Utilidad del hierro parenteral en pacientes con ferropenia con o sin anemia en una Unidad Multidisciplinaria de Insuficiencia Cardíaca: una experiencia nacional

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Abstract: Introduction: Patients with Heart Failure (HF) are a very complex group, with multiple comorbidities and multi-medicated with a high rate of readmission due to decompensation. Iron deficiency has emerged as a frequent comorbidity that needs to be systematically investigated, given the importance of a timely and adequate treatment to improve quality of life and reduce hospitalization and mortality. Parenteral iron treatment has shed light on a holistic approach to patient care and has favorably impacted the evolution of patients in international studies, which has resulted in the incorporation of parenteral iron use in international guidelines for the management of patients with iron deficiency in HF. Regarding available types of iron, carboxymaltose iron is chosen because its administration is convenient, and it is possible to provide high doses of iron in a single administration. Objective: To determine the clinical impact of parenteral iron administration in a population of HF patients with reduced ejection fraction who present iron deficiency with or without anemia in a Multidisciplinary Heart Failure Unit (UMIC, in Spanish). Methodology: This is a prospective cohort study. Patients with HF who presented a reduced ejection fraction < 40% were included; over 18 years of age, of any gender; with HF of any etiology; in a stable clinical situation and with prior informed consent. Patients on previous iron or erythropoietin treatment, transfused in the last 3 months and / or with a history of iron anaphylaxis were excluded. Iron metabolism and blood count were requested at the beginning. Iron deficiency was defined as ferritin < 100ug/ l or between 100 and 300ug / l and an IST < 20%. Iron carboxymaltose was administered according to weight and baseline hemoglobin. NYHA Functional Class (NYHA FC) was recorded and a quality-of-life test (Minnesota questionnaire) and a 6-minute walk test were performed before and after iron administration. The statistical software used for data processing was STATA v.16.0. The statistical significance value was set at alpha 0.05. Results: 47 patients were included: 29 women and 18 men. Ischemic etiology was the most prevalent: 44.7%; idiopathic 23.4%, hypertensive 10.6% and valvular 10.6%. Out of the patients with iron deficiency included, 44.7% did not have anemia. Before the iron administration 79% were in NYHA FC I or II, 21% in NYHA FC III, no patients were in NYHA FC IV; the average value of the Minnesota questionnaire was 59 and the average 6-minute walk test (TM6M) was 180m. After iron administration, the Minnesota questionnaire value was 41.5 and the mean 6M walk was 240m, which was a statistically significant difference (p < 0.05). Conclusions: The experience with the use of parenteral iron in patients with iron deficiency and HF at UMIC has clearly been beneficial. A positive impact is evidenced in the quality-of-life test and the 6-minute walk test. The results support the search and treatment of iron deficiency not related to the existence of anemia. This first national experience places us at the same level of international centers, prioritizing the systematic consideration of treatment.

Resumo: Introdução: Pacientes com Insuficiência Cardíaca (IC) são um grupo muito complexo, com múltiplas comorbidades e multimedicados, com alto índice de readmissão por descompensação. A deficiência de ferro tem surgido como uma comorbidade frequente, a ser sistematicamente investigada dada a importância de seu tratamento oportuno e adequado, a fim de melhorar a qualidade de vida e reduzir hospitalizações e mortalidade. O tratamento parenteral com ferro lançou luz sobre uma abordagem holística aos pacientes e impactou favoravelmente a evolução dos pacientes em estudos internacionais, levando ao posicionamento do uso do ferro parenteral nas diretrizes internacionais para o manejo de pacientes com deficiência de ferro na IC. Em relação aos tipos de ferro disponíveis, o ferro carboximaltose é de escolha pela praticidade de sua administração, podendo-se administrar altas doses de ferro em uma única administração. Objetivo: Determinar o impacto clínico da administração parenteral de ferro em uma população de pacientes com IC com fração de ejeção reduzida que apresentam deficiência de ferro com ou sem anemia em uma Unidade Multidisciplinar de Insuficiência Cardíaca (UMIC). Metodologia: Este é um estudo de coorte prospectivo. Foram incluídos pacientes com IC que apresentavam fração de ejeção reduzida < 40%; maiores de 18 anos, de qualquer gênero; com IC de qualquer etiologia; em situação clínica estável e com consentimento prévio informado. Pacientes em tratamento prévio com ferro ou eritropoietina, transfundidos nos últimos 3 meses e / ou com história de anafilaxia por ferro foram excluídos. O metabolismo do ferro e o hemograma foram solicitados no início. A deficiência de ferro foi definida como ferritina < 100ug / l ou entre 100 e 300ug / le um IST < 20%. A carboximaltose de ferro foi administrada de acordo com o peso e a hemoglobina basal. A CF NYHA foi registrada e um teste de qualidade de vida (questionário de Minnesota) e um teste de caminhada de 6 minutos foram realizados antes e após a administração de ferro. O software estatístico utilizado para o processamento dos dados foi o STATA v.16.0. O valor de significância estatística foi estabelecido em alfa 0,05. Resultados: foram incluídos 47 pacientes: 29 mulheres e 18 homens. A etiologia isquêmica foi a mais prevalente: 44,7%; idiopáticos 23,4%, hipertensos 10,6% e valvares 10,6%. Dos pacientes com deficiência de ferro incluídos, 44,7% não apresentavam anemia. A administração anterior de ferro 79% estavam em CF I ou II, 21% em CF III, nenhum paciente em CF IV; o valor médio do questionário de Minnesota foi 59 e a média do teste de caminhada de 6 minutos (TM6M) 180m. Após a administração do ferro, o valor do questionário de Minnesota foi de 41,5 e a média de 6M foi de 240m, sendo esta diferença estatisticamente significativa (p < 0,05). Conclusões: A experiência com o uso de ferro parenteral em pacientes com deficiência de ferro e IC na UMIC tem sido claramente benéfica. Um impacto positivo é evidenciado no teste de qualidade de vida e no teste de caminhada de 6 minutos. Os resultados apóiam a busca e o tratamento da deficiência de ferro independente da existência de anemia. Esta primeira experiência nacional nos coloca em pé de igualdade com os centros internacionais, priorizando a consideração sistemática do tratamento.

Hospital de día en la unidad de insuficiencia cardíaca como una estrategia de abordaje integral: análisis de un único centro en América Latina / Heart Failure Day Hospital as a Comprehensive Approach Strategy in the Heart Failure Unit: Analysis of a Single Center in Latin America

RESUMEN Objetivos: Describir las características clínicas, el impacto en la calidad de vida, la clase funcional (CF), el número de internaciones y la supervivencia de los pacientes que ingresaron a un hospital de día (HD) de insuficiencia cardíaca (IC). Material y métodos: Se analizaron en forma retrospectiva aquellos pacientes que ingresaron a un HD para la infusión de hierro, furosemida, levosimendán o la combinación de estos dos últimos fármacos, durante un período de 3 años. Las variables analizadas, al inicio y a los 6 meses, fueron la CF (NYHA), la prueba de marcha de 6 minutos (PM6M) y calidad de vida mediante el cuestionario de Minnesota (MLHFQ). El número de internaciones por IC fue comparado con el del año previo al ingreso al HD y la supervivencia fue evaluada al año de seguimiento. Resultados: Se observó una mejoría significativa de la CF en los 4 grupos, y del número de internaciones por IC en los primeros 3. Conclusiones: El desarrollo del HD puede modificar el presente y futuro de esta población.

ABSTRACT Objectives: To describe the clinical characteristics, impact on quality of life, functional class (FC), number of hospitalizations, and survival rate of patients with heart failure (HF) enrolled in an outpatient heart failure clinic (HFC). Methods: Patients enrolled in a HFC for infusion of iron, furosemide, levosimendan -or the combination of these two drugsover a 3-year period were retrospectively analyzed. Baseline and 6-month variables were FC (NYHA), 6-minute walk test (6MWT) and quality of life using the Minnesota questionnaire (MLHFQ). The number of HF hospitalizations was compared with that of the year prior to HFC enrollment, and survival was assessed at 1-year follow-up. Results: A significant improvement in FC was observed in all four groups, and a decrease of HF hospitalizations in the first three. Conclusions: Outpatient HFC development can change the present and future of this population.

Etiological profile in patients with heart failure

Background: The incidence and prevalence rates of heart failure (HF) are increasing worldwide. The prevalence of HF rises exponentially with increasing age and affects 4% to 8% of people older than 65. The leading causes of HF in India include coronary artery disease (CAD), diabetes, hypertension, rheumatic valvular heart diseases and primary cardiac muscle diseases. Rheumatic heart disease (RHD) is still a common cause of HF in India. Epidemiological studies have estimated that 1.5% to 2% population experience HF and it is the main reason for hospital admission of elderly patients. The objective of this study was to establish the etiological factors of heart failureMethods: A cross sectional study of 150 patients above the age of 18 years presented with heart failure diagnosed clinically on the basis of Framingham heart failure criteria and echocardiography, done over a period of one year in department of medicine in BRD medical college Gorakhpur Uttar Pradesh.Results: A total of 150 patients were include in this analysis the majority of patients were male (57.3%). Age of patients ranged from 18 - 70 years and 84% patients were above the age of 40 years.Conclusions: Heart failure was more prevalent in elderly male above 40 years of age. Myocardial infarction, DCMP, rheumatic heart disease and hypertensive heart failure are the common etiology leading to heart failure.

Comunicación interauricular en adultos. Experiencia de resultados quirúrgicos en el Hospital Carlos Andrade Marín durante 13 años. ¿Morbimortalidad alta o baja? / Atrial septal defects in adults. Experience of surgical results at the Carlos Andrade Marín Hospital for 13 years. High or low morbidity and mortality?

La población de adultos con cardiopatías congénitas ha aumentado en las últimas décadas. La cardiopatía congénita del tipo comunicación interauricular (CIA) puede manifestarse mediante síntomas de intolerancia al ejercicio con discapacidad significativa en un paciente previamente asintomático. Los síntomas se inician generalmente a partir de la cuarta década de la vida. La reparación quirúrgica tiene una mortalidad baja en edades tempranas (< 1% en pacientes sin comorbilidad relevante) y buenos resultados a largo plazo. Materiales y métodos: realizamos un estudio descriptivo retrospectivo, considerando todos los casos de CIA intervenidos quirúrgicamente en adultos (> 18 años de edad), desde enero de 2003 a junio de 2015, valorando el beneficio quirúrgico a corto y mediano plazo, y evaluando el mejoramiento, deterioro o mantenimiento de la clase funcional, determinación del "shunt" residual, tamaño y función del ventrículo derecho, insuficiencia tricuspídea y presión arterial pulmonar por ecocardiografía transtorácica, así como la evaluación de arritmias por antecedentes conocidos o no. Resultados y discusión: Un total de 163 pacientes fueron sometidos a cierre de CIA en el período descrito. El grupo más representativo en cuanto a género fue el sexo femenino (n=114), en relación al género masculino (n=49). Se comprobó el beneficio quirúrgico en todos los operados (100%). La mortalidad fue nula. En cuanto a la clase funcional catorce pacientes regresaron de clase funcional II a I (28% mejora de clase funcional II), tres pasaron de clase III a II 100% mejora de clase funcional NYHA III), y diecisiete (13.38%) se sumaron a la clase funcional I, de los 110 pacientes previos que se tenía. En todos los casos se realizó un ecocardiograma transtorácico de control a los 3 y 6 meses, excepto en los que fueron operados en 2015. Resultados finales: : La función del ventrículo derecho (TAPSE) mejoró en 17 casos luego de la intervención quirúrgica, con 9 pacientes cuya mejoría se evidenció dentro de los 3 primeros meses y 8 pacientes a los 6 meses; la presión sistólica de la arteria pulmonar (PSAP) mejoró en 26 casos. Se documentaron 4 tipos de arritmias: 2 bradiarritmias (un bloqueo AV de II grado y un bloqueo AV total) y 2 taquiarritmias (un paciente con fibrilación auricular y uno con aleteo auricular) que ameritaron manejo y control, sin aumentar o complicar la morbimortalidad.. Conclusiones: la reparación quirúrgica de una CIA en adultos en nuestra institución tiene una mortalidad nula y buenos resultados; la esperanza de vida es normal y la morbilidad baja a corto, mediano y largo plazo. El resultado es mejor si la reparación se realiza en pacientes menores de 30 años. El cierre de la CIA después de los 40 años parece no afectar la frecuencia de aparición de arritmias durante el seguimiento. No obstante, los pacientes se benefician del cierre a cualquier edad en lo que a morbilidad se refiere (capacidad de ejercicio, disnea, insuficiencia cardíaca derecha, enfermedad cerebrovascular).

Introduction: The population of adults with congenital heart disease has increased in recent decades. Congenital heart disease, atrial septal defect (ASD) type, can lead to symptoms such as exercise intolerance with significant disability in a previously asymptomatic patient. Symptoms usually start from the fourth decade of life. Surgical repair has low mortality at an early age (<1% in patients without significant comorbidity) and good long-term results. Materials and methods: We conducted a retrospective study, considering all cases of atrial septal defect underwent surgery in adults (> 18 years), from January 2003 to June 2015, assessing the surgical benefit in the short and medium term, and evaluating improvement, deterioration or maintenance of functional class, determination of residual shunt, size and function of the right ventricle, tricuspid regurgitation and pulmonary artery pressure by transthoracic echocardiography and assessment of arrhythmias known or background. Results and discussion: A total of 163 patients were collected from all cardiac surgeries performed in the period described, of which the most representative group was the women (n = 114) compared to males (n = 49) . Of these it was found that; Surgical Benefit: it was 100% in all operated without mortality data; Functional Class: 14 patients returned to functional class II to I (28% improvement in functional class II), 3 patients underwent functional class III to II (100% improvement in NYHA functional class III), and 17 patients (13,38%) joined functional class I, from the previous 110 patients who had. In all cases it was possible to perform a control transthoracic echocardiography at 3 and 6 months, except for those who were operated in 2015, and the end result can be concluded that; Right Ventricular Function (TAPSE): improved in 17 cases after surgery, with 9 patients within the first three months and 8 patients at 6 months; whereas Systolic Pulmonary Artery Pressure (SPAP): improved in 26 cases. Documented 4 types of Arrhythmias, 2 bradyarrhythmias (II degree AV block and AV Total Lock) and 2 tachyarrhythmias (atrial fibrillation and atrial flutter), which merited management and control without increasing morbidity or complicate documented. Conclusions: Surgical repair of an ASD in adults in our institution has a zero mortality and good results with normal life expectancy and low morbidity in the short, medium and long term. The result is better if the repair is performed in patients under 30 years. The closure of the CIA after 40 years seems not affect the frequency of arrhythmias during follow-up. However, patients benefit closure at any age when it refers to morbidity (exercise capacity, breathlessness, right heart failure, cerebrovascular disease).

Correlação entre classe funcional e qualidade de vida em usuários de marcapasso cardíaco / Correlation between functional class and quality of life among cardiac pacemaker users

INTRODUÇÃO: Os crescentes avanços tecnológicos desenvolvidos para o tratamento de distúrbios de condução cardíaca vêm proporcionando aos pacientes melhores condições de vida. As escalas de classificação funcional e questionários de qualidade de vida (QV) constituem uma forma suplementar de avaliação dos aspectos físicos, emocionais e funcionais dos pacientes. Entretanto, permanece a seguinte questão: existe correlação entre a classe funcional (CF) e a percepção da QV em usuários de marcapasso (MP)? OBJETIVO: O objetivo do estudo foi avaliar se existe correlação entre classe funcional (CF) e QV em portadores de MP cardíaco definitivo. MÉTODOS: Foram avaliados 14 usuários de MP. Para avaliar CF, foi utilizada a escala de atividade específica proposta por Goldman, e, com objetivo de avaliação da QV, foi aplicado o questionário Aquarel associado ao SF-36. Com o objetivo de verificar se existe correlação entre as variáveis, foi aplicado o teste de correlação de Spearman, considerando como significativo a< 0,05. Para a análise dos dados, foi utilizado Software SPSS for Windows versão 10.0. RESULTADOS: A CF correlacionou-se inversa e significativamente com a QV avaliada pelo Aquarel em seus três domínios: desconforto no peito (r= -0,666; p= 0,009); dispnéia (r= -0,604; p= 0,022) e arritmia (r= -0,550; p= 0,041). Já em relação ao SF-36, dos seus oito domínios, três estabeleceram uma correlação significativa com a CF: capacidade funcional (r= -0,745; p= 0,002); dor (r= -0,667; p= 0,009) e vitalidade (r= -0,591; p= 0,026). CONCLUSÃO: No presente estudo, encontrou-se correlação significativa entre CF e QV, sugerindo que as escalas de classificação funcional podem refletir aspectos da QV de portadores de MP.

INTRODUCTION: Growing technological progress in treating patients with heart conduction disturbances has provided such patients with better life conditions. Functional classification (FC) scales and quality of life (QOL) questionnaires are additional means for evaluating patients' physical, emotional and functional characteristics. However, the question remains as to whether there is any association between FC and perception of QOL among pacemaker users. OBJECTIVE: To evaluate whether there is any correlation between FC and QOL among definitive cardiac pacemaker users. METHOD: Fourteen pacemaker users were evaluated. To assess FC, the specific activity scale proposed by Goldman was used. To evaluate QOL, the Aquarel questionnaire was used in association with SF-36. The Spearman correlation test was applied to investigate whether there was any association between the variables, considering p< 0.05 to be significant. The SPSS for Windows software, version 10.0, was used for the data analysis. RESULTS: There was a significant negative correlation between FC and QOL through evaluation by Aquarel questionnaire in its three domains: chest discomfort (r= -0.666; p= 0.009); dyspnea (r= -0.604; p= 0.022); and arrhythmia (r= -0.550; p= 0.041). Among the eight domains of SF-36, three showed a significant correlation with FC: physical functioning (r= -0.745; p= 0.002); pain (r= -0.667; p= 0.009); and vitality (r= -0.591; p= 0.026). CONCLUSION: In the present study, a significant correlation was found between FC and QOL, thus suggesting that functional classification scales may reflect aspects of QOL among pacemaker users.

A study on the adaptation of head posture after activator therapy in functional Class III malocclusion patients / 대한치과교정학회지

This study was carried out to research the adaptation patterns of head posture after activator therapy in functional class ill malocclusion patients. For this purpose, 29 functional class III malocclusion patients, from the ages of 8 to 13 years old, were used. 1. Increase in capacity of oral cavity capacity were found in all the samples, but craniocervical angulation were varied into increased group and decreased group after activator therapy. 2. Head posture exhibited the compensatory adaptation in the relative growth increments of the vertical dimension, ALFH and PLFH. 1) A group with more PLFH and less sagittal angle showed relatively small growth increment in PLFH during the treatment period, thus craniocervical angulation was increased. 2) A group with less PLFH and more sagittal angle showed relatively great growth incrmenet in PLFH during the treatment period, thus craniocervical angulation was decreased.

Surgical treatment of atrial septal defect in adult patients / 영남의대학술지

The study consisted of all patients over 35yerars old undergoing surgical repair of atrial septal defect for the period from June 1985, to August 1992. The following results were observed. 1. ASD was closed with patch in 11 (73%) patients. 2. The relationship of pulmonary artery systolic pressure to Qp/Qs ratio was not significant. 3. Before operation 6 patients were in NYHA functional class II. 8 were in class III, After operation 8 patients were in class I, 6 were in class II. 4. Atrial fibrillation has persisted in 3 patients and returned regular rhythm in 1 patient after surgery. 5. There was no operative mortality and we had good surgical results regardless of patient's age.