Resumo Fundamento O escore Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) é uma ferramenta de estratificação de risco utilizada para prever mortalidade na insuficiência cardíaca (IC). Entretanto, possíveis diferenças relacionadas ao sexo em seu desempenho e sua aplicabilidade à população brasileira permanecem incertas. Objetivos Avaliar diferenças baseadas no sexo no desempenho do escore MAGGIC e validar o escore em uma coorte brasileira de IC. Métodos Este estudo de coorte retrospectivo incluiu 866 pacientes acompanhados em um ambulatório de IC. O desfecho primário foi mortalidade por todas as causas em 3 anos. O escore MAGGIC foi calculado para cada paciente. A discriminação foi avaliada por meio da área sob a curva característica de operação do receptor, e a calibração foi avaliada pelo teste de Hosmer-Lemeshow. As análises foram realizadas para a coorte total e estratificadas por sexo. Considerou-se valor de p < 0,05 como estatisticamente significativo. Resultados A taxa global de mortalidade em 3 anos foi de 33,4% (36,4% em homens e 27,8% em mulheres; p = 0,010). A mortalidade predita foi de 20,9% (escore médio de 18,3 ± 7), sendo 22,7% em homens e 19,1% em mulheres. O escore demonstrou boa discriminação (área sob a curva = 0,72; intervalo de confiança de 95%: 0,686-0,754), com desempenho semelhante em homens (0,704 [0,661-0,747]) e mulheres (0,733 [0,674-0,792]). A calibração mostrou boa concordância: qui-quadrado (χ2) global = 1,1 (p = 0,998), χ2 para homens = 0,9 (p = 0,999) e χ2 para mulheres = 1,3 (p = 0,995). A mortalidade observada foi maior nos grupos de risco moderado, sem diferença significativa entre os grupos de risco moderado e alto (p = 0,236). Conclusão O escore MAGGIC apresentou bom desempenho em uma coorte brasileira de IC, sem diferenças significativas relacionadas ao sexo, embora tenha sido identificada maior mortalidade observada entre pacientes de risco moderado.

BACKGROUND:Treatment with intravenous iron has been shown to improve symptoms, functional capacity, and quality of life in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency. However, the mechanisms underlying these beneficial effects remain unknown. Sodium-glucose cotransporter-2 inhibitor (SGLT2i) seems to alter hematocrit and other hematologic markers of iron content. This study aims to measure cardiac magnetic resonance changes in myocardial iron content after the administration of intravenous iron with or without SGLT2i and to assess changes in left ventricular function in patients with HFrEF and iron deficiency. METHODS:Outpatients with symptomatic HFrEF, left ventricular ejection fraction (LVEF) <40%, SGLT2i-naive, and iron deficiency will be assigned to receive intravenous iron + SGLT2i; intravenous iron + a placebo of SGLT2i; or placebo of both therapies for 30 days. The total sample size was calculated to be 99 patients. Myocardial iron will be evaluated by T2-star cardiac magnetic resonance sequence before intravenous iron infusion. After 30 days, all patients will be reassessed with T2-star cardiac magnetic resonance sequencing. The primary endpoint will be changes in LVEF and myocardial iron content at 30 days. Secondary endpoints will include correlations of these changes with myocardial iron content, functional capacity, quality of life, and cardiac biomarkers. CONCLUSIONS:This study will determine the effect of ferric carboxymaltose and its combination with SGLT2i on LVEF and its relationship with measures of myocardial iron content, functional capacity, and biomarkers in HFrEF and iron deficiency.

BACKGROUND:The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score is a risk stratification tool used to predict mortality in heart failure (HF). However, potential sex-related differences in its performance and its applicability to the Brazilian population remain uncertain. OBJECTIVES:To evaluate sex-based differences in the performance of the MAGGIC score and to validate the score in a Brazilian HF cohort. METHODS:This retrospective cohort study included 866 patients followed at a HF outpatient clinic. The primary outcome was 3-year all-cause mortality. The MAGGIC score was calculated for each patient. Discrimination was assessed using the area under the receiver operating characteristic curve, and calibration was evaluated using the Hosmer-Lemeshow test. Analyses were performed for the overall cohort and stratified by sex. A p-value < 0.05 was considered statistically significant. RESULTS:The overall 3-year mortality rate was 33.4% (36.4% in men and 27.8% in women; p = 0.010). Predicted mortality was 20.9% (mean score 18.3 ± 7), with 22.7% for men and 19.1% for women. The score demonstrated good discrimination (area under the curve = 0.72; 95% CI: 0.686-0.754), with similar performance in men (0.704 [0.661-0.747]) and women (0.733 [0.674-0.792]). Calibration showed good agreement: overall chi-square (χ2) = 1.1 (p = 0.998), men χ2 = 0.9 (p = 0.999), and women χ2 = 1.3 (p = 0.995). Observed mortality was higher in moderate-risk groups, with no significant difference between moderate- and high-risk groups (p = 0.236). CONCLUSION:The MAGGIC score showed good performance in a Brazilian HF cohort, with no significant sex-based differences, although higher observed mortality was identified among moderate-risk patients.

Resumo Fundamento A estimulação do sistema de condução (ESC) surgiu como uma alternativa à estimulação biventricular (EBV) para terapia de ressincronização cardíaca (TRC), com potenciais benefícios clínicos e menores custos. O PhysioSync-HF é um estudo multicêntrico e randomizado que compara essas estratégias sob as perspectivas clínica e econômica em pacientes com insuficiência cardíaca e fração de ejeção reduzida (ICFER). Objetivo Descrever a justificativa e o desenho da avaliação econômica baseada em ensaio clínico incorporada ao estudo PhysioSync-HF. Métodos O estudo PhysioSync-HF incluiu 179 pacientes com seguimento de 1 ano. Os dados de custo do procedimento serão coletados utilizando a abordagem de custeio baseado em atividades e tempo. Os custos associados ao dispositivo, eventos clínicos adversos e cuidados ambulatoriais durante o seguimento serão estimados por meio de métodos de contabilidade baseados em recursos consumidos. Métodos apropriados serão empregados para tratar dados ausentes, e as análises estatísticas considerarão a distribuição assimétrica das variáveis de custo. Resultados O desfecho econômico primário é a diferença entre os grupos no custo médico direto total por paciente ao longo de 1 ano de seguimento (ESC vs. EBV). Os desfechos secundários incluem a decomposição dos custos diretos em componentes e uma análise de impacto orçamentário que estima o efeito anual no sistema de saúde brasileiro se todos os pacientes elegíveis recebessem ESC em vez de EBV. Conclusão Aproveitando um ensaio cardiovascular multicêntrico para mensurar os custos da ESC em comparação à EBV, esta avaliação econômica busca identificar oportunidades de redução de custos que possam ampliar o acesso com equidade à TRC para indivíduos com ICFER no Brasil, além de fornecer informações relevantes para outros sistemas de saúde no mundo. Registro do Ensaio NCT05572736.

Resumo Fundamentos Apesar de as características clínicas da Cardiomiopatia Chagásica Crônica (CCC) estarem bem estabelecidas, os dados clínicos sobre os pacientes são escassos. Objetivos Esta análise relata os resultados do I Registro Brasileiro de Insuficiência Cardíaca (BREATHE) avaliando as características basais e desfechos clínicos de pacientes com insuficiência cardíaca aguda secundária à CCC. Métodos O BREATHE incluiu 3013 pacientes adultos internados com insuficiência cardíaca aguda. Nós analisamos comparativamente 261 (8,7%) pacientes com CCC e 2752 (91,3%) pacientes com outras etiologias. Dados clínicos e demográficos, informações da estrutura e da função cardíaca no ecocardiograma e desfechos durante a internação hospitalar e após a alta foram avaliados em ambos os grupos. Testes univariados e multivariados foram realizados, e um p-valor < 0,05 foi considerado estatisticamente significativo. Resultados Pacientes com CCC apresentaram pressão arterial sistólica (108,3 ± 26,1 vs. 128,3 ± 30,3 mmHg, p<0,001) e fração de ejeção ventricular esquerda [25,4 (19 – 36)% vs. 37 (27 – 54) %, p<0,001) mais baixas, com taxas mais altas de distensão da veia jugular (54,8% vs. 38,9%, p<0,001), hepatomegalia (47,9% vs. 25,6%, p<0,001), e de perfil “frio e úmido” (27,2% vs. 10,6%, p<0,001). Pacientes com CCC apresentaram taxas mais altas do desfecho composto de morte ou transplante cardíaco (17,4% vs. 11,1%, p=0,004), e incidência cumulativa mais alta de morte após três meses (16,5% vs. 10,8%, p=0,017), seis meses (25,3% vs. 17,2%, p=0,006), e 12 meses (39,4% vs. 26,6%, p<0,001). Além disso, CCC associou-se independentemente com risco de mortalidade em 12 meses, com um odds ratio de 2,02 (IC95%: 1,47-2,77). Conclusão Em comparação a outras etiologias, os pacientes com CCC internados por insuficiência cardíaca aguda apresentaram um perfil de maior risco que foi associado com um pior desfecho durante a internação hospitalar e após a alta.

Objectives Mineralocorticoid receptor antagonists (MRAs) are cornerstones in the management of heart failure (HF) with reduced ejection fraction (HFrEF). New MRAs with improved safety profile, such as finerenone and eplerenone, were recently introduced. However, because of typical budget restrictions in middle-income countries, evaluating their cost-effectiveness is essential for optimizing treatment strategies. Methods We used a Bayesian network and Markov influence diagrams to estimate the incremental cost-effectiveness ratios (ICERs) in international dollars (Int$) per quality-adjusted life-year (QALY). Our model was fed by a systematic review and a network meta-analysis to compare MRAs effectiveness and used data from a cohort of 1066 Brazilian individuals with HFrEF (36% with ischemic and 64% with nonischemic disease). Results Over a 10-year time horizon, the treatment with spironolactone, eplerenone, and finerenone compared with no MRA utilization yielded discounted QALY per person of 0.072, 0.111, and 0.034, respectively. The ICERs were Int$7955, Int$6460, and Int$109 840 per QALY gained, respectively. Compared with spironolactone, eplerenone showed an ICER of Int$6178 per QALY gained. Assuming a willingness-to-pay threshold of 1 Brazilian per capita gross domestic product (Int$17 589) per QALY gained, the probabilistic sensitivity analyses suggest that spironolactone and eplerenone were cost-effective, respectively, in 87% and 92% of iterations. The 95% CIs were Int$2282 to Int$13 149 for spironolactone and Int$1795 to Int$12 351 for eplerenone per QALY gained. These findings were consistent across several scenarios including ischemic/nonischemic HF. Conclusions Eplerenone is likely the most cost-effective MRA in Brazil considering individuals with both ischemic and nonischemic HFrEF.

BACKGROUND:Although the clinical features of chronic Chagas' cardiomyopathy (CCC) have been well established, clinical data about the patients are scarce. OBJECTIVES:The current analysis reports the results of the I Brazilian Heart Failure Registry (BREATHE) assessing baseline characteristics and clinical outcomes of patients with acute heart failure due to CCC. METHODS:BREATHE enrolled a total of 3,013 adult patients hospitalized with acute heart failure. We analyzed comparatively 261 (8.7%) patients with chronic CCC and 2,752 (91.3%) patients with other etiologies. Clinical and demographic information, cardiac structure/function data on echocardiogram and outcomes during the hospital stay and after discharge were assessed in both groups. Uni and multivariate tests were performed and a p-value <0.05 was considered statistically significant. RESULTS:Patients with CCC presented lower systolic blood pressure (108.3 ± 26.1 vs 128.3 ± 30.3 mmHg, p<0.001) and left ventricle ejection fraction (25.4 [19 - 36]% vs 37 [27 - 54] %, p<0.001) with higher rates of jugular vein distension (54.8% vs 38.9%, p<0.001), hepatomegaly (47.9% vs 25.6%, p<0.001), and "cold and wet" clinical hemodynamic profile (27.2% vs 10.6%, p<0.001). Patients with CCC presented higher rate of the composite death or heart transplantation (17.4% vs. 11.1%, p=0.004), and higher cumulative incidence of death after 3 months (16.5% vs 10.8%, p=0.017), 6 months (25.3% vs 17.2%, p=0.006), and 12 months (39.4% vs 26.6%, p<0.001). Besides, CCC was independently associated with 12-month mortality risk with odds ratio = 2.02 (95% IC: 1.47-2.77). CONCLUSION:Patients with CCC, hospitalized due to acute heart failure, in comparison to other etiologies, presented a higher risk profile that was associated with a poorer outcome during hospital stay and after discharge.

Sudden cardiac death (SCD) is an unpredictable and common mode of death in patients with heart failure (HF). Alterations in calcium handling may lead to malignant arrhythmias, resulting in SCD, and variants in calcium signaling-related genes have a significant association with SCD. Therefore, the aim of the present retrospective cohort study was to investigate the association of Ser96Ala [histidine-rich calcium-binding protein (HRC)], Ser49Gly [β1-adrenergic receptor (ADRB1)], Arg389Gly (ADRB1) and Gly1886Ser [ryanodine receptor 2 (RYR2)] polymorphisms with serious arrhythmic events and overall mortality in patients with HF with reduced left ventricular ejection fraction of non-ischemic etiology. In total, 136 patients with HF underwent physical examination, routine laboratory tests, non-invasive assessment of cardiac function and an invasive electrophysiological study. The primary outcome was the occurrence of serious arrhythmic events, set as either SCD or appropriate implantable cardioverter-defibrillator (ICD) therapy, and the secondary outcome was all-cause death. During a median follow-up of 37 months, arrhythmic events occurred in 26 patients (19%) and 41 patients (30%) died. Patients carrying the Ser allele of the Ser96Ala polymorphism in HRC had worse survival than those with the Ala/Ala genotype (log-rank P=0.043). Despite the difference in survival time, the Ala/Ala genotype was not associated with all-cause death in the regression analysis [unadjusted hazard ratio (HR)=0.17; 95% CI, 0.02-1.21]. Regarding the Ser49Gly and Arg389Gly polymorphisms in ADRB1, homozygosity for the major alleles at both sites (Ser49Ser and Arg389Arg) was associated with a two-fold increased risk of all-cause death compared with the other genotype combinations (unadjusted HR=1.98; 95% CI, 1.02-3.82). However, this association was lost after controlling for clinical covariates. No association was observed for the Gly1886Ser polymorphism in RYR2. Overall, the present findings are concurrent with the hypothesis that the Ser96Ala (HRC), Ser49Gly (ADRB1) and Arg389Gly (ADRB1) polymorphisms may be associated with HF prognosis. In particular, the Ser96Ala polymorphism might aid in risk stratification and patient selection for ICD implantation.

Background: Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain. Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the costeffectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. Methods: We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. Results: In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to- pay threshold. Conclusions: Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Resumo Fundamento O choque cardiogênico (CC) refratário está associado com altas taxas de mortalidade, e o uso de oxigenação por membrana extracorpórea venoarterial (VA-ECMO, do inglês venoarterial extracorporeal membrane oxygenation) como uma opção terapêutica tem gerado discussões. Nesse sentido, sua custo-efetividade, principalmente em países de baixa e média renda como o Brasil, continua incerto.Objetivos: Conduzir uma análise de custo-efetividade na perspectiva do Sistema Único de Saúde (SUS) para avaliar a custo-efetividade de VA-ECMO combinado com o tratamento padrão em comparação ao tratamento padrão isolado em pacientes adultos com CC refratário. Métodos Acompanhamos uma coorte de pacientes com CC refratário tratados com VA-ECMO em centros de assistência terciária do sul brasileiro. Coletamos dados de desfechos e custos hospitalares. Realizamos uma revisão sistemática para complementar nossos dados e usamos o modelo de Markov para estimar a razão de custo-efetividade incremental (RCEI) por ano de vida ajustado pela qualidade (QALY) e por ano de vida ganho. Resultados Na análise do caso-base, a VA-ECMO gerou uma RCEI de Int$ 37 491 por QALY. Análises de sensibilidade identificaram o custo de internação, o risco relativo de sobrevida, e a sobrevida do grupo submetido à VA-ECMO como principais variáveis influenciando os resultados. A análise de sensibilidade probabilística mostrou um benefício do uso de VA-ECMO, com uma probabilidade de 78% de custo-efetividade no limiar recomendado de disposição a pagar. Conclusões Nosso estudo sugere que, dentro do SUS, VA-ECMO pode ser uma terapia custo-efetiva para o CC refratário. Contudo, a escassez de dados sobre a eficácia e de ensaios clínicos recentes que abordem seus benefícios em subgrupos específicos de pacientes destaca a necessidade de mais pesquisas. Ensaios clínicos rigorosos, incluindo perfis diversos de pacientes, são essenciais para confirmar a custo-efetividade com uso de VA-ECMO e assegurar acesso igualitário a intervenções médicas avançadas dentro dos sistemas de saúde, especialmente em países com desigualdades socioeconômicas como o Brasil.

AbstractAimsIn this multicentre study, we compared cardio‐pulmonary exercise test (CPET) parameters between heart failure (HF) patients classified as New York Heart Association (NYHA) class I and II to assess NYHA performance and prognostic role in mild HF.Methods and resultsWe included consecutive HF patients in NYHA class I or II who underwent CPET in three Brazilian centres. We analysed the overlap between kernel density estimations for the per cent‐predicted peak oxygen consumption (VO2), minute ventilation/carbon dioxide production (VE/VCO2) slope, and oxygen uptake efficiency slope (OUES) by NYHA class. Area under the receiver‐operating characteristic curve (AUC) was used to assess the capacity of per cent‐predicted peak VO2 to discriminate between NYHA class I and II. For prognostication, time to all‐cause death was used to produce Kaplan–Meier estimates. Of 688 patients included in this study, 42% were classified as NYHA I and 58% as NYHA II, 55% were men, and mean age was 56 years. Median global per cent‐predicted peak VO2 was 66.8% (IQR 56–80), VE/VCO2 slope was 36.9 (31.6–43.3), and mean OUES was 1.51 (±0.59). Kernel density overlap between NYHA class I and II was 86% for per cent‐predicted peak VO2, 89% for VE/VCO2 slope, and 84% for OUES. Receiving‐operating curve analysis showed a significant, albeit limited performance of per cent‐predicted peak VO2 alone to discriminate between NYHA class I vs. II (AUC 0.55, 95% CI 0.51–0.59, P = 0.005). Model accuracy for probability of being classified as NYHA class I (vs. NYHA class II) across the spectrum of the per cent‐predicted peak VO2 was limited, with an absolute probability increment of 13% when per cent‐predicted peak VO2 increased from 50% to 100%. Overall mortality in NYHA class I and II was not significantly different (P = 0.41), whereas NYHA class III patients displayed a distinctively higher death rate (P < 0.001).ConclusionsPatients with chronic HF classified as NYHA I overlapped substantially with those classified as NYHA II in objective physiological measures and prognosis. NYHA classification may represent a poor discriminator of cardiopulmonary capacity in patients with mild HF.

Resumo Fundamento A precisão da classificação da New York Heart Association (NYHA) para avaliar o prognóstico pode ser limitada em comparação com os parâmetros objetivos do teste de exercício cardiopulmonar (TECP) na insuficiência cardíaca (IC). Objetivo Investigar o valor prognóstico da classificação da NYHA e da classe Weber. Métodos Foram incluídos pacientes ambulatoriais adultos com IC submetidos a TECP em um centro terciário brasileiro. A classe NYHA atribuída pelo médico e a classe Weber derivada do TECP foram estratificadas como “favorável” (NYHA I ou II com Weber A ou B) ou “adversa” (NYHA III ou IV com Weber C ou D). Pacientes com uma classe favorável e uma classe adversa foram definidos como “discordantes”. O desfecho primário foi o tempo para mortalidade por todas as causas. Um valor de p bilateral < 0,05 foi considerado estatisticamente significativo. Resultados Foram incluídos 834 pacientes. A mediana de idade foi de 57 anos; 42% (351) eram do sexo feminino e a mediana da fração de ejeção do ventrículo esquerdo foi de 32%. Entre os pacientes com classes NYHA e Weber concordantes, aqueles com classes NYHA e Weber adversas tiveram mortalidade por todas as causas significativamente maior em comparação com aqueles com classes favoráveis ( hazard ratio [HR]: 5,65; intervalo de confiança de 95%: 3,38 a 9,42). Entre os pacientes com classes discordantes, não houve diferença significativa na mortalidade por todas as causas (HR: 1,38; intervalo de confiança de 95%: 0,82 a 2,34). No modelo multivariado, incrementos na classe NYHA (HR: 1,55 por aumento na classe; intervalo de confiança de 95%: 1,26 a 1,92) e reduções no VO 2 pico (HR: 1,47 por diminuição de 3 ml/kg/min; intervalo de confiança de 95%: 1,28 a 1,70) previu significativamente a mortalidade. Conclusões A classe NYHA atribuída pelo médico e as medidas objetivas do TECP fornecem informações prognósticas complementares para pacientes com IC.

Background: The accuracy of the New York Heart Association (NYHA) classification to assess prognosis may be limited compared with objective cardiopulmonary exercise test (CPET) parameters in heart failure (HF). Objective: To investigate the prognostic value of the NYHA classification in addition to Weber class.Methods: Adult outpatients with HF undergoing CPET in a Brazilian tertiary care center were included. The physician-assigned NYHA class and the CPET-derived Weber class were stratified into "favorable" (NYHA I or II; Weber A or B) or "adverse" (NYHA III or IV; Weber C or D). Patients with one favorable class and one adverse class were defined as "discordant." The primary endpoint was time to all-cause mortality. A 2-sided p value < 0.05 was considered statistically significant.Results: A total of 834 patients were included. Median age was 57 years; 42% (351) were female, and median left ventricular ejection fraction was 32%. Among patients with concordant NYHA and Weber classes, those with adverse NYHA and Weber classes had significantly higher all-cause mortality compared to those with favorable classes (hazard ratio [HR]: 5.65; 95% confidence interval [CI]: 3.38 to 9.42). Among patients with discordant classes, there was no significant difference in all-cause mortality (HR: 1.38; 95% CI: 0.82 to 2.34). In the multivariable model, increments in NYHA class (HR: 1.55 per class increase; 95% CI: 1.26 to 1.92) and reductions in peak VO2 (HR: 1.47 per 3 ml/kg/min decrease; 95% CI: 1.28 to 1.70) significantly predicted mortality.Conclusions: Physician-assigned NYHA class and objective CPET measures provide complementary prognostic information for patients with HF.

By definition, myocardiopathies or cardiomyopathies (CM) are heart muscle diseases that cause structural and functional myocardial abnormalities in the absence of coronary artery disease, hypertension, valvular disease, and congenital heart disease., CM constitute a very heterogeneous group of heart diseases and are one of the leading causes of death either from end-stage heart failure or sudden death due to arrythmias. According to the phenotype, CM may be classified into hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and [...]

Abstract Background Heart failure represents a common cause of hospitalization associated with poor short-term clinical outcomes. Little is known about the long-term prognosis of these patients in Latin America. Methods The rationale and design of the study were previously published (1). Briefly, BREATHE was the first nation-wide prospective observational study that included patients hospitalized due to acute heart failure in Brazil. In-hospital management as well as 12-month clinical outcomes were assessed. Patients were included during two time periods: from February 2011 to December 2012 (BREATHE I) and from June 2016 to July 2018 (BREATHE Extension). Adherence to evidence-based therapies was also evaluated. Results A total of 3,013 patients were included in 71 centers in Brazil. The median follow-up was 346 days. The BREATHE population included 39.3% of women, had a mean age of 65.2 (± 15.6) with a mean ejection fraction of 39.7% (± 17.5). Among the comorbidities, systemic arterial hypertension was the most common, present in almost 75% of the sample. At hospital admission, 83.8% of patients had clear signs of pulmonary congestion and the main cause of decompensation was poor adherence to heart failure medications, representing 27.8% of cases. Among patients with reduced ejection fraction, the concomitant use of renin-angiotensin-aldosterone inhibitors, beta-blocker and spironolactone at hospital discharge was 44.5% and decreased to 35.2% after 3 months (p<0.01). Mortality rate at 12 months was 28.9 for every 100 patient years with 26.2% readmission at 90 days and 46.4% at 365 days. The most common etiology of heart failure was ischemic disease (Figure 1) but the worst prognosis was associated with Chagas disease (Figure 2) including an analysis of a composite outcome encompassing death, myocardial infarction, stroke or cardiac arrest after discharge. Conclusions In this large national prospective registry of patients hospitalized with acute heart failure, mortality and readmission were higher than what have been reported globally. Poor adherence to evidence-based therapies was a common both at hospital discharge and 1-year of follow-up. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Brazilian Society of Cardiology

Aims: Treatment with mechanical circulatory support (MCS) has been proposed to mitigate mortality in cardiogenic shock (CS). However, there is a lack of data on MCS programs implementation and the effect of the learning curve on its outcomes in limited resources countries such as Brazil. Methods: Prospective cohort of patients with CS admitted in four tertiary-care centers treated with Impella CP or veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Clinical outcomes were peri-procedural complications, short-term mortality rate, and the centers' learning curve. The cohort was divided into two periods: from April 2017 to July 2018 (n = 24), and from August 2018 to December 2020 (n = 25). Results: The study enrolled 49 patients [age 59 (43-63) years; 34 (70%) males]. The most common causes for CS were acute myocardial infarction in 22 (45%) and acute decompensation of chronic heart failure in 10 (20%). VA-ECMO was employed in 35 (71%) and Impella CP in 14 (29%) of patients. Overall complications occurred in 37 (76%) of patients, where major bleeding in 19 (38%) was the most common. The overall mortality rate was 61%, but it was lower in the second period (40%) in comparison to the first period (83%), p = 0.002. The learning curve analysis showed a decrease in the mortality rate after 40 consecutive cases. Conclusions: Implementation of a temporary MCS program for refractory CS in a limited resource country is feasible. The learning curve effect might have played a role on survival rate since high morbimortality has decreased within time reaching optimal results by the end of the study.

PARADIGM-HF, published in 2014, was a landmark in the modern pharmacological treatment of heart failure (HF). After several years and numerous clinical trials with disappointing results,– a new class of drugs was able to produce concrete results in clinically relevant outcomes. In this pivotal study, sacubitril-valsartan, a molecule consisting of a neprilysin inhibitor and an angiotensin-receptor blocker (ARB), drastically reduced hospitalizations for HF, cardiovascular mortality, and overall mortality. The study included more than 8,000 outpatients, mostly New York Heart Association [...]

BACKGROUND:The physical examination enables prognostic evaluation of patients with decompensated heart failure (HF), but lacks reliability and relies on the professional's clinical experience. Considering hemodynamic responses to "fight or flight" situations, such as the moment of admission to the emergency room, we proposed the calculation of the acute hemodynamic index (AHI) from values of heart rate and pulse pressure. OBJECTIVE:To evaluate the in-hospital prognostic ability of AHI in decompensated HF. METHODS:A prospective, multicenter, registry-based observational study including data from the BREATHE registry, with information from public and private hospitals in Brazil. The prognostic ability of the AHI was tested by receiver-operating characteristic (ROC) analyses, C-statistics, Akaike's information criteria, and multivariate regression analyses. p-values < 0.05 were considered statistically significant. RESULTS:We analyzed data from 463 patients with heart failure with low ejection fraction. In-hospital mortality was 9%. The median AHI value was used as cut-off (4 mmHg⋅bpm). A low AHI (≤ 4 mmHg⋅bpm) was found in 80% of deceased patients. The risk of in-hospital mortality in patients with low AHI was 2.5 times that in patients with AHI > 4 mmHg⋅bpm. AHI independently predicted in-hospital mortality in acute decompensated HF (sensitivity: 0.786; specificity: 0.429; AUC: 0.607 [0.540-0.674]; p = 0.010) even after adjusting for comorbidities and medication use [OR: 0.061 (0.007-0.114); p = 0.025). CONCLUSIONS:The AHI independently predicts in-hospital mortality in acute decompensated HF. This simple bed-side index could be useful in an emergency setting. (Arq Bras Cardiol. 2021; 116(1):77-86).

Autores da Diretriz: Fabiana G. Marcondes-Braga,1 Lídia Ana Zytynski Moura,2 Victor Sarli Issa,3 Jefferson Luis Vieira,4 Luis Eduardo Rohde,5,6,7 Marcus Vinícius Simões,8 Miguel Morita Fernandes-Silva,9,10 Salvador Rassi,11 Silvia Marinho Martins Alves,12,13 Denilson Campos de Albuquerque,14 Dirceu Rodrigues de Almeida,15 Edimar Alcides Bocchi,1 Felix José Alvarez Ramires,1,17 Fernando Bacal,1 João Manoel Rossi Neto,18 Luiz Claudio Danzmann,19,20 Marcelo Westerlund Montera,21 Mucio Tavares de Oliveira Junior,1 Nadine Clausell,5 Odilson Marcos Silvestre,22 Reinaldo Bulgarelli Bestetti,23 Sabrina Bernadez-Pereira,16 Aguinaldo F. Freitas Jr,11 Andréia Biolo,5 Antonio Carlos Pereira Barretto,1 Antônio José Lagoeiro Jorge,24 Bruno Biselli,1 Carlos Eduardo Lucena Montenegro,12,13 Edval Gomes dos Santos Júnior,25,26 Estêvão Lanna Figueiredo,27,28 Fábio Fernandes,1 Fabio Serra Silveira,29,30 Fernando Antibas Atik,31 Flávio de Souza Brito,32 Germano Emílio Conceição Souza,33,34 Gustavo Calado de Aguiar Ribeiro,35 Humberto Villacorta,24 João David de Souza Neto,4 Livia Adams Goldraich,5 Luís Beck-da-Silva,5,7 Manoel Fernandes Canesin,36 Marcelo Imbroinise Bittencourt,14,37 Marcely Gimenes Bonatto,38 Maria da Consolação Vieira Moreira,39 Mônica Samuel Avila,1 Otavio Rizzi Coelho Filho,40 Pedro Vellosa Schwartzmann,41,42 Ricardo MourilheRocha,14 Sandrigo Mangini,1 Silvia Moreira Ayub Ferreira,1 José Albuquerque de Figueiredo Neto,43 Evandro Tinoco Mesquita24,44

Resumo Nos últimos anos, vários biomarcadores estão ganhando importância clínica na avaliação diagnóstica e prognóstica de pacientes com doenças cardiovasculares. O fator de crescimento e diferenciação celular-15 (GDF-15) é uma citocina induzida por estresse e inflamação, membro da família do TGF-, cuja produção no miocárdio foi demonstrada experimentalmente em resposta à injúria isquêmica ou sobrecarga cardíaca. Este novo marcador foi positivamente correlacionado com aumento do risco de eventos cardiovasculares em estudos populacionais e configurou-se preditor independente de mortalidade e prognóstico adverso em pacientes com doença arterial coronariana e insuficiência cardíaca. Este trabalho tem como objetivo revisar o valor diagnóstico e prognóstico do GDF-15 em diferentes cenários na cardiologia.