In 2008, about one-half of the population self-identified their race or skin color as either brown (43.8%) or black (6.8%), and 0.6% thought of themselves as indigenous to Brazil (5). Since 1988, ...Brazil has developed a dynamic, complex health system (Unified Health System SUS), which is based on the principles of health as a citizen’s right and the state’s duty. Currently, the health system has 3 subsectors: the public subsector (SUS), in which services are financed and provided by the state at the federal, state, and municipal levels, including military health services; the private (for-profit and nonprofit) subsector, in which services are financed in various ways with public or private funds; and the private health insurance subsector, with different types of health plans, varying insurance premiums, and tax subsidies (5). The availability of the Journal of the American College of Cardiology (JACC) in Portuguese is an opportunity for cardiologists and interns-in-training to have access to the most up-to-date and significant cardiology information.The Role of JACC Portuguese in Improving Care in Portuguese-Speaking Countries “Good science, good research, and patients will be the victims unless there is a free exchange of health information worldwide…
Trypanosoma cruzi (T. cruzi) infection is endemic in Latin America and is becoming a worldwide health burden. It may lead to heterogeneous phenotypes. Early diagnosis of T. cruzi infection is ...crucial. Several biomarkers have been reported in Chagas heart disease (ChHD), but most are nonspecific for T. cruzi infection. Prognosis of ChHD patients is worse compared with other etiologies, with sudden cardiac death as an important mode of death. Most ChHD patients display diffuse myocarditis with fibrosis and hypertrophy. The remodeling process seems to be associated with etiopathogenic mechanisms and neurohormonal activation. Pharmacological treatment and antiarrhythmic therapy for ChHD is mostly based on results for other etiologies. Heart transplantation is an established, valuable therapeutic option in refractory ChHD. Implantable cardioverter-defibrillators are indicated for prevention of secondary sudden cardiac death. Specific etiological treatments should be revisited and reserved for select patients. Understanding and management of ChHD need improvement, including development of randomized trials.
Heart Failure in South America Bocchi, Edimar Alcides
Current cardiology reviews,
05/2013, Letnik:
9, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Continued assessment of temporal trends in mortality and epidemiology of specific heart failure in South
America is needed to provide a scientific basis for rational allocation of the limited health ...care resources, and strategies to
reduce risk and predict the future burden of heart failure. The epidemiology of heart failure in South America was reviewed.
Heart failure is the main cause of hospitalization based on available data from approximately 50% of the South
American population. The main etiologies of heart failure are ischemic, idiopathic dilated cardiomyopathy, valvular, hypertensive
and chagasic etiologies. In endemic areas, Chagas heart disease may be responsible by 41% of the HF cases.
Also, heart failure presents high mortality especially in patients with Chagas etiology. Heart failure and etiologies associated
with heart failure may be responsible for 6.3% of causes of deaths. Rheumatic fever is the leading cause of valvular
heart disease. However, a tendency to reduction of HF mortality due to Chagas heart disease from 1985 to 2006, and reduction
in mortality due to HF from 1999 to 2005 were observed in selected states in Brazil. The findings have important
public health implications because the allocation of health care resources, and strategies to reduce risk of heart failure
should also consider the control of neglected Chagas disease and rheumatic fever in South American countries.
Anthracycline (ANT) chemotherapy is associated with cardiotoxicity. Prevention with β-blockers remains controversial.
This prospective, randomized, double-blind, placebo-controlled study sought to ...evaluate the role of carvedilol in preventing ANT cardiotoxicity.
The authors randomized 200 patients with HER2-negative breast cancer tumor status and normal left ventricular ejection fraction (LVEF) referred for ANT (240 mg/m
) to receive carvedilol or placebo until chemotherapy completion. The primary endpoint was prevention of a ≥10% reduction in LVEF at 6 months. Secondary outcomes were effects of carvedilol on troponin I, B-type natriuretic peptide, and diastolic dysfunction.
Primary endpoint occurred in 14 patients (14.5%) in the carvedilol group and 13 patients (13.5%) in the placebo group (p = 1.0). No differences in changes of LVEF or B-type natriuretic peptide were noted between groups. A significant difference existed between groups in troponin I levels over time, with lower levels in the carvedilol group (p = 0.003). Additionally, a lower incidence of diastolic dysfunction was noted in the carvedilol group (p = 0.039). A nonsignificant trend toward a less-pronounced increase in LV end-diastolic diameter during the follow-up was noted in the carvedilol group (44.1 ± 3.64 mm to 45.2 ± 3.2 mm vs. 44.9 ± 3.6 mm to 46.4 ± 4.0 mm; p = 0.057).
In this largest clinical trial of β-blockers for prevention of cardiotoxicity under contemporary ANT dosage, the authors noted a 13.5% to 14.5% incidence of cardiotoxicity. In this scenario, carvedilol had no impact on the incidence of early onset of LVEF reduction. However, the use of carvedilol resulted in a significant reduction in troponin levels and diastolic dysfunction. (Carvedilol Effect in Preventing Chemotherapy-Induced Cardiotoxicity CECCY; NCT01724450).
Exercise is an effective intervention for treating hypertension and arterial stiffness, but little is known about which exercise modality is the most effective in reducing arterial stiffness and ...blood pressure in hypertensive subjects. Our purpose was to evaluate the effect of continuous vs. interval exercise training on arterial stiffness and blood pressure in hypertensive patients. Sixty-five patients with hypertension were randomized to 16 weeks of continuous exercise training (n=26), interval training (n=26) or a sedentary routine (n=13). The training was conducted in two 40-min sessions a week. Assessment of arterial stiffness by carotid-femoral pulse wave velocity (PWV) measurement and 24-h ambulatory blood pressure monitoring (ABPM) were performed before and after the 16 weeks of training. At the end of the study, ABPM blood pressure had declined significantly only in the subjects with higher basal values and was independent of training modality. PWV had declined significantly only after interval training from 9.44+/-0.91 to 8.90+/-0.96 m s(-1), P=0.009 (continuous from 10.15+/-1.66 to 9.98+/-1.81 m s(-1), P=ns; control from 10.23+/-1.82 to 10.53+/-1.97 m s(-1), P=ns). Continuous and interval exercise training were beneficial for blood pressure control, but only interval training reduced arterial stiffness in treated hypertensive subjects.
Background:The neurohumoral and endothelial responses to the blood pressure (BP) lowering effects of heated water-based exercise (HEx) in resistant hypertension (HT) patients remain undefined.Methods ...and Results:We investigated these in 44 true resistant HT patients (age 53.3±0.9 years, mean±SEM). They were randomized and allocated to 2 groups, 28 to a HEx training protocol, which consisted of callisthenic exercises and walking in a heated pool for 1 h, three times weekly for 12 weeks and 16 patients to a control group maintaining their habitual activities. Measurements made before and after 12 weeks of HEx included clinic and 24-h BP, plasma levels of nitric oxide, endothelin-1, aldosterone, renin, norepinephrine and epinephrine, as well as peak V̇O2, and endothelial function (reactive hyperemia). After 12 weeks of HEx patients showed a significant decrease in clinic and 24-h systolic and diastolic BPs. Concomitantly, nitric oxide increased significantly (from 25±8 to 75±24 μmol/L, P<0.01), while endothelin-1 (from 41±5 to 26±3 pg/mL), renin (from 35±4 to 3.4±1 ng/mL/h), and norepinephrine (from 720±54 to 306±35 pg/mL) decreased significantly (P<0.01). Plasma aldosterone also tended to decrease, although not significantly (from 101±9 to 76±4 pg/mL, P=NS). Peak V̇O2increased significantly after HEx (P<0.01), while endothelial function was unchanged. No significant change was detected in the control group.Conclusions:The BP-lowering effects of HEx in resistant HT patients were accompanied by a significant reduction in the marked neurohumoral activation characterizing this clinical condition.
The Reality of Heart Failure in Latin America Bocchi, Edimar Alcides, MD, PhD; Arias, Alexandra, MD; Verdejo, Hugo, MD ...
Journal of the American College of Cardiology,
09/2013, Letnik:
62, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Heart failure (HF) data in Latin America (LA) were reviewed to guide health service planning in the prevention and treatment of HF. The HF epidemiology and the adequacy of relevant health service ...provision related to HF in LA are not well delineated. A systematic search of the electronic databases and the World Health Organization website was undertaken for HF in LA. LA countries have reduced gross income and lower total expenditure on health per capita. LA is a heterogeneous region with HF risk factors of developed and nondeveloped countries, including lower risk of raised blood glucose levels, obesity, tobacco, and aging, whereas systemic hypertension (SH), rheumatic fever, and Chagas’ disease (C’D) are higher in LA. Main etiologies of HF in LA are idiopathic dilated cardiomyopathy (from 1.3% to 37%), C’D (from 1.3% to 21%), ischemic (from 68% to 17%), SH (from 14% to 76%), valvular (from 3% to 22%), and alcohol related (from 1.1% to 8%). The prognosis of C’D HF is worse than for other etiologies. Chronic HF is the cause of death in 6.3% of cases. Decompensated HF is the main cause of cardiovascular hospitalization. The prevalence of systolic HF varies from 64% to 69%. LA is under the awful paradox of having the HF risk factors and HF epidemiology of developed countries with the added factors of SH, C’D, and rheumatic fever. Overall, in the scenario of lower total expenditure on health per capita and lower gross national income per capita, new strategies are essential for prevention and treatment of HF in LA.
Abstract
Chagas disease (CD) is a neglected infectious disease associated with early mortality and substantial disability. Three-dimensional speckle tracking (3D STE) may play a role in the ...evaluation of CD. We aim to characterize new echocardiographic variables in patients with CD and to assess the hypothesis that 3D STE may predict outcomes. Seventy-two patients with CD were included. Clinical and conventional 2D and 3D STE analysis were performed. Patients were followed up for 60 months. Clinical events were defined as hospitalization for heart failure, complex ventricular arrhythmias, heart transplant and all-cause death. Seventy-two patients were recruited and enrolled in three groups: left ventricular ejection fraction (LVEF) < 0.40 (N = 22; reduced LVEF or rLVEF); 0.40 ≤ LVEF ≤ 0.50 (N = 10; mildly reduced LVEF or mrLVEF) and LVEF > 0.50 (N = 30; preserved LVEF or pLVEF). After a Cox model analysis, the top predictors of composite endpoints were 2D LV global longitudinal strain (GLS) ≤ − 11.3% (AUC = 0.87), 2D LV global circumferential strain (GCS) ≤ − 10.1% (AUC = 0.79), 3D LV GLS ≤ − 13% (AUC = 0.82), 3D LV area strain ≤ − 16% (AUC = 0.81) and right ventricle (RV) GLS ≤ − 17.2% (AUC = 0.78). Patients with CD and mrLVEF were morphologically similar to the rLVEF patients despite the benign evolution as the pLVEF group. RV GLS, 2D LV GLS, 2D LV GCS, 3D LV GLS, and 3D LV area strain are strong predictors of 60 months outcomes in patients with CD.
Exercise oscillatory ventilation (EOV) is an abnormal breathing pattern that occurs in ~20% of patients with heart failure (HF) and is associated with poor prognosis and exercise intolerance. ...β-blockers (βb) are prescribed for most HF patients; however, their effect on EOV remains unclear. We evaluated the effect of βb on EOV in HF patients with reduced ejection fraction (HFrEF).
Fifteen patients diagnosed with HF, ejection fraction < 45%, aged from 18 to 65 years, were included before starting βb therapy. Patients underwent clinical evaluation, cardiopulmonary exercise testing, echocardiography, laboratory exams (norepinephrine levels, B type natriuretic peptide) at baseline and after βb therapy optimized for six months. Presence of exercise oscillatory breathing was determined by two experienced observers who were blinded to the moment of the test (pre or post).
Fifteen patients (1 female), aged 49.5 ± 2.5 years, with HFrEF, NYHA I-III enrolled in the study. The etiologies of the HFrEF were idiopathic (n = 8) and hypertensive (n = 7). LVEF increased after βb therapy from 25.9 ± 2.5% to 33 ± 2.6%, P = 0.02; peak VO2 did not significantly change (21.8 ± 1.7 vs 24.7 ± 1.9, P = 0.4); VE/VCO2 slope changed from 32.1 ± 10.6–27.5 ± 9.1, P = 0.03. Before βb initiation, nine patients (60%) had EOV, but only two (13%) did after optimized therapy. McNemar test was used to evaluate the significance of the association between the two moments (P = 0.02).
In patients with HF, medical therapy with βb can reverse EOV. This may explain why these patients experience symptom improvement after βb therapy.
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•The pattern of presentation and the clinical course of EOV suggest distinct pathophysiological mechanisms during sleep and exercise.•Carvedilol appears to play an important role in normalizing EOV. This effect is independent of the beneficial effects of digoxin, diuretics, and ACE inhibitors.•Patients with HF, especially those experiencing EOV, the maximum tolerated dose of carvedilol should be considered.•Heart failure patients with reduced ejection fraction may merit special attention in the presence of EOV.
Abstract Background Regular exercise is an effective intervention to decrease blood pressure (BP) in hypertension, but no data are available concerning the effects of heated water-based exercise ...(HEx). This study examines the effects of HEx on BP in resistant hypertensive patients. Methods This is a parallel, randomized controlled trial. 125 nonconsecutive sedentary patients with resistant hypertension from a hypertension outpatient clinic in a university hospital were screened; 32 patients fulfilled the study requirements. The training was performed for 60-minute sessions in a heated pool (32 °C), three times a week for 12 weeks. The HEx protocol consisted of callisthenic exercises and walking inside the pool. The control group was asked to maintain habitual activities. The main outcome measure was change in mean 24-hour ambulatory BP (ABPM). Results 32 patients (HEx n = 16; control n = 16) were randomized; none were lost to follow-up. Office BPs decreased significantly after heated water exercise (36/12 mm Hg). HEx decreased 24-hour systolic (from 137 ± 23 to 120 ± 12 mm Hg, p = 0.001) and diastolic BPs (from 81 ± 13 to 72 ± 10 mm Hg, p = 0.009); daytime systolic (from 141 ± 24 to 120 ± 13 mm Hg, p < 0.0001) and diastolic BPs (from 84 ± 14 to 73 ± 11 mm Hg, p = 0.003); and nighttime systolic (from 129 ± 22 to 114 ± 12 mm Hg, p = 0.006) and diastolic BPs (from 74 ± 11 to 66 ± 10 mm Hg, p < 0.0001). The control group after 12 weeks significantly increased in 24-hour systolic and diastolic BPs, and daytime and nighttime diastolic BPs. Conclusion HEx reduced office BPs and 24-hour ABPM levels in resistant hypertensive patients. These effects suggest that HEx may be a potential new therapeutic approach in these patients.
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