and dietary sodium restriction in the management of patients with heart failure and preserved ejection fraction: study protocol for a randomized controlled trial.

Trials 2014 Sep 4;15:347. Epub 2014 Sep 4.

Graduate Program in Health Sciences, Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 200, 90035-003 Porto Alegre, RS, Brazil.

Background: Although half of all patients with heart failure (HF) have a normal or near-normal ejection fraction and their prognosis differs little from that of patients with a reduced ejection fraction, the pathophysiology of HF with preserved ejection fraction (HF-PEF) is still poorly understood, and its management poorly supported by clinical trials. Sodium and fluid restriction is the most common self-care measure prescribed to HF patients for management of congestive episodes. However, its role in the treatment of HF-PEF remains unclear. This trial seeks to compare the effects of a sodium- and fluid-restricted diet versus an unrestricted diet on weight loss, neurohormonal activation, and clinical stability in patients admitted for decompensated HF-PEF.

Methods/design: This is a randomized, parallel trial with blinded outcome assessment. The sample will include adult patients (aged ≥18 years) with a diagnosis of HF-PEF admitted for HF decompensation. The patients will be randomized to receive a diet with sodium and fluid intake restricted to 0.8 g/day and 800 mL/day respectively (intervention group) or an unrestricted diet, with 4 g/day sodium and unlimited fluid intake (control group), and followed for 7 days or until hospital discharge. The primary outcome shall consist of weight loss at 7 days or discharge. The secondary outcome includes assessment of clinical stability, neurohormonal activation, daily perception of thirst and readmission rate at 30 days.

Discussion: Assessment of the effects of sodium and fluid restriction on neurohormonal activation and clinical course of HF-PEF can promote a deeper understanding of the pathophysiology and progression of this complex syndrome.

Trial Registration Number: ClinicalTrials.gov identifier: NCT01896908 (date of registration: 8 August 2013).
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http://dx.doi.org/10.1186/1745-6215-15-347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162967PMC
September 2014

A nurse-based strategy reduces heart failure morbidity in patients admitted for acute decompensated heart failure in Brazil: the HELEN-II clinical trial.

Eur J Heart Fail 2014 Sep 17;16(9):1002-8. Epub 2014 Jul 17.

Graduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil; Instituto de Cardiologia-Fundação Universitária de Cardiologia, Porto Alegre, RS, Brazil.

Aims: Home-based interventions for heart failure (HF) patients might be particularly effective in middle-income countries, where social, cultural, and economic constraints limit the effectiveness of HF treatment outside the hospital environment.

Methods And Results: HELEN-II was a randomized clinical trial conducted in Brazil designed to evaluate the clinical efficacy of a nurse-based strategy, started after discharge following an acute decompensated HF (ADHF) admission. HELEN-II compares the efficacy of home visits and telephone reinforcement (n = 123) with that of the conventional strategy, which is based on medical follow-up (n = 129). The primary outcome was a composite endpoint of a first visit to the emergency department (≤ 24 h), a hospital readmission (> 24 h), or all-cause death, assessed during the first 6 months of follow-up. Most enrolled subjects were middle-aged (62 ± 13 years) males (63%) in NYHA functional class II-III (84%) with severe LV dysfunction (mean LVEF 29.6 ± 9%). The primary composite endpoint was decreased by 27% in the interventional group (relative risk 0.73; 95% confidence interval 0.54-0.99; P = 0.049). At the end of follow-up, the rate of use of the standard-of-care HF medications was similar in both groups, except for the higher use of furosemide in the interventional group. Also, HF knowledge and self-care were significantly increased in the interventional group.

Conclusions: A post-discharge, nurse-led management strategy significantly decreases the morbidity of ADHF patients in the public health system of a developing middle-income country.
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http://dx.doi.org/10.1002/ejhf.125DOI Listing
September 2014

QRS widening rates and genetic polymorphisms of matrix metalloproteinases in a cohort of patients with chronic heart failure.

Can J Cardiol 2014 Mar 20;30(3):345-51. Epub 2013 Nov 20.

Experimental and Molecular Cardiovascular Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil. Electronic address:

Background: QRS duration is considered to be an indicator of adverse outcome in patients with heart failure (HF), and genetic polymorphisms may be involved in this conductivity impairment. We studied the prognostic impact of the QRS widening rate (QRS-WR) on patients with HF and the influence of the matrix metalloproteinases gene polymorphisms on the QRS-WR.

Methods: This prospective cohort study included 184 patients with left ventricular (LV) systolic dysfunction (LV ejection fraction [LVEF] < 45%). The QRS-WR was calculated as the difference between 2 electrocardiogram assessments (in ms) divided by the time elapsed between each evaluation (months). The MMP-1 -1607 1G/2G, MMP-2 -790G/T and -1575G/A, MMP-3 -1171 5A/6A, MMP-9 -1562 C/T and R279Q, and MMP-12 -82A/G polymorphisms were genotyped using polymerase chain reaction-restriction fragment length polymorphism.

Results: Patients were predominantly white (68%) men (67%) in New York Heart Association functional classes I and II (77%). Patients with HF with a QRS-WR ≥ 0.5 ms/month had more HF-related deaths and more combined clinical events than those with a QRS-WR < 0.5 ms/month (P = 0.03 and P = 0.01, respectively). After adjusting for other covariates, the QRS-WR remained an independent predictor of combined clinical events (hazard ratio, 1.6; 95% confidence interval, 1.1-2.5; P = 0.02). The MMP-1 2G2G genotype was associated with nearly a 2-fold increase in QRS-WR (P = 0.03). Conversely, patients with the MMP-3 5A5A genotype and a nonischemic cause of HF were protected against QRS enlargement (P = 0.03).

Conclusions: QRS-WR retains prognostic value in patients with chronic HF receiving guideline-based pharmacologic treatment. MMP gene polymorphisms can influence the rate of QRS enlargement over time.
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http://dx.doi.org/10.1016/j.cjca.2013.11.014DOI Listing
March 2014

Sodium and fluid restriction--reply.

JAMA Intern Med 2014 Jan;174(1):163-4

Heart Failure and Cardiac Transplant Unit, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil3Postgraduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

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http://dx.doi.org/10.1001/jamainternmed.2013.11088DOI Listing
January 2014

Critical appraisal of costly therapy modalities for heart failure in a developing country.

Curr Heart Fail Rep 2013 Dec;10(4):421-6

Hospital de Clinicas de Porto Alegre, Division of Cardiology, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, Brazil, 90035-903.

Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas' disease is epidemiologically important in Brazil; outcomes of patients with Chagas' on electric devices are unclear while these patients fare better post-transplant than non-Chagas' patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.
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http://dx.doi.org/10.1007/s11897-013-0159-3DOI Listing
December 2013

Iron therapy in patients with heart failure. A straight shot.

Int J Cardiol 2013 Oct 30;168(5):5071-2. Epub 2013 Jul 30.

Heart Failure and Cardiac Transplant Unit, Cardiology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Post-Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2013.07.199DOI Listing
October 2013

Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial.

JAMA Intern Med 2013 Jun;173(12):1058-64

Postgraduate Program in Cardiovascular Sciences, Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

Importance: The benefits of fluid and sodium restriction in patients hospitalized with acute decompensated heart failure (ADHF) are unclear.

Objective: To compare the effects of a fluid-restricted (maximum fluid intake, 800 mL/d) and sodium-restricted (maximum dietary intake, 800 mg/d) diet (intervention group [IG]) vs a diet with no such restrictions (control group [CG]) on weight loss and clinical stability during a 3-day period in patients hospitalized with ADHF.

Design: Randomized, parallel-group clinical trial with blinded outcome assessments.

Setting: Emergency room, wards, and intensive care unit.

Participants: Adult inpatients with ADHF, systolic dysfunction, and a length of stay of 36 hours or less.

Intervention: Fluid restriction (maximum fluid intake, 800 mL/d) and additional sodium restriction (maximum dietary intake, 800 mg/d) were carried out until the seventh hospital day or, in patients whose length of stay was less than 7 days, until discharge. The CG received a standard hospital diet, with liberal fluid and sodium intake.

Main Outcomes And Measures: Weight loss and clinical stability at 3-day assessment, daily perception of thirst, and readmissions within 30 days.

Results: Seventy-five patients were enrolled (IG, 38; CG, 37). Most were male; ischemic heart disease was the predominant cause of heart failure (17 patients [23%]), and the mean (SD) left ventricular ejection fraction was 26% (8.7%). The groups were homogeneous in terms of baseline characteristics. Weight loss was similar in both groups (between-group difference in variation of 0.25 kg [95% CI, -1.95 to 2.45]; P = .82) as well as change in clinical congestion score (between-group difference in variation of 0.59 points [95% CI, -2.21 to 1.03]; P = .47) at 3 days. Thirst was significantly worse in the IG (5.1 [2.9]) than the CG (3.44 [2.0]) at the end of the study period (between-group difference, 1.66 points; time × group interaction; P = .01). There were no significant between-group differences in the readmission rate at 30 days (IG, 11 patients [29%]; CG, 7 patients [19%]; P = .41).

Conclusions And Relevance: Aggressive fluid and sodium restriction has no effect on weight loss or clinical stability at 3 days and is associated with a significant increase in perceived thirst. We conclude that sodium and water restriction in patients admitted for ADHF are unnecessary.

Trial Registration: clinicaltrials.gov Identifier: NCT01133236.
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http://dx.doi.org/10.1001/jamainternmed.2013.552DOI Listing
June 2013

IRON-HF study: a randomized trial to assess the effects of iron in heart failure patients with anemia.

Int J Cardiol 2013 Oct 13;168(4):3439-42. Epub 2013 May 13.

Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre-RS, Brazil. Electronic address:

Background: Anemia in heart failure patients and has been associated with increased morbi-mortality. Previous studies have treated anemia in heart failure patients with either erythropoietin alone or combination of erythropoietin and intravenous (i.v.) iron. However, the effect of i.v. or oral (p.o.) iron supplementation alone in heart failure patients with anemia was virtually unknown.

Aim: To compare, in a double-blind design, the effects of i.v. iron versus p.o. iron in anemic heart failure patients.

Methods: IRON-HF study was a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that enrolled anemic heart failure patients with preserved renal function, low transferrin saturation (TSat) and low-to-moderately elevated ferritin levels. Interventions were Iron Sucrose i.v. 200 mg, once a week, for 5 weeks, ferrous sulfate 200 mg p.o. TID, for 8 weeks, or placebo. Primary endpoint was variation of peak oxygen consumption (peak VO2) assessed by ergospirometry over 3 month follow-up.

Results: Eighteen patients had full follow-up data. There was an increment of 3.5 ml/kg/min in peak VO2 in the i.v. iron group. There was no increment in peak VO2 in the p.o. iron group. Patients' ferritin and TSat increased significantly in both treated groups. Hemoglobin increased similarly in all groups.

Conclusion: I.v. iron seems to be superior in improving functional capacity of heart failure patients. However, correction of anemia seems to be at least similar between p.o. iron and i.v. iron supplementation.
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http://dx.doi.org/10.1016/j.ijcard.2013.04.181DOI Listing
October 2013

Anemia in heart failure: association of hepcidin levels to iron deficiency in stable outpatients.

Acta Haematol 2013 7;129(1):55-61. Epub 2012 Nov 7.

Division of Hematology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

Background: Anemia is a prevalent condition in heart failure with multiple potential causes. The complex interaction between iron stores, hepcidin, inflammation and anemia is poorly comprehended. We tested the hypothesis that, in stable heart failure patients with anemia, hepcidin is associated with iron deficiency status irrespective of inflammation.

Methods And Results: Stable systolic heart failure outpatients with and without anemia underwent a complete iron panel, erythropoietin, hepcidin and tumor necrosis factor (TNF)-α assessment. Sixty outpatients were studied. Anemic patients (n = 38, mean hemoglobin 11.4 ± 1 g/dl) were older (69.6 ± 9.6 vs. 58 ± 10.8 years old, p < 0.01) compared with nonanemic patients (n = 22, mean hemoglobin 13.8 ± 1.1 g/dl). Iron deficiency was present in 42% of patients with anemia. TNF-α and hepcidin were 29 and 21% higher in patients with anemia, respectively, compared to nonanemic patients; however, no correlations were found between hepcidin and TNF-α levels. Hepcidin levels in the lower tertile (<31.7 ng/ml) were strongly associated with iron deficiency (OR 16.5, 95% CI 2.2-121.2; p < 0.01).

Conclusion: In stable heart failure patients with anemia, hepcidin levels may be more importantly regulated by patients' iron stores than by inflammation.
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http://dx.doi.org/10.1159/000342110DOI Listing
February 2013

Poster: a practice to be revised!

Arq Bras Cardiol 2011 Aug;97(2):e37-8

Hospital de Clínicas de Porto Alegre, RS, Brazil.

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August 2011

Mortality reduction of cardiac resynchronization and implantable cardioverter-defibrillator therapy in heart failure: an updated meta-analysis. Does recent evidence change the standard of care?

J Card Fail 2011 Oct 23;17(10):860-6. Epub 2011 Jul 23.

Postgraduate Program in Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

Background: The recent publication of the MADIT-CRT and RAFT trials has more than doubled the number of patients in which a direct comparison of the combination of cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillator (ICD) versus ICD alone was carried out. The present meta-analysis aims to assess the impact of combined CRT and ICD therapy on survival of heart failure (HF) patients.

Methods And Results: Medline, Embase, and the Cochrane Library databases were searched, and all randomized controlled trials of CRT alone or combined with ICDs in HF resulting from left ventricular systolic dysfunction were included. Main outcome was all-cause mortality. Summary relative risk (RR) and 95% confidence interval (CI) were calculated employing random-effects models. Twelve studies were included, with a total of 8,284 randomized patients. For the comparison of CRT alone versus medical therapy, pooled analysis of 5 available trials demonstrated a significant reduction in all-cause mortality with CRT (RR 0.76, 95% CI: 0.64-0.9). Pooled analysis of 6 trials that compared the combination of CRT and ICD therapy to ICD alone also showed a statistically significant reduction in all-cause mortality (RR 0.83, 95% CI: 0.72-0.96). Stratified analysis showed significant mortality reductions in all New York Heart Association class subgroups, with greater effect in classes III-IV (RR 0.70; 95% CI: 0.57-0.88). Pooled estimates of implant-related risks were 0.6% for death and 8% for implant failure.

Conclusion: Combined CRT and ICD therapy reduces overall mortality in HF patients when compared with ICD alone.
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http://dx.doi.org/10.1016/j.cardfail.2011.06.372DOI Listing
October 2011
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