Esta atualização da Diretriz de Insuficiência Cardíaca Crônica (IC) - 2012 surge para reavaliar as recomendações através de uma avaliação criteriosa das pesquisas (considerando-se a qualidade dos estudos), fundamental para que se atinja esse propósito. Para tanto, foi dada ênfase ao efeito em desfechos de morte, à qualidade "CONSORT" (Consolidated Standards of Reporting Trials), à descrição qualitativa e quantitativa da otimização da medicação, à população realmente incluída, às metanálises somente de estudos qualidade "CONSORT", à custo-efetividade, à existência de efeito de classe, ao número de pacientes incluídos e à análise de subgrupos apenas para gerar hipóteses. Na área da epidemiologia, as recentes abordagens das características da IC com fração de ejeção preservada (ICFEP) e da importância da IC como causa de morte no Brasil foram revisadas. Além disso, este documento contempla a reavaliação do valor dos biomarcadores no diagnóstico e no seguimento da IC, o papel diagnóstico da angiotomografia coronariana nos casos de risco intermediário ou baixo risco de doença coronariana, a não recomendação de rotina do telemonitoramento; o surgimento da avaliação familiar como recomendação importante, e a reavaliação da restrição da adição de sal na dieta. As clínicas de IC e reabilitação física, apesar de alguns resultados negativos ou controversos quanto à mortalidade, continuam com recomendação importante. No campo do tratamento farmacológico, abrange-se a reavaliação da indicação do nebivolol, introduz-se a ivabradina como um novo paradigma no tratamento, os antagonistas da aldosterona não têm efeito de classe reconhecido, o ômega 3 passa a ser recomendado, o ferro administrado por via endovenosa e o sildenafil recebem indicação em casos selecionados. Todas as recomendações para outras etiologias são expandidas para a Doença de Chagas. Na área da anticoagulação, recomenda-se a utilização dos escores CHA2DS2VASC e o HAS-BLED na fibrilação atrial, com introdução de inibidores da trombina e do fator Xa como alternativas na anticoagulação. No tratamento cirúrgico da IC, considerou-se que resultados neutros do estudo STICH influenciaram as recomendações, o transplante cardíaco continua a ser o tratamento indicado nas fases evolutivas tardias de IC, os dispositivos de assistência circulatória mecânica para terapia de destino passam a ter recomendação, a duração do QRS foi fundamental na indicação de TRV-AV, e o CDI continua com recomendação I para miocardiopatia isquêmica. Entretanto, baseada em análise crítica dos estudos considerando-se o custo-efetividade, o CDI não atingiu recomendação I para classes menos graves devido as limitações dos estudos. Também a importância da cardiotoxicidade por drogas para tratamento de neoplasias foi ressaltada, o tratamento da IC na gravidez e da miocardite foi revisado. Novos potenciais métodos de tratamento em fase de pesquisa são apresentados e novos fluxogramas de diagnóstico e tratamento da IC, reformulados, foram incluído

This surgical technique for Ebstein's anomaly can be performed with low mortality and morbidity. Early echocardiograms showed significant reduction of tricuspid insufficiency, and the follow-up showed improvement in patients' clinical status and low incidence of reoperation.

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...

Differently from what was thought, in ischemic or idiopathic dilated cardiomyopathy, dilation of mitral ring is proportional and does not exclusively affect the posterior portion. The degree of left ventricular dilation does not determine the degree of dilation of the mitral ring because they are independent processes. These observations shed new light on the techniques used to correct mitral valve insufficiency in dilated cardiomyopathy.

No abstract

Heart transplantation (HT) remains the treatment of choice for advanced chagasic cardiomyopathy. New immunosuppression protocols have provided better control of rejection (RJ) and cardiac allograft vasculopathy. However, their influence on infection and Chagas disease reactivation (CDR) is not well established. The aim of this study was to compare the CDR rate in patients under two different immunosuppression protocols. We studied 39 chagasic patients who had undergone orthotopic HT between April, 1987 and June, 2004. They were divided into two groups, one taking azathioprine (group 1 = 24 patients) and the other taking mycophenolate mofetil (group 2 = 15 patients), in the standard doses (2 mg/kg/day and 2 g/day, respectively), beside prednisone and cyclosporine, in equivalent doses. The number of CDR and RJ episodes were analyzed in the first and second years after HT. CDR rates were 8% ± 5% at 1 year and 12% ± 6% at 2 years of follow-up in group 1. Otherwise, patients in group 2 presented CDR rates of 75% ± 10% and 81% ± 9% at the same periods, respectively (p < 0.0001, hazard ratio = 6.06). When comparing RJ rates in the first year after HT, both groups had similar behavior under both immunosuppression protocols (p = 0.88). These data show that current prescribed doses of mycophenolate mofetil increase the early risk of CDR without changing RJ incidence in this period.

Classe I: evidência ou concordância geral de que o tratamento é benéfico, útil e eficaz.Classe II: evidência conflitante e/ou divergência de opinião quanto à utilidade e à eficácia do tratamento.Classe IIa: forças das evidências/opiniões em favor da utilidade e da eficácia.Classe IIb: forças das evidências/opiniões menos bem estabelecidas quanto à utilidade e à eficácia.Classe III: evidência ou concordância geral de que o tratamento não é útil/eficaz e em alguns casos pode ser prejudicial. Nível de evidência A: presença de múltiplos estudos clínicos randomizados.Nível de evidência B: presença de um único estudo clínico randomizado ou de estudos não-randomizados.Nível de evidência C: consenso de especialistas.O nível de evidência será apresentado apenas para os tratamentos do infarto do miocárdio, não se aplicando aos procedimentos diagnósticos. Todos os métodos complementares deverão ser realizados por profissionais experientes, segundo as recomendações específicas de cada especialidade.

OBJECTIVE:Experimental findings support clinical evidence that brain death impairs the viability of organs for transplantation, triggering hemodynamic, hormonal, and inflammatory responses. However, several of these events could be consequences of brain death–associated trauma. This study investigated microcirculatory alterations and systemic inflammatory markers in brain-dead rats and the influence of the associated trauma.METHOD:Brain death was induced using intracranial balloon inflation; sham-operated rats were trepanned only. After 30 or 180 min, the mesenteric microcirculation was observed using intravital microscopy. The expression of P-selectin and ICAM-1 on the endothelium was evaluated using immunohistochemistry. The serum cytokine, chemokine, and corticosterone levels were quantified using enzyme-linked immunosorbent assays. White blood cell counts were also determined.RESULTS:Brain death resulted in a decrease in the mesenteric perfusion to 30%, a 2.6-fold increase in the expression of ICAM-1 and leukocyte migration at the mesentery, a 70% reduction in the serum corticosterone level and pronounced leukopenia. Similar increases in the cytokine and chemokine levels were seen in the both the experimental and control animals.CONCLUSION:The data presented in this study suggest that brain death itself induces hypoperfusion in the mesenteric microcirculation that is associated with a pronounced reduction in the endogenous corticosterone level, thereby leading to increased local inflammation and organ dysfunction. These events are paradoxically associated with induced leukopenia after brain damage.