Three-year follow-up study of respiratory and systemic manifestations of chronic obstructive pulmonary disease

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Relationship between disease severity and quality of life in patients with chronic obstructive pulmonary disease

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Left cardiac sympathetic denervation for treatment of symptomatic systolic heart failure patients: a pilot study

To evaluate the feasibility, safety, and potential beneficial effects of left cardiac sympathetic denervation (LCSD) in systolic heart failure (HF) patients. In this prospective, randomized pilot study, inclusion criteria were New York Heart Association (NYHA) functional class II or III, left ventricular ejection fraction (LVEF) 40, sinus rhythm, and resting heart rate 65 b.p.m., despite optimal medical therapy (MT). Fifteen patients were randomly assigned either to MT alone or MT plus LCSD. The primary endpoint was safety, measured by mortality in the first month of follow-up and morbidity according to pre-specified criteria. Secondary endpoints were exercise capacity, quality of life, LVEF, muscle sympathetic nerve activity (MSNA), brain natriuretic peptide (BNP) levels and 24 h Holter mean heart rate before and after 6 months. We studied clinical effects in long-term follow-up. Ten patients underwent LCSD. There were no adverse events attributable to surgery. In the LCSD group, LVEF improved from 25 6.6 to 33 5.2 (P 0.03); 6 min walking distance improved from 167 35 to 198 47 m (P 0.02). Minnesota Living with Heart Failure Questionnaire (MLWHFQ) score physical dimension changed from 21 5 to 15 7 (P 0.06). The remaining analysed variables were unchanged. During 848 549 days of follow-up, in the MT group, three patients either died or underwent cardiac transplantation (CT), while in the LCSD group six were alive without CT. LCSD was feasible and seemed to be safe in systolic HF patients. Its beneficial effects warrant the development of a larger randomized trial. Trail registration: NCT01224899.

Pulmonary hypertension diagnosed by right heart catheterisation in sickle cell disease

Recent studies have recognised the importance of pulmonary hypertension (PH) in sickle cell disease (SCD). The aim of this study was to determine the prevalence and prognostic impact of PH and its features in patients with SCD. 80 patients with SCD underwent baseline clinical evaluation, laboratory testing, 6-min walk tests (6MWTs) and echocardiography. Patients with a peak tricuspid regurgitant jet velocity (TRV) of >= 2.5 m.s(-1) were further evaluated through right heart catheterisation (RHC) to assure the diagnosis of PH. Our study evidenced a 40% prevalence of patients with elevated TRV at echocardiography. RHC (performed in 25 out of 32 patients) confirmed PH in 10% (95% CI 3.4-16.5%) of all patients, with a prevalence of post-capillary PH of 6.25% (95% CI 0.95-11.55%) and pre-capillary PH of 3.75% (95% CI -0.4-7.9%). Patients with PH were older, had worse performance in 6MWTs, and more pronounced anaemia, haemolysis and renal dysfunction. Survival was shorter in patients with PH. Our study reinforced the use of echocardiography as a screening tool for PH in SCD and the mandatory role of RHC for proper diagnosis. Our findings confirmed the prognostic significance of PH in SCD as its association to pronounced haemolytic profile.

Right ventricular systolic function and cardiac resynchronization therapy

AIMS: The effect of cardiac resynchronization therapy (CRT) on right ventricular ejection fraction (RVEF) has not been well studied. Furthermore, it is unclear whether baseline RVEF influences response to CRT. To evaluate the acute and chronic effects of CRT on right ventricular systolic function, and to investigate whether baseline RVEF impacts response to CRT. METHODS AND RESULTS: Forty-four patients with a standard indication for CRT underwent radionuclide angiography at baseline and after at least 6 months' follow-up for measuring RVEF, right ventricular synchrony (using phase analysis), and left ventricular ejection fraction (LVEF). In addition, NYHA functional class and 6-min walking distance (6MWD) were evaluated. There were no significant acute changes in RVEF with CRT. After a mean follow-up of 9 +/- 5 months, RVEF was slightly improved (by 1.9 +/- 5.0% in absolute terms, P = 0.016), and to a lesser extent than LVEF (5.1 +/- 9.0%, P = 0.009 compared with RVEF). Right ventricular dyssynchrony was significantly improved at follow-up (P = 0.016). Patients with a baseline RVEF < or = 0.35 (n = 19) were less likely to improve in NYHA class (P = 0.016), and also tended to improve less in 6MWD and LVEF (P < 0.06). CONCLUSION: Cardiac resynchronization therapy has no acute effect on RVEF, and only slightly improves RVEF at follow-up. Patients with reduced RVEF at baseline were less likely to respond to CRT, indicating that right ventricular systolic dysfunction may play a role in patient selection.

Lung volume reduction surgery versus conservative treatment in severe emphysema

Lung volume reduction surgery (LVRS) has been proposed for patients with severe emphysema to improve dyspnoea and pulmonary function. It is unknown, however, whether prognosis and pulmonary function in these patients can be improved compared to conservative treatment. The effect of LVRS and conservative therapy were compared prospectively in 57 patients with emphysema, who fulfilled the standard criteria for LVRS. The patients were divided into two groups according to their own decision. Patients in group 1 (n=29, eight females, mean+/-SEM 58.8+/-1.7 yrs, forced expiratory volume in one second (FEV1) 27.6+/-1.3% of the predicted value) underwent LVRS. Patients in group 2 (n=28, five females, 58.5+/-1.8 yrs, FEV1 30.8+/-1.4% pred) preferred to postpone LVRS. There were no significant differences in lung function between the two groups at baseline; however, there was a tendency towards better functional status in the control group. The control group had a better modified Medical Research Council (MMRC) dyspnea score (3.1+/-0.15 versus 3.5+/-0.1, p<0.04). Model-based comparisons were used to estimate the differences between the two groups over 18 months. Significant improvements were observed in the LVRS group compared to the control group in FEV1, total lung capacity (TLC), Residual volume (RV), MMRC dyspnea score and 6-min walking distance on all follow up visits. The estimated difference in FEV1 was 33% (95% confidence interval 13-58%; p>0.0001), in TLC 12.9% (7.9-18.8%; p>0.0001), in RV 60.9% 32.6-89.2%; p>0.0001), in 6-min walking distance 230 m (138-322 m; p<0.002) and in MMRC dyspnoea score 1.17 (0.79-1.55; p<0.0001). In conclusion, lung volume reduction surgery is more effective than conservative treatment for the improvement of dyspnoea, lung function and exercise capacity in selected patients with severe emphysema.

Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy

OBJECTIVES This study was designed to predict the response and prognosis after cardiac resynchronization therapy (CRT) in patients with end-stage heart failure (HF). BACKGROUND Cardiac resynchronization therapy improves HF symptoms, exercise capacity, and left ventricular (LV) function. Because not all patients respond, preimplantation identification of responders is needed. In the present study, response to CRT was predicted by the presence of LV dyssynchrony assessed by tissue Doppler imaging. Moreover, the prognostic value of LV dyssynchrony in patients undergoing CRT was assessed. METHODS Eighty-five patients with end-stage HF, QRS duration >120 ins, and left bundle-branch block were evaluated by tissue Doppler imaging before CRT. At baseline and six months follow-up, New York Heart Association functional class, quality of life and 6-min walking distance, LV volumes, and LV ejection fraction were determined. Events (death, hospitalization for decompensated HF) were obtained during one-year follow-up. RESULTS Responders (74%) and nonresponders (26%) had comparable baseline characteristics, except for a larger dyssynchrony in responders (87 +/- 49 ms vs. 35 +/- 20 ms, p < 0.01). Receiver-operator characteristic curve analysis demonstrated that an optimal cutoff value of 65 ms for LV dyssynchrony yielded a sensitivity and specificity of 80% to predict clinical improvement and of 92% to predict LV reverse remodeling. Patients with dyssynchrony :65 ms had an excellent prognosis (6% event rate) after CRT as compared with a 50% event rate in patients with dyssynchrony <65 ins (p < 0.001). CONCLUSIONS Patients with LV dyssynchrony greater than or equal to65 ms respond to CRT and have an excellent prognosis after CRT. (C) 2004 by the American College of Cardiology Foundation.

El concepto y la práctica de la actividad física y su relación con calidad de vida en los modelos teóricos de la salud

Los estudios acerca del concepto actividad física (AF) son diversos, presentando diferentes concepciones; su relación con calidad de vida suele estar generada dentro del discurso médico, que propende por la ejecución de la Actividad Física desde una mirada netamente biológica. Si bien esta disertación es importante, se debe tener en cuenta que los estudios relacionados con calidad de vida y la AF se basan en la condición de bienestar y percepción frente al estado de salud; dichos estudios no se han realizado desde las condiciones de vida y del contexto social. Si bien es cierto que la mirada médica y lo estudios objetivos son relevantes, ya que arrojan estadísticas que permiten abordar recomendaciones en cuanto a la actividad física, en este documento se elaboró una investigación de tipo cualitativo por medio de la revisión documental del concepto de actividad física, sus prácticas y su relación con calidad de vida, que abordan diferentes autores. Para ello se elige la base de datos PubMed por su énfasis en las publicaciones de salud; se seleccionan artículos publicados del 2004 y 2014, que estudien el concepto de actividad física, sus prácticas y relaciones con calidad de vida, para finalmente hacer un análisis desde los modelos de determinación y determinantes sociales. De esta forma se analiza la posición de los autores con respecto al concepto, sus prácticas y las relaciones que puede llegar a surgir con la calidad de vida. En esta investigación se obtuvo como resultados tendencias biológicas, psicológicas, sociales y culturales, en los cuales los autores dejan clara la posición médica ya que en la mayoría de investigaciones centran sus relaciones en la funcionalidad, y es a través de la visión terapéutica donde buscan el bienestar, la satisfacción de los pacientes que padecen cualquier enfermedad. Además, aparecen categorías emergentes como: cuerpo como medio de publicidad, cibernética que avanza vertiginosamente y el papel del poder en la actividad física que pueden ser contempladas para otros estudios.

Strategia terapeutica nei pazienti con ipertensione arteriosa polmonare a rischio intermedio

Le attuali linee guida stratificano il rischio dei pazienti con ipertensione arteriosa polmonare (IAP) in basso, intermedio e alto (rispettivamente con mortalità a 1 anno <5%, 5-10% e >10%). La maggior parte dei pazienti è però classificata nella categoria intermedia. Per stratificare ulteriormente questi pazienti, abbiamo valutato il ruolo prognostico dello stroke volume index (SVI) misurato al cateterismo cardiaco destro (CCDx) in 725 pazienti naïve da terapia con IAP idiopatica/ereditaria, associata a malattie del tessuto connettivo o cardiopatie congenite. I pazienti sono stati valutati al basale e 3-4 mesi dopo l'inizio della terapia (1° F-UP) con CCDx, livelli plasmatici di peptide natriuretico cerebrale (BNP), test dei 6 minuti (T6M) e classe funzionale OMS. Abbiamo applicato una tabella di rischio semplificata utilizzando i criteri: classe funzionale OMS, T6M, pressione atriale destra o livelli plasmatici di BNP e indice cardiaco (IC) o saturazione di ossigeno venoso misto (SvO2). Le classi di rischio sono state definite come: basso= almeno 3 criteri a basso rischio e nessun criterio ad alto rischio; alto= almeno 2 criteri ad alto rischio inclusi IC o SvO2; intermedio= tutti gli altri casi. Lo SVI, mediante la regressione di Cox, stratifica la prognosi dei pazienti a rischio intermedio al 1° F-UP [p=0.008] ma non al basale [p=0.085]. Considerandone l’ottimale cut-off predittivo (38 ml/m2) i pazienti a rischio intermedio sono ulteriormente classificabili in intermedio-basso e intermedio-alto. Considerando l'effetto dei 3 principali farmaci che agiscono sulla via della prostaciclina in aggiunta alla duplice terapia di combinazione con inibitori della fosfodiesterasi-5 e antagonisti dell'endotelina, i pazienti trattati con epoprostenolo e.v. hanno ottenuto un maggiore miglioramento rispetto ai pazienti trattati con selexipag; col treprostinil s.c. vi è stata una risposta intermedia. Abbiamo quindi proposto un algoritmo di terapia con selexipag in pazienti a rischio intermedio-basso e con prostanoidi parenterali in pazienti a rischio intermedio-alto.

Evaluation of the six-minute walk test in patients with chronic heart failure associated with Chagas' disease and systemic arterial hypertension

INTRODUCTION: To evaluate physical capacity as determined by the six-minute walk test (6MWT) in patients with chronic heart failure due to Chagas' disease associated with systemic arterial hypertension (Chagas-SAH). METHODS: A total of 98 patients routinely followed at the Cardiomyopathy Outpatient Service were recruited. Of these, 60 (61%) were diagnosed with Chagas disease and 38 (39%) with Chagas-SAH. RESULTS: The distance walked during 6 min was 357.9 ±98 m for Chagas-SAH patients and 395.8 ± 121m for Chagas cardiomyopathy patients (p >0.05). In patients with Chagas-SAH, a negative correlation occurred between the 6MWT and the total score of the Minnesota Living with Heart Failure Questionnaire (r= -0.51; p=0.001). No other correlations were determined between 6MWT values and continuous variables in patients with Chagas-SAH. CONCLUSIONS: The results of the 6MWT in Chagas-SAH patients are similar to those verified in Chagas cardiomyopathy patients with chronic heart failure. Coexistence of SAH does not seem to affect the functional capacity of Chagas cardiomyopathy patients with chronic heart failure.

Six-minute walk test: functional capacity of severely obese before and after bariatric surgery

Background: The 6-minute walk test (6MWT) is a well-known instrument for assessing the functional capacity of a variety of groups, including the obese. It is a simple, low-cost and easily applied method to objectively assess the level of exercise capacity. The aim of the present study was to study the functional capacity of a severely obese population before and after bariatric surgery. Methods: A total of 51 patients were studied. Of the 51 patients, 86.2% were women, and the mean age was 40.9 +/- 9.2 years. All 51 patients were evaluated preoperatively and 49 were evaluated 7-12 months postoperatively. The initial body mass index was 51.1 +/- 9.2 kg/m(2), and the final body mass index was 28.2 +/- 8.1 kg/m(2). All patients underwent Roux-en-Y gastric bypass. The 6MWT was performed in a hospital corridor, with patients attempting to cover as much distance as they could, walking back and forth for as long as possible within 6 minutes at their regular pace. The total distance, Borg Scale of perceived exhaustion, modified Borg dyspnea scale for shortness of breath, and physical complaints at the end of the test were recorded. In addition, the heart rate and respiratory frequency were assessed before and after the test. Results: The tolerance was good, and no injuries occurred at either evaluation. The patients` mean distance for the 6MWT was 381.9 +/- 49.3 m before surgery and 467.8 +/- 40.3 m after surgery (p < .0001). Similar results were observed for the other parameters assessed. Conclusion: The 6MWT provided useful information about the functional status of the obese patients undergoing bariatric surgery. A simple, safe, and powerful method to assess functional capacity of severely obese patients, the 6MWT is an objective test that might replace the conventional treadmill test for these types of patients. (Surg Obes Relat Dis 2009;5:540-543.) (C) 2009 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Avaliação da capacidade de caminhar do portador de obesidade mórbida utilizando teste de caminhada de 6 minutos

Introduction: The ability to walk is impaired in obese by anthropometric factors (BMI and height), musculoskeletal pain and level of inactivity. Little is known about the influence of body adiposity and the acute response of the cardiovascular system during whole the 6-minute walk test (6mWT). Objective: To evaluate the effect of anthropometric measures (BMI and WHR waist-to-hip ratio), the effort heart and inactivity in ability to walk the morbidly obese. Materials and Methods: a total 36 morbidly obese (36.23 + 11.82 years old, BMI 49.16 kg/m2) were recruited from outpatient department of treatment of obesity and bariatric surgery in University Hospital Onofre Lopes and anthropometric measurements of obesity (BMI and WHR), pulmonary function, pattern habitual physical activity (Baecke Questionnaire) and walking capacity (6mWT). The patient was checking to measure: heart rate (HR), breathing frequency (BF), peripheral oxygen saturation, level of perceived exertion, systemic arterial pressure and duplo-produto (DP), moreover the average speed development and total distance walking. The data were analysed between gender and pattern of body adiposity, measuring the behavior minute by minute of walking. The Pearson and Spearmam correlation coefficients were calculated, and stepwise multiple Regression examined the predictors of walking capacity. All analyses were performed en software Statistic 6.0. Results: 20 obese patients had abdominal adiposity (WHR = 1.01), waist circumference was 135.8 cm in women (25) and 139.8 cm in men (10). Walked to the end of 6mWT 412.43 m, with no differences between gender and adiposity. The total distance walked by obesity alone was explained by BMI (45%), HR in the sixth minute (43%), the Baecke (24%) and fatigue (-23%). 88.6% of obese (31) performed the test above 60% of maximal HR, while the peak HR achieved at 5-minute of 6mWT. Systemic arterial pressure and DP rised after walking, but with no differences between gender and adiposity. Conclusion: The walk of obese didn´t suffers influence of gender or the pattern of body adiposity. The final distance walked is attributed to excess body weight, stress heart, the feeling of effort required by physical activity and level of sedentary to obese. With a minute of walking, the obeses achieved a range of intensity cardiovascular trainning

Short-Term Effects of Using Pedometers to Increase Daily Physical Activity in Smokers: A Randomized Trial

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Efeito do treinamento intradialítico resistido e aeróbio sobre a função cognitiva e capacidade funcional de pacientes em hemodiálise: estudo controlado

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology

Therapy has improved the survival of heart failure (HF) patients. However, many patients progress to advanced chronic HF (ACHF). We propose a practical clinical definition and describe the characteristics of this condition. Patients that are generally recognised as ACHF often exhibit the following characteristics: 1) severe symptoms (NYHA class III to IV); 2) episodes with clinical signs of fluid retention and/or peripheral hypoperfusion; 3) objective evidence of severe cardiac dysfunction, shown by at least one of the following: left ventricular ejection fraction<30%, pseudonormal or restrictive mitral inflow pattern at Doppler-echocardiography; high left and/or right ventricular filling pressures; elevated B-type natriuretic peptides; 4) severe impairment of functional capacity demonstrated by either inability to exercise, a 6-minute walk test distance<300 m or a peak oxygen uptake<12-14 ml/kg/min; 5) history of >1 HF hospitalisation in the past 6 months; 6) presence of all the previous features despite optimal therapy. This definition identifies a group of patients with compromised quality of life, poor prognosis, and a high risk of clinical events. These patients deserve effective therapeutic options and should be potential targets for future clinical research initiatives.