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Background and aim Frailty Phenotype (FP) is very common in Heart Failure (HF) and both syndromes worsen one another. The aim of this study is to first describe FP in a sample of Portuguese HF patients, and to analyse its association with nutritional and clinical statuses, namely muscle mass, obesity and functional class. Methods and results In this cross-sectional study, a sample of 136 heart failure outpatients (24-81 years, 33.8% women) was randomly selected from the appointments’ listings of a HF and Transplant clinic in a Portuguese University Hospital. FP was assessed according to Fried et al.; muscle mass was estimated from mid-upper arm muscle circumference; weight status was assessed using body mass index; HF functional classes were registered. The association between participants’ characteristics and FP categories was analysed using logistic ordinal regression. The frequency of pre-frailty and frailty is 57.4% and 15.4%, respectively. Within frail individuals, 52.4% were under the age of 65. In multivariable analysis, frailty was positively associated with being 70 or older (OR = 3.44) and obese (OR = 2.66), and negatively associated with muscle mass (OR = 0.77) and with being at class I (OR = 0.14) or class II (OR = 0.29) of HF functional classes. Conclusion Muscle mass seems to be an important predictor of frailty in HF patients and should be taken into account when designing intervention plans that allow for reverting or modifying frailty and pre-frailty. Younger patients should be monitored for the presence and evolution of FP.

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 (−2 increment in body mass index was associated with a 21% decrease in the likelihood of sarcopenia (OR = 0.79; 95% CI = 0.65, 0.96). The daily use of five or more medicines was also directly associated with sarcopenia (OR = 26.87; 95% CI = 2.01, 359.26). On the other hand, being a man and being physically active were inversely associated with sarcopenia (OR = 0.01; 95% CI = 0.00, 0.07 and OR = 0.09; 95% CI = 0.01, 0.65, respectively). Conclusions Contrary to what was expected, patients medicated with statins were less likely to be sarcopenic. Although this finding deserves further research, we hypothesise that this might be related to the pleiotropic effects of statins on endothelial function, contributing to better neuromuscular fitness.

Background: Inflammatory responses play an important role in the pathophysiology of cardiogenic shock (CS). The aim of this study was to investigate the kinetics of procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6) in CS and to assess their relation to clinical presentation, other biochemical variables, and prognosis. Methods: Levels of PCT, CRP and IL-6 were analyzed in serial plasma samples (0-120h) from 183 patients in the CardShock study. The study population was dichotomized by PCTmax >= and < 0.5 mu g/L, and IL-6 and CRPmax above/below median. Results: PCT peaked already at 24 h [median PCTmax 0.71 mu g/L (IQR 0.24-3.4)], whereas CRP peaked later between 48 and 72 h [median CRPmax 137mg/L (59-247)]. PCT levels were significantly higher among non-survivors compared with survivors from 12 h on, as were CRP levels from 24 h on (p < 0.001). PCTmax >= 0.5 mu g/L (60% of patients) was associated with clinical signs of systemic hypoperfusion, cardiac and renal dysfunction, acidosis, and higher levels of blood lactate, IL-6, growth-differentiation factor 15 (GDF-15), and CRPmax. Similarly, IL-6 > median was associated with clinical signs and biochemical findings of systemic hypoperfusion. PCTmax >= 0.5 mu g/L and IL-6 > median were associated with increased 90-day mortality (50% vs. 30% and 57% vs. 22%, respectively; p < 0.01 for both), while CRPmax showed no prognostic significance. The association of inflammatory markers with clinical infections was modest. Conclusions: Inflammatory markers are highly related to signs of systemic hypoperfusion in CS. Moreover, high PCT and IL-6 levels are associated with poor prognosis. (C) 2020 Elsevier B.V. All rights reserved.

© The Author(s) 2020, Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new drug class designed to treat patients with type 2 diabetes (T2D). However, cardiovascular outcome trials showed that SGLT2i also offer protection against heart failure (HF)–related events and cardiovascular mortality. These benefits appear to be independent of glycaemic control and have recently been demonstrated in the HF population with reduced ejection fraction (HFrEF), with or without T2D. This comprehensive, evidence-based review focuses on the published studies concerning HF outcomes with SGLT2i, discussing issues that may underlie the different results, along with the impact of these new drugs in clinical practice. The potential translational mechanisms behind SGLT2i cardio-renal benefits and the information that ongoing studies may add to the already existing body of evidence are also reviewed. Finally, we focus on practical management issues regarding SGLT2i use in association with other T2D and HFrEF common pharmacological therapies. Safety considerations are also highlighted. Considering the paradigm shift in T2D management, from a focus on glycaemic control to a broader approach on cardiovascular protection and event reduction, including the potential for wide SGLT2i implementation in HF patients, with or without T2D, we are facing a promising time for major changes in the global management of cardiovascular disease., This paper had a non-restrictive financial support of Boehringer Ingelheim and Lilly Portugal.

Advanced chronic kidney disease (CKD) frequently aggravates heart failure (HF). However, these patients have inherently been excluded from most HF trials. We aim to provide updated estimates of the representation of patients with advanced CKD and the provision of baseline renal function indices in HF trials with a focused interest on the landmark trials. Updated systematic review was performed from the inception of MEDLINE to 31 December 2019 to identify all chronic HF randomized trials published in the three major cardiology and medical journals, respectively, which included mortality endpoint. The included studies were analysed based on the representativeness of the advanced CKD population and the reporting of baseline renal function. A total of 187 eligible randomized trials with 322,374 participants were included in our analysis. One hundred and six trials (56.7%) had exclusion criteria related to renal function, which remained a continuing trend-55.1% (27/49) from inception-2000, 53.4% (39/73) from 2001-2010 and 61.5% (40/65) from 2011 (P = 0.64). The exclusion criteria, however, have become less restrictive. There was a temporal improvement in the likelihood of HF trials in providing baseline renal function indices (28.6% from inception-2000 versus 53.4% from 2001-2010 and 83.1% from 2011, P 0.001). Concordant findings were observed in the landmark trials. Patients with advanced CKD remain underrepresented in HF trials in the contemporary era, even though the exclusion criteria have become less restrictive, and the quality of renal function monitoring has improved. The continued underrepresentation of patients with advanced CKD in HF trials merits measured broadening of eligibility in further trial studies.

© The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/, Renin-angiotensin-aldosterone system inhibitors (RAASi) reduce morbidity and mortality in heart failure (HF) with reduced ejection fraction in a dose-dependent manner. They also have a positive impact in other cardiovascular diseases (CVDs). However, RAASi may induce hyperkalemia, a potentially life-threatening disorder. This risk is further increased in those with concomitant chronic kidney disease, diabetes mellitus, and/or in patients with hypertension. Current treatment guidelines recommend maximal RAASi dosing to improve clinical outcomes; however, this is often limited by the development of hyperkalemia. When this occurs, current guidelines recommend RAASi down-titration/interruption, which, while improving short-term prognosis, is associated with a negative long-term prognostic impact. At present, the European Society of Cardiology suggests the consideration of novel potassium binders (patiromer and sodium zirconium cyclosilicate) for the management of RAASi-associated hyperkalemia. Both drugs can reduce serum potassium levels and prevent recurrent hyperkalemia. Additionally, patiromer showed enabling of RAASi optimization in high-risk patients. Nevertheless, precise recommendations on the use of these drugs are lacking. Building upon current HF guideline recommendations, a multidisciplinary expert panel convened to design an algorithm providing practical guidance on the use of novel potassium binders/patiromer in patients with HF and/or other CVD. As a result of that effort, we present an evidence-based treatment algorithm for the management of hyperkalemia with novel potassium binders/patiromer in patients with HF and/or other CVD receiving RAASi, including the necessary monitoring to avoid induction of hypokalemia. This algorithm aims to maintain or up-titrate RAASi to optimized doses, while maintaining normokalemia, improved clinical outcomes, and long-term prognosis., This work was supported by Vifor Pharma, Portugal, via an educational grant.

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

Digital, Background: Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries. Methods: We used the Kansas City Cardiomyopathy Questionnaire–12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years. Results: The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa [mean± SE, 39.5±0.3], highest in Western Europe [62.5±0.4]). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17–1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 [95% CI, 1.03–1.14]; strongest association in Eastern Europe: HR, 1.31 [95% CI, 1.21–1.42]; interaction P, Ciencias Medicas y de la Salud

© Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/), Heart failure (HF) is a major health problem with a significant impact on morbidity, mortality, quality of life and healthcare costs. Despite the positive impact of disease-modifying therapies developed over the last four decades, HF mortality and hospitalization remain high. We aim at reviewing the evidence supporting the use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors, as a novel strategy for HF with reduced ejection fraction (HFrEF) treatment. The consistent observation of a reduction in HF hospitalizations in type-2 diabetes cardiovascular safety trials EMPA-REG OUTCOME, CANVAS, DECLARE-TIMI 58 and VERTIS raised the hypothesis that SGLT-2 inhibitors could have an impact in HF treatment. This hypothesis was first confirmed in 2019 with the DAPA-HF publication showing that dapagliflozin on top of optimized HFrEF therapy, reduced HF-hospitalizations and cardiovascular mortality. This was reinforced by the EMPEROR-Reduced publication in 2020 showing that empagliflozin on top of optimized HFrEF therapy, reduced HF-hospitalizations. Both studies established SGLT-2 inhibitors as a fourth pillar of HFrEF prognosis-modifying therapy, in addition to the gold standard triple neurohormonal modulation/blockade.

Aims The EMPERIAL (Effect of EMPagliflozin on ExeRcise ability and HF symptoms In patients with chronic heArt faiLure) trials evaluated the effects of empagliflozin on exercise ability and patient-reported outcomes in heart failure (HF) with reduced and preserved ejection fraction (EF), with and without type 2 diabetes (T2D), reporting, for the first time, the effects of sodium-glucose co-transporter-2 inhibition in HF with preserved EF (HFpEF). Methods and results HF patients with reduced EF (HFrEF) (≤40%, N = 312, EMPERIAL-Reduced) or preserved EF (>40%, N = 315, EMPERIAL-Preserved), with and without T2D, were randomized to empagliflozin 10 mg or placebo for 12 weeks. The primary endpoint was 6-minute walk test distance (6MWTD) change to Week 12. Key secondary endpoints included Kansas City Cardiomyopathy Questionnaire Total Symptom Score (KCCQ-TSS) and Chronic Heart Failure Questionnaire Self-Administered Standardized format (CHQ-SAS) dyspnoea score. 6MWTD median (95% confidence interval) differences, empagliflozin vs. placebo, at Week 12 were −4.0 m (−16.0, 6.0; P = 0.42) and 4.0 m (−5.0, 13.0; P = 0.37) in EMPERIAL-Reduced and EMPERIAL-Preserved, respectively. As the primary endpoint was non-significant, all secondary endpoints were considered exploratory. Changes in KCCQ-TSS and CHQ-SAS dyspnoea score were non-significant. Improvements with empagliflozin in exploratory pre-specified analyses of KCCQ-TSS responder rates, congestion score, and diuretic use in EMPERIAL-Reduced are hypothesis generating. Empagliflozin adverse events were consistent with those previously reported. Conclusion The primary outcome for both trials was neutral. Empagliflozin was well tolerated in HF patients, with and without T2D, with a safety profile consistent with that previously reported in T2D. Hypothesis-generating improvements in exploratory analyses of secondary endpoints with empagliflozin in HFrEF were observed.

© 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/)., 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., This work was supported by OM Pharma (Amadora, Portugal) for the payment of medical writing support. OM Pharma had no role in the study design, or in the collection, analysis and interpretation of data, or in the writing of the manuscript, or the decision to submit the manuscript for publication. The views expressed in the manuscript are those of the authors and not necessarily those of OM Pharma.

[Abstract] Aim. To investigate the characteristics long-term prognostic implications (up to ∼2.2 years) of atrial fibrillation (AF) compared to sinus rhythm (SR), between acute and chronic heart failure (HF) with reduced (HFrEF

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: 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

Sodium glucose cotransporter 2 (SGLT2) inhibitors are a class of drugs that were primarily developed for the treatment of type 2 diabetes mellitus. However, these agents have shown to provide additional beneficial effects. We will discuss three main topics regarding the use of SGLT2 inhibitors: noncardiovascular effects, cardiovascular benefits, and novel clinical indications. Multiple clinical trials and preliminary studies across varying disciplines have shown that these agents exhibit cardiorenal-protective benefits, retinoprotective benefits, and may aid in weight loss without causing marked hypoglycemia. Therefore, these agents represent an avenue in clinical practice to manage comorbid conditions in the hyperglycemic patient. Because of their multifaceted effects and robust action, SGLT2 inhibitors represent therapy options for providers that not only provide beneficial clinical results but also reduce total patient drug burden.钠-葡萄糖协同转运蛋白-2(SGLT2)抑制剂是一类主要用于治疗2型糖尿病的药物。然而, 这些制剂已经显示额外的益处。我们将讨论有关SGLT2抑制剂使用的三个主要方向:非心血管效果、心血管益处和新的临床适应症。跨学科的多项临床试验和初步研究表明, 这些药物显示出保护心肾以及视网膜的好处, 并可能有助于减肥, 而且不会导致明显的低血糖。因此, 这些药物代表了临床实践中管理高血糖患者共存疾病的一条途径。由于SGLT2抑制剂的多方面效应和强大的作用, SGLT2抑制剂提供了新的治疗选项, 不仅有好的临床结果, 而且减少了患者的总药物负担。.

Introduction: Cardiogenic shock complicating acute myocardial infarction has a very high mortality. Our present study focuses on serial measurement of lactate during admission due to cardiogenic shock and the prognostic effect of lactate and a relative change in lactate in patients after admission and the institution of intensive care treatment. Methods and Results: This is a secondary analysis of the CardShock study. Data on lactate at baseline were available on 217 of 219 patients. In the study population, the median baseline lactate was 2.8 mmol/L (min-max range, 0.5-23.1 mmol/L). At admission, lactate was predictive of 30-day mortality with an adjusted Hazard ratio (HR) of 1.20 mmol/L (95% confidence interval, CI 1.14-1.27). Within the first 24 h of admission, baseline lactate remained predictive of 30-day mortality. Lactate at 6 h had a HR of 1.14 (95% CI 1.06-1.24) and corresponding values at 12 and 24 h had a HR of 1.10 (1.04-1.17), and of HR 1.19 (95% CI 1.07-1.32), respectively. A 50% reduction in lactate within 6 h resulted in a HR of 0.82 (95% CI 0.72-0.94). Corresponding hazard ratios at 12 and 24 h, were 0.87 (95% CI 0.76-0.98) and 0.74 (95% CI 0.60-0.91), respectively. Conclusion: The main findings of the present study are that baseline lactate is a powerful predictor of 30-day mortality, lactate at 6, 12, and 24 h after admission are predictors of 30-day mortality, and a relative change in lactate is a significant predictor of survival within the first 24 h after instituting intensive care treatment adding information beyond the information from baseline values.

Background: Cardiogenic shock (CS) is the most life-threatening manifestation of acute heart failure. Its complexity and high in-hospital mortality may justify the need for invasive monitoring with a pulmonary artery catheter (PAC). Methods: Patients with CS included in the CardShock Study, an observational, prospective, multicenter, European registry, were analyzed, aiming to describe the real-world use of PAC, evaluate its impact on 30-day mortality, and the ability of different hemodynamic parameters to predict outcomes. Results: Pulmonary artery catheter was used in 82 (37.4%) of the 219 patients. Cardiogenic shock patients who managed with a PAC received more frequently treatment with inotropes and vasopressors, mechanical ventilation, renal replacement therapy, and mechanical assist devices ( P < .01). Overall 30-day mortality was 36.5%. Pulmonary artery catheter use did not affect mortality even after propensity score matching analysis (hazard ratio = 1.17 [0.59-2.32], P = .66). Cardiac index, cardiac power index (CPI), and stroke volume index (SVI) showed the highest areas under the curve for 30-day mortality (ranging from 0.752-0.803) and allowed for a significant net reclassification improvement of 0.467 (0.083-1.180), 0.700 (0.185-1.282), 0.683 (0.168-1.141), respectively, when added to the CardShock risk score. Conclusions: In our contemporary cohort of CS, over one-third of patients were managed with a PAC. Pulmonary artery catheter use was associated with a more aggressive treatment strategy. Nevertheless, PAC use was not associated with 30-day mortality. Cardiac index, CPI, and SVI were the strongest 30-day mortality predictors on top of the previously validated CardShock risk score.

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

The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%.Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy.PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event.PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants. Resumo: O paradigma atual da terapêutica médica da insuficiência cardíaca com fração de ejeção reduzida (ICFEr) é o triplo bloqueio neuro-hormonal com inibidores da enzima conversora da angiotensina (IECA), bloqueadores beta-adrenérgicos (BB) e antagonistas dos recetores mineralocorticóides (ARM). Contudo, a mortalidade a três anos destes doentes mantém-se superior a 30%.A estimulação de sistemas contra-reguladores em adição ao bloqueio neuro-hormonal constitui um novo paradigma designado por modulação neuro-hormonal. O sacubitril/valsartan é o primeiro passo desta nova estratégia.O PARADIGM-HF foi o maior estudo aleatorizado realizado na ICFEr, tendo incluído 8442 doentes. Comparou a eficácia e segurança do sacubitril/valsartan versus enalapril. O objetivo primário foi o composto mortalidade cardiovascular/hospitalização por IC. Este ocorreu em 914 (21,8%) doentes sob sacubitril/valsartan e 1117 (26,5%) doentes sob enalapril (hazard ratio (HR) 0,8, IC95% [0,73-0,87], p=0,0000002, número de doentes necessário para prevenir um evento [NNT]=21). O sacubitril/valsartan reduziu ambos os componentes do objetivo primário. Diminuiu a morte súbita cardíaca, a devida a agravamento da IC e também a morte por todas as causas. Nos doentes sob sacubitril/valsartan ocorreu menos frequentemente agravamento da IC, deterioração da qualidade de vida e interrupção da medicação em consequência de um efeito adverso.O PARADIGM-HF demonstrou superioridade do sacubitril/valsartan relativamente ao enalapril, sendo o seu efeito sobre a mortalidade cardiovascular 20% superior ao dos IECAs. Assim, as Sociedades Europeia (ESC) e Americanas (ACC/AHA/HFSA) de Cardiologia incluíram, simultaneamente, em 2016 uma recomendação de Classe I para substituição dos IECAs pelo sacubitril/valsartan em doentes com características semelhantes aos participantes do ensaio PARADIGM-HF. Keywords: Heart failure with reduced ejection fraction, Neurohormonal modulation, Angiotensin-receptor neprilysin inhibitor, Sacubitril/valsartan, Cardiovascular mortality, Hospitalization due to heart failure, PARADIGM-HF, Palavras-chave: Insuficiência cardíaca com fração de ejeção reduzida, Modulação neuro-hormonal, Inibidor da neprilisina e dos recetores da angiotensina (INRA), Sacubitril/valsartan, Mortalidade cardiovascular, Hospitalização por insuficiência cardíaca, PARADIGM-HF

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

Background High amounts of coronary artery calcium limit image quality and diagnostic accuracy of multidetector computed tomography (MDCT) angiography (CTA) regarding the assessment of obstructive coronary artery disease (CAD). CT myocardial perfusion imaging may represent an opportunity to overcome this limitation. Objective To explore the additive value of CT myocardial perfusion to CTA depending on the patient's calcium score and in comparison to the reference standard of invasive coronary angiography plus fractional flow reserve (FFR) measurement. Methods Symptomatic patients with intermediate pretest probability of CAD were prospectively recruited and underwent both cardiac MDCT (64-slice scanner, retrospectively-gated stress–rest protocol) and invasive coronary angiography including FFR assessment. We defined hemodynamically significant CAD by the presence of occlusive or subocclusive (99%) stenosis, >50% stenosis in left main or FFR≤0.80. Stress CT myocardial perfusion imaging was performed in all patients in addition to CTA. The additive value of CT myocardial perfusion to rule in or rule out the presence of hemodynamically relevant stenosis on a per-patient basis was assessed and analyzed relative to the patient's calcium score. Results 95 patients were included in the analysis (62 ± 8.2 years, 68%males). Hemodynamically significant CAD was present in 42 patients. Sixty-four patients had a fully evaluable CTA examination. Per-patient, CTA alone had a sensitivity, specificity and AUC of 100%, 59% and 0.79 respectively (77% patients correctly classified). Adding CT myocardial perfusion to evaluate uninterpretable vessel territories in CTA in 66 patients with a calcium score>100 yielded a sensitivity of 88%, a specificity of 74% and an AUC of 0.81 (81% patients correctly classified), and in 52 patients with a calcium score>400 sensitivity was 91%, specificity 70%, and AUC 0.80 (82% patients correctly classified, p = 0.733 versus using perfusion imaging in all patients). Conclusions From a pragmatic standpoint, limiting the use of CT perfusion to individuals with a calcium score above 400 might be a feasible strategy to optimize the diagnostic accuracy of CT imaging for diagnosis of obstructive CAD.

To evaluate the treatment of type 2 diabetes from a cardiologist’s view. A new era in the treatment of type 2 diabetes began for the cardiologist in 2015 with the publication of the EMPA-REG outcome trial finding a significant reduction in CV death with empagliflozin (oral sodium-glucose co-transporter-2 [SGLT2] inhibitor) in patients with type 2 diabetes at increased cardiovascular risk. Shortly thereafter, the injectable glucagon-like peptide agonists (GLP-1) liraglutide and semaglutide found a significant reduction in composite major cardiovascular events (CV death, non-fatal MI, or stroke). Both classes have demonstrated significant renal protection when added to usual care. Moreover, there may be some exciting new benefits of SGLT2 inhibitors for patients with heart failure. These research studies are underway. These two new classes of cardiovascular drugs for type 2 diabetes usher in a new era for the cardiologist who sees greater than 50% of patients with diabetes. The off-target effect of these agents is different as with all new cardiovascular compounds. While safety profiles in these populations are consistent with the known effects of these classes, new off-target effects have been seen with some agents in this class. Ongoing collaboration between cardiologists and other care providers remains important in the implementation of the evidence and care of patients with type 2 diabetes.

BACKGROUND Late after tetralogy of Fallot (TOF) repair some patients exhibit aortic dilatation and stiffness. Noninvasive assessment of aortic stiffness could contribute to understand this aortopathy and may be important in risk stratification for major aortic event. METHODS We included prospectively 82 adults after TOF repair and 41 age- and sex-matched normal controls. Aortic diameters were measured by two-dimensional transthoracic echocardiography and the aortic z-score was estimated. Aortic deformation was assessed by M-mode strain and global peak circumferential ascending aortic strain (CAAS), derived from two-dimensional speckle tracking echocardiography (2D-STE). Corrected CAAS was calculated as CAAS/pulse pressure. Ascending aorta (AAo) distensibility and stiffness index were calculated. RESULTS TOF patients (age 29.7 ± 8.4 years; follow-up since TOF repair 23.0 ± 6.8 years) had smaller body surface area but a larger aorta compared to controls. TOF patients had lower AAo distensibility (2.2 [0.0-21.0] vs 5.6 [0.0-12.5] cm2 dyne-1 10-6 , P

BackgroundThe most common aetiology of cardiogenic shock (CS) is acute coronary syndrome (ACS), but even up to 20%-50% of CS is caused by other disorders. ST-segment deviations in the electrocardiogram (ECG) have been investigated in patients with ACS-related CS, but not in those with other CS aetiologies. We set out to explore the prevalence of different ST-segment patterns and their associations with the CS aetiology, clinical findings and 90-day mortality. MethodsWe analysed the baseline ECG of 196 patients who were included in a multinational prospective study of CS. The patients were divided into 3 groups: (a) ST-segment elevation (STE). (b) ST-segment depression (STDEP). (c) No ST-segment deviation or ST-segment impossible to analyse (NSTD). A subgroup analysis of the ACS patients was conducted. ResultsST-segment deviations were present in 80% of the patients: 52% had STE and 29% had STDEP. STE was associated with the ACS aetiology, but one-fourth of the STDEP patients had aetiology other than ACS. The overall 90-day mortality was 41%: in STE 47%, STDEP 36% and NSTD 33%. In the multivariate mortality analysis, only STE predicted mortality (HR 1.74, CI95 1.07-2.84). In the ACS subgroup, the patients were equally effectively revascularized, and no differences in the survival were noted between the study groups. ConclusionST-segment elevation is associated with the ACS aetiology and high mortality in the unselected CS population. If STE is not present, other aetiologies must be considered. When effectively revascularized, the prognosis is similar regardless of the ST-segment pattern in ACS-related CS.

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

© 2016 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved., 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., 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.

Background: Despite scarce data, invasive mechanical ventilation (MV) is widely recommended over noninvasive ventilation (NIV) for ventilatory support in cardiogenic shock (CS). We assessed the real-life use of different ventilation strategies in CS and their influence on outcome focusing on the use of NIV and MV. Methods: 219 CS patients were categorized by the maximum intensity of ventilatory support they needed during the first 24 h into MV (n= 137; 63%), NIV(n= 26; 12%), and supplementary oxygen (n= 56; 26%) groups. We compared the clinical characteristics and 90-day outcome between the MV and the NIV groups. Results: Mean age was 67 years, 74% were men. The MV and NIV groups did not differ in age, medical history, etiology of CS, PaO2/FiO(2) ratio, baseline hemodynamics or LVEF. MV patients predominantly presented with hypoperfusion, with more severe metabolic acidosis, higher lactate levels and greater need for vasoactive drugs, whereas NIV patients tended to be more often congestive. 90-day outcome was significantly worse in the MV group (50% vs. 27%), but after propensity score adjustment, mortality was equal in both groups. Confusion, prior CABG, ACS etiology, higher lactate level, and lower baseline PaO2 were independent predictors of mortality, where as ventilation strategy did not have any influence on outcome. Conclusions: Although MV is generally recommended mode of ventilatory support in CS, a fair number of patients were successfully treated with NIV. Moreover, ventilation strategy was not associated with outcome. Thus, NIV seems a safe option for properly chosen CS patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

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)

Objective: To assess the prognostic significance of iron deficiency (ID) in a chronic heart failure (CHF) outpatient population. Methods and Results: We prospectively evaluated 127 patients with stable CHF and left ventricular ejection fraction ≤45%. Clinical and analytical data as well as information regarding the occurrence of the composite endpoint of overall mortality and nonfatal cardiovascular events were assessed. Among the 127 patients enrolled [81% men, median age: 62 years (25th-75th percentile: 53-68)], 46 (36%) patients had ID. Women, patients with higher plasma brain natriuretic peptide levels (>400 pg/ml) and with right ventricular systolic dysfunction presented ID more frequently (p < 0.05 for all). At 225 ± 139 days of follow-up, the composite endpoint occurred in 15 (12%) patients. It was more frequent in ID (24 vs. 5%, p = 0.001) and anemic patients (25 vs. 8%, p = 0.014). In a Cox regression analysis, ID was associated with a higher likelihood of composite endpoint occurrence (HR 5.00, 95% CI 1.59-15.78, p = 0.006). In a multivariable analysis adjusted for clinical variables, including the presence of anemia, ID remained a significant predictor of the composite endpoint (HR 5.38, 95% CI 1.54-18.87, p = 0.009). Conclusion: In a CHF outpatient population, ID carried a higher risk of unfavorable outcome, irrespectively of the presence of anemia.

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

Transcatheter aortic valve implantation (TAVI) techniques have been presenting good procedural success and favorable clinical outcomes. However, optimal management of aortic valve disease in elderly patients depends on quality of life (QoL) improvement. In this study we aimed to evaluate changes in QoL in patients referred for TAVI.Prospective analysis of 74 consecutive patients (34 male), aged 81.6 ± 8 years with symptomatic severe aortic valve stenosis (AS) ineligible for conventional aortic valve replacement, referred to TAVI in one tertiary center. For the assessment of QoL, the Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used before the procedure and at 6.5 months. The mortality was 9.5% at 30 days and 20.2% at 6.5 months follow-up. Fifty three (71.6%) patients completed MLHFQ at baseline and at follow-up. All patients showed good hemodynamic results and no signs of prosthesis dysfunction were observed on transthoracic echocardiography. The New York Heart Association (NYHA) class (2.9 ± 0.4 to 1.4 ± 0.7; p0.001), and the MLHFQ scores [overall (37.0 ± 14.7 vs. 14.4 ± 10.1; p0.001), physical dimension (23.2 ± 9.5 vs. 8.6 ± 5.9; p0.001) and emotional dimension (5.4 ± 4.2 vs. 2.6 ± 3.0; p0.001)] were significantly improved 6.5 months after TAVI. Patients with peripheral vascular disease (PVD) had an inferior improvement in QoL caused by a lower enhancement in physical dimension MLHFQ score (mean difference: -17.0 ± 10.2 vs. -10.1 ± 11.5; p=0.036).TAVI significantly improves symptoms and QoL in patients with severe AS and high surgical risk. Patients with PVD might be expected to have a less impressive improvement in QoL after TAVI.

Left ventricular noncompaction is an unusual but increasingly recognized cardiomyopathy, the etiology of which is still not definitely established. Clinical presentation includes a wide spectrum of scenarios, including heart failure, thromboembolism and malignant arrhythmias, with half of deaths occurring suddenly. Early detection of LVNC is therefore essential to prevent sudden cardiac death. To our knowledge, this is the first report of the presence of cardiac sympathetic nervous dysfunction, assessed by 123iodine-metaiodobenzylguanidine myocardial scintigraphy, in a patient with LVNC, preserved left ventricular systolic function and exercise-induced nonsustained ventricular tachycardia. This finding may be related to the increased arrhythmic risk observed in this cardiomyopathy, giving a new insight into the pathophysiology of LVNC. Resumo: O miocárdio não-compactado (MNC) é uma miocardiopatia que, embora rara, tem sido gradualmente mais descrita. O espectro de apresentação clínica é variável, incluindo insuficiência cardíaca, fenómenos tromboembólicos e arritmias, sendo que metade das mortes ocorre subitamente (MSC). Por conseguinte, o diagnóstico precoce e correto do MNC é fundamental para a prevenção da MSC. O presente artigo ilustra pela primeira vez a presença de disfunção neuronal simpática, avaliada por cintigrafia cardíaca com 123I-metaiodobenzilguinadina, num doente com MNC, função sistólica ventricular esquerda preservada e taquicardia não sustentada induzida pelo esforço. A presença de alterações na actividade adrenérgica cardíaca pode estar relacionada com o maior risco arrítmico característico desta miocardiopatia, podendo contribuir para o melhor esclarecimento da sua patofisiologia. Keywords: Cardiac 123I-MIBG scintigraphy, Left ventricular noncompaction, Arrhythmias, Palavras-chave: Cintigrafia cardíaca com 123I-MIBG, Miocárdio não-compactado, Arritmias

Rate control and rhythm control are accepted management strategies for atrial fibrillation (AF).RealiseAF aimed to describe the success of either strategy and the impact of control on symptomatic status of patients with AF.This international, observational, cross-sectional survey of patients with any history of AF in the previous year, recorded AF characteristics, management and frequency of control (defined as sinus rhythm or AF with resting heart rate ≤80 bpm).Overall, 9665 patients were evaluable for AF control, with 59.0% controlled (sinus rhythm 26.5%, AF ≤80 bpm 32.5%) and 41.0% uncontrolled. Symptom prevalence in the previous week was lower in controlled than uncontrolled AF (55.7% vs 68.4%; p0.001) and similar for patients in sinus rhythm versus AF ≤80 bpm (54.8% vs 56.4%; p=0.23). At the visit, AF-related functional impairment (EHRA classI) was seen in 67.4% of patients with controlled AF and 82.1% of patients with uncontrolled AF (p0.001). Quality-of-life (QoL, measured using EQ-5D) was better for patients with controlled versus uncontrolled AF using the Visual Analogue Scale (mean (SD) score 67.1 (18.4) vs 63.2 (18.9); p0.001), single index utility score (median 0.78 vs 0.73; p0.001), or five dimensions of well-being (all p0.001). Irrespective of AF control, cardiovascular events had led to hospitalisation in the past year in 28.1%.AF control is not optimal. Control appears to be associated with fewer symptoms and better QoL, but even patients with controlled AF have frequent symptoms, functional impairment, altered QoL and cardiovascular events. New treatments are needed to improve control and minimise the functional and QoL burden of AF.

Aims Data regarding the effects of TAVI on LV after are scarce and conflicting results have been reported immediately after aortic valvuloplasty. This study aimed to determine the acute haemodynamic effects of transcatheter aortic valve implantation (TAVI) in left ventricle (LV) diastolic performance, immediately after aortic valvuloplasty and prosthesis deployment. Methods and results Sixty-one patients with severe aortic valve stenosis, and preserved LV systolic function submitted to successful TAVI, were included. All procedures were guided through transoesophageal echocardiography, and parameters of diastolic function were evaluated before and minutes after TAVI. The mean age was 83.5 ± 6 years and mean log EuroSCORE was 18.2 ± 9.4. Before the procedure, all patients presented LV diastolic dysfunction. Immediately after TAVI, fewer patients presented a restrictive pattern [27 (44.3%), before the procedure, vs. 20 (34.4%), after TAVI ( P = 0.047)], and an increase in E wave deceleration time (211.2 ± 75.5 vs. 252.7 ± 102.3 cm/s, P = 0.001), in E wave velocity (109.5 ± 41.2 vs. 120.3 ± 43.6 cm/s, P = 0.025), and in isovolumetric relaxation time (83 ± 36.5 vs. 97.1 ± 36.0 ms, P = 0.013) was observed. On multivariate analysis of covariance (ANCOVA), adjusting to LV systolic function, heart rate, blood pressure, and haematocrit values, the results remained significant. Patients referred to percutaneous approach had invasive haemodynamic data collected, showing a decrease in LV end-diastolic pressure after valve implantation [18.8 ± 5.7 vs. 14.7 ± 4.7, mean difference −4.1 (95% CI: −5.9; −2.9)]. Patients with a restrictive pattern immediately after TAVI presented a smaller decrease in LV end diastolic pressure (−3.3 ± 4.7) than those with diastolic dysfunction grade I or II (−9.5 ± 4.7; P = 0.017). Conclusion This is the first study describing LV diastolic performance during TAVI. Our results show improvement in diastolic function parameters in patients with preserved LV systolic function, immediately after successful TAVI.

Familial dilated cardiomyopathy (FDCM) is characterized by genetic heterogeneity, incomplete age-dependent penetrance, and a multifactorial pathogenesis ([1][1]). Diagnosis is still dependent on clinical criteria and familial investigation ([2][2]). On the other hand, several abnormalities have been

In the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (n=6632), eplerenone-associated reduction in all-cause mortality was significantly greater in those with a history of hypertension (Hx-HTN). There were 4007 patients with Hx-HTN (eplerenone: n=1983) and 2625 patients without Hx-HTN (eplerenone: n=1336). Propensity scores for eplerenone use, separately calculated for patients with and without Hx-HTN, were used to assemble matched cohorts of 1838 and 1176 pairs of patients. In patients with Hx-HTN, all-cause mortality occurred in 18% of patients treated with placebo (rate, 1430/10 000 person-years) and 14% of patients treated with eplerenone (rate, 1058/10 000 person-years) during 2350 and 2457 years of follow-up, respectively (hazard ratio [HR]: 0.71; 95% CI: 0.59 to 0.85; P P =0.003). In patients without Hx-HTN, eplerenone reduced heart failure hospitalization (HR: 73; 95% CI: 0.55 to 0.97; P =0.028) but had no effect on mortality (HR: 0.91; 95% CI: 0.72 to 1.15; P =0.435) or on the composite end point (HR: 0.91; 95% CI: 0.76 to 1.10; P =0.331). Eplerenone should, therefore, be prescribed to all of the post–acute myocardial infarction patients with reduced left ventricular ejection fraction and heart failure regardless of Hx-HTN.

Inherited dilated cardiomyopathy (DCM) is a genetically and phenotypically very heterogeneous disease. DCM is caused by mutations in multiple genes encoding proteins that are involved in force generation, force transmission, energy production and several signalling pathways. Thus, the pathophysiology of heart failure is complex and not yet fully understood. Familial forms of DCM let the way to identify new key proteins by positional cloning and to study respective pathomechanisms that are critical for normal cardiac function, but may not have been correlated with heart disease before. Here we report a three-generation pedigree including 16 individuals affected by dilated cardiomyopathy without additional phenotypes. The pedigree is consistent with autosomal-dominant inheritance and age-related penetrance. A genome-wide linkage analysis excluded linkage to all known DCM genes and loci, whereas several close markers on chromosome 7q22.3-31.1 segregated with the disease (maximum logarithm of odds score, 4.20 at D7S471 and D7S501). The disease causing mutation lies in a 9.73 Mb interval between markers D7S2545 and D7S2554 that contains no known cytoskeletal genes. Coding exons of the candidate genes LAMB1, LAMB4 and PIK3CG were screened but no mutations were identified.

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

Aims: Although active-controlled trials with renin–angiotensin inhibitors are ethically mandated in heart failure with reduced ejection fraction, clinicians and regulators often want to know how the experimental therapy would perform compared with placebo. The angiotensin receptor-neprilysin inhibitor LCZ696 was compared with enalapril in PARADIGM-HF. We made indirect comparisons of the effects of LCZ696 with putative placebos.\ud \ud Methods and results: We used the treatment-arm of the Studies Of Left Ventricular Dysfunction (SOLVD-T) as the reference trial for comparison of an ACE inhibitor to placebo and the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity-Alternative trial (CHARM-Alternative) as the reference trial for comparison of an ARB to placebo. The hazard ratio of LCZ696 vs. a putative placebo was estimated through the product of the hazard ratio of LCZ696 vs. enalapril (active-control) and that of the historical active-control (enalapril or candesartan) vs. placebo. For the primary composite outcome of cardiovascular death or heart failure hospitalization in PARADIGM-HF, the relative risk reduction with LCZ696 vs. a putative placebo from SOLVD-T was 43% (95%CI 34–50%; P < 0.0001) with similarly large effects on cardiovascular death (34%, 21–44%; P < 0.0001) and heart failure hospitalization (49%, 39–58%; P < 0.0001). For all-cause mortality, the reduction compared with a putative placebo was 28% (95%CI 15–39%; P < 0.0001). Putative placebo analyses based on CHARM-Alternative gave relative risk reductions of 39% (95%CI 27–48%; P < 0.0001) for the composite outcome of cardiovascular death or heart failure hospitalization, 32% (95%CI 16–45%; P < 0.0001) for cardiovascular death, 46% (33–56%; P < 0.0001) for heart failure hospitalization, and 26% (95%CI 11–39%; P < 0.0001) for all-cause mortality.\ud \ud Conclusion: These indirect comparisons of LCZ696 with a putative placebo show that the strategy of combined angiotensin receptor blockade and neprilysin inhibition led to striking reductions in cardiovascular and all-cause mortality, as well as heart failure hospitalization. These benefits were obtained even though LCZ696 was added to comprehensive background beta-blocker and mineralocorticoid receptor antagonist therapy.

We evaluated left ventricular function by echocardiography in a prospective study that included 98 consecutive human immunodeficiency virus (HIV)-infected patients and 40 HIV-seronegative normal controls. When compared with controls, HIV patients showed increased isovolumic relaxation time (101+/-18 ms versus 71+/-10 ms; p

We evaluated the effect of chronic Pneumocystis carinii pneumonia (PCP) prophylaxis, with a once a month dose of 300 mg of inhalatory pentamidine isethionate, on QT interval duration. We included 22 human immunodeficiency virus (HIV)-infected patients: 11 were on this medication and 11 were not. The two groups were matched for age, sex and HIV infection stage. No patient had any clinical condition or was under any medication known to affect the duration of the QT interval. The heart rate-corrected QT (QTc) was obtained by averaging the observations of three independent observers. QTc duration was similar in both groups. The time separating pentamidine administration and the performance of the ECG did not influence the results, neither did the duration of inhalatory pentamidine therapy. Our results suggest that inhalatory pentamidine does not prolong the QT interval duration and so, as opposed to what has been reported concerning intravenous pentamidine therapy, does not seem to induce an increased risk of torsades de pointes.

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

Background— Cardiovascular magnetic resonance (CMR) myocardial perfusion imaging (MPI) is a state-of-the-art noninvasive modality for detection of myocardial ischemia and coronary artery disease. Magnetic resonance coronary angiography (MRCA) allows visualization of the coronary tree, but its incremental value as part of a CMR protocol including MPI and late gadolinium enhancement (LGE) is not well established. We aimed to evaluate the additive diagnostic value of a 3-dimensional whole-heart MRCA integration into a 1.5T CMR-MPI/LGE protocol for the detection of functionally significant coronary artery disease. Methods and Results— Forty-three symptomatic patients (61±8.3 years; 65% men) with suspected coronary artery disease and intermediate/high-pretest probability underwent CMR (including CMR-MPI, MRCA, and LGE) and x-ray invasive coronary angiography (XA) with fractional flow reserve evaluation. Diagnostic performances of MRCA, CMR-MPI/LGE, and MRCA+CMR-MPI/LGE integration were determined having XA+fractional flow reserve as standard for coronary artery disease (≥90% stenosis/occlusion or fractional flow reserve≤0.80 in vessels>2 mm). MRCA inclusion into the CMR protocol was associated with a mean increase of 7.9±4.69 (0–17.7) minutes in total examination duration (14%). On patient-based analysis, MRCA had 96% sensitivity, 68% specificity, positive predictive value of 79%, and negative predictive value of 93%. CMR-MPI/LGE had 79% sensitivity, 95% specificity, positive predictive value of 95%, and negative predictive value of 78%. Integration of MRCA with CMR-MPI/LGE further improved CMR performance to 96% sensitivity, 89% specificity, positive predictive value of 92%, and negative predictive value of 94%, with a global accuracy of 93%. Conclusions— In this intermediate/high-pretest population, integration of noncontrast-enhanced whole-heart MRCA nonsignificantly improved per-patient diagnostic accuracy of a comprehensive 1.5-T stress-rest CMR-MPI/LGE protocol at a cost of longer scanning times.

BACKGROUND: Atrial fibrillation (AF) and heart failure (HF) often coexist; the consequences of such coexistence are unclear. HYPOTHESIS: HF in patients with AF is associated with poor outcomes. METHODS: This post hoc analysis of RealiseAF, a survey of AF patients, compared symptoms, hospitalizations, management, and AF control in patients with vs without HF. A total of 10,523 AF patients were analyzed according to presence/absence of HF. RESULTS: History of HF was present in 45.8%, and in more patients with permanent vs persistent, paroxysmal, or first‐episode AF (55.6%, 44.3%, 32.9%, and 29.8%, respectively; P

This study sought to compare computed tomography delayed enhancement (CTDE) against cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) for detection of ischemic scar and to test the additive value of CTDE as part of a comprehensive multidetector computed tomography (MDCT) stress-rest protocol including computed tomography perfusion (CTP) and computed tomography angiography (CTA) for the diagnosis of significant coronary artery disease (CAD).CTDE has been recently described as a promising tool for noninvasive detection of myocardial scar, similarly to CMR-LGE techniques. Despite its theoretical potential as an adjunctive tool to improve MDCT accuracy for detection of CAD, its clinical performance has not been validated.One hundred five symptomatic patients with suspected CAD (age 62.0 ± 8.0 years, 67% men) underwent MDCT, CMR, and x-ray invasive coronary angiography. The MDCT protocol consisted of calcium scoring, stress CTP under adenosine 140 μg/kg/min, rest CTP + CTA, and a low-dose radiation prospective scan for detection of CTDE. CMR-LGE was used as the reference standard for assessment of scar. Functionally significant CAD was defined as the presence of ≥90% stenosis/occlusion or fractional flow reserve measurements ≤0.80 in vessels2 mm.CTDE had good accuracy (90%) for ischemic scar detection with low sensitivity (53%) but excellent specificity (98%). Positive and negative predictive values were 82% and 91%, respectively. On a patient-based model, MDCT protocol without integration of CTDE results had a sensitivity, specificity, and positive and negative predictive values of 90%, 81%, 80%, and 90%, respectively, for the detection of functionally significant CAD. Addition of CTDE results did not improve MDCT performance (90%, 77%, 77%, and 90%, respectively).CTDE has moderate accuracy for detection of ischemic scar in patients with suspected CAD. Integration of CTDE into a comprehensive MDCT protocol including stress-rest CTP and CTA does not improve MDCT accuracy for detection of significant CAD in intermediate-to-high pre-test probability populations.

We prospectively studied, with 24-h Holter monitoring, 21 consecutive human immunodeficiency virus (HIV) infected patients, at all stages of the infection, in order to assess their dysrhythmic profile. Three (14.3%) patients presented one isolated run of supraventricular tachycardia, with10 beats, that was considered clinically irrelevant. No patient presented other clinically relevant supraventricular or ventricular tachy or bradydysrhythmias. One (4.8%) patient presented intermittent Mobitz type I second-degree AV block, two (9.5%) patients paroxistic 2:1 AV block and one (4.8%) patient presented a bifascicular block on the 12-lead ECG that persisted during the ambulatory recording. This study suggests that clinically relevant cardiac tachydysrhythmias are rare in our population of HIV infected patients. On the other hand we found an unexpectedly high incidence of cardiac impulse conduction disturbances.

Background 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. Methods 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. Results 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. Conclusions 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.