RESUMO
BACKGROUND: Nearly two-thirds of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular dysfunction, previously identified as an independent predictor of reduced functional capacity and poor prognosis. Beta-blocker therapy (ß-BT) reduces mortality and hospitalizations in patients with HFrEF and is approved as first-line therapy regardless of concomitant right ventricular function. However, the exact role of sympathetic nervous system activation in right ventricular dysfunction and the potential usefulness (or harmfulness) of ß-BT in these patients are still unclear. OBJECTIVES: The aim of the study is to evaluate the medium-term effect of ß-BT discontinuation on functional capacity and right ventricular remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable biventricular dysfunction. METHODS: In this single-centre, open-label, prospective trial, 16 patients were enrolled using the following criteria: patients were clinically stable without signs of peripheral congestion; NYHA II-III while on optimal medical therapy (including ß-BT); LVEF 40% or less; echocardiographic criteria of right ventricular dysfunction. Patients were randomized 1â:â1 either to withdraw (group 0) or continue (group 1) ß-BT. In group 0, optimal heart rate was obtained with alternative rate-control drugs. Echo and serum biomarkers were performed at baseline, after 3 and 6âmonths; CPET was performed at baseline and 6âmonths. Mann--Whitney U test was adopted to determine the relationships between ß-BT discontinuation and effects on right ventricular dysfunction. RESULTS: At 6 months' follow up, S' DTI improved (ΔS': 1.01 vs. -0.92âcm/s; Pâ=â0.03), while estimated PAPs (ΔPAPs: 0.8 vs. -7.5âmmHg; Pâ=â0.04) and echo left ventricular-remodelling (ΔEDVi: 19.55 vs. -0.96âml/mq; Pâ=â0.03) worsened in group 0. In absolute terms, the only variables significantly affected by ß-BT withdrawal were left ventricular EDV and ESV, appearing worse in group 0 (mean EDVi 115 vs. 84âml/mq; mean ESVi 79 vs. 53.9âml/mq, Pâ=â0.03). No significant changes in terms of functional capacity were observed after ß-BT withdrawal. CONCLUSION: In HFrEF patients with concomitant right ventricular dysfunction, ß-BT discontinuation did not produce any beneficial effects. In addition, despite maintenance of optimal heart rate control, ß-BT discontinuation induced worsening of left ventricular remodelling. Our study corroborates the hypothesis that improvement in left ventricular function may likewise be a major determinant for improvement in right ventricular function, reducing pulmonary wedge pressure and right ventricular afterload, with only a marginal action of its negative inotropic effect. In conclusion, ß-BT appears beneficial also in heart failure patients with biventricular dysfunction.
Assuntos
Antagonistas Adrenérgicos beta , Insuficiência Cardíaca , Disfunção Ventricular Esquerda , Disfunção Ventricular Direita , Humanos , Biomarcadores , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/tratamento farmacológico , Estudos Prospectivos , Volume Sistólico/fisiologia , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/tratamento farmacológico , Disfunção Ventricular Direita/etiologia , Suspensão de TratamentoRESUMO
Cardiac onset of a diffuse large B-cell lymphoma (DLBCL) in a HIV+ patient with hypertrophic obstructive cardiomyopathy. The sequence of diagnosis, therapeutical planning and final outcome underlines the importance of an early diagnosis that cannot be conceived without an increased attention in this clinical setting (aspecific symptoms in an HIV positive subject) by the General Practitioner.