Anemia e mortalidade

J Am Coll Cardiol, 2008; 52:818-827, doi:10.1016/j.jacc.2008.04.061

Anemia and Mortality in Heart Failure Patients
A Systematic Review and Meta-Analysis Hessel F. Groenveld, MD*, James L. Januzzi, MD, FACC, Kevin Damman, MD*, Jan van Wijngaarden, MD, PhD, Hans L. Hillege, MD, PhD*, Dirk J. van Veldhuisen, MD, PhD, FACC* and Peter van der Meer, MD, PhD,*
*(Email: pvandermeer@partners.org
Objectives: The aim of this study was to assess the effect of anemia on mortality in chronic heart failure (CHF).
Background: Anemia is frequently observed in patients with CHF, and evidence suggests that anemia might be associated with an increased mortality.
Methods: A systematic literature search in MEDLINE (through November 2007) for English language articles was performed. In addition, a manual search was performed. We included cohort studies and retrospective secondary analyses of randomized controlled trials whose primary objective was to analyze the association between anemia and mortality in CHF. Of a total of 1,327 initial studies, we included 34 studies, comprising 153,180 patients. Information on study design, patient characteristics, outcome, and potential confounders were extracted.
Results: Anemia was defined by criteria used in the original articles. Of the 153,180 CHF patients, 37.2% were anemic. After a minimal follow-up of 6 months, 46.8% of anemic patients died compared with 29.5% of nonanemic patients. Crude mortality risk of anemia was odds ratio 1.96 (95% confidence interval: 1.74 to 2.21, p < 0.001). Lower baseline hemoglobin values were associated with increased crude mortality rates (r = –0.396, p = 0.025). Adjusted hazard ratios showed an increased adjusted risk for anemia (hazard ratio 1.46 [95% confidence interval: 1.26 to 1.69, p < 0.001]). Subgroup analysis showed no significant difference between mortality risk of anemia in diastolic or systolic CHF.
Conclusions: Anemia is associated with an increased risk of mortality in both systolic and diastolic CHF. Anemia should, therefore, be considered as a useful prognosticator, and therapeutic strategies aimed to increase hemoglobin levels in CHF should be investigated.
Key Words: heart failure • anemia • prognosis

Cardiopatia diabética

Diabetic Cardiomyopathy: Insights into Pathogenesis, Diagnostic Challenges, and Therapeutic Options
Ashish Aneja MDa, W.H. Wilson Tang MDb, Sameer Bansilal MDa, Mario J. Garcia MDa and Michael E. Farkouh MD, MSca, ,
aThe Mount Sinai Cardiovascular Institute, New York, NY bSection of Heart Failure, Department of Cardiology, Cleveland Clinic, Ohio
Am J Medicine.
Abstract
Diabetic cardiomyopathy is the presence of myocardial dysfunction in the absence of coronary artery disease and hypertension. Hyperglycemia seems to be central to the pathogenesis of diabetic cardiomyopathy and to trigger a series of maladaptive stimuli that result in myocardial fibrosis and collagen deposition. These processes are thought to be responsible for altered myocardial relaxation characteristics and manifest as diastolic dysfunction on imaging. Sophisticated imaging technologies also have permitted the detection of subtle systolic dysfunction in the diabetic myocardium. In the early stages, these changes appear reversible with tight metabolic control, but as the pathologic processes become organized, the changes are irreversible and contribute to an excess risk of heart failure among diabetic patients independently of common comorbidities, such as coronary artery disease and hypertension. Therapeutic agents specifically targeting processes that lead to these pathophysiologic changes are in the early stages of development. Although glycemic control and early administration of neurohormonal antagonists remain the cornerstones of therapeutic approaches, newer treatment targets are currently being explored.

Hemoglobina glicada, internação, mortalidade na insuficiência cardíaca

The Hemoglobin A1c Level as a Progressive Risk Factor for Cardiovascular Death, Hospitalization for Heart Failure, or Death in Patients With Chronic Heart Failure. An Analysis of the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program
Hertzel C. Gerstein, MD, MSc; Karl Swedberg, MD, PhD; Jonas Carlsson, MSc; John J. V. McMurray, MD; Eric L. Michelson, MD; Bertil Olofsson, PhD; Marc A. Pfeffer, MD, PhD; Salim Yusuf, DPhil; for the CHARM Program Investigators
Arch Intern Med. 2008;168(15):1699-1704.
Background A progressive relationship between hemoglobin A1c (HbA1c) levels and cardiovascular (CV) events has been observed in persons with and without diabetes. To our knowledge, the nature of such a relationship in patients with symptomatic chronic heart failure (HF) has not been studied.
Methods A total of 2412 participants (907 with prior diabetes) in the Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program with at least 1 HbA1c level were followed up for a median of 34 months. The incidence of the primary outcome (CV death or HF hospitalization), CV death, and total mortality was calculated according to eighths of the usual HbA1c level ranging from 5.8% or less to greater than 8.6%. Adjusted and unadjusted hazard ratios per 1% rise in HbA1c levels were also calculated.
Results A total of 99.6% of eligible participants were followed up until they developed an outcome or the study finished. The risk of the primary composite outcome, CV death, hospitalization for worsening HF, and total mortality rose progressively with higher levels of usual HbA1c (P for trend <.001). After age and sex were adjusted for, hazards of these outcomes per 1% higher HbA1c level were 1.25 (95% confidence interval [CI ],1.20-1.31), 1.24 (95% CI, 1.17-1.31), 1.25 (95% CI, 1.19-1.31), and 1.22 (95% CI, 1.16-1.29), respectively. This relationship was evident in patients with and without diabetes and with reduced or preserved ejection fraction and persisted after adjustment for diabetes, other risk factors, and allocation to candesartan.
Conclusion In diabetic and nondiabetic patients with symptomatic chronic HF, the HbA1c level is an independent progressive risk factor for CV death, hospitalization for HF, and total mortality.

TNFalfa e mortalidade por Insuficiência Cardíaca

Circulation. 2008;118:625-631

Tumor Necrosis Factor- and Mortality in Heart Failure
A Community Study Shannon M. Dunlay, MD; Susan A. Weston, MS; Margaret M. Redfield, MD; Jill M. Killian, BS; Véronique L. Roger, MD, MPH
E-mail roger.veronique@mayo.edu
Background— Tumor necrosis factor- (TNF), an inflammatory cytokine, was reported to be elevated in trials of heart failure (HF) with reduced ejection fraction (EF) and associated with mortality. Whether this is true for HF with preserved EF is unknown, and community data are lacking. We evaluated the distribution of TNF, its association with baseline characteristics and mortality, and its benefit in assessing risk in community HF patients.
Methods and Results— Olmsted County residents with active HF from July 2004 to March 2007 (n=486; mean age, 76.7 years; EF 50%, 55%) were prospectively recruited. Clinical characteristics and TNF were measured. Elevated TNF (more than the assay limit of normal of 2.8 pg/mL) was present in 143 (29%). Higher TNF was associated with decreased creatinine clearance, nonsmoking status, anemia, and greater comorbidity (Ptrend<0.05 for all). Mortality increased with increasing TNF (P=0.016), with 1-year mortality estimates of 16%, 18%, 23%, and 32% from the lowest to highest quartile, respectively. After adjustment for age, sex, and EF, the hazard ratios for death were 1.24, 1.37, and 1.90 from the second to the highest TNF quartile, respectively (Ptrend=0.007). TNF contributed to risk assessment as indicated by increases in the area under the receiver operating characteristic curves in all models examined (P<0.05 for all). Results did not differ by EF (P=0.60 interaction term of TNF and EF).
Conclusions— TNF was elevated in a large portion of community HF patients, was associated with a large decrease in survival, and provided a significant incremental increase in risk assessment above established indicators. TNF is useful for risk assessment in HF patients with preserved and reduced EF