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1.
Eur J Heart Fail ; 23(3): 352-380, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33605000

RESUMO

In this document, we propose a universal definition of heart failure (HF) as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. We also propose revised stages of HF as: At risk for HF (Stage A), Pre-HF (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D). Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). This includes HF with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41-49%; HF with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40%.


Assuntos
Cardiologia , Insuficiência Cardíaca , Austrália , Canadá , China , Humanos , Índia , Japão , Nova Zelândia , Prognóstico , Volume Sistólico , Função Ventricular Esquerda , Redação
2.
Eur J Heart Fail ; 20(6): 1031-1038, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29761861

RESUMO

AIM: There is limited information on the outcomes after primary prevention implantable cardioverter-defibrillator (ICD) implantation in patients with heart failure (HF) and diabetes. This analysis evaluates the effectiveness of a strategy of ICD plus medical therapy vs. medical therapy alone among patients with HF and diabetes. METHODS AND RESULTS: A patient-level combined-analysis was conducted from a combined dataset that included four primary prevention ICD trials of patients with HF or severely reduced ejection fractions: Multicenter Automatic Defibrillator Implantation Trial I (MADIT I), MADIT II, Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE), and Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). In total, 3359 patients were included in the analysis. The primary outcome of interest was all-cause death. Compared with patients without diabetes (n = 2363), patients with diabetes (n = 996) were older and had a higher burden of cardiovascular risk factors. During a median follow-up of 2.6 years, 437 patients without diabetes died (178 with ICD vs. 259 without) and 280 patients with diabetes died (128 with ICD vs. 152 without). ICDs were associated with a reduced risk of all-cause mortality among patients without diabetes [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.46-0.67] but not among patients with diabetes (HR 0.88, 95% CI 0.7-1.12; interaction P = 0.015). CONCLUSION: Among patients with HF and diabetes, primary prevention ICD in combination with medical therapy vs. medical therapy alone was not significantly associated with a reduced risk of all-cause death. Further studies are needed to evaluate the effectiveness of ICDs among patients with diabetes.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Diabetes Mellitus/epidemiologia , Insuficiência Cardíaca/terapia , Prevenção Primária/métodos , Volume Sistólico/fisiologia , Comorbidade/tendências , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
3.
Eur J Heart Fail ; 20(2): 304-314, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29082629

RESUMO

AIMS: Patients hospitalized for heart failure (HF) are at high risk for 30-day readmission. This study sought to examine the timings and causes of readmission within 30 days of an HF hospitalization. METHODS AND RESULTS: Timing and cause of readmission in the ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide and Decompensated Heart Failure) trial were assessed. Early and late readmissions were defined as admissions occurring within 0-7 days and 8-30 days post-discharge, respectively. Patients who died in hospital or remained hospitalized at day 30 post-randomization were excluded. Patients were compared by timing and cause of readmission. Logistic and Cox proportional hazards regression analyses were used to identify independent risk factors for early vs. late readmission and associations with 180-day outcomes. Of the 6584 patients (92%) in the ASCEND-HF population included in this analysis, 751 patients (11%) were readmitted within 30 days for any cause. Overall, 54% of readmissions were for non-HF causes. The median time to rehospitalization was 11 days (interquartile range: 6-18 days) and 33% of rehospitalizations occurred by day 7. Rehospitalization within 30 days was independently associated with increased risk for 180-day all-cause death [hazard ratio (HR) 2.38, 95% confidence interval (CI) 1.93-2.94; P < 0.001]. Risk for 180-day all-cause death did not differ according to early vs. late readmission (HR 0.99, 95% CI 0.67-1.45; P = 0.94). CONCLUSIONS: In this hospitalized HF trial population, a significant majority of 30-day readmissions were for non-HF causes and one-third of readmissions occurred in the first 7 days. Early and late readmissions within the 30-day timeframe were associated with similarly increased risk for death. Continued efforts to optimize multidisciplinary transitional care are warranted to improve rates of early readmission.


Assuntos
Insuficiência Cardíaca/terapia , Readmissão do Paciente/tendências , Idoso , Alberta/epidemiologia , Causas de Morte/tendências , Método Duplo-Cego , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Itália/epidemiologia , Masculino , Países Baixos/epidemiologia , Alta do Paciente/tendências , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
4.
Acad Emerg Med ; 25(1): 85-93, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28990334

RESUMO

Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either "inpatient" or "ED-based." Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas.


Assuntos
Medicina de Emergência , Insuficiência Cardíaca/terapia , Pesquisa/tendências , Doença Aguda , Gerenciamento Clínico , Medicina de Emergência/tendências , Humanos , Alta do Paciente , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Estados Unidos
5.
Eur J Heart Fail ; 18(11): 1342-1350, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27813304

RESUMO

AIMS: Guided by predictive characteristics of cardiovascular biomarkers, we explored the clinical implications of a simulated biomarker-guided heart failure (HF) and major adverse cardiovascular events (MACE) prevention strategy in the community. METHODS AND RESULTS: In a community cohort (n = 1824), the predictive characteristics for HF and MACE of galectin-3 (Gal-3), ST2, high-sensitivity cardiac troponin I (hscTnI), high-sensitivity C-reactive protein (hsCRP), N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) were established. We performed number needed to screen (NNS) and treat (NNT) with the intervention analyses according to biomarker screening strategy and intervention efficacy in persons with at least one cardiovascular risk factor. In the entire cohort, for both HF and MACE, the predictive characteristics of NT-proBNP and hscTnI were superior to other biomarkers; alone, in a multimarker model, and adjusting for clinical risk factors. An NT-proBNP-guided preventative intervention with an intervention effect size (4-year hazard ratio for intervention in biomarker positive cohort) of ≤0.7 would reduce the global burden of HF by ≥20% and MACE by ≥15%. From this simulation, the NNS to prevent one HF event or MACE in 4 years would be ≤100 with a NNT to prevent one HF event of ≤20 and one MACE of ≤10. CONCLUSIONS: The predictive characteristics of NT-proBNP and hscTnI for HF or MACE in the community are superior to other biomarkers. Biomarker-guided preventative interventions with reasonable efficacy would compare favourably to established preventative interventions. This data provides a framework for biomarker selection which may inform design of biomarker-guided preventative intervention trials.


Assuntos
Proteína C-Reativa/metabolismo , Doenças Cardiovasculares/sangue , Galectina 3/sangue , Insuficiência Cardíaca/sangue , Proteína 1 Semelhante a Receptor de Interleucina-1/sangue , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Troponina I/sangue , Idoso , Fibrilação Atrial/sangue , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/metabolismo , Biomarcadores , Doenças Cardiovasculares/metabolismo , Doenças Cardiovasculares/mortalidade , Estudos de Coortes , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/metabolismo , Humanos , Vida Independente , Ataque Isquêmico Transitório/sangue , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/metabolismo , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/metabolismo , Modelos de Riscos Proporcionais , Embolia Pulmonar/sangue , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/metabolismo , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/metabolismo
6.
Heart Fail Clin ; 11(4): 603-14, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26462100

RESUMO

In-hospital worsening heart failure represents a clinical scenario wherein a patient hospitalized for acute heart failure experiences a worsening of their condition, requiring escalation of therapy. Worsening heart failure is associated with worse in-hospital and postdischarge outcomes. Worsening heart failure is increasingly being used as an endpoint or combined endpoint in clinical trials, as it is unique to episodes of acute heart failure and captures an important event during the inpatient course. While prediction models have been developed to identify worsening heart failure, there are no known FDA-approved medications associated with decreased worsening heart failure. Continued study is warranted.


Assuntos
Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Doença Aguda , Ensaios Clínicos como Assunto/estatística & dados numéricos , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Sistema de Registros , Estados Unidos/epidemiologia
7.
Eur Heart J ; 35(1): 16-24, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24216390

RESUMO

The natriuretic peptides are important tools to establish diagnosis and prognosis in heart failure (HF). With application of therapies for HF, changes in both B-type natriuretic peptide (BNP) and its amino terminal cleavage fragment (NT-proBNP) parallel the benefits of the HF therapy applied. This dynamic nature of BNP and NT-proBNP relative to therapeutic intervention in HF has led to the concept of using the biomarkers as a 'guide' for intensification of HF care with a goal of not only achieving guideline-directed medical therapy goals accompanied by targeted natriuretic peptide suppression below prognostic thresholds. In studies achieving this combination of therapy optimization and BNP/NT-proBNP suppression, superior outcomes have been observed, and the approach was well tolerated. Natriuretic peptide-guided HF therapy has recently been given a recommendation in US HF guidelines to achieve guideline-directed medical therapy (Class IIa) and possibly improve outcome (Class IIb), while other clinical practice guidelines (including those from the European Society of Cardiology) await results from emerging clinical trial data. We will review lessons learned in the past regarding this novel concept of biomarker guided HF care, and discuss future directions for the approach.


Assuntos
Insuficiência Cardíaca/terapia , Peptídeo Natriurético Encefálico/metabolismo , Fragmentos de Peptídeos/metabolismo , Fatores Etários , Assistência Ambulatorial , Biomarcadores/metabolismo , Ensaios Clínicos como Assunto , Análise Custo-Benefício , Previsões , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/fisiopatologia , Humanos , Metanálise como Assunto , Segurança do Paciente , Prognóstico , Fatores de Risco , Volume Sistólico/fisiologia , Fatores de Tempo , Disfunção Ventricular Esquerda/fisiopatologia
8.
J Am Heart Assoc ; 2(6): e000399, 2013 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-24200688

RESUMO

BACKGROUND: Currently available screening tools for left ventricular (LV) hypertrophy (LVH) and systolic dysfunction (LVSD) are either expensive (echocardiography) or perform suboptimally (B-type natriuretic peptide [BNP]). It is unknown whether newer biomarkers are associated with LVH and LVSD and can serve as screening tools. METHODS AND RESULTS: We studied 2460 Framingham Study participants (mean age 58 years, 57% women) with measurements of biomarkers mirroring cardiac biomechanical stress (soluble ST-2 [ST2], growth differentiation factor-15 [GDF-15] and high-sensitivity troponin I [hsTnI]) and BNP. We defined LVH as LV mass/height(2) ≥the sex-specific 80th percentile and LVSD as mild/greater impairment of LV ejection fraction (LVEF) or a fractional shortening <0.29. Adjusting for standard risk factors in logistic models, BNP, GDF-15, and hsTnI were associated with the composite echocardiographic outcome (LVH or LVSD), odds ratios (OR) per SD increment in log-biomarker 1.29, 1.14, and 1.18 (95% CI: 1.15 to 1.44, 1.004 to 1.28, and 1.06 to 1.31), respectively. The C-statistic for the composite outcome increased from 0.765 with risk factors to 0.770 adding BNP, to 0.774 adding novel biomarkers. The continuous Net Reclassification Improvement was 0.212 (95% CI: 0.119 to 0.305, P<0.0001) after adding the novel biomarkers to risk factors plus BNP. BNP was associated with LVH and LVSD in multivariable models, whereas GDF-15 was associated with LVSD (OR 1.41, 95% CI: 1.16 to 1.70), and hsTnI with LVH (OR 1.22, 95% CI: 1.09 to 1.36). ST2 was not significantly associated with any outcome. CONCLUSIONS: Our community-based investigation suggests that cardiac stress biomarkers are associated with LVH and LVSD but may have limited clinical utility as screening tools.


Assuntos
Hipertrofia Ventricular Esquerda/diagnóstico , Estresse Fisiológico , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico , Função Ventricular Esquerda , Idoso , Biomarcadores/sangue , Ecocardiografia Doppler , Feminino , Fator 15 de Diferenciação de Crescimento/sangue , Humanos , Hipertrofia Ventricular Esquerda/sangue , Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Proteína 1 Semelhante a Receptor de Interleucina-1 , Modelos Logísticos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Análise Multivariada , Peptídeo Natriurético Encefálico/sangue , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Prognóstico , Receptores de Superfície Celular/sangue , Fatores de Risco , Troponina I/sangue , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/fisiopatologia
9.
Congest Heart Fail ; 16 Suppl 1: S68-72, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20653715

RESUMO

Many of the primary clinical manifestations of heart failure are due to fluid retention and congestion, and therefore treatments targeting congestion play a central role in heart failure management. Diuretic therapy remains the cornerstone of congestion treatment, and diuretics are prescribed to the majority of heart failure patients. Despite this ubiquitous use, there is limited evidence from prospective randomized studies to guide the use of diuretics. Some observational data have suggested that diuretics may actually be harmful in heart failure, potentially contributing to worsening renal function, neurohormonal activation, and even heart failure progression. Recent clinical trial data have provided new insights into the balance of risks and benefits from diuretics. This review describes the mechanism of action of available diuretic classes, reviews their clinical use based on current guidelines, and briefly discusses evolving alternatives to diuretic therapy in the management of congestion in heart failure patients.


Assuntos
Anti-Hipertensivos/uso terapêutico , Diuréticos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Volume Sanguíneo/fisiologia , Progressão da Doença , Diuréticos/classificação , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Inibidores de Simportadores de Cloreto de Sódio/uso terapêutico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Resultado do Tratamento , Equilíbrio Hidroeletrolítico
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