Supra-Normal Left Ventricular Function.

Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with ß blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.

The Paramount Importance of Renal Dysfunction in Heart Failure Prognosis - Results from the REFERENCE study / La importancia primordial de la disfunción renal en el pronóstico de la insuficiencia cardíaca - Resultados del estudio REFERENCE

Aims: In heart failure patients renal dysfunction represents impaired tissue perfusion. We investigated the association of customarily used renal function parameters with short-term prognosis in patients admitted with acute decompensated heart failure in class III or IV of New York Heart Association. Material and Methods: Univariate Cox proportional hazard model was used to assess the relationship between variables and outcomes. Survival curves were designed using the Kaplan-Meier method. Results: We followed 65 patients for a median of 13.7 (Q1-Q3 6.7-18.9) months. Variables associated with an increased risk for short-term rehospitalization were baseline urea (HR: 1.098, 95% CI: 1.022-1.179, P-value=0.01), admission urea (HR: 1.048, 95% CI: 1.013-1.084, P-value=0.006), baseline creatinine (HR: 1.111, 95% CI: 1.004-1.229, P-value=0.041), admission creatinine (HR: 1.047, 95% CI: 1.005-1.092, P-value=0.027) and admission glomerular filtration rate <30 mL/min (HR: 3.535, 95% CI: 1.467-8.518, P-value=0.005). Increased risk for short-term mortality was associated with baseline urea (HR: 1.145, 95% CI: 1.032-1.270, P-value=0.010), admission urea (HR: 1.076, 95% CI: 1.021-1.135, P-value=0.006), baseline creatinine (HR: 1.157, 95% CI: 1.009-1.328, P value=0.037), admission creatinine (HR: 1.127, 95% CI: 1.055-1.204, P-value<0.001) and admission glomerular filtration rate <30 mL/min (HR: 9.791, 95% CI: 2.855-33.580, P-value<0.001). Variables associated with an increased risk for end of follow-up mortality were admission urea (HR: 1.056, 95% CI: 1.019-1.094, P-value=0.003), admission creatinine (HR: 1.104, 95% CI: 1.054-1.156, P- value<0.001) and admission glomerular filtration rate <30 mL/min (HR: 3.906, 95% CI: 1.7208.871, P- value=0.001). Conclusion: Renal dysfunction was a reliable predictor of worse prognosis as several parameters correlated with short-term prognosis. (AU)

Introducción: En la insuficiencia cardíaca, la disfunción renal representa hipoperfusión tisular. Investigamos la asociación entre parámetros utilizados cotidianamente y el pronóstico precoz de enfermos ingresados por insuficiencia cardíaca descompensada en clase III o IV de la New York Heart Association. Material y métodos: Aplicamos el modelo de riesgo proporcional de Univariante Cox y curvas de supervivencia de Kaplan-Meier. Resultados: La mediana de seguimiento de los 65 enfermos fue de 13.7 (Q1-Q3 6.7-18.9) meses. Se correlacionaron con el reingreso precoz la urea basal (HR: 1.098, 95% CI: 1.022-1.179, P-value=0.01), la urea al ingreso (HR: 1.048, 95% CI: 1.013-1.084, P-value=0.006), la creatinina basal (HR: 1.111, 95% CI: 1.004-1.229, P-value=0.041), creatinina al ingreso (HR: 1.047, 95% CI: 1.005-1.092, P-value=0.027) y la tasa de filtración glomerular <30 mL/min al ingreso <30 mL/min (HR: 3.535, 95% CI: 1.467-8.518, P-value=0.005). El riesgo de mortalidad precoz se correlacionó con la urea basal (HR: 1.145, 95% CI: 1.032-1.270, P-value=0.010), la urea al ingreso (HR: 1.076, 95% CI: 1.021-1.135, P-value=0.006), la creatinina basal (HR: 1.157, 95% CI: 1.009-1.328, P value=0.037), creatinina al ingreso (HR: 1.127, 95% CI: 1.055-1.204, P-value<0.001) y la tasa de filtración glomerular <30 mL/min al ingreso <30 mL/min (HR: 9.791, 95% CI: 2.855-33.580, P-value<0.001). Se correlacionarón con la mortalidad al final del seguimiento la urea al ingreso (HR: 1.056, 95% CI: 1.019-1.094, P-value=0.003), la creatinina al ingreso (HR: 1.104, 95% CI: 1.054-1.156, P- value<0.001) y la tasa de filtración glomerular <30 mL/min al ingreso (HR: 3.906, 95% CI: 1.7208.871, P- value=0.001). Conclusiones: La disfunción renal fue un predictor de peor pronóstico precoz. (AU)

[Tricuspid valve endocarditis in a patient with congenital heart disease]. / Endocardite da válvula tricúspide em doente com cardiopatia congénita.

A case of tricuspid valve infective endocarditis is presented. Since this was not the first episode, the patient had not undergone invasive procedures and there was no history of intravenous drug abuse, the possibility of congenital heart disease was considered, a hypothesis that was confirmed.

Decreased erythrocyte activity of methemoglobin and glutathione reductases may explain age-related high blood pressure.

OBJECTIVES: Erythrocytes may play an important role in regulating blood pressure as storage sites for nitric oxide (NO). The objective of this work was to determine whether factors related to variations in erythrocyte metabolism associated with NO bioavailability, such as the activity of two enzymes--methemoglobin reductase (MHbR) and glutathione reductase (GSHR)--may help explain age-related increased blood pressure. METHODS: The sample consisted of 468 individuals of both sexes, 237 hypertensive (HT) and 231 normotensive (NT), aged between 18 and 98 years (48.81 +/- 19.46). The activity of MHbR (micromol.g Hb-1.min-1) and of GSHR (micromol.g Hb-1.min-1) was determined in erythrocytes by spectrophotometry. The statistical methods used were the Mann-Whitney test, Spearman's correlation coefficient and binary logistic regression. RESULTS: In this population, age was a risk factor for hypertension (OR=1.055, 95% CI = 1.045-1.065, p < 0.001). There was a significant difference in erythrocyte activity of these enzymes between normotensive and hypertensive subjects, with lower values in hypertensives: MHbR-NT = 16.97 (3.82-34.63), HT = 16.26 (3.26-37.10), p = 0.012; and GSHR-NT=57.60 (21.59-96.58), HT = 39.26 (23.07-90.27), p < 0.001. Enzyme activity was inversely correlated with age (MHbR: r = -0.193, p < 0.001; GSHR: r = -0.757, p < 0.001). MHbR correlated directly with GSHR only in hypertensive patients (r = 0.343, p = 0.034), which was not observed in normotensives. CONCLUSIONS: Age was a risk factor for hypertension. The erythrocyte activity of glutathione and metahemoglobin reductases, essential for redox balance and nitric oxide bioavailability in erythrocytes, may contribute only partially to the increased prevalence of age-related hypertension, and other factors should be taken into consideration, such as nutrition and antihypertensive medication.

Alterations in plasma semicarbazide-sensitive amine oxidase activity in hypertensive heart disease with left ventricular systolic dysfunction.

BACKGROUND: Semicarbazide-sensitive amine oxidase (SSAO) is found in various mammalian tissues, particularly in vascular smooth muscle cells, but also in plasma. It has been suggested that it plays an important role in vascular endothelial damage and in progression of atherosclerosis through conversion of endogenous amines into cytotoxic aldehydes, ammonia and hydrogen peroxide. In patients with diabetes mellitus and chronic heart failure, plasma activity appears to rise in parallel with disease severity. METHODS AND RESULTS: Plasma SSAO and monoamine oxidase (MAO) activity was measured in 39 patients with hypertensive heart disease and left ventricular systolic dysfunction, in NYHA heart failure class II-IV, and compared to values in 89 controls. SSAO was found to be elevated in patients compared to controls (2.781 +/- 1.599 vs. 1.627 +/- 0.751 micromol/l/h; p = 0.000). Plasma MAO was also significantly increased in the patient group (3.837 +/- 1.899 vs. 3.077 +/- 1.559 (micromol/l/h; p = 0.018). No significant differences were seen between different NYHA classes, but class IV patients presented the highest SSAO activity. SSAO and MAO activity showed a trend for a positive correlation (R = 0.265; p = 0.092). CONCLUSION: The finding of elevated plasma SSAO and MAO activity in congestive heart failure supports the hypothesis that amine oxidases may be involved in the pathogenesis of vascular endothelial damage.

GST M1/T1 and MTHFR polymorphisms as risk factors for hypertension.

The aim of this study is to investigate GSTM1, GSTT1 and MTHFR genetic polymorphisms and its relation with total plasma glutathione (tGSH) levels in hypertension. Genotype distributions of GSTM1 and GSTT1 deletion polymorphisms and C677T variant of MTHFR were examined in a sample of 94 hypertensive patients with congestive heart failure and 207 healthy unrelated Portuguese individuals using PCR techniques. Plasma GST activity was determined spectrophotometrically. The antioxidant status was evaluated by fluorometric assays of tGSH. Genotype distributions of GSTT1 (chi2 test; p < 0.01) and MTHFR (chi2 test; p < 0.01) differ significantly between control and hypertensive patients with a greater prevalence of "non-null GSTT1/M1" and CT (heterozygous) genotypes. Moreover, GST activity and tGSH were markedly decreased in hypertension but there is no correlation with the studied polymorphisms. GSH depletion confirmed the possible involvement of oxidative stress in this pathology. Deletion of GSTT1 gene might be considered as protective factor for hypertension.

BNP and ANP as diagnostic and predictive markers in heart failure with left ventricular systolic dysfunction.

BACKGROUND: The prevalence of chronic heart failure (CHF) with systolic dysfunction is increasing. Plasma natriuretic peptides have been envisaged as diagnostic and predictive markers. AIMS: To investigate the relationship between the levels of B-type natriuretic peptide (BNP) and A-type natriuretic peptide (ANP) and the clinical and functional parameters of CHF in outpatients with CHF at baseline, compared with normal healthy controls; to find out the differences in a randomised controlled trial between patients treated with an angiotensin-converting enzyme (ACE) inhibitor, captopril, or an angiotensin receptor blocker (ARB), irbesartan. These differences were assessed throughout the six-month treatment period and at the sixth month. METHODS: Plasma BNP (pmol/L) and ANP (pmol/L) were determined in 68 hypertensive patients with dilated cardiomyopathy, NYHA class III-IV and ejection fraction (EF) < or = 40%, and in 26 normal controls. Statistical analysis for BNP and ANP was done by Students t-test. The patient group was randomly subdivided into two subgroups of 34 patients, each treated with either an ARB, irbesartan, or an ACE inhibitor (ACE-I), captopril. BNP and ANP were measured in both subsamples and correlated with clinical, functional and neurohormonal parameters throughout a follow-up period of six months and at the sixth month. RESULTS: The mean EF in the patient sample was 33.43+/-6.52% and in the controls was 61.96 +/-3.53% (p=0.000). The mean BNP (pmol/L) in patients was 44.78+/-54.36 and in the controls was 7.12+/-8.28 (p=0.000) and the mean ANP (pmol/L) was 30.32+/-25.97 in patients and 11.18+/-7.92 in controls (p=0.000). A statistically significant difference was found between patients and healthy controls. Significant correlations were found between natriuretic peptides and EF. Between the baseline phase and the sixth month, BNP and ANP decreased significantly in the ARB group. At the sixth month, both BNP and ANP were lower in the ARB group. Evidence of clinical benefit was found with both ARB or ACE-I treatment throughout the six months, with patients moving from classes III and IV to class II NYHA. Improvement of EF was also found, with transition of patients with lower EF (even <30%) to higher values. EF was higher in the ARB group at the sixth month. CONCLUSIONS: BNP and ANP can be useful diagnostic tools in hypertensive CHF patients with moderate-to-severe LV dysfunction. The decrease in BNP and ANP in the ARB group throughout six months, as well as the lower value at the sixth month, suggest a prognostic value of these parameters.

[Pulmonary embolism. Modern concepts]. / Tromboembolismo pulmonar. Conceitos actuais.

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography have shown promise. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractioned heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused in the epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.