Background-The effectiveness of heart failure disease management programs in patients under cardiologists' care over long-term follow-up is not established. Methods and Results-We investigated the effects of a disease management program with repetitive education and telephone monitoring on primary (combined death or unplanned first hospitalization and quality-of-life changes) and secondary end points (hospitalization, death, and adherence Key Words: heart failure Ⅲ education Ⅲ disease program management Ⅲ case management Ⅲ controlled clinical trials Ⅲ quality of life Ⅲ patient compliance R ecent disease management program (DMP) meta-analyses have reported reductions in mortality and hospitalizations of heart failure (HF) patients. 1-4 However, important issues in DMP for HF remain to be resolved. For example, few investigations include non-high-risk HF for early hospitalization managed by cardiologists or report long-term results. [3][4][5][6] No studies have reported the long-term effects of a repetitive-cyclic reeducation program. 3,4,7,8 Most DMPs have been tested in high-risk HF patients that have been discharged from the hospital, and it has been suggested that DMPs are less effective when patients are already being treated by an HF specialist. 1,3,7,9,10 Improved survival is associated with cardiologist care and with multidisciplinary teams providing specialized follow-up. 4,8 Whether both together could benefit HF is not well defined. Clinical Perspective see p 124We tested whether a DMP consisting of a long-term repetitive multidisciplinary education program and telephone monitoring could benefit HF outpatients in usual ambulatory care already under the care of a cardiologist with experience in HF. Figure 1). The first patient was randomized on October 5, 1999, and the last on January 18, 2005, in the Heart Institute of the São Paulo University Medical School. At least an 18-month follow-up from inclusion of the last patient was planned to initiate the trial analysis. Referred patients, with no exclusion criteria, were randomized in a 2:1 ratio between the intervention and control parallel groups, respectively. A computer-generated randomization list was drawn up by the statistician. The randomization 2:1 was used based on the previously published benefit of DMP in HF. The 2:1 randomization sequence was developed in blocks of 3, including 2 interventions and 1 control. The order of interventions and control within each block was also randomly assigned. To avoid deduction of the next treatment allocation and for arrangement of education classes, researchers were blinded for block size; each randomization included a number of patients in multiples of 3, with at least 15 eligible participants, except for the last group. The order of subjects in each group was randomized using a computer program. For allocation concealment, sequential, numbered, opaque, and sealed envelopes were used. Investigators ensured that the envelopes were opened sequentially only after the participants' names were written on the app...

Sildenafil was tolerated and effective for ED treatment in CHF, and improved the exercise capacity. The reduction of HR during exercise with sildenafil could theoretically decrease the myocardial oxygen consumption during sexual activity.

Continued assessment of temporal trends in mortality and epidemiology of specific cardiovascular diseases in South America is needed to provide a scientific basis for rational allocation of the limited healthcare resources and introduction of strategies to reduce risk and predict the future burden of cardiovascular disease. The epidemiology of cardiomyopathies, adult valve disease and heart failure (HF) in South America is reviewed here. Diseases of the circulatory system are the main cause of death based on data from about 50% of the South American population. Among the cardiovascular causes of death, cerebrovascular disease is predominant followed by ischaemic heart disease, other heart diseases and hypertensive disease. Of note, cerebrovascular disease is the main cause of death in women, and race also influenced cardiovascular mortality rates. HF is the most important cardiovascular reason for admission to hospital due to cardiovascular disease of ischaemic, idiopathic dilated cardiomyopathic, valvular, hypertensive and chagasic aetiologies. Also, mortality due to HF is high, especially owing to Chagas' disease. HF and aetiologies associated with HF are responsible for 6.3% of deaths. Rheumatic fever is the leading cause of valvular heart disease. The findings have important public health implications because the allocation of healthcare resources, and strategies to reduce the risk of HF should also consider controlling Chagas' disease and rheumatic fever in South American countries.

IMPORTANCE Limited evidence suggests exercise reduces blood pressure (BP) in individuals with resistant hypertension, a clinical population with low responsiveness to drug therapy. OBJECTIVE To determine whether an aerobic exercise training intervention reduces ambulatory BP among patients with resistant hypertension. DESIGN, SETTINGS, AND PARTICIPANTS The Exercise Training in the Treatment of Resistant Hypertension (EnRicH) trial is a prospective, 2-center, single-blinded randomized clinical trial performed at 2 hospital centers in Portugal from March 2017 to December 2019. A total of 60 patients with a diagnosis of resistant hypertension aged 40 to 75 years were prospectively enrolled and observed at the hospitals' hypertension outpatient clinic. INTERVENTIONS Patients were randomly assigned in a 1:1 ratio to a 12-week moderateintensity aerobic exercise training program (exercise group) or a usual care control group. The exercise group performed three 40-minute supervised sessions per week in addition to usual care. MAIN OUTCOMES AND MEASURESThe powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcomes included daytime and nighttime ambulatory BP, office BP, and cardiorespiratory fitness.RESULTS A total of 53 patients completed the study, including 26 in the exercise group and 27 in the control group. Of these, 24 (45%) were women, and the mean (SD) age was 60.1 (8.7) years. Compared with the control group, among those in the exercise group, 24-hour ambulatory systolic BP was reduced by 7.1 mm Hg (95% CI, −12.8 to −1.4; P = .02). Additionally, 24-hour ambulatory diastolic BP (−5.1 mm Hg; 95% CI, −7.9 to −2.3; P = .001), daytime systolic BP (−8.4 mm Hg; 95% CI, −14.3 to −2.5; P = .006), and daytime diastolic BP (−5.7 mm Hg; 95% CI, −9.0 to −2.4; P = .001) were reduced in the exercise group compared with the control group. Office systolic BP (−10.0 mm Hg; 95% CI, −17.6 to −2.5; P = .01) and cardiorespiratory fitness (5.05 mL/kg per minute of oxygen consumption; 95% CI, 3.5 to 6.6; P < .001) also improved in the exercise group compared with the control group.CONCLUSIONS AND RELEVANCE A 12-week aerobic exercise program reduced 24-hour and daytime ambulatory BP as well as office systolic BP in patients with resistant hypertension. These findings provide clinicians with evidence to embrace moderate-intensity aerobic exercise as a standard coadjutant therapy targeting this patient population.

(4)RESUMO O nitrogênio é o nutriente mineral requerido em maior quantidade pelo milho e o que mais influencia a produtividade de grãos. Com o objetivo de avaliar a melhor época e forma de aplicação do N na cultura do milho no sistema plantio direto, em solo de cerrado, foi realizado um experimento na Fazenda Vargem Grande, localizada no município de Montividiu (GO), em Latossolo Vermelho distrófico no ano agrícola 1996/97. A área experimental apresentava um histórico de 16 anos com plantio convencional e cinco anos de plantio direto com culturas anuais, sendo no último ano agrícola cultivada com soja, sucedida por aveia preta na entressafra. Utilizou-se o delineamento experimental de blocos casualizados com quatro repetições, e os tratamentos foram constituídos pela combinação de quatro épocas de aplicação do N (120 kg ha -1 ): 20 dias antes da semeadura do milho, todo na semeadura, 15 dias após a emergência (DAE) e 35 DAE; duas formas de aplicação do N: superficial a lanço e incorporado na entrelinha da cultura; e dois tratamentos adicionais, correspondentes ao manejo do N predominantemente utilizado na região (16 kg ha -1 de N na semeadura + 90 kg ha -1 aos 35 DAE, a lanço em superfície), e no sistema-padrão da fazenda experimental (24 kg ha -1 de N na linha de semeadura + 102 kg ha -1 , incorporado na entrelinha). A época e o modo de aplicação do N influenciaram a produtividade do milho, sendo os melhores resultados obtidos com a incorporação do fertilizante na semeadura ou 15 DAE. O sistema de manejo da adubação nitrogenada predominantemente utilizado na região, 16 kg ha -1 de N na semeadura + 90 kg ha -1 em superfície aos 35 DAE, proporcionou menor produtividade de grãos de milho. A aplicação do N em pré-semeadura do milho, 20 dias antes, demonstrou não ser recomendável para as condições edafoclimáticas estudadas.Termos de indexação: adubação nitrogenada, matéria orgânica do solo, uréia, plantas de cobertura.

Background-Peculiar aspects of Chagas cardiomyopathy raise concerns about efficacy and safety of sympathetic blockade. We studied the influence of ␤-blockers in patients with Chagas cardiomyopathy. Methods and Results-We examined REMADHE trial and grouped patients according to etiology (Chagas versus non-Chagas) and ␤-blocker therapy. Primary end point was all-cause mortality or heart transplantation. Altogether 456 patients were studied; 27 (5.9%) were submitted to heart transplantation and 202 (44.3%) died. compared with those who received ␤-blockers. Survival was lower in patients with Chagas heart disease as compared with other etiologies. When only patients under ␤-blockers were considered, the survival of patients with Chagas disease was similar to that of other etiologies. The survival of patients with ␤-blockers was higher than that of patients without ␤-blockers. In Cox regression model, left ventricle end-diastolic diameter (hazard ratio, 1.78; CI, 1.15 to 2.76; Pϭ0.009) and ␤-blockers (hazard ratio, 0.37; CI, 0.14 to 0.97; Pϭ0.044) were associated with better survival. Conclusions-Our study suggests that ␤-blockers may have beneficial effects on survival of patients with heart failure and Chagas heart disease and warrants further investigation in a prospective, randomized trial. Clinical Trial Registration-clinicaltrials.gov. Identifier: NCT00505050.(Circ Heart Fail. 2010;3:82-88.)

Background: Although a low-sodium diet is indicated for Heart Failure (HF), there is no evidence this dietary restriction is beneficial to all patients.

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