Insuficiencia cardíaca de novo: Un reto diagnóstico / Di novo heart failure: A diagnostic challenge

Introducción: El término insuficiencia cardíaca de novo hace referencia a pacientes sin diagnóstico previo de dicha enfermedad. La revisión de este tema deviene de un problema real, pues muchos pacientes acuden a la atención secundaria sin diagnóstico previo de insuficiencia cardíaca y además en estadios avanzados. Objetivo: Describir los elementos claves para el diagnóstico precoz de insuficiencia Cardíacas. Métodos: Se llevó a cabo una búsqueda bibliográfica en las siguientes bases de datos: Pubmed, SciELO, ESBCO, Cochrane y BVS, así como en diferentes webs médicas durante tres meses entre febrero de 2021 al 31 de mayo de 2021. Conclusiones: El diagnóstico precoz de insuficiencia cardíaca permitió disminuir el número de pacientes que llegan a la Atención Secundaria sin diagnóstico previo. Existen clasificaciones que identifican estadios tempranos de la enfermedad y la de la ACC/AHA es relevante para lograr este objetivo. En atención primaria esto es un reto si no se emplean pruebas diagnósticas como el ecocardiograma. Es importante la determinación de las concentraciones circulantes del péptido natriurético tipo B (BNP) y del fragmento N-terminal de su protohormona (N-terminal BNP). Este biomarcador debería estar accesible en las consultas ambulatorias para pacientes que presentan sospecha clínica de insuficiencia cardíaca «de novo»(AU)

Introduction: The term di novo heart failure refers to patients without a previous diagnosis of this disease. The review of this issue comes from a real problem, since a group of patients attend secondary care without a previous diagnosis of heart failure and also have in advanced stages. Objective: The objective is to provide a clue that facilitates the early diagnosis of heart failure. Methods: A bibliographic search was carried out in the following databases: Pubmed, SciELO, ESBCO, Cochrane and BVS, as well as in different medical websites for three months (February 1, 2021 to May 31, 2021). Conclusions: The early diagnosis of heart failure will allow us to reduce the number of patients who arrive at Secondary Care without a previous diagnosis. There are classifications that identify early stages of the disease, being in our opinion the ACC / AHA classification the one that should carry the most weight. In primary care this can be a challenge if diagnostic tests such as echocardiography are not used. Dosification of serum levels of type B natriuretic peptide (BNP) and the N-terminal fragment of its protohormone (N-terminal BNP) is very useful. This biomarker should be accessible in outpatient clinics for patients with clinical suspicion of di novo heart failure(AU)

Valor pronóstico de biomarcadores cardíacos en la enfermedad por COVID-19 / value of cardiac biomarkers in COVID-19 disease

Resumen Introducción: En la enfermedad por COVID-19 se ha establecido que los pacientes con enfermedad cardiometabólica de base tienen mayor riesgo de presentar desenlaces adversos. Esto ha incrementado el interés en estudiar variables cardiovasculares relevantes, para plantear su correlación con los desenlaces clínicos en esta población. Objetivo: Describir el valor pronóstico de los biomarcadores cardíacos en la enfermedad por COVID-19. Métodos: Revisión no sistemática de la literatura en bases de datos como PubMed, Google Scholar, Clinical Key, SciELO, entre otras, utilizando palabras clave, términos planos y términos MeSh. Resultados: Se eligieron 22 bibliografías, entre ellas artículos de revisión de tema, revisiones sistemáticas, metaanálisis, estudios observacionales y artículos originales publicados hasta la fecha (mayo 13 de 2020), que en su mayoría describen la alteración de biomarcadores cardiacos y su relación con la evolución clínica de los pacientes con COVID-19. Discusión: Se encontró que la troponina y el péptido natriurético se comportan como factores de riesgo independientes para compromiso clínico severo, requerimiento de soporte ventilatorio o hemodinámico, estancia en la UCI, y aumento de la mortalidad. Conclusiones: Es razonable plantear el uso de estos biomarcadores en la estratificación del riesgo en pacientes con COVID-19 y enfermedad cardiovascular establecida.

Abstract Introduction: It has been established that patients with an underlying cardiometabolic disease and COVID-19 infections, have a higher risk of an adverse outcome. This has led to an increase in the interest of studying relevant cardiovascular variables, in order to establish their association with clinical outcomes in this population. Objective: To describe the prognostic value of cardiac biomarkers in disease caused by COVID-19. Methods: A non-systematic review of the literature was carried out in data bases that included PubMed, Google Scholar, Clinical Key, SciELO, using the key words, plain terms, and MeSH terms. Results: A total of 22 articles were chosen. They consisted of review articles on the subject, systematic reviews, meta-analyses, observational studies, and original articles published up until 13 May 2020. The majority of them described the changes in cardiac biomarkers and their relationship with the clinical outcome of patients COVID-19. Discussion: It was found that Troponin and Natriuretic Peptide behaved as independent risk factors for severe clinical compromise, requiring ventilatory or haemodynamic support, admission to ICU, and an increase in mortality. Conclusions: It is reasonable to recommend the use of these biomarkers in the risk stratification in patients with COVID-19 and an established cardiovascular disease.

Anestesia cardiovascular en cirugía no cardiaca / Cardiovascular anesthesia in noncardiac surgery

Clinical evaluation remains one of the main issues while considering anesthetic and surgical risk. Different scores for cardiac evaluation in non-cardiac surgery are traditionally based on the exclusion of active cardiac conditions, the risk of surgery, the functional capacity of the patient and the presence of specific cardiac risk factors. In recent decades, new guidelines incorporate an association between cardiac biomarkers and adverse cardiac events. For the management of coronary patients receiving double antiplatelet therapy, derived for non-cardiac surgery, the risk of stent thrombosis, the consequences of delaying the surgical procedure and the risk of bleeding must be considered. At this moment, there is no evidence regarding which is the best anesthetic management that decreased peri-operative cardiovascular complications in this group of patients. This article refers to the differences in preoperative assessment for non-cardiac surgery incorporated in the guidelines of the American College of Cardiology, the American Heart Association, the European Society of Cardiology and the Canadian Cardiovascular Society. Consideration are also given to the management of coronary patients on double antiplatelet therapy and its main complications as well as intraoperative management maneuvers that may decrease cardiovascular complications.

La valoración clínica sigue siendo uno de los pilares fundamentales en la evaluación del riesgo anestésico-quirúrgico. Los scores de riesgo para la evaluación cardiovascular y cirugía no cardíaca se basan tradicionalmente en la exclusión de condiciones cardíacas activas, la determinación del riesgo de cirugía, la capacidad funcional del paciente y la presencia de factores de riesgo cardíaco. En las últimas décadas, nuevas guías incorporan una asociación entre los biomarcadores cardiacos y los eventos cardiacos adversos. Para el manejo de pacientes coronarios en tratamiento antiagregante doble, derivados a cirugía no cardiaca, hay que considerar el riesgo de trombosis del stent, las consecuencias de retrasar el procedimiento quirúrgico y el aumento del riesgo de hemorragia. Hasta la fecha no existe evidencia acerca de cuál es el mejor manejo anestésico que disminuya las complicaciones cardiovasculares perioperatorias en este grupo de pacientes. Este artículo, hace referencia a las diferencias de la valoración preoperatoria para cirugía no cardiaca incorporados en las guías del American College of Cardiology, la American Heart Association, la European Society of Cardiology y la Canadian Cardiovascular Society. Algunas consideraciones acerca del manejo de pacientes coronarios, terapia antiplaquetaria dual y eventuales complicaciones. Se incluyen algunas estrategias farmacológicas, así como consideraciones específicas para el perioperatorio, con el fin de reducir morbilidad de origen cardiovascular.

Biomarcadores en la falla cardíaca / Biomarkers in heart failure

RESUMEN La insuficiencia o falla cardíaca es una enfermedad cada día más prevalente y precisa de complementarios que no solo confirmen lo presumido clínicamente, sino que también sean útiles en la evaluación pronóstica de quienes la padecen. En ese contexto aparecen en las guías de insuficiencia cardíaca, a inicios del año 2000, los biomarcadores con utilidad práctica. Con indicaciones diagnósticas, pronósticas y evolutivas, en cada momento clínico de esta enfermedad, tanto en fase aguda como crónica, su utilización traza pautas y estrategias en el tratamiento adecuado de estos enfermos. En este artículo de revisión se hace un breve acercamiento al tema.

ABSTRACT Heart failure is an increasingly prevalent disease, which requires additional blood tests that not only confirm what is clinically presumed, but also be useful in the prognostic evaluation of those who suffer from it. In this context, biomarkers with practical utility appeared in the heart failure guidelines, at the beginning of the year 2000. With diagnostic, prognostic and evolutionary indications in each clinical stage of this disease, both in acute and chronic stages, its use draws guidelines and strategies in the adequate treatment of these patients. In this review article, a brief approach to the subject is made.

Evaluation of the vasoactive-inotropic score, mid-regional pro-adrenomedullin and cardiac troponin I as predictors of low cardiac output syndrome in children after congenital heart disease surgery.

OBJECTIVE: To determine the predictive value of the inotropic score (IS) and vasoactive-inotropic score (VIS) in low cardiac output syndrome (LCOS) in children after congenital heart disease surgery involving cardiopulmonary bypass (CPB), and to establish whether mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I), associated to the IS and VIS scores, increases the predictive capacity in LCOS. DESIGN: A prospective observational study was carried out. SETTING: A Paediatric Intensive Care Unit. PATIENTS: A total of 117children with congenital heart disease underwent CPB. Patients were divided into two groups: LCOS and non-LCOS. INTERVENTIONS: The clinical and analytical data were recorded at 2, 12, 24 and 48h post-CPB. Logistic regression was used to develop a risk prediction model using LCOS as dependent variable. MAIN OUTCOME MEASURES: LCOS, IS, VIS, MR-proADM, cTn-I, age, sex, CPB time, PIM-2, Aristotle score. RESULTS: While statistical significance was not recorded for IS in the multivariate analysis, VIS was seen to be independently associated to LCOS. On the other hand, VIS>15.5 at 2h post-CPB, adjusted for age and CPB timepoints, showed high specificity (92.87%; 95%CI: 86.75-98.96) and increased negative predictive value (75.59%, 95%CI: 71.1-88.08) for the diagnosis of LCOS at 48h post-CPB. The predictive power for LCOS did not increase when VIS was combined with cTn-I >14ng/ml at 2h and MR-proADM >1.5nmol/l at 24h post-CPB. CONCLUSIONS: The VIS score at 2h post-CPB was identified as an independent early predictor of LCOS. This predictive value was not increased when associated with LCOS cardiac biomarkers. The VIS score was more useful than IS post-CPB in making early therapeutic decisions in clinical practice post-CPB.

Cardiac Biomarkers of Low Cardiac Output Syndrome in the Postoperative Period After Congenital Heart Disease Surgery in Children.

INTRODUCTION AND OBJECTIVES: To assess the predictive value of atrial natriuretic peptide, ß-type natriuretic peptide, copeptin, mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I) as indicators of low cardiac output syndrome in children with congenital heart disease undergoing cardiopulmonary bypass (CPB). METHODS: After corrective surgery for congenital heart disease under CPB, 117 children (aged 10 days to 180 months) were enrolled in a prospective observational pilot study during a 2-year period. The patients were classified according to whether they developed low cardiac output syndrome. Biomarker levels were measured at 2, 12, 24, and 48 hours post-CPB. The clinical data and outcome variables were analyzed by a multiple logistic regression model. RESULTS: Thirty-three (29%) patients developed low cardiac output syndrome (group 1) and the remaining 84 (71%) patients were included in group 2. cTn-I levels >14 ng/mL at 2hours after CPB (OR, 4.05; 95%CI, 1.29-12.64; P=.016) and MR-proADM levels>1.5 nmol/L at 24hours following CPB (OR, 15.54; 95%CI, 4.41-54.71; P<.001) were independent predictors of low cardiac output syndrome. CONCLUSIONS: Our results suggest that cTn-I at 2hours post-CPB is, by itself, an evident independent early predictor of low cardiac output syndrome. This predictive capacity is, moreover, reinforced when cTn-I is combined with MR-proADM levels at 24hours following CPB. These 2 cardiac biomarkers would aid in therapeutic decision-making in clinical practice and would also enable clinicians to modify the type of support to be used in the pediatric intensive care unit.

Creatine-kinase and dialysis patients, a helpful tool for stratifying cardiovascular risk?

BACKGROUND AND AIMS: Hemodialysis patients have an enhanced risk for cardiovascular events. Cardiac biomarkers provide useful information for stratifying their risk. However the prognosis value of creatine kinase MB isoenzyme (CKMB) has not yet been validated in this population. The aim of the present study is to determine the predictable value of CK-MB in hemodialysis. METHODS: A cohort of 211 hemodialysis patients (58.3% male, median age 73 (60-80) years) were followed for 39 (19-56) months. Cardiac biomarkers including CKMB were recorded at baseline. Factors associated to CKMB and prognosis value of this biomarker was studied. RESULTS: The median value of CKMB was 1 (1-2) ng/mL with no patient exceeding normal laboratory values. Previous heart disease, diabetes mellitus, peripheral vascular disease and systolic and diastolic dysfunction were associated with higher levels of CKMB. Ninety-four patients (44.5%) cardiovascular events were recorded. CKMB levels ≥2ng/mL was independently associated to cardiovascular events during the follow up after adjusting. Adding CKMB to a model including several variables for predicting cardiovascular events, resulted in 17% improvement in risk discrimination (IDI) with a relative IDI of 9.9% (p=0.04). CONCLUSIONS: CKMB is a good marker for stratifying cardiovascular risk in hemodialysis patients and adds prognosis information to other well known independent predictors for cardiovascular events.

Função renal, hepática e cardíaca de cães hígidos sob terapia prolongada com celecoxibe / Renal, hepatic and cardiac function in healthy dogs during long-term celecoxib therapy

O presente estudo teve como objetivo avaliar os efeitos da terapia prolongada com celecoxibe sobre a função renal, hepática e cardíaca em cães hígidos. Foram utilizados 12 cães fêmeas, divididos em 2 grupos: Gcelecoxibe: terapia com celecoxibe, na dose de 5mg kg-1 por via oral, a cada 12 horas, durante 20 dias (peso médio de 8,9±1,6); Gcontrole: terapia com placebo, a cada 12 horas, por via oral, 20 dias (peso médio de 9,8±1,8). O exame físico, a função renal (urinálise; gamaglutamil transpeptidase -GGT e sódio urinários; ureia, creatinina, sódio e potássio séricos; e clearance endógeno de creatinina), tempo de coagulação (TC), biomarcadores cardíacos (creatinofosfoquinase -CK e creatinofosfoquinase fração MB- CK-MB) e função hepática (alanina aminotransferase -ALT, aspartato aminotransferase -AST e albumina) foram avaliados antes, aos 5, 10 e 20 dias (T0, T5, T10 e T20) do tratamento. No Gcelecoxibe, os valores de clearance de creatinina revelaram diminuição significativa no T20, em relação ao T0 e T5, bem como redução em relação ao Gcontrole em T10 e T20. A urinálise, sódio, potássio, ureia e creatinina séricos, enzima GGT urinária e o TC não apresentaram variação entre os momentos ou grupos avaliados. Houve aumento significativo de CK-MB no T20 e ALT no T5, T10 e T20 no Gcelecoxibe, entretanto, com valores dentro da normalidade para cães. Conclui-se que o celecoxibe revelou-se seguro em relação ao perfil cardíaco e hepático em cães sadios, mesmo sob terapia prolongada. Sob vigência de terapia prolongada, deve ser usado cautelosamente em cães portadores de alterações renais.

The aim of this study was to evaluate the effects of long-term celecoxib therapy on renal, hepatic and cardiac profiles in healthy dogs. Twelve female were randomly assigned to 2 groups (G): Gcelecoxib: treated with celecoxib orally (5mg kg-1), every 12 hours, for 20 days (8.9±1.6 body weight); Gcontrol: received placebo orally, every 12 hours, for 20 days (9.8±1.8 body weight). Physical examination, renal function (urinalysis, urinary sodium and gamma-glutamyl transpeptidase -GGT), serum urea, creatinine, potassium and sodium, and endogenous creatinine clearance), clotting time (CT), cardiac biomarkers (creatine phosphokinase -CK and CK-MB) and liver function (aspartate aminotransferase -AST, alanine aminotransferase -ALT and albumin) were evaluated before, at 5, 10 and 20 days (T0, T5, T10 and T20) of treatment. The creatinine clearance values showed significant decrease at T20, in relation to T0 and T5 in the Gcelecoxib, and reduction in relation to Gcontrol at T10 and T20. The urinalysis, values of sodium, potassium, urea and creatinine serum and urinary GGT enzyme showed no difference through the study between moments or groups. There was a significant increase on CK values at T20 and on ALT values at T5, T10 and T20 in the Gcelecoxib, however with normal range values for dogs. Celecoxib revealed to be safe in relation to cardiac and hepatic profiles, even under prolonged therapy. However, it should be used judiciously during long-term therapy in dogs with renal dysfunction.

Cardiac markers: profile in rats experimentally infected with Toxocara canis / Marcadores cardíacos: perfil em ratos infectados experimentalmente com Toxocara canis

The aim of this study was to evaluate the profile of the enzymes creatine kinase (CK), creatine kinase MB (CK-MB) and lactate dehydrogenase (LDH) in Wistar rats infected with 250 (GI, n = 24) or 1000 (GII, n = 24) Toxocara canis eggs. Animals were evaluated on days 7, 15, 30, 60, 120 and 180 post-infection (DPI). Only the GI rats showed an increase in CK and CK-MB, at 15 and 30 DPI, respectively. Anti-Toxocara spp. antibodies were detected by ELISA in infected animals. Despite of the presence of eosinophilic infiltrate in the heart of three infected animals, none larva was recovered from the organ neither by acid digestion nor by Baermann procedure. Eosinophilia was observed in both groups but there was no significant difference in the eosinophil counts between GI and GII (p = 0.2239). It is possible to consider that cardiac lesion is an eventual finding in murine model for toxocariasis

O objetivo do presente estudo foi avaliar o perfil das enzimas creatinoquinase (CK), creatinoquinase-MB (CK-MB) e lactato desidrogenase (LDH) em ratos Wistar infectados com 250 (GI, n = 24) ou 1000 (GII, n = 24) ovos de Toxocara canis. Os animais foram avaliados nos dias 7, 15, 30, 60, 120 e 180 pós-infecção (DPI). Observou-se que apenas os animais do GI apresentaram aumento da atividade de CK e CK-MB aos 15 e 30 DPI, respectivamente. Anticorpos anti-T. canis foram detectados por ELISA nos animais infectados. Apesar da presença de infiltrado eosinofílico em três animais infectados, nenhuma larva foi recuperada do coração pela digestão ácida ou pela técnica de Baermann. Eosinofilia foi observada em todos os momentos em GI e GII, sem diferença significativa entre os grupos (p = 0,2239). Pode-se considerar que as lesões cardíacas foram um achado eventual no modelo murino para toxocaríase.