2021;1(1) – ABC CARDIOL

Review Article

Acute Myocarditis in Childhood and Adolescence in the Covid-19 Era

Ana Flávia Malheiros Torbey et al. Aurea Lúcia Alves de Azevedo Grippa de Souza Ana Catarina Durán Bustamante Carmen Z. Brandão … Luan Rodrigues Abdallah Yves P. D. March e Souza Evandro Tinoco Mesquita

Abstract

Myocarditis in children and adolescents is an inflammatory myocardial disease with a heterogeneous presentation ranging from oligosymptomatic, with no impaired ejection fraction to catastrophic clinical presentation with cardiogenic shock (fulminant myocarditis) or sudden death. Thus, this condition remains a major challenge from the diagnostic and therapeutic points of view. Despite the different etiologies listed, the most frequent form may be related to viral diseases, and new forms of myocarditis, such allergic ones (eosinophilic and use of medications, particularly cancer immunotherapy), have been currently described. Increasing the rate of suspicion is crucial. Measurement of serum levels of troponin and N-terminal B-type natriuretic peptide, as well as the use of advanced methods of cardiac imaging, such as strain echocardiogram, positron emission tomography, and cardiac magnetic resonance, are integral part of multimodal assessment in suspected patients. Although endomyocardial biopsy remains is still the gold standard for disease diagnosis, currently it tends to be performed in specific situations, such as fulminant clinical presentation and chronic or recurrent myocarditis. The management of this condition includes general supportive care, treatment of heart failure, control of arrhythmias when present, assessment of mechanical support and cardiac transplantation. Treatments based on immunosuppression and immunotherapy are still controversial. In this article, we propose a broad review of diagnostic and treatment methods, as well as the different etiologies in the pediatric population.

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Editorial

The Role of the Heart Failure Specialist: Benefits for Both the Patient and the Cardiology Community

Livia A. Goldraich et al. Jefferson L. Vieira Nadine Clausell

In recent decades, the advancement of knowledge of cardiovascular diseases has been remarkable. Heart failure (HF) has a prominent role among the conditions of greatest epidemiological relevance for the population, given its high prevalence and incidence worldwide, including Brazil.^– Thus, mastery of this condition is key to cardiologist training. However, the understanding of the complexity of the different diseases and pathophysiological mechanisms potentially involved in the development, progression, and prognosis of HF has advanced, and a broad and intricate spectrum of therapeutic options has emerged, especially in the past two decades. These advances allowed a significant improvement in the clinical outcomes of HF patients; however, as knowledge and consequent therapeutic challenges became more complex, it was clear that a new type of training and expertise in the field of Cardiology was needed.

The American Heart Association (AHA) and the European Society of Cardiology (ESC) were the first to encourage the growth and strengthening of the HF specialty, with the creation of study groups, departments, and journals focused on this condition.^– Several specific HF congresses have been organized and brought together a growing number of participants for about 20 years. Concomitantly, several cardiology centers of worldwide relevance have developed fellowship programs in HF and heart transplantation, many of which more recently also cover mechanical circulatory support. Finally, certification examinations for HF specialist by the American Board of Internal Medicine (ABIM) and the ESC Heart Failure Association were created in 2013 and 2014, respectively.^, In 2020, an expert consensus of the American College of Cardiology (ACC) together with the Heart Failure Society of America (HFSA) and the International Society for Heart and Lung Transplantation (ISHLT) introduced a list of requirements for HF specialist training, based on the core competencies of the Accreditation Council for Graduate Medical Education (ACGME). This document outlines, in particular, the expectations for physicians who treat advanced HF patients or heart transplant recipients, and recommends specific skills in mechanical circulatory support, cardiac resynchronization therapy, heart transplantation, and pulmonary hypertension. The authors also recommend that there be a maintenance of certification process based on participation in continuing medical education programs and collaboration with national databases and registries. exemplifies and adapts the HF training model used at Brigham and Women’s Hospital, Harvard University, Boston, United States.

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Brief Communication

Lessons Learned by a Multidisciplinary Heart Failure Clinic In The Midst Of A Pandemic

Jefferson Luís Vieira et al. Maria Gyslane Vasconcelos Sobral Raquel Sampaio Florêncio Viviane Moreira Alves … Glauber Gean Vasconcelos Germana Porto Linhares Almeida Laura Leite da Escóssia Marinho Juliana Rolim Fernandes Juan Alberto Cosquillo Mejia João David de Souza Neto

Abstract

In addition to the deaths caused by coronavirus disease (COVID-19), several countries also observed an increase in the overall number of cardiovascular deaths during the pandemics compared with the same period in previous years. The presence of heart failure (HF) in the context of COVID-19 identifies a subgroup with complex management and may represent both a risk factor for worse infection outcomes and a severe cardiovascular complication caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with advanced HF require regular rigorous multidisciplinary medical follow-up, performed ideally through face-to-face consultation. However, due to the reallocation of health care professionals and the implementation of measures of isolation and social distancing, telemedicine strategies have strengthened as important allies in the management of HF patients. In the present document, we report the brief experience of the unit of advanced HF and heart transplant of Hospital de Messejana, a reference center in the confrontation of COVID-19 in the state of Ceará, Brazil, with the primarily remote monitoring rather than face-to-face consultation from March to July 2020.

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Case Report

Heart Failure Due to Anomalous Pulmonary Vein Connection Associated with Atrial Septal Defect

Marcely Gimenes Bonatto et al. Ana Karyn Ehrenfried de Freitas Letícia dos Santos de Oliveira Rocha Claudinei Collatusso … Rafael de Almeida Torres Gustavo Gavazzoni Blume Lídia Zytynski Moura

Introduction

Anomalous pulmonary vein dreinage (APVD) is a rare disease, accounting for nearly 1 to 3% of congenital heart diseases. It may be total, when all PVs are involved, or partial, when only some PVs drain anomalously into one or more systemic veins or directly into the right atrium (RA).^, This condition occurs alone or in association with an interatrial septal defect, more often sinus venosus interatrial communication (IAC) (which accounts for nearly 5% of all IAC cases).

Patients with this condition may remain asymptomatic until adulthood. However, overload of right chambers may trigger symptoms, especially reduced functional capacity and progressive dyspnea, in addition to the development of pulmonary hypertension (PH) and ventricular dysfunction, which is the most severe disease scenario. Recognizing these symptoms and establishing early diagnosis and treatment is crucial to avoid disease progression and its prognostic implications.

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Brief Communication

The Challenge of HFpEF Diagnosis in Brazil

Luiz Cláudio Danzmann et al. Evgeny Belyavskiy Antônio José Lagoeiro Jorge Evandro Tinoco Mesquita Marco Antonio Rodrigues Torres

Abstract

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent in Brazil and worldwide. However, the recent diagnostic criteria for this condition are complex and difficult to apply in the Brazilian health system. This review proposes adapting the modern diagnostic criteria to the needs of each patient, from the primary care to the most complex one, using a system of three steps of complexity and highlighting the importance of searching specific disease etiology.

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Review Article

Possible Mechanisms of Action of SGLT2 Inhibitors in Heart Failure

Camila Nicolela Geraldo Martins et al. Adriana Aparecida Bau Luis Miguel da Silva Otavio Rizzi Coelho Filho

Abstract

In mid-2013, sodium-glucose co-transporter 2 (SGLT2) inhibitors such as canagliflozin, dapagliflozin, and empagliflozin were introduced as possible treatments for type 2 diabetes mellitus (DM2). Cardiovascular safety studies demonstrated that not only were SGLT2 inhibitors safe, but they were also associated with a significant reduction in cardiovascular mortality and heart failure (HF) outcomes including hospitalizations. These findings encouraged the development of clinical trials aimed specifically at investigating the effects of this new drug class on HF with reduced ejection fraction (EF), including the DAPA-HF and EMPEROR-reduced studies. The demonstration of beneficial effects of SGLT2 inhibitors on the reduction of cardiovascular events in treated patients with symptomatic HF and reduced left ventricular EF (LVEF < 40 %) resulted in the extension of SGLT2 inhibitor indication to patients with symptomatic HF with reduced EF. The mechanisms behind these beneficial effects of SGLT2 inhibitors are not entirely known. In this review, we analyze several current hypotheses for the cardioprotective effects of SGLT2 inhibitors, including reduced blood pressure, increased natriuresis, improved energy metabolism, prevention of inflammation, weight loss, improved glycemic control, inhibition of the sympathetic nervous system, prevention of myocardial remodeling, prevention of ischemia/reperfusion injury, inhibition of Na+/H+ channels, increased autophagy and lysosomal degradation, SGLT1 inhibition, reduced hyperuricemia, reduced epicardial fat, increased erythropoietin levels, increased progenitor/precursor cells, reduced oxidative stress, and improved vascular function.

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Original Article

Acute Inspiratory Muscle Training Modifies Hemodynamic Indices in Patients with Heart Failure with Preserved Ejection Fraction

Márcio Garcia Menezes et al. Eduardo Lima Garcia Leandro Tolfo Franzoni Vanessa Grings Luiz Claudio Danzmann

Abstract

Background:

Heart failure with preserved ejection fraction (HFpEF), a syndrome associated to decrease functional capacity, is quite difficult to manage. Inspiratory muscle training (IMT) has been used to treat symptoms and to improve functional capacity of patients with HFpEF. Thus, we aimed to evaluate the immediate effects and after 1 h of IMT on arterial pulsatile hemodynamics and on hemodynamic indices of left ventricular filling derived from Doppler echocardiography in patients with HFpEF.

Methods:

Eighteen patients with HFpEF who underwent IMT at an intensity of 80% of maximum inspiratory pressure were evaluated by Doppler echocardiogram in the pre, post-immediate and post-late periods; furthermore, pulsatile hemodynamic variables were collected. Functional capacity was assessed using the 6-minute walk test.

Results:

The population was composed predominantly of women (66.7%), mean age of 61.3 (7.2) years. Modifications were observed in the non-invasive LV filling pressure index (E/e’) (pre: 10.33 (SD, 3.15) vs post: 8.73 (SD, 2.24); p < 0.001) and in the pulse wave velocity (pre: 8.33 (SD, 1.67) vs post: 7.63 (SD, 1.66) m/s; p < 0.001), as well as pulse pressure (pre: 54.81 (SD, 18.73) vs post: 48.52 (SD, 15.74) mm Hg; p = 0.023).

Conclusion:

Our results demonstrated that a unique session of high-intensity IMT improved hemodynamic indices of LV filling and arterial stiffness in patients with HFpEF.

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Special Article

Beyond the Disease – History of the House for Patients with Chagas Disease and Heart Failure of Pernambuco (Casa do Portador de Doença de Chagas e Insuficiência Cardíaca de Pernambuco)/PROCAPE-UPE/Brazil

Silvia Marinho Martins et al. Cassandra Barros Correia de Moura Maria da Glória Aureliano de Melo Cavalcanti Cristina de Fátima Velloso Carrazzone … Carolina de Araújo Medeiros Wilson Oliveira Junior

Where it all began

The history of the Chagas Disease and Heart Failure Outpatient Clinic of the Prof. Luiz Tavares Cardiology Emergency Unit of Pernambuco, at Universidade de Pernambuco (UPE), began in August 1987 at Hospital Universitário Oswaldo Cruz (HUOC). When it was created, in 1884, this hospital worked mainly providing care for patients with infectious and parasitic diseases. Since that time, the hospital worked with diseases that later became known as unassisted (nowadays named and classified as neglected diseases by the World Health Organization, WHO) and became a breeding ground for the inauguration of the Chagas Disease Outpatient Clinic.

In 1964, HUOC became a teaching hospital and started receiving medical students from Faculdade de Ciências Médicas de Pernambuco. At this moment, the hospital became the first referral center for clinical and surgical cardiology in the state, being the main and only public emergency unit exclusively dedicated to this specialty. The emergency demand was massive and various sectored wards were established for treating and caring for patients with heart disease. Among them, the myocardiopathies and heart failure ward, in the late 1970s, was coordinated by Professor Wilson de Oliveira Jr. In general, patients arrived at the cardiology emergency unit with decompensated heart failure, being cared for and referred to the myocardiopathy ward (). Once compensated, these patients were discharged without systematic outpatient care, which resulted in various new hospitalizations. Many of these patients had chagasic heart failure.

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Review Article

Diuretics and Clinical Management of Congestion in Heart Failure: A Review

Diogo Silva Piardi et al. Maurício Butzke Luís Beck-da-Silva

Abstract

Heart failure is a syndrome with variable presentations; congestion is the most common form in acutely decompensated patients. In this scenario, the main drug to resolve congestion is a loop diuretic. However, a portion of the population has diuretic resistance. In this context, adjuvant diuretic therapies are needed to resolve congestion in patients with heart failure. The main strategies studied so far are thiazide diuretics, mineralocorticoid receptors antagonists, vasopressin antagonists, nesiritide, sacubitril/valsartan, sodium-glucose cotransporter 2 inhibitors, hypertonic saline, and fluid and salt restriction. The purpose of this article is to review pharmacological modalities for management of congestion, associated or not with diuretic resistance, their positive and negative points, and the current state of knowledge about each drug.

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Editorial

Cardiovascular Burden of COVID-19 and the Post-Covid Era

Samuel D. Moscavitch et al. Jefferson L. Vieira Peter Libby

Why COVID-19 became an issue for cardiovascular specialists? SARS-CoV-2- related myocardial injury and myocarditis

Approximately 20-30% of hospitalized patients with COVID-19 have evidence of cardiac injury, as indicated by elevated levels of high-sensitivity troponins. The presence and magnitude of troponin elevation is associated with more severe disease and worse outcomes, even after adjusting for relevant risk factors. Myocardial injury portends a fatal outcome of COVID-19, while the prognosis of patients without myocardial injury, even with underlying cardiovascular disease, is more favorable.

The pathophysiology of SARS-CoV-2-induced myocardial injury remains a topic of active research. COVID-19 can unfavorably affect the balance between myocardial oxygen supply and demand, as with other overwhelming viral or bacterial infections (). Fever, metabolic stress, sympathetic activation, and tachycardia increase the energy expenditure and oxygen consumption of the myocardium.^, This imbalance can provoke type 2 (or “demand” type) myocardial infarction. Hypoxia from respiratory impairment can favor the production of reactive oxygen species and oxidative stress, acidosis, mitochondrial damage, and cell death.^,^, Other mechanisms of myocardial injury during COVID-19 include ischemia from microvascular thrombi and toxic levels of cytokines. Cardiac damage due to direct SARS-CoV-2 infection of cardiac myocytes appears uncommon.^– Indeed, the pericytes, smooth-muscle like cells that surround microvessels, express high levels of the receptor for SARS-CoV-2, angiotensin converting enzyme 2 (ACE2), while cardiac myocytes themselves have few, if any, of these portals of entry used by the virus.

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