Gonçalo Cunha

A prova de esforço cardiorrespiratória (PECR) fornece uma avaliação não invasiva e integrada das respostas ao exercício dos sistemas respiratório, cardiovascular e músculo-esquelético. Essas informações melhoram o diagnóstico, a estratificação de risco e a abordagem terapêutica de diversas condições clínicas. Além disso, a PECR é o teste gold standard para a quantificação da aptidão cardiorrespiratória e a prescrição de exercício, tanto em doentes com doença cardiopulmonar em programas de reabilitação cardíaca ou pulmonar, como em indivíduos saudáveis, incluindo atletas de alto rendimento. Neste contexto, o conhecimento prático da relevância deste exame é útil e transversal a diversas especialidades médicas para além da cardiologia. No entanto, apesar das suas múltiplas vantagens reconhecidas, a PECR continua subutilizada. Este artigo tem como objetivo aumentar a consciencialização do valor da PECR para a prática clínica e informar os médicos sobre as suas principais indicações, aplicações e interpretação básica. Cardiopulmonary exercise testing (CPET) provides a noninvasive and integrated assessment of the response of the respiratory, cardiovascular, and musculoskeletal systems to exercise. This information improves the diagnosis, risk stratification, and therapeutic management of several clinical conditions. Additionally, CPET is the gold standard test for cardiorespiratory fitness quantification and exercise prescription, both in patients with cardiopulmonary disease undergoing cardiac or pulmonary rehabilitation programs and in healthy individuals, such as high-level athletes. In this setting, the relevance of practical knowledge about this exam is useful and relevant to several medical specialties other than cardiology. However, despite its multiple established advantages, CPET remains underused. This article aims to increase awareness of the value of CPET in clinical practice and to inform clinicians about its main indications, applications, and basic interpretation.

BACKGROUND: In patients with heart failure (HF) and reduced ejection fraction (HFrEF) with or without type 2 diabetes mellitus, the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin was recently shown to reduce the risk of worsening HF or death from cardiovascular causes in the dapagliflozin in patients with heart failure and reduced ejection fraction (DAPA-HF) trial. Our goal was to investigate how many patients in a real-world setting would be eligible for dapagliflozin according to the DAPA-HF enrolment criteria. METHODS: This is a single-center retrospective study enrolling consecutive, unselected patients followed up in an HF clinic from 2013 to 2019. Key DAPA-HF inclusion criteria (i.e., left ventricular ejection fraction [LVEF] ≤40% and NT-proBNP ≥600 pg/mL [or ≥900 pg/mL if atrial fibrillation]) and exclusion criteria (estimated glomerular filtration rate [eGFR] <30 mL/kg/1.73 m2 and systolic blood pressure [SBP] <95 mm Hg) were considered. RESULTS: Overall, 479 patients (age 76 ± 13 years; 50.5% male; 78.9% hypertensive; 45.1% with an eGFR <60 mL/min/1.73 m2; 36.5% with TD2M; and 33.5% with ischaemic HF) were assessed. The median SBP was 128.5 (112.0-146.0) mm Hg, mean eGFR was 50.8 ± 23.7 mL/min/1.73 m2, and median NT-proBNP was 2,183 (IQR 1,010-5,310) pg/mL. Overall, 155 (32.4%) patients had LVEF ≤40%. According to the DAPA-HF trial key criteria, 90 patients (18.8%) would be eligible for dapagliflozin. The remainder would be excluded due to LVEF >40% (67.6%), eGFR <30 mL/min/1.73 m2 (19.4%), NT-proBNP below the cutoff (16.7%), and/or SBP <95 mm Hg (6.5%). If we center the analysis to those with LVEF ≤40%, 58.1% would be eligible for dapagliflozin. The remainder would be excluded due to an eGFR <30 mL/min/1.73 m2 (20%), NT-proBNP below the cutoff (16.1%), and/or SBP <95 mm Hg (8.4%). CONCLUSION: Roughly half of our real-world HFrEF cohort would be eligible for dapagliflozin according to the key criteria of the DAPA-HF trial. The main reason for non-eligibility was an eGFR <30 mL/min/1.73 m2. However, two-thirds of patients had LVEF >40%. These findings show that dapagliflozin is a promising complementary new drug in the therapeutic armamentarium of most patients with HFrEF, while highlighting the urgent need for disease-modifying drugs in mid-range and preserved LVEF and the need to assess the efficacy and safety of SLGT2i in advanced kidney disease patients. The results of ongoing SGLT2i trials in these LVEF subgroups are eagerly awaited.

We describe a case of fulminant eosinophilic myocarditis as the first presentation of eosinophilic granulomatosis with polyangiitis, promptly managed with extracorporeal membrane oxygenation. This case highlights the multidisciplinary work involving all health care professionals in the acute management of these patients and discusses it from an educational point of view. (Level of Difficulty: Intermediate.)