Heart Failure – ABC CARDIOL

IJCS

Letter to the Editor

Prognostic Value of C-reactive Protein (CRP) in Patients With Acute Heart Failure (AHF) Admitted to General Wards in Brazil

Vanessa Souza Silva Medrado et al. João Emmanuel Coelho de Morais Domingos Sávio de Oliveira e Silva João Pedro Lopes Azevedo … Thalisson Gonçalves Almeida Pedro Pereira Tenório

Dear Editor,

We read with great interest the article by Ferigato et al. investigating the prognostic value of C-reactive protein (CRP) in patients with acute heart failure (AHF) admitted to general wards in Brazil. We would like to congratulate the authors for addressing a topic of substantial practical relevance: the search for accessible biomarkers in settings where gold-standard tools, such as natriuretic peptides, have inconsistent availability.

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IJCS

Original Article

Assessment of Adherence to Drug Therapy in Patients with Heart Failure Followed at a Specialized Outpatient Clinic

Breno Gabriel Araújo Sampaio de Jesus et al. Felipe Barros Oliveira Felipe Caires Araújo Meira Lívia Brito Oliveira … Fabio Figueirêdo Costa Adriana Lopes Latado

Abstract

Background:

Heart failure (HF) is a severe syndrome with high global prevalence. Despite safe and effective pharmacological therapies, its prognosis remains unfavorable, and low treatment adherence is the leading cause of rehospitalizations and worse outcomes.

Objective:

To assess treatment adherence and its determinants in patients with HF followed at cardiology outpatient clinics of a specialized hospital.

Methods:

A single-center, cross-sectional, observational study was conducted, with data collection via in-person interviews. Treatment adherence was measured using the Brief Medication Questionnaire (BMQ). Variables associated with adherence with p < 0.10 were included in a multivariate model, considering a significance level of 5%.

Results:

A total of 200 patients were included; 79.6% showed low adherence according to the BMQ, and 52.6% showed low adherence in the “regimen” domain. Only 3 (1.6%) patients presented no barriers to adherence. In multivariate analysis, being married (odds ratio [OR] 0.40; 95% confidence interval [CI] 0.16–0.96; p = 0.042), prior acute coronary syndrome (ACS) (OR 0.21; 95% CI 0.08–0.51; p < 0.001), education level (OR 0.90; 95% CI 0.82–0.98; p = 0.018), higher number of prescribed medications (OR 1.44; 95% CI 1.03–2.05; p = 0.037), and HF with improved ejection fraction (OR 2.76; 95% CI 1.06–7.63; p = 0.042) were independent predictors of low adherence.

Conclusion:

Low therapeutic adherence among patients with HF is prevalent and influenced by socioeconomic factors, social support, polypharmacy, and clinical characteristics. The results reinforce the need for health education and the simplification of therapeutic regimens.

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IJCS

Letter to the Editor

Access to Guideline-Directed Heart Failure Therapy in Brazil: Methodological and Policy Considerations

While the study’s findings are valuable, some methodological aspects could affect how we interpret them. The analysis is based solely on the presence of medications in Municipal Lists of Essential Medicines (REMUMEs), rather than on actual dispensing records or pharmacy inventory data. However, the fact that a medication is on an official list does not mean that patients can actually receive it in practice. Local procurement rules, supply chain issues, and prescribing practices can significantly affect the availability of drugs when patients need them. Conversely, medications absent from REMUMEs may still be accessible through other mechanisms within SUS. Therefore, relying solely on documentary evidence may not fully reflect the real accessibility of HF therapies. Dispensing records or pharmacy-level availability data could provide a more accurate representation of patient access.

Another important point to consider is how we understand the limited use of newer HF treatments, particularly angiotensin receptor–neprilysin inhibitors and sodium–glucose cotransporter-2 inhibitors. These treatments are often provided through specific national programs, such as the Specialized Pharmaceutical Assistance Component (CEAF), rather than being included in REMUMEs. Consequently, assessing REMUMEs alone may underestimate the availability of these agents within the broader SUS framework. Moreover, the regulatory and reimbursement processes for drugs like dapagliflozin and sacubitril/valsartan have changed quickly in recent years. This makes it especially important to understand how long they have been available.

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Original Article

Echocardiographic Changes Associated With Sacubitril/Valsartan Therapy in Patients With Heart Failure With Reduced Ejection Fraction (HFrEF): A Descriptive 12-Month Follow-Up Analysis

Marcely Bonatto et al. Ana Karyn Ehrenfried de Freitas Caio Berwanger Takatuzi Luiz Gustavo Esmanhoto Franco … Danielle Rodrigues Vendramini Luka David Lechinewski Gustavo Gavazzoni Blume Lidia Zytynski Moura

Abstract

Background:

Although randomized controlled trials have demonstrated the efficacy of Sacubitril/Valsartan in heart failure (HF), real-world evidence regarding its impact on cardiac remodeling, particularly in Heart Failure With Reduced Ejection Fraction (HFrEF), remains limited.

Objectives:

This real-world study aimed to evaluate echocardiographic changes, including ejection fraction (EF), in a cohort of patients with HFrEF treated at a public hospital in Curitiba, Brazil, and to assess clinical outcomes at 6 and 12 months of follow-up.

Methods:

Longitudinal data were collected from 200 patients with HFrEF at baseline and at 6- and 12-month follow-up. Echocardiographic assessments included EF, left ventricular (LV) dimensions, and other cardiac parameters. Clinical outcomes included HF-related hospitalizations and New York Heart Association (NYHA) functional class.

Results:

Sacubitril/Valsartan therapy was associated with improvements in EF, with the median increasing from 28% at baseline to 31.5% at 6 months and 34% at 12 months (Teichholz method). Structural remodeling was observed, including reductions in LV end-systolic and end-diastolic dimensions, as well as left atrial (LA) diameter. HF-related hospitalization rates decreased from 31.8% at baseline to 20.6% at 6 months and 11.3% at 12 months. NYHA functional class improved, with the proportion of patients in Classes III and IV decreasing from 53.2% at baseline to 17.4% at 6 months. Renal function remained stable throughout treatment. Improvements in EF were associated with a lower risk of hospitalization at 6 months (OR = 0.95) and 12 months (OR = 0.93), whereas a larger LA diameter was associated with a higher risk of hospitalization at 12 months (OR = 1.06).

Conclusions:

Sacubitril/Valsartan therapy was associated with improvements in EF, echocardiographic parameters, and NYHA functional class, as well as reductions in hospitalization rates. These findings underscore the role of the therapy in promoting reverse remodeling and suggest that its clinical benefits may extend beyond direct effects on cardiac structure.

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IJCS

Editorial

AI-Enhanced ECGs for the Diagnosis of HFpEF: A Promising Frontier, But Not Yet a Standalone Solution

Humberto Villacorta

Heart Failure with preserved Ejection Fraction (HFpEF) is among the most challenging syndromes in contemporary cardiology. Despite accounting for nearly half of all heart failure cases, HFpEF remains chronically underdiagnosed and is associated with significant morbidity and mortality.^, The diagnosis of HFpEF is challenging and relies on clinical history, natriuretic peptide measurements, and echocardiography. Diagnostic scores have been developed that integrate these three key elements.^, Echocardiography is indispensable for identifying structural and functional criteria, but its availability and cost make population-level screening impractical in many healthcare systems. In addition, in many places, a comprehensive echocardiogram is not performed. Likewise, natriuretic peptides are not always available. Therefore, new solutions to facilitate diagnosis are welcome.

In this context, the systematic review and meta-analysis presented in this issue of International Journal of Cardiovascular Sciences, provide important insights into an increasingly discussed alternative: Artificial Intelligence-enhanced Electrocardiography (AI-ECG). Drawing from more than 170,000 patients across three observational studies, the authors report a pooled sensitivity of 0.89, specificity of 0.80, and an AUC of 0.89 for AI-ECG in detecting HFpEF. These findings suggest that deep learning models can extract subtle electrical signatures associated with diastolic dysfunction – signals that may be visually imperceptible on standard ECGs. The appeal is clear: the ECG is universal, inexpensive, rapid, and deeply embedded in clinical workflows. If Artificial Intelligence could reliably identify patients requiring echocardiographic confirmation, screening strategies might be revolutionized.

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Original Article

Use of Diuretics in the Emergency Department Among Patients with Heart Failure: A Cohort Study

Nichollas Costa Rosa et al. Camila Neumaier Alves Maria Antonieta Pereira de Moraes

Abstract

Introduction:

Evidence suggests that patients with decompensated heart failure who receive loop diuretics earlier experience reduced morbidity and mortality rates.

Objectives:

To determine the time from admission to administration of the first dose of diuretics in patients with heart failure and to evaluate the risk of readmission within 30 days after hospital discharge.

Methods:

A prospective and retrospective cohort study of patients with decompensated heart failure treated in a cardiac emergency department between December 2018 and June 2020 was conducted. The risk of readmission was classified using the LACE score. The statistical analysis included the Shapiro–Wilk test for normality, the chi-square test for associations, and the Mann–Whitney test for comparisons, adopting a significance level of 5%.

Results:

A total of 361 patients were included in the study, with a predominance of males (56%), an average age of 68 ± 12 years, reduced ejection fraction (57%), functional class III (73%), and hemodynamic profile B (81%). The average time from admission to diuretic infusion was 87 (60 to 128) minutes, with 26.3% of patients receiving the infusion within 60 minutes. A significant association was found between receiving diuretics within 60 minutes and a stay in the emergency department of less than 6 hours (early discharge) (p < 0.05). The LACE score indicated that 62% of patients were at moderate risk for readmission, with 21% readmitted within 30 days. Among patients at high risk for readmission (38%), abnormal lung sounds and jugular venous distention were each significantly associated with the high-risk classification (p < 0.05). For clinical follow-up, 274 patients were included; after 180 days, 15% had died, and 46% had been readmitted.

Conclusion:

In this population, patients who received the medication early (within 60 minutes) had shorter stays in the emergency department.

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Original Article

Overview of Heart Failure in Brazil over 15 Years of Analysis: Impacts and Perspectives for the Health System

Gabriel Dalves Lauretti Betez et al. Eduarda Braga Rossi Sofia Liz Gutierrez Natalia Puschnick Gimenez Giovanna Brian de Moura

Abstract

Background:

Heart failure (HF) remains one of the leading causes of hospital admissions and in-hospital mortality in Brazil. As the population ages, understanding how these hospitalizations have evolved over time is crucial for improving healthcare planning and reducing the burden on the public health system.

Objectives:

To evaluate temporal trends in HF hospitalizations in Brazil from 2010 to 2024, considering factors such as time, region, patient profile, and hospital-related costs.

Methods:

This observational study used data from the Brazilian Unified Health System’s Hospital Information System (SIH/SUS). Hospitalization rates per 100,000 inhabitants were adjusted using population estimates from the Brazilian Institute of Geography and Statistics. Temporal trends were assessed using annual percent change (APC) and average annual percent change (AAPC), with statistical significance set at p < 0.05.

Results:

Over 3 million HF hospitalizations were recorded during the study period. Annual admissions declined from 264,000 in 2010 to 205,000 in 2024, representing an average annual decrease of 1.8%. Adjusted rates fell from 135.3 to 94.3 per 100,000 inhabitants (AAPC: −2.55%; p < 0.001). In-hospital mortality peaked in 2021, reaching 13.5%. The average cost per hospitalization more than doubled, rising from BRL 1,151.42 to BRL 2,459.57.

Conclusion:

Despite a significant reduction in hospitalization rates, HF continues to pose a major challenge to Brazil’s healthcare system due to its high case volume and the steadily rising economic burden.

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IJCS

Original Article

Evidence-Based Pharmacological Treatment for Heart Failure in Brazil

Luísa Preiss Marques da Rocha et al. Kathleen Asturian Isabel Machado Canabarro Lidia Einsfeld Diogo Pilger

Abstract

Background:

Heart failure (HF) affects an estimated 64 million individuals globally. Current guideline-directed medical therapy (GDMT) comprises four cornerstone pharmacological medications proven to reduce hospitalization and/or mortality: renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i).

Objective:

This study aimed to describe, through an exploratory analysis, access to HF drug therapy in Primary Health Care in Brazil, via the Brazilian Unified Health System (SUS).

Methods:

This was a descriptive, cross-sectional study based on data extracted from Municipal Lists of Essential Medicines (REMUMEs) published on official municipalities’ websites from Brazilian metropolitan regions in June 2024.

Results:

A total of 387 municipalities were included, of which only 50.9% had a REMUME publicly available. Among these, 61.4% had been published within the previous 2 years. The frequency of each drug class was as follows: angiotensin-converting enzyme inhibitors in 92.4% of municipalities, angiotensin II receptor blockers in 80.2%, cardioselective beta-blockers in 91.9%, and MRAs in 85.8%. No REMUME simultaneously included all four GDMT medications. In 22.3% of the metropolitan cities, only two or fewer drug classes were available to patients’ access.

Conclusion:

The remarkable variability in the composition of REMUMEs, along with the frequent omission of at least one of the four essential pharmacological pillars, indicates a potential suboptimal management of HF at the population level. Given the importance of comprehensive pharmacological treatment in HF, these findings highlight ongoing challenges in access to essential medicines within the SUS, even in metropolitan areas.

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Original Article

Long-Term Clinical Outcomes of Catheter Ablation in Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Systematic Review and Meta-Analysis

Acácio Fernandes Cardoso et al. Fernanda Cristina Poscai Ribeiro Luiz Claudio Behrmann Martins Glaucylara Reis Geovanini … Cynthia Aparecida da Silva Rocha Nemer Luiz Pichara Áleff Mascarenhas da Silva

Abstract

Background:

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of atrial fibrillation (AF). However, the benefits of catheter ablation (CA) for reducing adverse clinical outcomes in this population are not well established.

Objective:

To assess the long-term impact of CA on clinical outcomes in patients with HCM and AF through a systematic review and meta-analysis.

Methods:

Controlled studies of patients with HCM and AF undergoing CA were identified through PubMed/MEDLINE, Embase, LILACS, and Cochrane. Meta-analysis employed a random-effects model in R Studio, version 4.3.2, with p < 0.05 considered significant.

Results:

Four retrospective cohort studies met inclusion criteria, all with long follow-up period (5.52 ± 0.91 years). Arrhythmia-free survival after multiple CA ranged from 36.3% to 82%. Combined event analysis (mortality, stroke, and heart failure) yielded odds ratio 0.22 (95% confidence interval 0.08 to 0.60; p < 0.05; I² = 64%). In individual analysis, only heart failure hospitalizations were significantly lower in the CA group (odds ratio 0.32; 95% confidence interval 0.13 to 0.82; p = 0.01).

Conclusions:

This study suggests that CA may improve clinical outcomes in patients with HCM and AF, particularly by improving heart failure hospitalizations. Studies with greater methodological rigor are needed to prove this hypothesis, since only four studies were included in this systematic review.

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Editorial

C-Reactive Protein as a Prognostic Tool in Acute Heart Failure: Evidence from Low-Resource Settings

Cristhian Espinoza Romero et al. Hernán Patricio García Mejía Fábio Fernandes

Acute heart failure (AHF) remains a leading cause of hospitalization and cardiovascular mortality worldwide, with an even greater burden in low- and middle-income countries. In Brazil, in-hospital mortality for AHF is approximately 12%, compared to 4% reported in high-income countries.^,

In this context, the prospective study by Ferigato et al., conducted at a public hospital in São Paulo, assessed the prognostic value of C-reactive protein (CRP) in patients with AHF. This investigation is particularly relevant given the structural limitations of the Brazilian public healthcare system, where conventional biomarkers such as natriuretic peptides are often unavailable. Therefore, CRP—a low-cost and widely accessible inflammatory marker—emerges as a promising alternative for risk stratification during hospitalization.

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Original Article

Prognostic Implications of Increased C-Reactive Protein in Patients With Acute Heart Failure Admitted to a General Hospital Ward

Vinicius Ferigato et al. Fernanda Takeyama Mario De Divitiis Giulio Checchinato Facchini … Bruna Gandra Bruno Maciel Goncalves Helder Jorge Andrade Gomes Gustavo A. B. Boros Alcides Rocha de Figueredo Junior

Abstract

Background:

C-reactive protein (CRP) is a widely available inflammatory biomarker. Its prognostic role during hospitalization in patients with acute heart failure (HF) remains unclear.

Objective:

To assess whether CRP measured at hospital admission predicts in-hospital mortality in patients with acute HF admitted to a general public hospital ward.

Methods:

This prospective study enrolled patients (≥18 years old) admitted to a medical ward with a primary diagnosis of acute HF directly from the emergency department. CRP was measured within 72 hours of hospital admission. All patients underwent a structured clinical assessment by a cardiologist and transthoracic echocardiography (TTE). A p-value <0.05 was considered statistically significant.

Results:

A total of 44 patients were included (mean age 68 ± 16 years). TTE showed left ventricular ejection fraction (LVEF) <50% in 43% of patients, preserved LVEF in 43%, and specific causes of HF in the remaining 14%. The median CRP level (2.5 mg/dL) was used to define high and low CRP groups. Reduced LVEF (<50%) was more common, and heart failure with preserved ejection fraction (HFpEF) was less frequent, in the high CRP group (p = 0.014). Clinical assessment showed no differences in hemodynamic profiles (congestion vs. perfusion). Comorbidities, renal function, and infection diagnoses were also similar between groups. In-hospital mortality was 30% in the high CRP group versus 4.8% in the low CRP group (p = 0.046). In multivariable analysis, increased CRP remained independently associated with in-hospital mortality.

Conclusion:

CRP measured near the time of hospital admission may serve as a prognostic marker for in-hospital mortality in patients with acute HF.

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Original Article

Feasibility and Safety of One-Minute Step Test in Patients with Heart Failure Hospitalized in the Cardio-Intensive Care Unit: A Pilot Study.

Andresa Narcizo Volotão et al. Clara Pinto Diniz Ana Carolina Cossio Rodriguez Vivian de Freitas Martins da Silva … Juliana Rega de Oliveira Ana Paula Nunes Carneiro Mariana Barcellos de Avila Carolina Nigro Di Leone

Abstract

Background:

The One-Minute Step Test (1MST) seems to be a useful tool for exploring the component of energy metabolism used in Activities of Daily Living (ADL), but it is still little explored in patients with Heart Failure (HF) in the hospital environment.

Objective:

To evaluate the feasibility and safety of performing 1MST in hospitalized patients with HF.

Methods:

Data were collected using electronic medical records and evaluative tests from patients with HF. The safety of the 1MST was assessed through vital signs records, perceived exertion, adverse events, and feasibility based on the ability to complete the test. The paired Student’s T-test and Wilcoxon test were employed to compare the data before and after the test, depending on the distribution of the data, while the relationship between the variables was examined using Pearson’s correlation test. The significance level set was p < 0.05.

Results:

Twenty patients were evaluated between May and December 2022. All patients completed the test, and no adverse events were recorded. Heart rate (HR) (p < 0.001), systolic blood pressure (SBP) (p = 0.01), mean arterial pressure (MBP) (p = 0.03), and respiratory rate (p < 0.001), and peripheral oxygen saturation showed a reduction (p = 0.04). A negative correlation was observed between 1MST and age (r = −0.46; p = 0.03) and a positive correlation between 1MST and length of stay in the CICU (r = 0.44; p = 0.04).

Conclusion:

It is concluded that the 1MST is a safe and viable tool for assessing the anaerobic metabolism of patients with HF.

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Editorial

Systemic Biomarkers in Heart Failure: To Measure or Not to Measure?

Humberto Villacorta

Heart failure (HF) is an aggressive disease with unfavorable prognosis if not treated properly. Even after optimal medical treatment, some patients may remain at high risk for clinical events. As such, it is important to identify patients at risk of death or hospitalization. Biomarkers have been used to establish prognosis in HF, and natriuretic peptides (NP) are considered the gold standard biomarker in HF, not only for diagnosis but also for prognosis.

NP are cardiac biomarkers, produced by the heart ventricles in response to wall stretch. However, several systemic biomarkers, reflecting different pathways, have been shown to be elevated in HF with the potential to add information on top of NP ().^– Nevertheless, these biomarkers have not been strongly recommended in HF guidelines because their utility in aiding decision-making is unclear.

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Original Article

Six-Month Remote Monitoring of Patients With Chronic Heart Failure Using Messaging Applications on Smartphones

Elena Zheleznykh et al. Anastasia Panova Aleksei Emelianov Daria Kutsakina … Andrei Nartov Valeria Nartova Nikolay Pavlov Yuri Belenkov Maria Kozhevnikova

Abstract

Background:

Patients with chronic heart failure (HF) require outpatient monitoring after hospital discharge. The ability to use a smartphone with a personal messaging application may help.

Objectives:

Tis study aimed to investigate the feasibility of remote monitoring and evaluate its impact on treatment adherence and prognosis in patients with HF.

Methods:

A total of 100 patients were enrolled in the study: 57 patients in the mHealth group and 43 in the control group. The observation period lasted six months. Remote monitoring included a daily survey sent to patients via a personal messaging application. This was an open, randomized trial. A p-value < 0.05 was considered statistically significant.

Results:

After six months, 46 patients (mean age 61.52 ± 13.05 years, 34 men) in the mHealth group and 43 patients (mean age 60.07 ± 10.19 years, 27 men) in the control group completed the study. A total of 11 patients were lost to follow-up. In the mHealth group, two patients (4%) reached the primary endpoint, compared to seven patients (7%) in the control group.

Conclusion:

The effectiveness of remote monitoring for patients with HF using self-reporting via a smartphone messaging application was demonstrated. Patient adherence to self-reporting was found to be 76%. Those in the mHealth group who reported regularly and consistently demonstrated greater engagement in self-monitoring of vital signs and higher adherence to prescribed therapy.

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Original Article

Procalcitonin and D-dimer in Predicting the Severity of Congestive Heart Failure

Bryan Gervais de Liyis et al. Jane Carissa Sutedja I Gede Krisna Arim Sadeva Viona Mareska … Albert Salim George David Made Favian Budi Gunawan Jocelin Nathaniela Desak Made Wihandani Bagus Ari Pradnyana Dwi Sutanegara

Abstract

Background:

Congestive heart failure (CHF) is an intricate clinical syndrome that significantly contributes to morbidity and mortality. Despite extensive advancements, research on markers of severity in CHF remains scarce.

Objectives:

This study aims to evaluate procalcitonin (PCT) and D-dimer as severity predictors in CHF.

Methods:

CHF patients were included in this retrospective single-center study between January to December 2022. The population group was randomized and classified as stages I to IV based on the New York Heart Association (NYHA) functional classification system. Mean differences and multivariate analysis were performed with a statistical significance at p < 0.05.

Results:

A total of 72 CHF patients were included in the study. The correlation analysis revealed that PCT (p ≤ 0.001), D-dimer (p ≤ 0.001), and systolic blood pressure (SBP) (p = 0.005) were all found to be correlated to the CHF stages. In the analysis of mean differences, PCT (p < 0.001) and D-dimer (p < 0.001) showed significant variation across the CHF stages. The optimal PCT and D-dimer cut-off values were 1.190 ng/mL and 2.110 ng/mL respectively. Conversely, the area under the receiver operating characteristic (ROC) curve was significant for both PCT (Area Under the Curve [AUC]: 0.962; 95% CI: 0.921-1.000; p < 0.001) and D-dimer (AUC: 0.929; 95% CI: 0.868-0.989; p < 0.001). Meanwhile, through multivariate analysis, D-dimer is significantly correlated with the various CHF stages (95% CI: 0.034-0.101, p < 0.001) but not for PCT (95% CI: 0.009–0.017, p = 0.561).

Conclusion:

A significant association between D-dimer levels and CHF stages was found, suggesting the potential of D-dimer as a valuable marker of severity in CHF patients.

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Original Article

Virtual Reality and Physical Activity in Patients with Heart Failure: Technology Validation and User Satisfaction – Pilot Study

Ariele dos Santos Costa et al. Caroline Bublitz Barbosa Solange Guizilini Vagner Rogério dos Santos … Carla Roberta Miura Múcio Tavares de Oliveira Junior Anabela Gonçalves da Silva Rita Simone Lopes Moreira

Abstract

Background

Digital health uses innovative information technology for healthcare needs. Virtual reality (VR) is increasingly adopted in healthcare, including cardiovascular rehabilitation (CVR), to improve performance and adherence. However, digital interventions must consider users’ perspectives to prevent VR from becoming a barrier.

Objective

This study aimed to assess the usability and enjoyment of physical activity associated with VR among inpatients with heart failure (HF).

Method

A prospective pilot study was conducted with ten patients diagnosed with HF. Participants completed an exercise program on a cycle ergometer with immersive VR for lower limb training. Anxiety and depression symptoms, physical activity enjoyment, and system usability were evaluated. Statistical analysis included descriptive and inferential analyses with a 5% significance level (p<0.05). Pearson's test was used for correlation analysis.

Results

The population’s tendency to experience anxiety and depression was evaluated, and the sample favorably assessed the system’s usability, with a mean score of 68.2 (standard deviation ±17.8); exercise enjoyment scored 79.6 (±7.7). No significant correlations were found between anxiety and depression profiles and usability or exercise enjoyment, suggesting further study phases.

Conclusions

VR can complement rehabilitation programs for HF patients, potentially improving performance and adherence. Additional research is required to evaluate the effectiveness of VR-associated physical activity on clinical outcomes in HF patients.

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Original Article

Inspiratory and Peripheral Muscle Training in Patients with Heart Failure: Randomized Controlled Trial

André Luiz Lisboa Cordeiro et al. Fernanda Andrade da Silva de Jesus Jéssica Conceição Santos Vaneide Machado Nogueira

Abstract

Background

Current guidelines recommend incorporating exercise and physical activity, such as inspiratory muscle training (IMT) and neuromuscular training, as adjunctive therapies alongside pharmacological treatments for patients with heart failure (HF).

Objective

To evaluate the effects of IMT and peripheral muscle training (PMT) on respiratory and peripheral muscle strength, lung function, and functional capacity in patients with HF.

Methods

This is a randomized controlled trial. Prior to randomization, all patients were assessed with the 6-minute walk test, inspiratory muscle strength (maximum inspiratory pressure [MIP]), expiratory muscle strength (maximum expiratory pressure [MEP]), vital capacity (VC), peak expiratory flow (PEF), and peripheral muscle strength (using the Medical Research Council [MRC] scale). Participants were then randomly assigned to one of four groups: group 1 (control), group 2 (IMT), group 3 (PMT), or group 4 (IMT + PMT). This study was registered in the Brazilian Registry of Clinical Trials (ReBEC) under number 2.382.698. One-way ANOVA with Bonferroni post-test was used to evaluate the four groups. The paired Student’s t test was used to compare the groups at different times. A p value < 0.05 was considered significant.

Results

A total of 52 patients were assessed. Regarding muscle strength, the group that underwent IMT combined with PMT showed a significant increase in both MIP (74 ± 15 at baseline versus 91 ± 16 at hospital discharge, p < 0.01) and MEP (92 ± 19 at baseline versus 102 ± 18 at hospital discharge, p < 0.01).

Conclusion

Based on these findings, it can be concluded that IMT combined with PMT has a positive impact in patients with HF, including improvements in both peripheral and respiratory muscle strength, reduction in dyspnea and fatigue, and enhanced tolerance to physical exercise.

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Original Article

Prognostic Value of the 6-Minute Walk Test and Clinical Characteristics of Patients With Transthyretin Amyloid Cardiomyopathy

Cristhian Espinoza Romero et al. Natalia Melo Pereira Georgina Del Cisne Jadán Luzuriaga Bruno Vaz Kerges Bueno … Suenia Carvalhal Thais Borges Barbara Reis Fábio Fernandes

Abstract

Background:

In transthyretin amyloid cardiomyopathy (ATTR-CM), the assessment of functional capacity is of great importance. A distance < 300m covered in the 6-minute walk test (6MWT) is linked to a poorer prognosis in heart failure (HF) patients. However, in ATTR-CM, this association is not well-established, particularly among its various presentations and variants.

Objectives:

To evaluate functional capacity and, the prognostic value of the 6MWT in patients with ATTR-CM and to identify their clinical characteristics according to the type of ATTR-CM.

Methods:

This was a retrospective, single-center study that included patients with a confirmed diagnosis of ATTR-CM who performed the 6MWT. Median follow-up was 19 months (8 – 29). The significance level was set at P < 0.05.

Results:

A total of 32 patients were analyzed; 59.4% had the hereditary form (ATTRh), of which 63.2% were Val142Ile. Mean left ventricular ejection fraction (LVEF) was lower in the ATTRh group when compared to the wild-type form (ATTRwt) [42 ±11 versus 52± 9 %; p = 0.029]. Median distance walked in the 6MWT was 328 m (269 – 397; IQR) in ATTRwt and 304 m (246 – 387; IQR) in ATTRh, with no difference between groups (p = 0.833). In patients with a distance <300 m in the 6MWT, survival was lower (28.8 vs 36.3 months; p = 0.041).

Conclusions:

A distance <300 m walked in the 6MWT was linked to shorter event-free survival in patients with ATTR-CM. Functional capacity of most patients was very low, and no differences were observed in the distance covered between the wild-type form and the hereditary form of ATTR.

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Review Article

Evolving Therapies for Transthyretin Cardiac Amyloidosis: New Clinical Trials with Amyloid Fibrils Depleter

Marcus Vinícius Simões et al. Fábio Fernandes André Dabarian Flavio Henrique Valicelli Claudio Tinoco Mesquita

Abstract

Amyloidosis is caused by the extracellular deposition of insoluble protein arrangements, formed from structural changes in different precursor proteins. The prominent clinical and epidemiological relevance of transthyretin amyloid cardiomyopathy (ATTR-CM), whose increased incidence is associated with the aging of the global population, given its high prevalence in the elderly population, has motivated the intensification of the search for specific therapeutic targets capable of altering the natural course of the disease. The past few years have been especially prolific with the emergence of significant new therapies for ATTR-CM, with important trials demonstrating positive results and changing the natural history of an inexorable and deadly disease. Up to now, the available drugs mainly promote stabilization of disease progression in patients with no advanced heart disease but grant no reversal of the structural cardiac disease in most cases. The transthyretin (TTR)-depleters based on monoclonal antibodies directed against the deposited amyloid fibers hold promise to fulfill these expectations. The DepleTTR-CM will test the safety and efficacy of a monoclonal antibody directed against TTR fibrils deposited in the myocardium of patients with ATTR-CM. This will be the first multicenter randomized controlled trial to test this new class of anti-amyloid treatment, the “amyloid fibril depleters”. This is a strategy designed to revert the amyloid accumulation in the cardiac interstitium, which is expected to translate into relevant clinical benefits, with the potential to close a gap in the ATTR-CM treatment strategies, mainly in patients with more severe disease.

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Review Article

The Role of Strain in the Prognosis of Transthyretin Amyloidosis

Ana Karolina Bento Bento da Silva et al. Leonardo Torreão Bezerra Cavalcanti Silvio Henrique Barberato Alex dos Santos Felix Marcelo Dantas Tavares de Melo

Abstract

Transthyretin amyloidosis (TTRA) is a systemic infiltrative disease where cardiac involvement is paramount for prognosis. The strain technique plays a crucial role in non-invasive cardiac screening for this condition. Research on the prognostic utility of cardiac deformation in TTRA indicates the significance of right ventricular (RV) free wall strain, global longitudinal strain (GLS), left and right atrium reservoir strain, in descending order of publication, respectively. The GLS has emerged as a promising tool for therapeutic monitoring. Analyzing myocardial deformation is vital due to its incremental value over other clinical, laboratory, and imaging parameters. However, caution is warranted due to limited data on its prognostic and therapeutic monitoring use in TTRA. Despite the strong rationale for employing myocardial deformation in patient stratification, further robust studies are necessary to establish it as a new prognostic marker in TTRA.

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Viewpoint

Heart Rate Control or Rhythm Control in Patients With Atrial Fibrillation and Cardiac Amyloidosis

Lígia Lopes Balsalobre Trevizan et al. Sandrigo Mangini

Introduction

Cardiac amyloidosis (CA) manifests as a gradually progressive infiltrative condition characterized by the accumulation of insoluble protein aggregates within the myocardium and cardiac conduction system. The majority of CA cases are associated with precursor proteins, particularly immunoglobulin light chains (AL-CA) and transthyretin (ATTR-CA), which represent over 95% of cases. ATTR precursor substances may originate from a broad spectrum, encompassing both wild-type (ATTRwt) and variant (ATTRv) genes.

Arrhythmias in CA result from a combination of factors. The deposition of amyloid fibrils and infiltration into the myocardium cause thickening of the atrial and ventricular walls, leading to compromised relaxation. Consequently, this cascade results in increased filling pressures and atrial dilation, making individuals more susceptible to atrial fibrillation (AF) and other atrial arrhythmias. While left atrial (LA) enlargement has historically been linked with AF, new-onset AF can occur even without LA enlargement, suggesting a complex pathophysiology of AF in CA, where various processes affect LA structure, function, and mechanics in different ways, thereby heightening the AF risk. The usual manifestation of LA remodeling involves substantial infiltration of the atrial walls, leading to gradual impairment of atrial function and heightened stiffness, often observed without significant LA dilation.

[…]

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Editorial

HFrEF, HFmrEF, and HFpEF: Are They a Continuum or Different Faces of a Syndrome?

Even Edilce Mol et al. Camila Hartmann Lídia Ana Zytynski Moura

Heart failure (HF) is a significant and growing public health problem. Recent projections have shown that the prevalence of HF in the United States will increase by 46% between 2012 and 2030. This is driven by an increase in the life expectancy of the population combined with a reduction in mortality from the disease resulting from advances in therapies in recent years.

Of all the classifications of HF, the most used one is based on left ventricular ejection fraction (LVEF), which is categorized into three groups: HF with preserved ejection fraction (HFpEF) (LVEF ≥50%), HF with reduced ejection fraction (HFrEF) (LVEF ≤40%), and HF with moderate or mildly reduced ejection fraction (HFmrEF) (LVEF 41–49%). Although the prognosis appears to be similar among HF subtypes based on ejection fraction, ^, there are differences between the groups in terms of clinical-epidemiologic profile and functional capacity.

[…]

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Review Article

Heart Failure Management of Patients with Amyloid Cardiomyopathy

Vanessa Simioni Faria et al. Ciro Mancilha Murad Fabiana G. Marcondes-Braga

Abstract

Cardiac amyloidosis (CA) can lead to progressive heart failure (HF) by depositing insoluble amyloid fibrils within the myocardial extracellular space, resulting in an infiltrative and restrictive cardiomyopathy. Although CA was previously perceived as rare and incurable, recent advances in diagnostics and emerging therapies have been changing this outlook. It is crucial to spread awareness about CA to facilitate earlier diagnosis and proper therapeutic interventions, enhancing patient prognosis and survival. Currently, there is an estimated delay of 2 years from symptom onset to diagnosis, typically involving consultation with an average of 5 different professionals. Advances in cardiovascular imaging have facilitated earlier and more accurate diagnosis, reducing the necessity for invasive procedures, such as endomyocardial biopsy. Presently, tafamidis is the only drug that has been shown to offer prognostic benefits in ATTR-CA. Tafamidis is a highly specific medication targeting the circulating TTR protein, stabilizing the TTR tetramer to prevent its dissociation into amyloidogenic monomers that deposit in the myocardium. Alongside specific amyloidosis therapy, supportive HF treatment may be required; however, managing CA with medications typically used for HF with reduced ejection fraction (HFrEF) can be challenging due to potential intolerance. The effectiveness of guideline-directed medical therapy (GDMT) remains undetermined and still requires evaluation through randomized controlled clinical trials (RCCTs). Thus, the treatment cornerstone remains the judicious use of loop diuretics and mineralocorticoid receptor antagonists to control volume overload. Due to the safety profile, not adversely affecting hemodynamics or renal function, sodium-glucose transport protein 2 (SGLT2) inhibitors may be an effective treatment for CA, but they also still require evaluation through RCCTs.

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Original Article

Sociodemographic, Clinical Condition, and Functional Aerobic Capacity in Patients With Heart Failure With Varying Ventricular Ejection Fraction

Jhonatan Betancourt Peña et al. Iago Portela Pino Maria Jose Martinez Patino

Abstract

Background

Recently, a new heart failure (HF) classification was made considering the left ventricular ejection fraction (LVEF) phenotype. Comprehensive assessments of the groups are required to guide patient management.

Objective

To determine the differences in sociodemographic, clinical, functional aerobic capacity, and health-related quality of life (HRQOL) variables in patients with HF classified with different LVEFs and to explore the correlations between the variables.

Methods

This work is a cross-sectional descriptive and correlational study. Three groups of patients with HF (LVEF≥50%, LVEF<40%, and LVEF40-49%) were compared. Sociodemographic, clinical variables and functional aerobic capacity with Sit to Stand (STS), 6-minute walk test (6MWT), Duke Activity Status Index (DASI), Minnesota Living with HF Questionnaire (MLFHQ), and Patient Health Questionnaire 9 (PHQ-9) were considered. The Chi-square test, one-way analysis of variance (ANOVA) test, and Spearman's correlation were used for statistical analysis. The statistical significance level was set at 5%.

Results

A total of 209 patients were admitted with a diagnosis of HF, with a more significant number of men. Marital status was a predominantly stable union in the HF with preserved ejection fraction (HFpEF) and HF with mid-range ejection fraction (HFmrEF) groups. A sedentary lifestyle was lower in the HF with reduced ejection fraction (HFrEF) group 59 (84.3%), p-value = 0.033, and the angina pectoris was higher in the HFpEF 30 (42.9%). Systolic blood pressure at the end of the 6MWT evidenced a higher score in HFpEF 132.0±17.25 concerning HFrEF 128.0±16.57, p-value=0.043. The fat percentage was higher in HFpEF 30.20±8.80 regarding the HFmrEF group 26.51±7.60, p-value = 0.028.

Conclusion

There were significant differences according to the LVEF classification in marital status, angina symptoms, fat percentage, and blood pressure at rest.

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