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Introduction and objectives: Current epidemiological data on heart failure (HF) in Portugal derives from studies conducted two decades ago. The main aim of this study is to determine HF prevalence in the Portuguese population. Using current standards, this manuscript aims to describe the methodology and research protocol applied. Methods: The Portuguese Heart Failure Prevalence Observational Study (PORTHOS) is a large, three-stage, population-based, nationwide, cross-sectional study. Community-dwelling citizens aged 50 years and older will be randomly selected via stratified multistage sampling. Eligible participants will be invited to attend a screening visit at a mobile clinic for HF symptom assessment, anthropomorphic assessment, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing, one-lead electrocardiogram (ECG) and a sociodemographic and health-related quality of life questionnaire (EQ-5D). All subjects with NT-proBNP ≥125 pg/mL or with a prior history of HF will undergo a diagnostic confirmatory assessment at the mobile clinic composed of a 12-lead ECG, comprehensive echocardiography, HF questionnaire (KCCQ) and blood sampling. To validate the screening procedure, a control group will undergo the same diagnostic assessment. Echocardiography results will be centrally validated, and HF diagnosis will be established according to the European Society of Cardiology HF guidelines. A random subsample of patients with an equivocal HF with preserved ejection fraction diagnosis based on the application of the Heart Failure Association preserved ejection fraction diagnostic algorithm will be invited to undergo an exercise echocardiography. Conclusions: Through the application of current standards, appropriate methodologies, and a strong research protocol, the PORTHOS study will determine the prevalence of HF in mainland Portugal and enable a comprehensive characterization of HF patients, leading to a better understanding of their clinical profile and health-related quality of life. Resumo: Introdução e objetivos: Os dados epidemiológicos atuais sobre insuficiência cardíaca (IC) em Portugal provêm de estudos realizados há mais de duas décadas. O objetivo principal deste estudo é determinar a prevalência da síndrome de IC na população portuguesa com 50 ou mais anos, sendo, especificamente, objetivo deste artigo descrever as abordagens metodológicas e o protocolo de investigação aplicados. Métodos: O Estudo de Prevalência de Insuficiência Cardíaca em Portugal (PORTHOS) é um estudo observacional transversal de grande dimensão, de base populacional, nacional, constituído por três fases. Serão selecionados aleatoriamente por amostragem estratificada multietapas cidadãos com 50 ou mais anos residentes na comunidade em Portugal. Os participantes elegíveis serão convidados a participar numa visita de triagem, que decorrerá numa clínica móvel, durante a qual serão submetidos a avaliação de sintomas de IC, avaliação antropomórfica, um teste de N-terminal pró-peptídeo natriurético tipo B (NT-proBNP), eletrocardiograma de 1 derivação, questionários sociodemográficos e questionário de qualidade de vida relacionada à saúde (EQ-5D). Todos os participantes com NT-proBNP ≥125 pg/mL ou história prévia de IC serão submetidos a uma avaliação diagnóstica confirmatória composta por eletrocardiograma de 12 derivações, ecocardiografia completa, questionário de IC (KCCQ) e colheita de sangue. Para validar o procedimento de triagem, um grupo controlo passará pela mesma avaliação diagnóstica. Os resultados dos ecocardiogramas realizados serão validados centralmente e o diagnóstico de IC será confirmado de acordo com as recomendações de IC da Sociedade Europeia de Cardiologia. Uma subamostra aleatória de participantes com diagnóstico questionável de IC com fração de ejeção preservada (ICFEp), após a aplicação do algoritmo de diagnóstico de fração de ejeção preservada da Heart Failure Association (HFA-PEFF) será convidada a realizar ecocardiografia de esforço. Conclusão: Através da aplicação das recomendações atuais e abordagens metodológicas adequadas, o estudo PORTHOS irá determinar a prevalência da IC em Portugal Continental e permitir uma caracterização abrangente dos doentes com IC, para melhor compreensão do seu perfil clínico e qualidade de vida relacionada com a saúde.

Background: Heart Transplant (HTx) is the ultimate chance of life for end stage Heart Failure (HF). Exercise training has consistently shown the potential to improve functional capacity in various chronic heart diseases. Still, the evidence in HTx recipients is scarcer. This study aims to systematically review the literature to evaluate the effectiveness and safety of Exercise-based Cardiac Rehabilitation (EBCR) in HTx recipients and to identify possible moderators of success. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials on the effect and safety of EBCR in adult HTx recipients. The primary outcome was functional capacity, measured by Peak Oxygen Uptake (pVO2). We searched CENTRAL, MEDLINE, Embase, Scopus, and Web of Knowledge databases until December 2020, reviewed references of relevant articles and contacted experts. Usual care (UC), the different dosages of exercise regimens and alternative settings were allowed as comparators. A quantitative synthesis of evidence was performed using random-effects meta-analyses. Results: A total of 11 studies with 404 patients were included. Nine studies comprising 306 patients compared EBCR with usual care. They showed that EBCR improved pVO2 compared to usual care (Mean Difference [MD] 3.03 mL/kg/min, 95% CI [2.28-3.77]; I 2 = 32%). In the subgroup analysis, including length of intervention and timing of enrollment after HTx, no significant moderator was found. Two trials, with 98 patients total, compared High Intensity Interval Training (HIIT) and Moderate Intensity Continuous Training (MICT). HIIT attained a significant edge over MICT (MD 2.23 mL/kg/min, 95% CI [1.79-2.67]; I 2 = 0%). No major adverse events associated with EBCR were reported. Conclusion: We found moderate quality evidence suggesting EBCR has a significant benefit on functional capacity improvement HTx recipients at the short-term. HIIT showed superiority when compared to MICT. Research focusing long term outcomes and standardized protocols are needed to improve evidence on EBCR effectiveness.

Introduction and Objectives: Dilated cardiomyopathy (DCM) is a myocardial disease that can progress to a terminal stage, requiring heart transplantation. In this work we aim to contribute to knowledge of genetic variants in adult patients undergoing heart transplantation due to end-stage DCM, reporting the results obtained in our single-center tertiary hospital series using target next-generation sequencing (NGS). Methods and Results: Genetic variants were screened in 15 genes, preselected based on variants previously identified in DCM patients. Thirteen unrelated patients were included, nine (69%) male, mean age at diagnosis 33±13 years, eight (62%) with familial DCM. Nine genetic variants were identified in six (46%) patients: five in LMNA, two in LBD3, one in TNNT2 and one in TCAP. These variants were new in most patients. The majority were classified as of uncertain significance. Two patients were double and triple heterozygotes in the LBD3 and LMNA genes, respectively. Conclusion: Our results highlight the potential of NGS in the genetic characterization of DCM patients. LMNA is one of the most frequently mutated genes and should be included in all target gene assessments of end-stage DCM patients until more data are available. Resumo: Introdução e objetivos: A miocardiopatia dilatada é uma doença miocárdica que pode evoluir para um estádio terminal, requerendo transplante cardíaco. Neste trabalho, pretendemos contribuir para o conhecimento das variantes genéticas presentes em pacientes adultos submetidos a transplante cardíaco, descrevendo os resultados obtidos utilizando técnicas de sequenciação de ADN de nova geração. Métodos e resultados: Variantes genéticas foram pesquisadas em 15 genes pré-selecionados com base em variantes previamente identificadas em pacientes com miocardiopatia dilatada. Foram incluídos 13 pacientes não relacionados, nove (69%) do sexo masculino, com idade média na altura do diagnóstico de 33±13 anos, oito (62%) com doença familiar. Foram identificadas nove variantes genéticas em seis (46%) pacientes: LMNA-5, LBD3-2, TNNT2-1 e TCAP- 1. A maioria das variantes genéticas foi classificada como de significado incerto. Dois pacientes eram heterozigotos duplos e triplos nos genes LBD3 e LMNA, respetivamente. Conclusões: Os nossos resultados reforçam o potencial das novas tecnologias de sequenciação na caracterização genética de doentes com miocardiopatia dilatada. Até que mais dados estejam disponíveis, o gene LMNA é um dos mais frequentemente envolvidos e deverá ser incluído na avaliação de pacientes com miocardiopatia dilatada em fase terminal. Keywords: Dilated cardiomyopathy, Heart transplantation, Next-generation sequencing, Genetic variants, Palavras-chave: Miocardiopatia dilatada, Transplante cardíaco, Sequenciação de nova geração, Variantes genéticas

Renin-angiotensin-aldosterone system (RAAS) inhibitors are a cornerstone in the treatment of heart failure with reduced ejection fraction (HFrEF). Sacubitril/valsartan modulates the neurohormonal axis by inhibiting both angiotensin receptors and neprilysin, and improves neurohormonal balance more than blocking the RAAS alone.The PARADIGM-HF trial validated this new treatment option for patients with HFrEF. Sacubitril/valsartan was also more effective than enalapril in slowing disease progression by decreasing the risk of worsening heart failure requiring hospitalization or emergency admission and the need for intensified therapy, heart failure devices or cardiac transplantation. More than 70% of patients included in PARADIGM-HF were in NYHA class II, and overall, the results indicate that sacubitril/valsartan should be started in the earliest symptomatic stages of the disease.As PARADIGM-HF has excellent robustness for a cardiovascular trial, sacubitril/valsartan has been included as a new treatment option with a strong level of recommendation in the main international guidelines.This expert task force proposes a practical guide to the use of this new drug that has been endorsed by the Working Group on Heart Failure of the Portuguese Society of Cardiology. Resumo: Os inibidores do sistema renina-angiotensina-aldosterona são uma das pedras basilares no tratamento da insuficiência cardíaca com fração de ejeção reduzida. O sacubitril/valsartan promove a modulação neuro-hormonal, bloqueando os recetores da angiotensina e inibindo a neprilisina, e produz um maior equilíbrio neuro-hormonal, mais do que o bloqueio do sistema renina-angiotensina-aldosterona isoladamente. O estudo PARADIGM-HF validou essa nova opção para o tratamento de doentes com insuficiência cardíaca e fração de ejeção reduzida, em alternativa ao IECA/ARA.O sacubitril/valsartan demonstrou ser mais eficaz do que o enalapril em retardar a progressão da doença, diminuindo o risco de agravamento da insuficiência cardíaca através da diminuição da necessidade de hospitalização e da menor necessidade de intensificação terapêutica, dispositivos ou transplante cardíaco. Mais de 70% dos doentes incluídos no estudo PARADIGM-HF estavam em classe II da NYHA, suportando a utilização do sacubitril/valsartan precocemente após o início dos sintomas.Como o estudo PARADIGM-HF apresentou uma robustez sem precedentes para um estudo cardiovascular, o sacubitril/valsartan foi incluído como uma nova opção de tratamento nas Recomendações internacionais mais relevantes, com um elevado nível de evidência (I-B).Este grupo de peritos em Insuficiência Cardíaca vem propor uma orientação prática para a utilização deste novo fármaco, subscrita pelo Grupo de Estudos de Insuficiência Cardíaca da Sociedade Portuguesa de Cardiologia. Keywords: Sacubitril/valsartan, PARADIGM-HF, Practical guidance, Heart failure with reduced ejection fraction, Palavras-chave: Sacubitril/valsartan, PARADIGM-HF, Guia prático, Insuficiência cardíaca com fração de ejeção reduzida

Introduction: Dilated cardiomyopathy (DCM) is a disease of the heart muscle characterized by ventricular dilatation and impaired systolic function. Familial forms account for 30-50% of cases. Autosomal dominant inheritance is the predominant pattern of transmission. Causal genetic variants have been identified in several genes and molecular diagnosis has implications for genetic counseling and risk stratification. Objective: We aimed to estimate the frequency of genetic variants and the molecular basis of DCM in Portugal. Methods: We performed a multicenter study of unrelated patients, recruited between 2013 and 2014. Variants in 15 genes were screened using PCR with direct sequencing (next-generation sequencing with at least 30-fold coverage combined with Sanger sequencing). Results: A total of 107 patients were included, 64 (60%) men, mean age at diagnosis 38±13 years, with 48 (45%) familial cases. In total, 31 rare variants in eight genes (mainly in MYBPC3, TNNT2 and LMNA) were identified, in 28 patients (26%). Only four variants had been previously described in association with DCM, 11 with hypertrophic cardiomyopathy, and nine variants were novel. Four variants were likely pathogenic and the remainder were of uncertain significance. We found no major differences in the main clinical and imaging characteristics between patients with or without rare variants and patients with likely pathogenic variants. Conclusions: Our results reflect the complexity and diversity of DCM genetics. For better interpretation of the pathogenicity of the variants found and their causative roles in DCM, molecular cascade screening of families is imperative. Further insight into genotype-phenotype correlations and risk stratification is desirable. Resumo: Introdução: A miocardiopatia dilatada (MCD) é uma doença do músculo cardíaco caracterizada por dilatação ventricular e compromisso da função sistólica. As formas familiares são responsáveis por 30 a 50% dos casos. O padrão de hereditariedade predominante é o autossómico dominante. Variantes genéticas causais foram identificadas em vários genes e o diagnóstico molecular tem implicações para o aconselhamento genético e estratificação de risco. Objetivo: Avaliar a base molecular da MCD em Portugal. Métodos: Estudo multicêntrico de doentes não relacionados, recrutados entre 2013 e 2014. Foram analisados 15 genes, através da técnica de PCR com sequenciação direta (NGS com pelo menos uma cobertura de 30 vezes combinada com sequenciação de Sanger). Resultados: Foram incluídos 107 pacientes, 64 (60%) homens, idade média ao diagnóstico de 38 ± 13 anos, com 48 (45%) casos familiares. Foram identificadas 31 variantes raras, em oito genes, (principalmente MYBPC3, TNNT2 e LMNA) em 28 pacientes (26%). Apenas quatro variantes tinham sido previamente descritas em associação com MCD, 11 com miocardiopatia hipertrófica e nove variantes eram novas. Quatro variantes foram classificadas como provavelmente patogénicas e as restantes de significado incerto. Não encontrámos diferenças significativas nas principais características clínicas e imagiológicas entre doentes com ou sem variantes raras e doentes com variantes provavelmente patogénicas. Conclusões: Estes resultados refletem a complexidade e diversidade genética da MCD. Para uma melhor interpretação da patogenicidade das variantes e potencial causalidade, o rastreio molecular das famílias é imperativo. Uma visão mais aprofundada das correlações genótipo-fenótipo e da estratificação de risco é desejável. Keywords: Dilated cardiomyopathy, Genetic variant, Next-generation sequencing, Palavras-chave: Miocardiopatia dilatada, Variante genética, Sequenciação massiva paralela

Background: Tele-rehabilitation (TR) may be an effective alternative or complement to centre-based cardiac rehabilitation (CBCR) with heart failure (HF) patients, helping overcome accessibility problems to CBCR. The aim of this study is to systematically review the literature in order to assess the clinical effectiveness of TR programs in the management of chronic HF patients, compared to standard of care and standard rehabilitation (CBCR). Methods and Results: We conducted a systematic review and meta-analysis of randomized controlled trials on the effect and safety of TR programs in HF patients, regarding cardiovascular death, heart failure-related hospitalizations, functional capacity and quality of life. We searched 4 electronic databases up until May 2020, reviewed references of relevant articles and contacted experts. A quantitative synthesis of evidence was performed by means of random-effects meta-analyses. We included 17 primary studies, comprising 2206 patients. Four studies reported the number of hospitalizations (TR: 301; Control: 347). TR showed to be effective in the improvement of HF patients’ functional capacity in the 6 Minute Walk-Test (Mean Difference (MD) 15.86; CI 95% [7.23; 24.49]; I2 = 74%) and in peak oxygen uptake (pVO2) results (MD 1.85; CI 95% [0.16; 3.53]; I 2 = 93%). It also improved patients’ quality of life (Minnesota Living with Heart Failure Questionnaire: MD −6.62; CI 95% [−11.40; −1.84]; I 2 = 99%). No major adverse events were reported during TR exercise. Conclusion: TR showed to be superior than UC without CR on functional capacity improvement in HF patients. There is still scarce evidence of TR impact on hospitalization and cv death reduction. Further research and more standardized protocols are needed to improve evidence on TR effectiveness, safety and cost-effectiveness.

Introduction and Objectives: Aortic dilatation can develop late after tetralogy of Fallot repair. Its extension beyond the aortic root is not clearly understood. We aimed to assess the prevalence and predictors of ascending aorta dilatation to set up an imaging protocol. Methods: In this prospective study including adult patients after tetralogy of Fallot repair followed at a referral center, we assessed the aorta by cardiovascular magnetic resonance and defined ascending aorta dilatation as an observed-to-expected ratio >1.5. Results: We included 78 adults (mean age 31±10 years; 56% female), with a mean follow-up of 23±7 years since tetralogy of Fallot repair. The prevalence of ascending aorta dilatation was 11.5%. The ascending aorta was larger than the sinuses of Valsalva in 12.8% of cases. Patients with ascending aorta dilatation were older, predominantly male, with later repair and larger left ventricular mass and volumes. By multivariate analysis left ventricular mass index (LVMI) was the only factor independently associated with ascending aorta dilatation (odds ratio 1.10, 95% confidence interval 1.01-1.20, p=0.03). A cut-off value of ≥57.9 g/m2 for LVMI had 89% sensitivity and 71% specificity for ascending aorta dilatation. Conclusions: Ascending aorta assessment as part of a routine cardiovascular magnetic resonance study after tetralogy of Fallot repair is recommended to screen for future aortic complications, particularly in males and older patients, and those with later repair and larger left ventricles. LVMI assessment has potential as a screening tool for ascending aorta dilatation with future clinical implications. Resumo: Introdução e objetivos: A dilatação da aorta é uma complicação tardia após correção da tetralogia de Fallot. A sua extensão além da raiz da aorta não está bem definida. Pretendemos avaliar a prevalência e os preditores de dilatação da aorta ascendente para elaborar um protocolo imagiológico. Métodos: Estudo prospetivo com adultos operados a tetralogia de Fallot seguidos num centro de referência. Estudamos a aorta por ressonância magnética cardiovascular e definimos dilatação da aorta ascendente pelo rácio observado-esperado > 1,5. Resultados: Incluímos 78 adultos (idade média 31 ± 10 anos; 56% mulheres); seguimento médio de 23 ± 7 anos desde a cirurgia. A prevalência de dilatação da aorta ascendente foi 11,5%. A aorta ascendente era maior do que os seios de Valsalva em 12,8% dos casos. Os doentes com dilatação da aorta ascendente eram mais velhos, maioritariamente homens, operados mais tarde, com massa e volumes ventriculares esquerdos maiores. Na análise multivariada a massa ventricular esquerda indexada foi a única variável independente associada a dilatação da aorta ascendente (odds ratio 1,10; intervalo de confiança de 95% 1,01-1,20; p = 0,03). A massa ventricular esquerda indexada ≥ 57,9 g/m2 apresentou uma sensibilidade de 89% e uma especificidade de 71% para dilatação da aorta ascendente. Conclusões: Recomendamos a inclusão da aorta ascendente na avaliação por ressonância magnética da tetralogia de Fallot operada, para prevenir complicações aórticas futuras, em particular em homens, doentes mais velhos, operados mais tarde e com ventrículos esquerdos maiores. A massa ventricular esquerda indexada tem potencial para ser usada no rastreio da dilatação da aorta ascendente com implicações clínicas futuras. Keywords: Aortic dilatation, Ascending aorta, Cardiovascular magnetic resonance, Tetralogy of Fallot, Palavras-chave: Dilatação da aorta, Aorta ascendente, Ressonância magnética cardiovascular, Tetralogia de Fallot

Introduction and Aims: Intrinsic aortopathy can lead to dilatation late after tetralogy of Fallot (TOF) repair. Its extent and prevalence are not known. We aimed to assess aortic dimensions and elasticity and to find predictors of aortic dilatation. Methods: A total of 126 adults were prospectively included after TOF repair and compared to 63 gender- and age-matched controls. Transthoracic echocardiography was used to assess aortic diameters at the level of the sinuses of Valsalva and ascending aorta and aortic dilatation was defined as z-score >+2. M-mode parameters of the ascending aorta were used to calculate strain, distensibility and stiffness index. Results: TOF patients (mean age 30±9 years; 52% male) had a complete repair at a median age of five (2-49) years; mean follow-up time since repair was 23±7 years. The prevalence of aortic dilatation at the sinuses of Valsalva and ascending aorta was 29% and 24%, respectively. Compared to controls, TOF patients had a higher ascending aorta z-score, lower strain (6.4% [0.0-61.5] vs. 15.2% [0.0-45.0], p +2. Parâmetros modo M da aorta ascendente foram usados para calcular strain, distensibilidade e índice de rigidez. Resultados: Doentes com tetralogia de Fallot (idade média 30 ± 9 anos; 52% homens) foram operados com uma idade mediana de 5 (2-49) anos; tempo médio de seguimento desde a cirurgia 23 ± 7 anos. A prevalência de dilatação dos seios de Valsalva e da aorta ascendente foi 29% e 24%, respetivamente. Comparado aos controlos, os doentes com tetralogia de Fallot apresentaram maior z-score da aorta ascendente, menor strain (6,4 [0,0-61,5] versus 15,2 [0,0-45,0]%; p < 0,01) e maior índice de rigidez (7,3 [0,8-23,6] versus 3,1 [0,9-14,1]; p < 0,01). Na análise multivariada o sexo masculino associou-se significativamente à dilatação dos seios de Valsalva (odds ratio 6,3, intervalo de confiança de 95% 1,5-26,3; p = 0,01). Conclusões: Na tetralogia de Fallot operada há uma prevalência significativa de dilatação tardia da aorta, com a aorta ascendente maior e mais rígida. O sexo masculino parece influenciar a dilatação da raiz da aorta. Esta aortopatia requer um seguimento cuidadoso para evitar complicações futuras. Keywords: Aortic dilatation, Aortic elasticity, Tetralogy of Fallot, Transthoracic echocardiography, Palavras-chave: Dilatação aórtica, Elasticidade aórtica, Tetralogia de Fallot, Ecocardiografia transtorácica

Resumo: A insuficiência cardíaca é uma síndrome com elevada prevalência, morbilidade e mortalidade, sendo, no entanto, pouco reconhecida junto dos cidadãos e decisores políticos. O presente documento foi elaborado por um conjunto de peritos constituído por médicos especialistas em cardiologia, medicina interna e medicina geral e familiar, e pretende expor detalhadamente o problema da insuficiência cardíaca em Portugal a vários níveis: peso da síndrome, diagnóstico, tratamento e acompanhamento dos doentes. Para tal, são identificados e discutidos em detalhe os diferentes aspetos inerentes ao manejo da síndrome durante o processo assistencial, nas várias fases da doença e que incluem doentes hospitalizados e em ambulatório. De modo a otimizar a assistência médica prestada a estes doentes, são apontadas diversas soluções e estratégias a curto, médio e longo prazo com potencial para melhorarem a articulação e utilização dos recursos disponíveis. Pretendeu‐se desta forma destacar estratégias que, não se traduzindo num modelo único de melhoria, poderão ser adaptadas às diferentes especificidades regionais, de modo a aumentar o reconhecimento e a atenção prestada à insuficiência cardíaca em Portugal. Abstract: Heart failure is a syndrome with high prevalence, morbidity and mortality, but awareness of the disease is poor among the general public and policy makers. This document, which was prepared by a group of experts consisting of cardiologists, internists and general practitioners, aims to set out in detail the problem of heart failure in Portugal at several levels: burden of the disease, diagnosis, treatment and monitoring. To this aim, different aspects of the management of the various stages of the disease are identified and discussed in detail, covering both outpatients and hospitalized patients. In order to optimize the medical care provided to these patients, various short‐, medium‐ and long‐term solutions and strategies are put forward that have the potential to improve the integration and use of available resources. The intention is to highlight strategies that are not based on a single model but can be adapted to different regional circumstances, in order to increase awareness and improve management of heart failure in Portugal. Palavras‐chave: Insuficiência cardíaca, Documento de consensos, Prevalência, Tratamento multidisciplinar integrado, Impacto socioeconómico, Keywords: Heart failure, Consensus statement, Prevalence, Integrated multidisciplinary treatment, Socioeconomic impact

Introduction and objectives: Heart failure (HF) is a clinical syndrome associated with substantial morbidity, mortality, and healthcare costs. Dapagliflozin has proven efficacy in reducing the risk of death and hospitalization in HF patients, regardless of left ventricular ejection fraction (LVEF). This paper aimed to project the potential impact of dapagliflozin on healthcare costs related to HF subsequent hospitalizations (HFHs) in Portuguese hospitals. Methods: The total number of HF-related hospitalizations (hHF), HFHs, and the average length of stay for patients with a primary diagnosis of HF from six Portuguese hospitals, between January 2019 and December 2021, were collected and aggregated by hospital classification. Costs associated with HFHs were calculated according to Portuguese legislation and considering conservative, average, and complex approaches. Cost-saving projections were based on extrapolations from hHF risk reductions reported in dapagliflozin clinical trials. Results: Considering a 26% risk reduction in hHF reported on pooled-analysis of DAPA-HF and DELIVER as the expected reduction in HFHs, the use of dapagliflozin would be associated with cost savings ranging from EUR 1 612 851.54 up to EUR 6 587 360.09, when considering all hospitals and the different approaches, between 2019 and 2021. A similar projection is observed based on 24% RRR derived by weighting DAPA-HF and DELIVER sub-analyses and PORTHOS epidemiological data. Conclusions: In this projection, dapagliflozin use in all eligible hHF patients is associated with a significant reduction in direct costs. Our data support that, in addition to the improvements in HF-related outcomes, dapagliflozin may have a significant economic impact on healthcare costs in Portuguese hospitals. Resumo: Introdução e objetivos: A insuficiência cardíaca (IC) é uma síndrome clínica associada a uma elevada morbidade, mortalidade e despesa com custos de saúde. A dapagliflozina demonstrou ser eficaz na redução do risco de morte e hospitalização em doentes com IC, independentemente da fração de ejeção do ventrículo esquerdo. Este artigo visa projetar o potencial impacto da dapagliflozina na redução dos custos relacionados com hospitalizações subsequentes por IC em hospitais portugueses. Métodos: Foi recolhido, e posteriormente analisado de forma agregada em clusters, o número total de hospitalizações por IC, hospitalizações subsequentes por IC e duração média de internamento dos doentes com diagnóstico primário de IC em seis hospitais portugueses, entre janeiro de 2019 e dezembro de 2021. Os custos relacionados com hospitalizações subsequentes por IC foram calculados de acordo com a legislação portuguesa e tendo em consideração três abordagens – conservadora, média e complexa. A projeção da redução de custos teve por base as reduções do risco relativo (RRR) de hospitalizações por IC (hIC) reportadas nos ensaios clínicos com dapagliflozina. Resultados: Considerando uma RRR de 26% do risco de hospitalização subsequente por IC, com base no valor reportado na análise agregada dos estudos DAPA-HF e DELIVER relativa à RRR de hIC, a nossa projeção indica que a utilização da dapagliflozina resulta numa redução de custos. De acordo com a nossa projeção a redução de custos oscila entre €1,612,851.54 e €6,587,360.09, entre 2019 e 2021, ao considerar todos os hospitais envolvidos e as diferentes abordagens metodológicas. A projeção aponta para um resultado similar tendo por base uma RRR de 24%, resultante da ponderação das subanálises de DAPA-HF e DELIVER, juntamente com dados epidemiológicos do estudo PORTHOS. Conclusões: Nesta projeção, a utilização de dapagliflozina, em todos os doentes hospitalizados por IC que sejam elegíveis, está associada a uma redução direta significativa nos custos hospitalares. Estes dados reforçam a ideia de que, para além da melhoria nos resultados de saúde relacionados com a IC, a dapagliflozina pode ter um impacto significativo nos hospitais portugueses ao nível dos custos de saúde.

Introduction and objective: The prognostic value of myocardium deformation measurements in chronic heart failure (CHF) is still poorly addressed. The purpose of this study was to evaluate the correlation of left ventricular (LV) global longitudinal strain (GLS) with clinical and prognostic indicators in patients with CHF and systolic dysfunction. Methods: Ambulatory patients with CHF and LV ejection fraction (LVEF)

Introduction and Aims: We describe the clinical characteristics, management and outcomes of patients hospitalized with acute heart failure in a south-west European cardiology department. We sought to identify the determinants of length of stay and heart failure rehospitalization or death during a 12-month follow-up period. Methods and Results: This was a retrospective cohort study including all patients admitted during 2010 with a primary or secondary diagnosis of acute heart failure. Death and readmission were followed through 2011.Of the 924 patients admitted, 201 (21%) had acute heart failure, 107 (53%) of whom had new-onset acute heart failure. The main precipitating factors were acute coronary syndrome (63%) and arrhythmia (14%). The most frequent clinical presentations were heart failure after acute coronary syndrome (63%), chronic decompensated heart failure (47%) and acute pulmonary edema (21%). On admission 73% had left ventricular ejection fraction

Resumo: Introdução: O ecocardiograma transtorácico é fundamental na avaliação de doentes operados a tetralogia de Fallot. A dilatação da raiz da aorta é uma complicação descrita. Neste estudo, avaliámos a sua prevalência e potenciais preditores. População e métodos: Estudo consecutivo de adultos operados a tetralogia de Fallot. O diâmetro interno máximo da aorta ao nível dos seios de Valsalva (DAo) foi avaliado por ecocardiograma transtorácico, em paraesternal eixo longo. Definimos dois grupos: grupo 1 com dilatação da raiz da aorta (DAo ≥ 38 mm) e grupo 2 sem dilatação (DAo

Telemedicine (TM) is potentially a way of escalating heart failure (HF) multidisciplinary integrated care. Despite the initial efforts to implement TM in HF management, we are still at an early stage of its implementation. The coronavirus disease 2019 pandemic led to an increased utilisation of TM. This tendency will probably remain after the resolution of this threat. Face-to-face medical interventions are gradually transitioning to the virtual setting by using TM. TM can improve healthcare accessibility and overcome geographic inequalities. It promotes healthcare system efficiency gains, and improves patient self-management and empowerment. In cooperation with human intervention, artificial intelligence can enhance TM by helping to deal with the complexities of multicomorbidity management in HF, and will play a relevant role towards a personalised HF patient approach. Artificial intelligence-powered/telemedical/heart team/multidisciplinary integrated care may be the next step of HF management. In this review, the authors analyse TM trends in the management of HF patients and foresee its future challenges within the scope of HF multidisciplinary integrated care.

Abstract Aims This study aimed to assess the utility of contemporary clinical risk scores and explore the ability of two biomarkers [growth differentiation factor‐15 (GDF‐15) and soluble ST2 (sST2)] to improve risk prediction in elderly patients with cardiogenic shock. Methods and results Patients (n = 219) from the multicentre CardShock study were grouped according to age (elderly ≥75 years and younger). Characteristics, management, and outcome between the groups were compared. The ability of the CardShock risk score and the IABP‐SHOCK II score to predict in‐hospital mortality and the additional value of GDF‐15 and sST2 to improve risk prediction in the elderly was evaluated. The elderly constituted 26% of the patients (n = 56), with a higher proportion of women (41% vs. 21%, P

Abstract Background Frailty and sarcopenia have been extensively studied in heart failure (HF) patients, but their coexistence is unknown. The aim of this work is to describe the coexistence of these conditions in a sample of HF outpatients and its association with the use of medication and left-ventricular ejection fraction. Methods Participants in this cross-sectional study were recruited from a HF outpatients’ clinic in northern Portugal. Frailty phenotype was assessed according to Fried et al. Sarcopenia was evaluated according to the revised consensus of the European Working Group on Sarcopenia in Older People. Results A total of 136 HF outpatients (33.8% women, median age 59 years) integrated this study. Frailty and sarcopenia accounted for 15.4% and 18.4% of the sample, respectively. Coexistence of frailty and sarcopenia was found in 8.1% of the participants, while 17.6% had only one of the conditions. In multivariable analysis (n = 132), increasing age (OR = 1.13;95%CI = 1.06,1.20), being a woman (OR = 65.65;95%CI = 13.50, 319.15), having heart failure with preserved ejection fraction (HFpEF) (OR = 5.61; 95%CI = 1.22, 25.76), and using antidepressants (OR = 11.05; 95%CI = 2.50, 48.82), anticoagulants (OR = 6.11; 95%CI = 1.69, 22.07), furosemide (OR = 3.95; 95%CI = 1.07, 14.55), and acetylsalicylic acid (OR = 5.01; 95%CI = 1.10, 22.90) were associated with increased likelihood of having coexistence of frailty and sarcopenia, while using statins showed the inverse effect (OR = 0.06; 95%CI = 0.01, 0.30). Conclusions The relatively low frequency of coexistence of frailty and sarcopenia signifies that each of these two conditions still deserve individual attention from health professionals in their clinical practice and should be screened separately. Being a woman, older age, having HFpEF, using anticoagulants, antidepressants, loop diuretics and acetylsalicylic acid, and not using statins, were associated with having concomitant frailty and sarcopenia. These patients can potentially benefit from interventions that impact their quality of life such as nutritional and mental health interventions and exercise training.

Abstract Background A patient’s knowledge of heart failure (HF) is associated with better outcomes. The more information patients have about their illness, the less likely they are to be readmitted to the hospital. Such knowledge includes the cause, symptoms, probable duration, and expected evolution of the clinical picture. In Portugal, a tool for testing patient knowledge is an unmet need. Therefore, this study aimed to adapt and test the Chronic Heart Failure Knowledge Questionnaire (KQCHF) for the Portuguese context. Methods This work includes three cross-sectional studies. In Study 1, subjects were divided between before and after receiving information about HF. In Study 2, participants answered the questionnaire before and after reading the brochure. In Study 3, KQCHF was applied to patients with HF. Studies 1 and 2 were carried out in the general population. Study 3 was carried out with HF outpatients. Convenience sampling was applied to participants in the three studies. Results In Study 1 (n = 45), those who received information had better scores (9.2 ± 1.9) than those who did not (6.0 ± 2.3). In Study 2 (n = 21), the scores were higher after reading the brochure (10.4 ± 1.7 vs. 6.5 ± 2.9). In Study 3 (n = 169), women had better scores than men (9.1 ± 2.1 vs. 8.3 ± 2.2, overall: 8.5 ± 2.2), and knowledge was correlated with education (r = .340, p

Introduction and objectives: Studies on younger frail and pre-frail subjects suffering from heart failure (HF) are scarce, except for those focusing on the critically ill. This work aims to describe differences between younger (

Abstract Background Sarcopenia is prevalent in heart failure (HF) patients, contributing to its poor prognosis. Statin use is postulated as a probable risk for developing sarcopenia, but little is known regarding this association in HF patients. This work aims at classifying and characterising sarcopenia and at describing the association of statin use with sarcopenia in a sample of Portuguese HF outpatients. Methods In this cross-sectional study, a sample of 136 HF patients (median age: 59 years, 33.8% women) was recruited from an HF outpatients’ clinic of a University Hospital in Portugal. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2. Clinical, nutritional, and dietary data were collected. Results A total of 25 (18.4%) individuals were categorised as sarcopenic, ranging from 12.2% in younger (

Introduction and objectives: Neurohormonal blockade (NB)/modulation is the combination of two renin-angiotensin-aldosterone system inhibitors (RAASi) with a beta blocker. It is the core therapy for heart failure with reduced ejection fraction (HFrEF). While improving long term prognosis, it also induces hyperkalemia (serum K+ >5.0 mEq/L) due to RAASi effects. This may cause lethal arrhythmias and increase mortality in the short term. Thus, hyperkalemia frequently leads to withholding or reducing the intensity of neurohormonal blockade/modulation, which is associated with worsening long term prognosis. We assessed the relevance of hyperkalemia as a limiting factor of neurohormonal blockade/modulation in real life clinical conditions. Methods: We reviewed the medical records of HFrEF patients attending a HF clinic at a tertiary Portuguese hospital during 2018 (n=240). The number of patients not tolerating maximal neurohormonal blockade/modulation due to hyperkalemia was determined. The incidence and characteristics of hyperkalemia episodes were also assessed. Results: Only six patients (3%) achieved maximal doses of neurohormonal blockade/modulation. Hyperkalemia was the limiting factor in 48 (20%) patients. A total of 185 hyperkalemia episodes occurred in 100 (42%) patients. Forty-five (24%) episodes were moderate or severe (serum K+ >5.5 mEq/L). In these HFrEF patients, the co-existence of hypertension, diabetes or renal failure was associated with the occurrence of hyperkalemia. Conclusions: In daily clinical practice, hyperkalemia is frequent and limits neurohormonal blockade/modulation by leading to the withholding or reducing of the intensity of RAAS inhibition. Considering the negative prognostic impact associated with sub-optimal neurohormonal blockade/modulation, addressing hyperkalemia is an important issue when treating HFrEF patients. Resumo: Introdução e objetivos: O bloqueio/modulação neuro-hormonal (BMNH) é a combinação de dois inibidores (i) do sistema Renina-Angiotensina-Aldosterona (RAAS) com um betabloqueador. Como principal terapêutica na insuficiência cardíaca (IC) com fração de ejeção reduzida (FEr), melhora o prognóstico em longo prazo, porém induz hipercaliemia (K+ sérico >5,0 mEq/L), pode causar arritmias letais e aumentar a mortalidade em curto prazo. A hipercaliemia evita ou reduz frequentemente a intensidade do BMNH, o que está associado a pior prognóstico em longo prazo. Avaliámos a relevância da hipercaliemia como fator limitante do BMNH em condições clínicas da vida real. Métodos: Reviram-se os registos médicos dos doentes com ICFEr num hospital terciário português em 2018 (n=240). Determinou-se o número de doentes sem tolerância de BMNH máximo por hipercaliemia e avaliou-se as incidências/características dos episódios de hipercaliemia. Resultados: Apenas seis doentes (3%) atingiram doses máximas de BMNH. A hipercaliemia foi o fator limitante em 48 (20%) doentes. Ocorreram 185 episódios de hipercaliemia em 100 (42%) doentes. Destes, 45 (24%) foram moderados ou graves (K+ sérico >5,5 mEq/L). A coexistência de hipertensão, diabetes ou insuficiência renal foi associada à ocorrência de hipercaliemia. Conclusões: Na prática clínica, a hipercaliemia é frequente e limita o BMNH, evitando ou reduzindo a intensidade da inibição de RAAS. Considerando o impacto prognóstico negativo associado ao BMNH subótimo, a abordagem da hipercaliemia é uma questão importante no tratamento de doentes com ICFEr.

Heart failure (HF) with reduced ejection fraction (HFrEF) is associated with high rates of hospitalization and death. It also has a negative impact on patients’ functional capacity and quality of life, as well as on healthcare costs. In recent years, new HFrEF prognosis-modifying drugs have emerged, leading to intense debate within the international scientific community toward a paradigm shift for the management of HFrEF. In this article, we report the contribution of a Portuguese HF expert panel to the ongoing debate.Based on the most recently published clinical evidence, and the panel members’ clinical judgment, three key principles are highlighted: (i) sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; (ii) the four foundation HFrEF drugs are the angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, regardless of the presence of type-2 diabetes mellitus; (iii) these four HFrEF drug classes should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks. Resumo: A insuficiência cardíaca (IC) com fração de ejeção reduzida (ICFEr) está associada a níveis elevados de hospitalização e mortalidade. A ICFEr também tem um impacto negativo na capacidade funcional e na qualidade de vida dos doentes, bem como na despesa em saúde. Nos últimos anos, surgiram novos medicamentos modificadores do prognóstico da ICFEr, originando um intenso debate na comunidade científica internacional em relação a uma mudança de paradigma para o tratamento da ICFEr. Neste artigo, relatamos a contribuição de um painel de especialistas portugueses em IC para o debate em curso.Com base na evidência clínica publicada mais recentemente e no julgamento clínico dos membros do painel, três princípios-chave são destacados: (i) sacubitril/valsartan deve ser preferido como terapia de primeira linha para a ICFEr, em vez de um inibidor da enzima de conversão da angiotensina ou um bloqueador do recetor da angiotensina; (ii) os quatro medicamentos básicos para a ICFEr são o inibidor do recetor da angiotensina e da neprilisina, os agentes bloqueadores beta-adrenérgicos, os antagonistas do recetor mineralocorticoide e os inibidores do cotransportador sódio-glucose 2, independentemente da presença de diabetes mellitus tipo 2; (iii) essas quatro classes de medicamentos para a ICFEr devem ser rapidamente introduzidas num período curto de 4-6 semanas, seguindo um protocolo de segurança, e depois tituladas durante as oito semanas seguintes.

Introduction and Objectives: Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis. Methods: We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018. Results: A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia. Conclusions: Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients. Resumo: Introdução e objetivos: Os inibidores do sistema renina-angiotensina-aldosterona (iSRAA) constituem pedras basilares para o tratamento da insuficiência cardíaca com fração de ejeção reduzida (IC-FER). A otimização dos iSRAA é dificultada pela ocorrência de hipercalemia, que obriga à redução/interrupção do iSRAA, podendo impactar negativamente na sobrevivência dos doentes com IC-FER. Esta questão é raramente abordada na literatura. Métodos: Realizámos uma revisão sistemática dos estudos sobre doentes com IC-FER para investigar a prevalência, incidência e fatores de risco para hipercaliemia, frequência de utilização de iSRAA, frequência de redução/interrupção dos iSRAA por hipercaliemia e o possível impacto negativo da redução/interrupção dos iSRAA no prognóstico. A pesquisa foi feita na Medline (PubMed) incluindo estudos observacionais e interventivos publicados entre janeiro de 1987 e maio de 2018. Resultados: Foram incluídos 30 estudos observacionais e 18 interventivos. A frequência relatada de hipercalemia variou entre 0% e 63% em estudos observacionais e entre 0% e 30% em ensaios clínicos. Fatores de risco para hipercalemia incluíram uso de iSRAA, idade avançada, diabetes e doença renal crónica. Em estudos de vida real, os iSRAA foram interrompidos em 3% a 22% dos doentes com IC-FER, sendo a hipercalemia a causa em 5% destes casos. Não foram encontrados relatos do impacto prognóstico da redução/interrupção dos iSRAA devida à hipercalemia. Conclusões: A hipercaliemia e redução/interrupção dos iSRAA são frequentes, principalmente em estudos de vida real de IC-FER. Novos estudos serão necessários para esclarecer o papel da redução/interrupção dos iSRAA devida a hipercalemia e para avaliar o seu impacto prognóstico a longo prazo em doentes com IC-FER.

Introduction: Biomarkers in dilated cardiomyopathy (DCM) reflect various pathobiological processes, including neurohormonal activation, oxidative stress, matrix remodeling, myocyte injury and myocyte stretch. We assessed the role of biomarkers in clinical and echocardiographic parameters and in left ventricular (LV) reverse remodeling (LVRR). Methods: In this prospective study of 50 DCM patients (28 men, aged 59±10 years) with LV ejection fraction (LVEF) 10 U in LVEF after optimal medical therapy. Results: Baseline LVEF was 25.4±9.8% and LV end-diastolic diameter (LVEDD)/body surface area (BSA) was 34.2±4.5 mm/m2. LVRR occurred in 34% of patients within 17.6±15.6 months. No correlation was found between B-type natriuretic peptide (BNP), 25-hydroxyvitamin D (25(OH)D), CA-125, high-sensitivity C-reactive protein (hs-CRP), lipoprotein(a) [Lp(a)], noradrenaline, adrenaline, renin or aldosterone and LVRR. Patients in NYHA class III or IV, with pulmonary congestion or ankle edema, had higher CA-125, cystatin C, BNP and hs-CRP levels (p10 U da LVEF, após a terapêutica médica otimizada. Resultados: A LVEF basal foi de 25,4±9,8% e o diâmetro do VE (LVD)/BSA de 34,2±4,5 mm/m2. A LVRR ocorreu em 34%, em 17,6±15,6 meses. Não houve correlação entre BNP, 25-OH-vit D, CA 125, hsCRP, Lp(a), noradrenalina, adrenalina, renina, aldosterona e LVRR. Doentes em classe NYHA (III-IV), com congestão pulmonar ou edema periférico apresentaram níveis mais elevados de CA 125, cistatina C, BNP e hsCRP (p

Background. Sudden cardiac death (SCD) risk stratification in dilated cardiomyopathy (DCM) has been based on left ventricular ejection fraction (LVEF), even though SCD may occur with LVEF > 35%. Family history of unexplained SCD, especially in the young, raises concern about potential inheritable risk factors. It remains largely unknown how genetic tests can be integrated into clinical practice, particularly in the selection of implantable cardioverter defibrillator (ICD) candidates. We aimed to assess the diagnostic yield of genetic testing in DCM patients with a class I recommendation for ICD implantation, based on current guidelines. Methods. We included ambulatory stable adult patients with idiopathic or familial DCM with previously implanted ICD. Molecular analysis included 15 genes (LMNA, MYH7, MYBPC3, TNNT2, ACTC1, TPM1, CSRP3, TCAP, SGCD, PLN, MYL2, MYL3, TNNI3, TAZ, and LDB3) using next-generation sequencing. Results. We evaluated 21 patients, 12 (57%) males and 9 (43%) with familial DCM, including 3 (14%) with a family history of premature unexplained SCD. Mean age at DCM diagnosis was 40 ± 2 years, and mean age at ICD implantation was 50 ± 12 years. LVEF was 27 ± 9%, and LV end-diastolic diameter was 65 ± 7 mm. Genetic variants were found in six (29%) patients, occurring in 5 genes: TPM1, TNNT2, MYH7, PLN, and MYBPC3. The majority were classified as variants of uncertain significance. Family history of SCD was present in both patients with PLN variants. Conclusion. In patients with DCM and ICD, genetic variants could be identified in a significant proportion of patients in several genes, highlighting the potential role of genetics in DCM SCD risk stratification.

Introduction: Cardiac remodeling is manifested as changes in size, shape and function of the heart. We studied the prevalence, prognosis and predictors of left ventricular reverse remodeling (LVRR) in idiopathic dilated cardiomyopathy (IDCM) after optimized medical therapy. Methods: A total of 113 IDCM patients were followed for 7.1±5.6 years. LVRR was defined as an increase of 10 units in ejection fraction (EF) and decrease in left ventricular diastolic diameter (LVDD), in the absence of resynchronization therapy. Results: Baseline EF was 27±8% and LVDD index was 37.1±6.3 mm/m2. LVRR occurred in 34.5% within 22.6 months. Final EF was 47.5±10.1%, LVDD index was 30.2±3.9 mm/m2. LVRR was associated with better NYHA class (I–II) and lower BNP (p

Introduction and Objective: In suspected coronary artery disease (CAD), invasive coronary angiography (ICA) is traditionally the diagnostic tool of choice. However, patients often have no significant disease. Moreover, assessment of fractional flow reserve (FFR) has been shown to have prognostic implications. Recently, coronary computed tomography angiography (CTA) and cardiac magnetic resonance (CMR) myocardial perfusion imaging (CMR-Perf) have gained increasing attention through their accurate anatomical and functional assessment, respectively. We studied the added value of integrating these tests (CT+CMRint) in the diagnosis of CAD, with FFR as the reference standard. Methods: We included 101 patients consecutively referred for outpatient assessment of CAD who underwent CTA and CMR-Perf prior to ICA with FFR assessment. Lesions were considered positive by CT+CMRint only if positive in the two tests alone. The mean follow-up was 2.9±0.6 years. Results: All patients completed the study protocol without adverse effects. Forty-four patients had CAD by FFR. CTA had excellent sensitivity and negative predictive value (100%) but, as expected, its specificity and positive predictive value were lower (61% and 67%, respectively). Diagnostic accuracy by FFR was 78% for CTA, 88% for CMR-Perf and 92% for CT+CMRint. Regarding diagnostic accuracy, CT+CMRint showed statistically significant superiority (AUC=0.917, 95% CI 0.845–0.963) compared with CTA (AUC=0.807, 95% CI 0.716–0.879, p=0.0057) or CMR-Perf (AUC=0.882, 95% CI 0.802–0.938, p=0.0398) alone. Regarding prediction of revascularization, the integrated protocol maintained its superior performance. Conclusions: CT+CMRint showed superior diagnostic accuracy and could thus lead to a considerable reduction in invasive procedures for CAD diagnosis, with less risk and greater patient comfort. Resumo: Introdução e Objetivo: Na suspeita de doença coronária, o cateterismo cardíaco (CC) é tradicionalmente o exame escolhido mas, frequentemente não surge doença significativa. Também, a avaliação da reserva fracional funcional (RFF) tem implicações prognósticas. Recentemente, tanto o angioTAC (CTC) como a ressonância magnética cardiovasculares (RMC) assumiram o seu lugar pela excelente acuidade, respetivamente, na avaliação anatómica e funcional de doença coronária. Foi nosso objetivo investigar o valor adicional da sua integração, tendo a RFF como referência. Métodos: 101 pacientes consecutivamente referenciados do ambulatório por suspeita de doença coronária foram submetidos a CTC e a RMC previamente ao CC. A avaliação integrada (CTC+RMCint) foi considerada positiva se anormalidades presentes simultaneamente nos dois testes. O período médio de follow-up foi de 2,9±0,6 anos. Resultados: Todos os pacientes completaram o protocolo sem adversidades. Doença coronária por RFF ocorreu em 44 pacientes. A CTC demonstrou uma excelente especificidade e VPN (100%) mas, como esperado, baixa especificidade e VPP (61 e 67%). A acuidade diagnóstica foi de 78% para a CTC, 88% para a RMC e 92% para a CT+CMRint. O protocolo integrado demonstrou superioridade estatisticamente significativa para prever doença coronária definida por RFF (AUC=0,917, IC 95% 0,845-0,963) quando comparado com a CTC (AUC=0,807, IC 95% 0,716-0,879, p=0,0057) e RMC (AUC=0,882, IC 95% 0,802-0,938, p=0,0398) isoladamente. Tal manteve-se quando considerada a revascularização no follow-up. Conclusão: A CTC+RMCint demonstrou acuidade diagnóstica superior o que poderá levar à diminuição da realização de CC diagnósticos, com menor risco e maior conforto para o paciente. Keywords: Coronary artery disease, Fractional flow reserve, Computed tomography angiography, Cardiac magnetic resonance myocardial perfusion imaging, Integrated assessment, Palavras-chave: Doença coronária, Reserva fracional funcional, Angio TC cardíaco, Estudo de perfusão por ressonância magnética cardiovascular, Avaliação integrada

Heart failure is associated with high costs which are mainly the result of recurrent hospital admissions. New strategies to detect early decompensation and prevent heart failure-related hospitalizations and reduce total health care costs are needed.Telemonitoring is a novel tool based on the use of recent communication technologies to monitor simple clinical variables, in order to enable early detection of heart failure decompensation, providing an opportunity to prevent hospitalization.From conventional telemonitoring to more recent strategies using implantable cardiac devices or implantable hemodynamic monitors, the subject is under active investigation. Despite the beneficial effects reported by meta-analyses of small non-controlled studies, major randomized controlled trials have failed to demonstrate a positive impact of this strategy. Additionally, evidence regarding the value of newer monitoring devices is somewhat contradictory, as some studies show benefits in prognosis which are not confirmed by others.This paper provides an overview of the existing evidence on telemonitoring in heart failure and a comprehensive state-of-the-art discussion on this topic. Resumo: A insuficiência cardíaca acarreta elevados custos, maioritariamente associados a internamentos recorrentes. Urge encontrar estratégias que possibilitem a deteção precoce dos episódios de descompensação da insuficiência cardíaca, de forma a prevenir as hospitalizações e, assim, reduzir o custo sanitário inerente à doença.A telemonitorização é uma ferramenta inovadora, baseada na utilização de tecnologias de comunicação recentes capazes de monitorizar variáveis clínicas simples que possibilitem a identificação precoce da descompensação da insuficiência cardíaca, proporcionando a oportunidade de evitar a hospitalização.Desde a telemonitorização convencional até estratégias mais recentes utilizando dispositivos cardíacos ou monitores hemodinâmicos implantáveis, esta é uma temática sob investigação ativa. Apesar de metanálises prévias de pequenos estudos não controlados terem documentado o potencial benefício da telemonitorização, os principais ensaios clínicos aleatorizados não conseguiram demonstrar o impacto positivo dessa estratégia. Adicionalmente, os dados relativos ao valor dos dispositivos de monitorização mais recentes são contraditórios, na medida em que alguns estudos documentam potencial benefício prognóstico enquanto outros não o conseguem confirmar.Este artigo fornece uma revisão da evidência científica referente à telemonitorização na insuficiência cardíaca, bem como uma discussão compreensiva acerca do tema. Keywords: Remote monitoring, Telemonitoring, Heart failure, Palavras-chave: Monitorização remota, Telemonitorização, Insuficiência cardíaca

Atrial fibrillation (AF) can be managed with rhythm- or rate-control strategies. There are few data from routine clinical practice on the frequency with which each strategy is used and their correlates in terms of patients' clinical characteristics, AF control, and symptom burden.RealiseAF was an international, cross-sectional, observational survey of 11,198 patients with AF. The aim of this analysis was to describe patient profiles and symptoms according to the AF management strategy used. A multivariate logistic regression identified factors associated with AF management strategy at the end of the visit.Among 10,497 eligible patients, 53.7% used a rate-control strategy, compared with 34.5% who used a rhythm-control strategy. In 11.8% of patients, no clear strategy was stated. The proportion of patients with AF-related symptoms (EHRA Class > = II) was 78.1% (n = 4396/5630) for those using a rate-control strategy vs. 67.8% for those using a rhythm-control strategy (p = II.In the RealiseAF routine clinical practice survey, rate control was more commonly used than rhythm control, and a change in strategy was uncommon, even in symptomatic patients. In almost 12% of patients, no clear strategy was stated. Physician awareness regarding optimal management strategies for AF may be improved.