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- A 2018 overview of diuretic resistance in heart failurePublication . Jardim, S; Ramos dos Santos, L; Araújo, I; Marques, F; Branco, P; Gaspar, A; Fonseca, CAbstract Heart failure is a disease with high direct and indirect costs. Current treatment includes drugs that alter disease progression and drugs that to improve symptoms. Loop diuretics are the cornerstone of congestion relief for acute management, as well as for chronic stabilization. In heart failure patients, maximal diuretic response is reduced by many individual factors. Diuretic resistance is defined as failure to achieve effective congestion relief despite appropriate or escalating diuretic doses. Its causes include impaired delivery of the diuretic to its luminal site of action, neurohormonal activation, tubular compensatory adaptation and drug interactions. Several strategies can be employed to aid decongestion of patients with impaired diuretic response. These include salt restriction, a higher effective single dose or higher dose frequency of loop diuretics, continuous infusion of diuretics and/or sequential nephron blockade through a synergistic combination of two or more diuretics from different classes. Ultrafiltration has also been found to be another effective and safe therapeutic option and should be considered in patients with refractory diuretic resistance. Overall, there is a lack of high-quality clinical data to guide the choice of treatment strategy and therapy should be tailored on a case-by-case basis.
- An extremely unusual pacemaker complication (image)Publication . Rodrigues, Ricardo C; Correia, André; Gomes, Susana; Pereira, Décio; Caires, Graça
- Assessment of perioperative mortality risk in patients with infective endocarditis undergoing cardiac surgery: performance of the EuroSCORE I and II logistic modelsPublication . Madeira, Sérgio; Rodrigues, Ricardo; Tralhão, António; Santos, Miguel; Almeida, Carla; Marques, Marta; Ferreira, Jorge; Raposo, Luís; Neves, José; Mendes, MiguelOBJECTIVES: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been established as a tool for assisting decision- making in surgical patients and as a benchmark for quality assessment. Infective endocarditis often equires surgical treatment and is associated with high mortality. This study was undertaken to (i) validate both versions of the EuroSCORE, the older logistic EuroSCORE I and the recently developed EuroSCORE II and to compare their performances; (ii) identify predictors other than those included in the EuroSCORE models that might further improve their performance. METHODS: We retrospectively studied 128 patients from a single-centre registry who underwent heart surgery for active infective endocarditis between January 2007 and November 2014. Binary logistic regression was used to find independent predictors of mortality and to create a new prediction model. Discrimination and calibration of models were assessed by receiver-operating characteristic curve analysis, calibration curves and the Hosmer–Lemeshow test. RESULTS: The observed perioperative mortality was 16.4% (n = 21). The median EuroSCORE I and EuroSCORE II were 13.9% interquartile range (IQ) (7.0–35.0) and 6.6% IQ (3.5–18.2), respectively. Discriminative power was numerically higher for EuroSCORE II {area under the curve (AUC) of 0.83 [95% confidence interval (CI), 0.75–0.91]} than for EuroSCORE I [0.75 (95% CI, 0.66–0.85), P = 0.09]. The Hosmer– Lemeshow test showed good calibration for EuroSCORE II (P = 0.08) but not for EuroSCORE I (P = 0.04). EuroSCORE I tended to overpredict and EuroSCORE II to under-predict mortality. Among the variables known to be associated with greater infective endocarditis severity, only prosthetic valve infective endocarditis remained an independent predictor of mortality [odds ratio (OR) 6.6; 95% CI, 1.1–39.5; P = 0.04]. The new model including the EuroSCORE II variables and variables known to be associated with greater infective endocarditis severity showed an AUC of 0.87 (95% CI, 0.79–0.94) and differed significantly from EuroSCORE I (P = 0.03) but not from EuroSCORE II (P = 0.4). CONCLUSIONS: Both EuroSCORE I and II satisfactorily stratify risk in active infective endocarditis; however, EuroSCORE II performed better in the overall comparison. Specific endocarditis features will increase model complexity without an unequivocal improvement in predictive ability.
- Cardiac arrhythmias in patients presenting with COVID-19 treated in Portuguese hospitals: A national registry from the Portuguese Association of Arrhythmology, Pacing and ElectrophysiologyPublication . Mesquita, Dinis; Carmo, Pedro; Cabanelas, Nuno; Santos, Nuno; Martins, Vítor; Sanfins, Victor; Costa, Helena Cristina; Fontes, José Paulo; Fonseca, Paulo; Parreira, LeonorIntroduction and objectives: In December 2019, SARS-CoV-2, was discovered as the agent of COVID-19 disease. Cardiac arrhythmias have been reported as frequent but their incidence is unknown. The aim of this research was to assess the real incidence of cardiac arrhythmias among COVID-19 patients admitted to Portuguese hospitals and to understand the underlying prognostic implications. Methods: The Portuguese Association of Arrhythmology, Pacing and Electrophysiology (APAPE) conducted a survey in Portuguese hospitals to assess the occurrence of arrhythmias in COVID-19 patients, their clinical characteristics, the use of experimental therapies and the impact on QT interval.
- Cardiomiopatia Dilatada por Vírus H1N1Publication . Filipe de Mendonça Arruda Gonçalves Café, Hugo; Filipe Gomes Serrão, Marco; Paula Moreira Faria, Ana; Jorge Rodrigues Araújo, JoséMulher de 58 anos, sem antecedentes médicos relevantes, apresenta infecção respiratória pelo vírus H1N1, requerendo internação na Unidade de Cuidados Intensivos. Após a alta, refere progressiva astenia e dispneia, sendo internada nove meses depois por derrame pleural e infecção respiratória. Avaliação específica pela Cardiologia revela cardiomiopatia dilatada com má função sistólica do ventrículo esquerdo, compatível com miocardite. A ressonância magnética se apresenta compatível com miocardite. Dados os antecedentes e havendo sido descartada doença autoimune e tóxica, associou-se a doença ao vírus H1N1. O prognóstico é muito positivo, com recuperação quase total da função do ventrículo esquerdo.
- Diabetes e Doença Cardiovascular:prognóstico após cinco anos de revascularização percutâneaPublication . Filipe de Mendonça Arruda Gonçalves Café, Hugo; Miguel Marçalo Santos, Nuno; Manuel Drummond Freitas, António; Filipe Gomes Serrão, Marco; Paula Moreira Faria, Ana; Manuel Drummond Freitas, António; Higino Silva Pereira, Décio; Jorge Rodrigues Araújo, JoséFundamentos: O diabetes mellitus (DM) é reconhecidamente fator de risco cardiovascular. Sabendose que a intervenção coronariana percutânea (ICP) melhora o prognóstico da doença coronariana (DC), pretendemos verificar se esse efeito é similar em doentes diabéticos (D) e não diabéticos (ND). Objetivo: Analisar o prognóstico em longo prazo do DM em pacientes submetidos a ICP. Métodos: Estudo de coorte, unicêntrico, retrospectivo, envolvendo pacientes consecutivos submetidos à ICP, eletiva ou de urgência, entre janeiro 2002 e dezembro 2003. Definiram-se dois grupos: pacientes com DM (D) e sem DM (ND). Compararam-se as variáveis clínicas e angiográficas da ICP com o resultado clínico ao final de cinco anos. Definiram-se como eventos maiores cardiovasculares (EMC): morte, nova síndrome coronariana aguda, acidente vascular encefálico (AVE) e nova revascularização cirúrgica ou ICP. Foram ainda avaliadas as taxas de trombose de stent, revascularização do vaso-alvo (RVA) e revascularização da lesão-alvo (RLA). Resultados: O seguimento em cinco anos foi 94%. Foram realizadas 446 ICP em 406 pacientes, média de idade =63,0±11 anos, 70,4% masculino. Destes, 128 (31,5%) eram do grupo D. Em cinco anos o valor de EMC foi 50,7% para D e 36,7% para N. Encontrou-se mortalidade global de 28,1% vs. 14,4% (p=0,0016) e mortalidade cardiovascular de 15,6% vs. 8,3% (p=0,039), respectivamente, para D vs. ND. Os restantes parâmetros não foram estatisticamente significativos. Não houve diferenças em termos de trombose de stent e tipos de stent utilizados nos dois grupos.
- Incomplete Shone’s complex: adult age diagnosisPublication . Rodrigues, Ricardo C.; Correia, André; Serrão, Gomes; Faria, Paula; Gomes, Susana; Pereira, DécioA 25-year-old male with previous history of heart surgery was referred for a control echocardiogram. He had been operated when he was 5 years old for reparation of aortic coarctation and the excision of a subaortic membrane, and was then lost to follow-up. No other changes were detected previously or during surgery. The patient was clinically stable without medication and the physical exam was unremarkable. The echocardiogram showed normal left ventricular function, but bicuspid aortic valve (figure 1 A), conditioning mild aortic stenosis, and a parachute mitral valve (figure 1 B, C) with single papillary muscle (figure 1 D, E – arrow) were present, with slight increase in transmitral velocity and mild regurgitation. No residual coarctation was present. Shone’s complex is a rare congenital heart disease consisting of several levels of left-sided obstructive lesions including supravalvar mitral ring, parachute mitral valve subaortic stenosis and coarctation of aorta, being classified as complete (if all levels are present) or incomplete (if only 2 or 3 lesions are present). Our patient had a previous surgical intervention and no correction was made for two undiagnosed lesions. Furthermore, the main critical problem associated with this condition appears to be mitral valve obstruction which was not significant in our patient. A conservative approach was decided and at 3-year follow-up no events occurred. This case highlights the importance of exhaustive preoperative echocardiographic evaluation and reminds us that, in the presence of two-levels of left-side cavities obstruction, other possible related anatomical lesions must be excluded.
- Interrupted aortic arch in a 58-year-old patientPublication . Rodrigues, Ricardo C.; Correia, André; Silva, Bruno; Gomes, Susana; Pereira, DécioA 58-year-old male patient was evaluated in the cardiology outpatient setting after an episode of hypertension and atrial fibrillation. He was also an ex-moker.Echocardiogram revealed slight left ventricular dilation with diastolic dysfunction and a systolic function in the lower normality level, as well as a rheumatic valvar disease with moderate mitral stenosis and slight aortic valve involvement, atrial enlargement and pulmonary hypertension. After an episode of acute pulmonar oedema the patient was referred for coronary catheterization. A right femoral approach was attempted and progression of the guidewire was not possible due to na interrupted aortic arch (IAA) (figure 1A), that was confirmed by right radial approach (figure 1B). The coronary arteries had no ignificant stenosis but the circumflex artery had an anomalous origin. A CT-scan confirmed an interrupted aortic arch (IAA) in the descending aorta, 27 mm below the left subclavian artery, and a short, 15-mm occluded segment Interrupted aortic arch in a 58-year-old patientcharacterized, originating from the right coronary Valsalva sinus and separated from the right coronary artery (figure 1D, arrow; figure 1F). The patient was submitted to cardiac correction surgery with the implantation of an intrapericardial Dacron conduit connecting both aortic ends. The periprocedural period was uneventful and at 1-year follow-up the patient was clinically stable with no cardiac complications. This IAA was an incidental finding, and it may have arisen from progression of an undiagnosed coarctation of the aorta while the absence of the ductus arteriosus was probably due to a progressive occlusion.
- KAsH Score predicts long term mortality after acute myocardialPublication . Monteiro, Joel Ponte; Sousa, João Adriano; Sousa Mendonça, Flávio; Neto, Micaela; Rodrigues, Ricardo; Gomes Serrão, Marco; Silva, Bruno; Mendonça, Maria Isabel; Faria, Ana Paula; Henriques, Eva; Drumond Freitas, AntónioIntroduction: Complex risk scores have limited applicability in the assessment of patients with myocardial infarction (MI). In this work, the authors aimed to develop a simple to use clinical score to stratify the in-hospital mortality risk of patients with MI at first medical contact. Methods: In this single-center prospective registry assessing 1504 consecutively admitted patients with MI, the strongest predictors of in-hospital mortality were selected through multivariate logistic regression. The KAsH score was developed according to the following formula: KAsH=(Killip class×Age×Heart rate)/systolic blood pressure. Its predictive power was compared to previously validated scores using the DeLong test. The score was categorized and further compared to the Killip classification. Results: The KAsH score displayed excellent predictive power for in-hospital mortality, superior to other well-validated risk scores (AUC: KAsH 0.861 vs. GRACE 0.773, p<0.001) and robust in subgroup analysis. KAsH maintained its predictive capacity after adjustment for multiple confounding factors such as diabetes, heart failure, mechanical complications and bleeding (OR 1.004, 95% CI 1.001-1.008, p=0.012) and reclassified 81.5% of patients into a better risk category compared to the Killip classification. KAsH’s categorization displayed excellent mortality discrimination (KAsH 1: 1.0%, KAsH 2: 8.1%, KAsH 3: 20.4%, KAsH 4: 55.2%) and better mortality prediction than the Killip classification (AUC: KAsH 0.839 vs. Killip 0.775, p<0.0001). Conclusion: KAsH, an easy to use score calculated at first medical contact with patients with MI, displays better predictive power for in-hospital mortality than existing scores. © 2019 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espa˜na, S.L.U. This is na open access article under the CC BY-NC-ND license
- Miocardiopatia Takotsubo: estado da artePublication . Nóbrega, SofiaTakotsubo cardiomyopathy is a reversible condition, characterized by transient left ventricular systolic dysfunction, that mimics an acute coronary syndrome. It usually occurs after physical or emotional stress, predominantly in postmenopausal women, although it also can affect younger age groups and males. It often presents as chest pain or dyspnea with electrocardiographic changes and mild elevation of cardiac enzymes suggesting acute myocardial infarction. Coronary angiography excludes obstructive coronary disease, and imaging reveals ventricular apical akinesia and compensatory hypercontractility of the basal segments. Various pathophysiological mechanisms have been proposed for the syndrome, such as occult atherosclerotic disease, multivessel spasm and/or microvascular dysfunction. However, the most widely accepted hypothesis at present is an excess of catecholamines causing calcium overload in cardiac myocytes, leading to disruption of contraction and ventricular function. Treatment is essentially supportive, with spontaneous and complete reversal of the changes within days or weeks. However, the presence of complications and comorbidities may predict a more adverse prognosis. As much is still unknown about takotsubo cardiomyopathy and the number of reported cases is growing, we present a literature review.