Fundamento: O tratamento da insuficiência cardíaca evoluiu nas últimas décadas, sugerindo que sua sobrevida tem aumentado. Objetivo: Verificar se houve melhora na sobrevida dos pacientes com insuficiência cardíaca avançada. Métodos: Comparamos retrospectivamente os dados de seguimento e tratamento de duas coortes de pacientes com insuficiência cardíaca sistólica admitidos para compensação até o ano 2000 (n = 353) e após 2000 (n = 279). Foram analisados: morte hospitalar, re-hospitalizações e morte no seguimento de 1 ano. Utilizamos os testes U de Mann-Whitney e qui-quadrado para comparação entre os grupos. Os preditores de mortalidade foram identificados pela análise de regressão por meio do método dos riscos proporcionais de Cox e análise de sobrevida pelo método de Kaplan-Meier. Resultados: Os pacientes internados até o ano 2000 eram mais jovens, tinham menor comprometimento ventricular esquerdo e receberam menor proporção de betabloqueadores na alta. A sobrevida dos pacientes hospitalizados antes de 2000 foi menor do que a dos hospitalizados após 2000 (40,1% vs. 67,4%; p < 0,001). Os preditores independentes de mortalidade na análise de regressão foram: a etiologia chagásica (hazard ratio: 1,9; intervalo de confiança de 95%: 1,3-3,0), inibidores da enzima conversora da angiotensina (hazard ratio: 0,6; intervalo de confiança de 95%: 0,4-0,9), betabloqueador (hazard ratio: 0,3; intervalo de confiança de 95%: 0,2-0,5), creatinina ≥ 1,4 mg/dL (hazard ratio: 2,0; intervalo de confiança de 95%: 1,3-3,0), sódio sérico ≤ 135 mEq/L (hazard ratio: 1,8; intervalo de confiança de 95%: 1,2-2,7). Conclusões: Pacientes com insuficiência cardíaca avançada apresentaram melhora significativa na sobrevida e redução nas re-hospitalizações. O bloqueio neuro-hormonal, com inibidores da enzima conversora da angiotensina e betabloqueadores, teve papel importante no aumento da sobrevida desses pacientes com insuficiência cardíaca avançada.

Background: The treatment of heart failure has evolved in recent decades suggesting that survival is increasing. Objective: To verify whether there has been improvement in the survival of patients with advanced heart failure. Methods: We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis. Results: The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7). Conclusions: Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.

FUNDAMENTO: Os pacientes com insuficiência cardíaca (IC) que necessitam ser hospitalizados para compensação constituem grupo de maior gravidade, que evoluem com alta mortalidade e alta taxa de re-hospitalizações. OBJETIVO: Procuramos avaliar a atual história natural da IC por meio da taxa de mortalidade e de re-hospitalizações, nessa nova era do bloqueio neuro-hormonal. MÉTODOS: Acompanhamos a evolução de 263 pacientes com FE média de 27,1%, internados para compensação, entre janeiro de 2005 e outubro de 2006. Foram hospitalizados somente os pacientes que após avaliação e medicação no PS não estavam em condições de ter alta. Os pacientes encontravam-se em CF III/IV, a idade média foi de 59,9±15,2 anos, a maioria homens e 63,1% necessitaram de inotrópicos para compensação na fase aguda. RESULTADOS: O tempo médio de internação foi de 25,1±16,7 dias. Durante a internação 23 (8,8%) morreram. Após a alta, no período médio de seguimento de 370 dias, dos 240 que tiveram alta, 123 (51,2%) procuraram o PS de 1 a 12 vezes (total de passagens: 350), sendo 76 re-internados, sendo a média de dias da re-hospitalização de 23,5±18,0. No primeiro ano de seguimento 62 (25,8%) pacientes morreram. CONCLUSÃO: A IC continua evoluindo com alta mortalidade e alta taxa de re-hospitalização. Ao final do primeiro ano 44,5% desses pacientes não necessitaram passar no PS ou morreram, números que indicam que devemos continuar dando grande atenção aos portadores de IC, na tentativa de mudar a história natural dos portadores dessa síndrome, cada vez mais freqüente.

BACKGROUND: Patients who require hospitalization because of decompensated HF represent a group of the most seriously ill individuals who evolve with high mortality and hospital readmission rates. OBJECTIVES: We sought to evaluate the current natural course of HF by analyzing mortality and readmission rates in this new era of neurohormonal blockage. METHODS: We followed the progress of 263 patients with a mean EF of 27.1%, admitted for decompensated HF between January 2005 and October 2006. Patients readmitted were only those whose health status precluded discharge after assessment and drug treatment in the Emergency Department. Patients were classified as HF-FC III/IV, mean age was 59.9±15.2 years, most were men, and 63.1% required inotropic drugs for cardiac compensation in the acute phase. RESULTS: Average hospital stay was 25.1±16.7 days. During hospitalization, 23 (8.8%) patients died. After discharge, over an average follow-up period of 370 days, of the 240 patients who were discharged 123 (51.2%) returned to the Emergency Department 1 to 12 times (total number of visits: 350); 76 of them were readmitted, and the average length of readmission stay was 23.5±18.0 days. Over the first year of follow-up, 62 (25.8%) patients died. CONCLUSIONS: HF remains a condition associated with high mortality and high hospital readmission rates. At the end of the first year, 44.5% of these patients had not needed to visit the ER or had died, which indicates that we should provide HF patients with the best possible care in an attempt to change the natural course of this increasingly frequent syndrome.

OBJETIVO: Verificar se o tratamento com levosimendan seria mais dispendioso que o usual com dobutamina, uma vez que o preço dos medicamentos não representa a maior despesa no tratamento da descompensação cardíaca. MÉTODOS: Comparou-se o custo do tratamento de 18 pacientes hospitalizados devido a descompensação cardíaca, 9 tratados com dobutamina (grupo dobuta) e 9 com levosimendan (grupo levo). Os grupos foram semelhantes quanto à idade, sexo, classe funcional e função cardíaca. RESULTADOS: O custo do tratamento foi semelhante para os dois grupos. No grupo levo as despesas com medicamentos foram maiores, mas as relativas ao período de terapia intensiva e do material empregado foram menores. Levo - medicamentos: R$ 5.414,00; materiais: R$ 399,90; diárias hospitalares: R$ 5.061,20; serviços profissionais: R$ 3.241,80; final: R$ 14.117,00. Dobuta - medicamentos: R$ 2.320,10; materiais: R$ 1.665,70; diárias hospitalares: R$ 6.261,90; serviços profissionais: R$ 3.894,30; final: R$ 14.142,00. CONCLUSÃO: Apesar do preço mais elevado da droga, o custo global do tratamento foi semelhante para os pacientes tratados com dobutamina ou levosimendan. O paciente tratado com levosimendan permaneceu menos tempo em terapia intensiva.

OBJECTIVE: To assess whether the treatment with levosimendan is more expensive than the usual one with dobutamine, since price of medications does not usually represent the greatest expense in the treatment of cardiac decompensation. METHODS: The cost of treatment of 18 inpatients with cardiac decompensation, 9 of which treated with dobutamine (dobuta group) and 9 with levosimendan (levo group), was compared. Groups were similar concerning age, sex, functional class and cardiac function. RESULTS: Treatment costs were similar for both groups. In the levo group, the costs with the drug were higher than in the dobuta group, but those related to the length of stay in intensive care unit and to the material used during admission were lower. Levo - drug: R$ 5,414.00; material: R$ 399.90; hospital daily rates: R$ 5,061.20; professional honorarium: R$ 3,241.80; total costs: R$ 14,117.00. Dobuta - drug: R$ 2,320.10; materials: R$ 1,665.70; hospital daily rates: R$ 6,261.90; professional honorarium: R$ 3,894.30; total costs: R$ 14,142.00. CONCLUSION: Despite the higher price of levosimendan, the global cost of the treatment was similar for patients who were treated either with dobutamine or levosimendan. Patients who were treated with levosimendan had a shorter length of stay in intensive care unit.

OBJETIVO: Estudar as principais características clínicas dos pacientes com insuficiência cardíaca sobreviventes há mais de 24 meses após hospitalização para compensação. MÉTODOS: Estudados 126 pacientes com insuficiência cardíaca, em classe funcional III ou IV, com idade média de 51,7 anos, a maioria homens (73%), com fração de ejeção (FE) média de 0,36 e diâmetro diastólico (DD) do VE de 7,13 cm. Avaliaram-se as principais características clínicas e laboratoriais e no seguimento identificaram-se 25 (19.8%) pacientes que sobreviveram mais de 24 meses após a alta hospitalar. Compararam-se os dados dos sobreviventes (G1) aos dos que faleceram (G2) antes de 24 meses. RESULTADOS: No G1 encontraram-se níveis mais elevados do sódio sérico (138,3±3,4 vs 134,5±5,8 mEq/l; p=0,001), da pressão arterial (120,0 vs 96,7 mmHg; p=0,003) e da FE do VE (0,40±0,08 vs 0,34±0,09; p=0,004) e valores menores da uréia (59,8 vs 76,3 mg/dl; p=0,007), do tempo de protrombina (12,9 vs 14,8s; p=0,001), do DDVE (6,78±0,55 vs 7,22±0,91; p=0,003) e do diâmetro do AE (4,77 vs 4,99cm; p=0,0003). Houve mais sobreviventes entre os portadores de cardiomiopatia idiopática e hipertensiva do que entre os chagásicos e doença coronariana. Na análise multivariada permaneceram como variáveis preditoras independentes da mortalidade o DDVE > 7,8 cm (HR 1,95), o Na < 132 mEq/l (HR 2,30) e o tempo de protrombina > 14 seg (HR 1,69). CONCLUSÃO: O estudo permite predizer quais os pacientes com insuficiência cardíaca que poderão apresentar uma boa sobrevida após a alta e os com maior possibilidade de longa sobrevivência após a alta.

OBJECTIVE: To study the major clinical characteristics of patients with heart failure who survived more than 24 months after hospitalization for compensation. METHODS: The study comprised 126 patients with heart failure in functional class III or IV, with a mean age of 51.7 years. Most patients were men (73%), had a mean ejection fraction (EF) of 0.36 and left ventricular diastolic diameter (DD) of 7.13 cm. The major clinical and laboratory characteristics were assessed, and, on follow-up, 25 (19.8%) patients, who survived more than 24 months after hospital discharge, were identified. Data of survivors (G1) were compared with those of patients who died (G2) before 24 months. RESULTS: In G1, the following levels were greater: serum sodium (138.3±3.4 vs 134.5±5.8 mEq/L; P=0.001); blood pressure levels (120.0 vs 96.7 mm Hg; P=0.003); and LVEF levels (0.40±0.08 vs 0.34±0.09; P=0.004); and the following levels were lower: urea (59.8 vs 76.3 mg/dL; P=0.007); prothrombin time (12.9 vs 14.8 seconds; P=0.001); LVDD (6.78±0.55 vs 7.22±0.91; P=0.003); and LA diameter (4.77 vs 4.99cm; P=0.0003). More survivors were found among patients with idiopathic cardiomyopathy and arterial hypertension than among patients with Chagas' disease and coronary artery disease. In multivariate analysis, the following variables remained as independent predictors of mortality: LVDD > 7.8 cm (HR 1.95); Na < 132 mEq/L (HR 2.30); and prothrombin time > 14 seconds (HR 1.69). CONCLUSION: The study allowed predicting which patients with heart failure will have a good survival after hospital discharge and those with a greater chance of a long survival after discharge.

OBJECTIVE: To verify whether the serum levels of N-Terminal ProBNP fraction (ProBNP) allow us to identify with accuracy the clinical functional status of patients with heart failure (HF), because the clinical diagnosis of this syndrome is based basically on clinical data when the complementary tests have lower specificity. METHODS: Sixty-nine patients with a history of HF were studied. Their mean age of was 53.5 years and 78.3% were males. All underwent clinical and echocardiographic evaluations and a test to determine the serum dosage of ProBNP. According to clinical manifestation, patients were in the following functional classes (FC), 14% FC I, 40.6% FC II, 28.1% FC III, and 23.4% FC IV. The mean ejection fraction (EF) was 0.28. RESULTS: ProBNP did not differ according to age, sex, and cause of cardiopathy. No correlation existed between EF and the ProBNP serum level. ProBNP levels were significantly lower in patients in FC I than those in FC II (42 vs 326.7 pmol/L; P=0.0001), and in FC II than those in FC III (P=0.01). ProBNP levels did not differ statically between FC III and IV patients (888.1 vs 1082.8 pmol/L; P=0.25). ProBNP values greater than 100 pmol/L identify patients with decompensated HF with a sensitivity of 98%. CONCLUSION: ProBNP values over 100 pmol/L were indicative of HF, and patients with advanced HF had values over 270 pmol/L. A ProBNP dosage test was an excellent auxiliary in the clinical characterization of patients with HF.