Suporte ventilatório na capacidade funcional de pacientes com insuficiência cardíaca: estudo piloto

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Abstract

FUNDAMENTO: A insuficiência cardíaca é um importante problema de saúde pública, apresentando a dispneia e a fadiga como principais sintomas clínicos. A utilização do suporte ventilatório não invasivo vem atuando como coadjuvante da reabilitação cardíaca na tentativa de melhorar a capacidade funcional dos pacientes. OBJETIVO: Avaliar a capacidade funcional de pacientes com insuficiência cardíaca submetidos ao suporte ventilatório. MÉTODOS: Foram avaliados dados sociodemográficos, qualidade de vida, FC, pressão arterial (PA), saturação periférica de oxigênio (SpO2), dispneia, concentração de lactato, antes e depois do teste de caminhada de 6 minutos, e a distância percorrida de pacientes com insuficiência cardíaca crônica (ICC), de ambos os sexos, com fração FEVE < 45,0%, randomizados em dois grupos: controle e CPAP (utilizou CPAP 10 cmH2O por 30 minutos). RESULTADOS: Participaram 12 pacientes com ICC classe funcional II e III (NYHA), com média de fração de ejeção do ventrículo esquerdo (FEVE, %) de 35,3 ± 8,7, sendo que 8 eram do sexo masculino. A média de idade foi de 46,3 ± 10,3 anos. Na comparação entre os grupos Controle e CPAP, no final do 6º min, foi encontrada diferença significativa nos valores de SpO2% entre os grupos (Controle: 93,6 ± 1,5 % vs CPAP: 96,1 ± 1,8%; p = 0,027), dispneia (Controle: 13,1 ± 1,16 vs CPAP: 11 ± 0,8; p = 0,009), concentração de lactato (Controle: 3,3 ± 0,7 mmol/l vs CPAP: 2,3 ± 0,5 mmol/l; p = 0,025), e distância percorrida no TC6 (Controle: 420,6 ± 73,8 m vs CPAP: 534 ± 89,91 m; p = 0,038). CONCLUSÃO: A realização prévia do CPAP apresentou efeitos benéficos na SpO2, na dispneia, na concentração de lactato, no duplo produto e na distância percorrida no TC6 de pacientes com ICC na realização do TC6.

Translated abstract

BACKGROUND: Heart failure (HF) is an important public health problem, of which main clinical symptoms are dyspnea and fatigue. Noninvasive ventilatory support has been used as adjuvant therapy in cardiac rehabilitation in order to improve the functional capacity of patients. OBJECTIVE: To evaluate the functional capacity of patients with HF submitted to ventilatory support. METHODS: We evaluated the sociodemographic information, as well as data on quality of life, blood pressure (BP), peripheral oxygen saturation (SpO2), dyspnea, lactate concentration before and after the 6-minute walk test (6MWT) and the distance walked by patients of both sexes with chronic heart failure (CHF), with left ventricular ejection fraction (LVEF) < 45.0% , randomized in two groups: control and CPAP (the group used CPAP - 10 cmH2O for 30 minutes). RESULTS: A total of 12 patients, of which 8 were males, with CHF functional class II and III (NYHA) participated in the study. The patients had mean LVEF of 35.3 ± 8.7 and mean age was 46.3 ± 10.3 years. When comparing the control group with the CPAP group at the end of the 6th minute, there was a significant difference between the groups regarding SpO2 values (Control: 93.6 ± 1.5 % vs CPAP: 96.1±1.8%; p = 0.027), index of dyspnea (Control: 13.1 ± 1.16 vs CPAP: 11 ± 0.8; p = 0.009), lactate concentration (Control: 3.3 ± 0.7 mmol/l vs CPAP: 2.3 ± 0.5 mmol/l; p = 0.025) and distance walked at the 6MWT (Control: 420.6 ± 73.8 m vs CPAP: 534 ± 89.91 m; p = 0.038). CONCLUSION: The previous use of the CPAP had beneficial effects on SpO2, index of dyspnea, lactate concentration, double product and the distance walked at the 6MWT in patients with CHF when performing the 6MWT.

Translated abstract

FUNDAMENTO: La insuficiencia cardiaca es un importante problema de salud pública, presentando la disnea y la fatiga como principales síntomas clínicos. La utilización del soporte ventilatorio no invasivo viene actuando como coadyuvante de la rehabilitación cardíaca en la tentativa de mejorar la capacidad funcional de los pacientes. OBJETIVO: Evaluar la capacidad funcional de pacientes con insuficiencia cardiaca sometidos al soporte ventilatorio. MÉTODOS: Se evaluaron datos sociodemográficos, calidad de vida, FC, presión arterial (PA), saturación periférica de oxígeno (SpO2) disnea, concentración de lactato, antes y después de la prueba de marcha de 6 minutos, y la distancia recorrida de pacientes con insuficiencia cardiaca crónica (ICC), de ambos sexos, con fracción FEVI < 45,0%, randomizados en dos grupos: Control y CPAP (utilizó CPAP 10 cmH2O por 30 minutos). RESULTADOS: Participaron 12 pacientes con ICC clase funcional II y III (NYHA), con media de fracción de eyección del ventrículo izquierdo (FEVI, %) de 35,3 ± 8,7, siendo que 8 eran del sexo masculino. El promedio de edad fue de 46,3 ± 10,3 años. En la comparación entre los grupos control y CPAP, al final del 6º min, se encontró diferencia significativa en los valores de SpO2% entre los grupos (Control: 93,6 ± 1,5 % vs CPAP: 96,1 ± 1,8%; p = 0,027), disnea (Control: 13,1 ± 1,16 vs CPAP: 11 ± 0,8; p = 0,009), concentración de lactato (Control: 3,3 ± 0,7 mmol/L vs CPAP: 2,3 ± 0,5 mmol/L; p = 0,025), y distancia recorrida en la PM6m (Control: 420,6 ± 73,8 m vs CPAP: 534 ± 89,91 m; p = 0,038). CONCLUSIÓN: La realización previa del CPAP presentó efectos benéficos en la SpO2, en la disnea, en la concentración de lactato, en el doble producto y en la distancia recorrida en el PM6m de pacientes con ICC en la realización del PM6m.

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Pathophysiology of chronic heart failure.

Gary Francis (2001)

Heart failure is a changing paradigm. The hemodynamic model, which served our needs well from the 1950s through the early 1980s, has now been largely abandoned, except for the management of decompensated patients in the hospital. The pathophysiology is exceedingly complex and involves structural changes, such as loss of myofilaments, apoptosis and disorganization of the cytoskeleton, as well as disturbances in Ca(2+) homeostasis, alteration in receptor density, signal transduction, and collagen synthesis. A more contemporary working hypothesis is that heart failure is a progressive disorder of left ventricular remodeling, usually resulting from an index event, that culminates in a clinical syndrome characterized by impaired cardiac function and circulatory congestion. This change in the framework of our understanding of the pathophysiology of heart failure is predicated on the results of numerous clinical trials conducted during the past 20 years. New therapies are now evolving that are designed to inhibit neuroendocrine and cytokine activation, whereas drugs specifically designed to heighten cardiac contractility and "unload" the left ventricle have proven to be unhelpful in long-term management of patients with chronic heart failure. However, the hemodynamic model is still relevant for patients in the hospital with decompensated heart failure, where positive inotropic drugs and vasodilators are still widely used. The modern treatment of chronic heart failure is now largely based on the neurohormonal hypothesis, which states that neuroendocrine activation is important in the progression of heart failure and that inhibition of neurohormones is likely to have long-term benefit with regard to morbidity and mortality. Thus, the evolution of treatment for chronic heart failure as a result of clinical trials has provided much enlightenment for our understanding of the fundamental biology of the disorder, a reversal of the usual flow of information from basic science to clinical investigation.

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Congestive heart failure: Diagnosis, pathophysiology, therapy, and implications for respiratory care.

Jay Peters, Michael Figueroa (2006)

Congestive heart failure (CHF) is a common clinical disorder that results in pulmonary vascular congestion and reduced cardiac output. CHF should be considered in the differential diagnosis of any adult patient who presents with dyspnea and/or respiratory failure. The diagnosis of heart failure is often determined by a careful history and physical examination and characteristic chest-radiograph findings. The measurement of serum brain natriuretic peptide and echocardiography have substantially improved the accuracy of diagnosis. Therapy for CHF is directed at restoring normal cardiopulmonary physiology and reducing the hyperadrenergic state. The cornerstone of treatment is a combination of an angiotensin-converting-enzyme inhibitor and slow titration of a beta blocker. Patients with CHF are prone to pulmonary complications, including obstructive sleep apnea, pulmonary edema, and pleural effusions. Continuous positive airway pressure and noninvasive positive-pressure ventilation benefit patients in CHF exacerbations.