Echocardiographic screening of pregnant women by non-physicians with remote interpretation in primary care.

BACKGROUND: Impact of heart disease (HD) on pregnancy is significant. OBJECTIVE: We aimed to evaluate the feasibility of integrating screening echocardiography (echo) into the Brazilian prenatal primary care to assess HD prevalence. METHODS: Over 13 months, 20 healthcare workers acquired simplified echo protocols, utilizing hand-held machines (GE-VSCAN), in 22 primary care centres. Consecutive pregnant women unaware of HD underwent focused echo, remotely interpreted in USA and Brazil. Major HD was defined as structural valve abnormalities, more than mild valve dysfunction, ventricular systolic dysfunction/hypertrophy, or other major abnormalities. Screen-positive women were referred for standard echo. RESULTS: At total, 1 112 women underwent screening. Mean age was 27 ± 8 years, mean gestational age 22 ± 9 weeks. Major HD was found in 100 (9.0%) patients. More than mild mitral regurgitation was observed in 47 (4.2%), tricuspid regurgitation in 11 (1.0%), mild left ventricular dysfunction in 4 (0.4%), left ventricular hypertrophy in 2 (0.2%) and suspected rheumatic heart disease in 36 (3.2%): all, with mitral valve and two with aortic valve (AV) involvement. Other AV disease was observed in 11 (10%). In 56 screen-positive women undergoing standard echo, major HD was confirmed in 45 (80.4%): RHD findings in 12 patients (all with mitral valve and two with AV disease), mitral regurgitation in 40 (14 with morphological changes, 10 suggestive of rheumatic heart disease), other AV disease in two (mild/moderate regurgitation). CONCLUSIONS: Integration of echo screening into primary prenatal care is feasible in Brazil. However, the low prevalence of severe disease urges further investigations about the effectiveness of the strategy.

Impact of incorporating echocardiographic screening into a clinical prediction model to optimise utilisation of echocardiography in primary care.

INTRODUCTION: Access to public subspecialty healthcare is limited in underserved areas of Brazil, including echocardiography (echo). Long waiting lines and lack of a prioritisation system lead to diagnostic lag and may contribute to poor outcomes. We developed a prioritisation tool for use in primary care, aimed at improving resource utilisation, by predicting those at highest risk of having an abnormal echo, and thus in highest need of referral. METHODS: All patients in the existing primary care waiting list for echo were invited for participation and underwent a clinical questionnaire, simplified 7-view echo screening by non-physicians with handheld devices, and standard echo by experts. Two derivation models were developed, one including only clinical variables and a second including clinical variables and findings of major heart disease (HD) on echo screening (cut point for high/low-risk). For validation, patients were risk-classified according to the clinical score. High-risk patients and a sample of low-risk underwent standard echo. Intermediate-risk patients first had screening echo, with a standard echo if HD was suspected. Discrimination and calibration of the two models were assessed to predict HD in standard echo. RESULTS: In derivation (N = 603), clinical variables associated with HD were female gender, body mass index, Chagas disease, prior cardiac surgery, coronary disease, valve disease, hypertension and heart failure, and this model was well calibrated with C-statistic = 0.781. Performance was improved with the addition of echo screening, with C-statistic = 0.871 after cross-validation. For validation (N = 1526), 227 (14.9%) patients were classified as low risk, 1082 (70.9%) as intermediate risk and 217 (14.2%) as high risk by the clinical model. The final model with two categories had high sensitivity (99%) and negative predictive value (97%) for HD in standard echo. Model performance was good with C-statistic = 0.720. CONCLUSION: The addition of screening echo to clinical variables significantly improves the performance of a score to predict major HD.

Left Ventricular Function in Patients with Pulmonary Arterial Hypertension: The Role of Two-Dimensional Speckle Tracking Strain.

BACKGROUND: Pulmonary arterial hypertension (PAH) is characterized by elevated mean pulmonary arterial pressure with abnormal right ventricular (RV) pressure overload that may alter left ventricular (LV) function. The aim of this study was to assess the impact of RV pressure overload on LV function in PAH patients using two-dimensional (2D) speckle tracking strain. METHODS: The study enrolled 37 group 1 PAH patients and 38 age- and gender-matched healthy controls. LV longitudinal and radial 2D strains were measured with and without including the ventricular septum. Six-minute walk test (6MWT) and brain natriuretic peptide (BNP) levels were also obtained in patients with PAH. RESULTS: The mean age of patients was 46.4 ± 14.8 years, 76% women, and 16 patients (43%) had schistosomiasis. Sixteen patients (43%) were in WHO class III or IV under specific treatment for PAH. The overall 6MWT distance was 441 meters, and the BNP levels were 80 pg/mL. Patients with PAH more commonly presented with LV diastolic dysfunction and impairment of RV function when compared to controls. LV global longitudinal and radial strains were lower in patients than in controls (-17.9 ± 2.8 vs. -20.5 ± 1.9; P < 0.001 and 30.8 ± 10.5 vs. 49.8 ± 15.4; P < 0.001, respectively). After excluding septal values, LV longitudinal and radial strains remained lower in patients than in controls. The independent factors associated with global LV longitudinal strain were LV ejection fraction, RV fractional area change, and tricuspid annular systolic motion. CONCLUSIONS: This study showed impaired LV contractility in patients with PAH assessed by speckle tracking strain, irrespective of ventricular septal involvement. Global LV longitudinal strain was associated independently with RV fractional area change and tricuspid annular systolic motion, after adjustment for LV ejection fraction.

Left ventricular remodeling in patients with sickle cell disease: determinants factors and impact on outcome.

Cardiovascular complications have been increasingly detected as a result of prolonged longevity of patients with sickle cell disease (SCD). Previous studies have focused especially on pulmonary hypertension and its consequences on the right-side heart chambers, whereas factors associated with morphological changes in left ventricle (LV) remain poorly understood. This study was designed to identify clinical, laboratorial, and echocardiographic parameters associated with LV remodeling and its impact on outcome in SCD. Ninety patients aged 28 ± 7 years and 20 age- and gender-balanced healthy subjects were enrolled. Laboratory tests, electrocardiogram, and an echocardiogram with tissue Doppler imaging were performed in all patients. Patients with SCD had larger left and right heart chambers dimensions, LV mass, and tricuspid regurgitation (TR) velocity compared to health controls with similar demographic features. Despite chambers enlargement, systolic function of both ventricles was preserved. The mitral inflow velocities were higher in the patients than in controls, whereas septal and lateral annular motion velocities were normal, suggesting normal ventricular relaxation. SCD patients who were on hydroxyurea therapy and/or hypertransfusion had higher hemoglobin concentrations, but similar echocardiographic findings in comparison to those without treatment. Systolic blood pressure, ferritin concentration, TR velocity, and parameters of diastolic function were independently associated with increased LV mass. In addition, the predictors of adverse events were ferritin concentration, lactate dehydrogenase levels, and TR velocity. LV remodeling in SCD patients seems to be influenced by a combination of factors including blood pressure, ferritin concentration, TR velocity, and parameters of LV diastolic function, and was not associated with adverse outcomes.

Early detection of left ventricular contractility abnormalities by two-dimensional speckle tracking strain in Chagas' disease.

BACKGROUND: Chagas' disease is an important cause of heart failure, and early identification of cardiac involvement may help to identify patients at risk for disease progression. Two-dimensional (2D) speckle tracking (ST) strain seems to be a useful tool to detect incipient ventricular dysfunction. This study aims to analyze if 2D strain can detect contractility abnormalities in asymptomatic patients with Chagas' disease. METHODS: Seventy-eight asymptomatic Chagas' disease patients (46% male; age 44.7 ± 8.6 years) with normal cardiovascular exams and a control group of 38 healthy subjects (58% male; age 44.1 ± 9.2 years) were included in the study. Using 2D strain software, left ventricular (LV) end-systolic longitudinal, radial, and circumferential strain were measured. Global right ventricular (RV) longitudinal strain was also assessed. RESULTS: Echocardiographic parameters of LV systolic and diastolic function were similar between patients and controls. 2D longitudinal strain in the basal inferior, and inferoseptal walls, as well as apical segment of the inferolateral wall were lower in patients compared with controls. 2D radial strain was reduced in several segments of the LV walls as well as the global radial strain. 2D circumferential strain at the basal segment of the anterior wall showed a lower value in patients compared with controls, whereas global circumferential strain was similar between patients and controls. 2D RV strain did not differ between groups. CONCLUSION: In a subgroup of asymptomatic patients with Chagas' disease without evident cardiac involvement, 2D strain was reduced compared with healthy individuals, suggesting incipient LV dysfunction in these patients. 2D ST strain has the potential for detecting early myocardial impairment in the setting of Chagas' disease.

The impact of right ventricular stroke work on B-type natriuretic peptide levels in patients with mitral stenosis undergoing percutaneous mitral valvuloplasty.

OBJECTIVES: We aimed to explore the relationship between brain natriuretic peptide (BNP) levels and right ventricular (RV) function in patients with mitral stenosis (MS), and to investigate the hemodynamic parameters that predict reduction of BNP levels after percutaneous mitral valvuloplasty (PMV). BACKGROUND: Few studies have evaluated BNP in the context of MS, specifically the impact of the RV stroke work (RVSW) on serum BNP levels has not been defined. METHODS: Thirty patients with symptomatic rheumatic MS in sinus rhythm who were referred for a PMV were enrolled. Right and left heart pressures were obtained before and after valvuloplasty. RVSW index (RVSWI) was calculated by cardiac catheterization. RESULTS: Basal BNP levels were elevated in MS patients and correlated with several hemodynamic parameters including pulmonary pressure, pulmonary vascular resistance index, cardiac index (CI), and RVSWI. In multivariate analysis, CI and RVSWI were independent predictors of raised basal BNP levels. PMV resulted in a significant decrease in the RVSWI with a concurrent increase in CI (2.4 ± 0.43 to 2.9 ± 0.8 L/min/m(2), P = 0.010). Overall, plasma BNP levels significantly decreased from 124 (63/234) to 73 (48/148) pg/ml postvalvuloplasty. Multivariate analysis revealed that the reduction of left atrial (LA) pressure post-PMV was an independent predictor of change in BNP levels. CONCLUSIONS: Elevated baseline BNP level in MS patients was independently associated with CI and RVSWI. Plasma BNP levels were reduced after successful PMV, which was associated with the reduction of the LA pressure.

Highlights from the fifth international symposium of thrombosis and anticoagulation (ISTA V), October 18-19, 2012, Belo Horizonte, Minas Gerais, Brazil.

To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Fifth International Symposium of Thrombosis and Anticoagulation was held in Belo Horizonte, Minas Gerais, Brazil, on October 18-19, 2012. This scientific program was developed by clinicians for clinicians and was promoted by three major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, and Hospital do Coração Research Institute. Comprising 2 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.

Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo.

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

Newer Doppler echocardiography techniques in assessment of heart function in obese patients.

Obesity is one of the major health problems of modem society. The prevalence of this condition has increased at an alarming rate, especially the most severe form (body mass index >40 kg/m2). The cardiovascular problems that generally accompany obesity are the focus of a large number of studies. Conventional echogram and more current modalities, such as tissue Doppler, strain and strain rate are valuable tools for the detection of subclinical dysfunction and the early diagnosis and treatment of patients.

Rest left ventricular function and contractile reserve by dobutamine stress echocardiography in peripartum cardiomyopathy.

AIMS: To assess whether contractile reserve during dobutamine stress echocardiography (DSE) can predict left ventricular functional recovery in patients with peripartum cardiomyopathy and to assess myocardial fibrosis by magnetic resonance imaging (MRI) in these patients. METHODS: Nine patients with peripartum cardiomyopathy were enrolled. All patients underwent DSE and were followed for six months, when a rest Doppler echocardiogram was repeated. MRI was also performed at the beginning of follow-up to identify myocardial fibrosis. RESULTS: Mean age was 29±7.9 years and mean left ventricular ejection fraction at baseline was 39.4±8.6% (range 24-49%). Eight of the nine patients showed left ventricular functional recovery with mean ejection fraction at follow-up of 57.1±13.8%. The ejection fraction response to DSE did not predict recovery at follow-up. On the other hand, left ventricular ejection fraction at baseline correlated with ejection fraction at follow-up. Mild fibrosis was detected in only one patient. CONCLUSION: Left ventricular ejection fraction at baseline was a predictor of left ventricular functional recovery in patients with peripartum cardiomyopathy. Dobutamine stress echocardiography at presentation of the disease did not predict recovery at follow-up. Myocardial fibrosis appeared to be uncommon in this cardiomyopathy.

"Subclinical atherosclerosis in acromegaly: Possible association with cardiovascular risk factors rather than disease activity".

OBJECTIVE: Cardiovascular (CV) disease is still a major cause of excessive morbidity and mortality in patients with active acromegaly, which may be attributed to a high prevalence of associated pro-atherosclerotic risk factors. However, a direct effect of GH/IGF-1 excess on the vasculature has been previously suggested, warranting further investigation. The present study was designed to investigate whether chronic GH/IGF-1 excess is associated with an increased prevalence of subclinical atherosclerosis in patients with acromegaly. DESIGN: We measured carotid intima-media thickness (cIMT) and assessed carotid plaques by ultrasonography along with classical CV risk factors in 54 acromegaly patients (34 females, 50 ± 12 years and compared those with 62 (42 females, 53 ± 13 years) age-, sex- and CV risk factors- matched controls. In order to compare cIMT measurements between patients and controls we analyzed common carotid artery far wall data as well as a combined measurement result, which consisted of the mean value of the six different measurements, three at each side. RESULTS: mean ± SD serum GH and IGF-1 levels were 2.76 ± 4.65 ng/mL and 1.7 ± 1.25 x ULN, respectively, in all acromegaly patients. Age, body mass index, blood pressure, lipid levels, fasting glucose and Framingham's global cardiovascular risk score classification were similar comparing patients and controls. Combined median [IQR] cIMT measurements were similar in acromegaly patients and matched controls (0.59 [0.52-0.66] mm vs. 0.59 [0.52-0.69] mm; P = 0.872) as well as in acromegaly patients with active and controlled disease (0.59 [0.51-0.68] mm vs. 0.60 [0.54-0.68] mm; P = 0.385). No significant correlations were observed between cIMT measurements and GH (Spearman r = 0.1, P = 0.49) or IGF-1 (Spearman r = 0.13, P = 0.37) levels in patients with acromegaly. Carotid atherosclerotic plaques prevalence was similar in patients and controls (26% vs. 32%; P = 0.54) as well as in patients with active and controlled acromegaly (22% vs. 30%; P = 0.537). CONCLUSIONS: Our data suggest that GH/IGF-1 excess itself is not one of the main drivers of subclinical morphological atherosclerosis changes in patients with acromegaly and that optimal control of acromegaly-associated CV risk factors may preserve vasculature structure even when strict biochemical control is not achieved.

Investigation of the Familial Risk of Rheumatic Heart Disease with Systematic Echocardiographic Screening: Data from the PROVAR+ Family Study.

We aimed to use echocardiographic (echo) screening to evaluate the risk of Rheumatic Heart Disease (RHD) among the relatives of patients with advanced RHD, who were enrolled in the University Hospital's outpatient clinics from February 2020 to September 2021. Consenting first-degree relatives were invited for echo screening using handheld devices (GE VSCAN) by non-physicians, with remote interpretation. Matched controls (spouses, neighbors) living in the same household were enrolled in a 1:5 fashion. A standard echo (GE Vivid-IQ) was scheduled if abnormalities were observed. In 16 months, 226 relatives and 47 controls of 121 patients were screened, including 129 children, 77 siblings and 20 parents. The mean age was 40 ± 17 years, 67% of the patients were women, and 239 (88%) lived with the index case for >10 years. Echo findings suggestive of RHD were confirmed in zero controls and 14 (7.5%) relatives (p = 0.05): 11 patients had mild/moderate mitral regurgitation, and four were associated with mitral stenosis and abnormal morphology. Two patients had mild aortic regurgitation and abnormal morphology, which were associated with mild aortic and mitral stenosis, and two patients with advanced RHD had bioprostheses in the mitral (2) and aortic (1) positions. In conclusion, first-degree relatives of individuals with clinical RHD are at greater risk of having RHD, on top of socioeconomic conditions.

The duration of the use of imatinib mesylate is only weakly related to elevated BNP levels in chronic myeloid leukaemia patients.

Cardiotoxicity has been feared as a potential side effect of imatinib therapy. Studies with short-term follow-up failed to identify an excess of cardiac events, but longer-term observations are needed to more definitely exclude this adverse effect. This study was designed to assess the cardiac effects of imatinib in patients under long-term treatment. We included 90 chronic myeloid leukaemia (CML) patients under imatinib therapy for a median treatment time of 3.3 years (mean age 48.9 ± 15.1 years). Patients underwent clinical evaluation, electrocardiography, echocardiography (two-dimensional, colour flow, tissue Doppler and strain imaging), brain natiuretic peptide (BNP) and troponin I measurements. Twenty healthy volunteers were included as a control group for strain measurements. The mean ejection fraction was 68 ± 7% and the median BNP level was 9.6 pg/ml (interquartile range [IQR] 5.7-17.0 pg/ml). Two patients had either an elevated BNP or a depressed ejection fraction (2.2%; 90%CI 0.9-6.8%). Most of troponin I measurements were lower than the detection limit, except for two patients. Longitudinal strain was similar to measurements in healthy controls. A weak relation was observed between log BNP and imatinib treatment duration and dose. There was no relation between these variables and left ventricle ejection fraction. In conclusion, matinib-related cardiotoxicity is an uncommon event in CML patients, even during long-term treatment. Therefore, its use should not be cause of great concern, and the usefulness of regular cardiac monitoring all patients while on imatinib therapy is questionable.

Effect of pacing-induced ventricular dyssynchrony on right ventricular function.

BACKGROUND: Asynchronous electrical activation induced by right ventricular (RV) pacing can cause several abnormalities in left ventricular (LV) function. However, the effect of ventricular pacing on RV function has not been well established. We evaluated RV function in patients undergoing long-term RV pacing. METHODS: Eighty-five patients and 24 healthy controls were included. After pacemaker implantation, conventional echocardiography and strain imaging were used to analyze RV function. Strain imaging measurements included peak systolic strain and strain rate. LV function and ventricular dyssynchrony by tissue Doppler imaging (TDI) were assessed. Intra- and interobserver variabilities of TDI parameters were tested on 15 randomly selected cases. RESULTS: All patients were in New York Heart Association functional class I or II and percentage of ventricular pacing was 96 ± 4%. RV apical induced interventricular dyssynchrony in 49 patients (60%). LV dyssynchrony was found in 51 patients (60%), when the parameter examined was the standard deviation of the time to peak myocardial systolic velocity of all 12 segments greater than 34 ms. Likewise, septal-to-lateral delay ≥ 65 ms was found in 31 patients (36%). All echocardiographic indexes of RV function were similar between patients and controls (strain: -22.8 ± 5.8% vs -22.1 ± 5.6%, P = 0.630; strain rate: -1.47 ± 0.91 s(-1) vs -1.42 ± 0.39 s(-1) , P = 0.702). Intra- and interobserver variability for RV strain was 3.1% and 5.3%, and strain rate was 1.3% and 2.1%, respectively. CONCLUSIONS: In patients with standard pacing indications, RV apical pacing did not seem to affect RV systolic function, despite induction of electromechanical dyssynchrony.

Is atrial function in Chagas dilated cardiomyopathy more impaired than in idiopathic dilated cardiomyopathy?

AIMS: Atrial function is an important component in overall cardiovascular performance. However, information on atrial function in dilated cardiomyopathy is limited. This study aimed to assess atrial function in dilated cardiomyopathy and to investigate if parameters of atrial function are more impaired in Chagas dilated cardiomyopathy (CDC) than in idiopathic dilated cardiomyopathy (IDC). METHODS AND RESULTS: Seventy-two patients with dilated cardiomyopathy (36 with CDC and 36 with IDC) and 32 healthy controls were evaluated by tissue Doppler, Doppler-based strain and strain rate (SR) imaging of the left atrium (LA) and right atrium (RA). Peak atrial strain during systole and SR during systole, early and late diastolic SR, were measured at the interatrial septum, LA inferior wall and at the lateral wall of the RA. The clinical characteristics and the parameters of LV function were similar between patients with CDC and IDC. Myocardial deformation indices during the reservoir phase of both RA and LA were lower in patients with dilated cardiomyopathy than in controls, suggesting atrial dysfunction in cardiomyopathies. However, LA and RA deformation parameters did not differ between CDC and IDC patients (interatrial septal strain during the reservoir phase: -25.2 ± 14.8 vs. -24.9 ± 16.0%, P = NS; strain rate during the reservoir phase: -1.3 ± 0.7 vs. -1.5 ± 0.9/s, P = NS). CONCLUSIONS: Atrial myocardial deformation properties are abnormal in patients with dilated cardiomyopathy. CDC does not seem to have more atrial involvement than IDC.

Early right cardiac dysfunction in patients with schistosomiasis mansoni.

BACKGROUND: Pulmonary hypertension (PH) is a complication of schistosomiasis mansoni (SM), mainly in the hepatosplenic form. However, its prevalence is not well established. We evaluated the usefulness of Doppler echocardiographic indexes to detect right heart dysfunction in SM. METHODS: A total of 83 patients divided into two groups were studied: Group 1: 44 patients with hepatosplenic SM, and Group 2: 39 patients with hepatointestinal SM who served as controls. All patients underwent a Doppler echocardiogram. Right ventricular end-diastolic area (RVEDA), the peak systolic tricuspid annular tissue velocity (S'), right ventricular index of myocardial performance (RVIMP) and right atrial area (RAA) were measured in all patients. Tricuspid regurgitation peak velocity (TR) was measured and the pressure gradient (TG) was obtained. RESULTS: The prevalence of patients with elevated systolic pulmonary artery pressure at echocardiography was 31% in hepatosplenic patients, while no patient with the hepatointestinal form presented PH. Patients with hepatosplenic SM had larger RVEDA (10.0 ± 2.8 vs. 8.5 ± 1.8 cm(2) /m, P = 0.006) and RAA (9.39 [8.3-11.0] vs. 7.7 [6.9-8.4 cm(2) /m], P < 0.001). There was correlation between TG and RVIMP (r = 0.58; P < 0.001) and between TG and RAA (r = 0.36; P = 0.03) in Group 1. CONCLUSION: Larger RAA and RVEDA were found in patients with hepatosplenic SM, when compared to patients with the hepatointestinal form, which may suggest early impairment of RV function in patients with hepatosplenic SM.

Functional capacity and right ventricular function in patients with Chagas heart disease.

AIMS: Right ventricular (RV) dysfunction is an important factor on effort tolerance in cardiopulmonary diseases. Nevertheless, the role of RV function in predicting exercise capacity in patients with Chagas disease has not been reported. This study aims to evaluate whether RV function assessed by tissue Doppler can predict functional capacity in patients with Chagas heart disease. METHODS AND RESULTS: We evaluated 65 patients (48.6 +/- 9.1 years, 60% men) with Chagas heart disease. Standard and tissue Doppler echocardiography were performed before maximal exercise testing. Tissue Doppler imaging (TDI) was used to measure RV peak annular systolic and diastolic velocities. Exercise testing was performed using a standard Bruce protocol. Linear regression analysis was used to determine multivariate peak oxygen consumption (VO(2)) predictors. All patients were in NYHA functional class I or II. Mean peak VO(2) was 32.4 +/- 10.2 mL/kg/min and mean LV ejection fraction was 43 +/- 11%. There was correlation between TDI RV peak systolic velocity and LV ejection fraction (r = 0.5; P < 0.001). In a multivariate analysis, after adjustment for age and gender, RV function emerged as an independent predictor of functional capacity, as demonstrated in the model: peak VO(2) (r = 0.71) was: 42.22-(9.77 x female gender)-(0.29 x age) + (1.54 x RV systolic velocity). CONCLUSION: In this cross-sectional study, RV function was an important, independent determinant of exercise capacity in patients with Chagas heart disease. TDI RV systolic annular velocity was most closely associated with peak VO(2), regardless of the influence of age, gender, and other echocardiographic parameters.

Health Education about Rheumatic Heart Disease: A Community-Based Cluster Randomized Trial: Rheumatic Heart Disease Educational Strategies.

Introduction: The burden of rheumatic heart disease (RHD) is still high in Brazil. Lack of population awareness about the disease limits the efficacy of prevention programs. We aimed to evaluate the effectiveness of education on RHD in schools, comparing the conventional expository teaching method with tablet-based worked examples. Method: A prospective, cluster randomized trial was conducted over eight months in six randomly selected low-income Brazilian public schools. Each class was considered a cluster (total: 90), being randomized 1:1 to receive one of the educational methods. Pre-test evaluated students' prior knowledge on RHD. Post-tests, 10 days, and three months later, evaluated retention of knowledge. Results: At total 1,301 students (52% female) completed the study, being 63% from high school. Baseline knowledge about RHD was universally low (average score expository classes [G1] 33.9% vs. worked examples [G2] 32.5%, p = 0.23). A significant but similar improvement was observed in both groups in the immediate post-test (pre- vs. post: p < 0.001): G1 57.5% vs. G2 56.7%, p = 0.69. In the late post-test, a significant 20% worsening was observed in both groups and the final scores were again similar: G1 45.0% vs. G2 45.9%, p = 0.87. Highschool students had higher scores (p < 0.001), and girls had better overall performances than boys (p < 0.001). Conclusion: The novel technology of tablet-based worked examples had similar results compared with expository classes for RHD education in schools. Both educational processes resulted in modest gains in knowledge, with low retention. More studies are needed to determine if increased knowledge leads to behavioral changes that could reduce RHD burden. Highlights: In a cluster-randomized trial, two different educational strategies about Rheumatic Heart Disease (RHD) for children - standard expository classes and worked examples based on interactive modules in tablet computers - were compared in public schools of underserved Brazilian neighborhoods.Baseline knowledge was low, and the novel tablet-based technology had similar results compared with traditional teaching for RHD education in schools, with no differences in acquisition and mid-term retention of knowledge.Both educational interventions resulted in similar 71% improvement in the immediate post-test, although with suboptimal retention, with over 20% worsening in three months in both groups.Our data suggests that the optimal strategy for RHD education is yet to be determined, and future studies should be warranted to determine if increased knowledge leads to behavioral changes that could reduce disease burden in endemic areas.

Atrial fibrillation detection with a portable device during cardiovascular screening in primary care.

INTRODUCTION: A novel handheld dual-electrode stick is a portable atrial fibrillation (AF) screening device (AFSD). We evaluated AFSD performance in primary care patients referred for echocardiogram (echo). METHODS: The AFSD has a light indication of irregular rhythm and single-lead ECG recording. Patients were instructed to hold the device for 1 min, and AF indication was recorded. A 12-lead ECG was performed for all AFSD-positive patients and 250 patients with negative AFSD screen. Echos were performed based on a clinical risk score: all high-risk patients and a sampling of low-risk patients underwent complete echo. Intermediate risk patients first had a screening echocardiogram, with a follow-up complete study if abnormality was suspected. RESULTS: In 5 days, 1518 patients underwent clinical evaluation and cardiovascular risk stratification: mean age 58±16 years, 66% women. The AFSD was positive in 6.4%: 12.6% high risk, 6.1% intermediate risk and 2.2% low risk. Older age was a risk factor (9.3% vs 4.8% in those more than and less than 65 years, p=0.001). AFSD positive was independently associated with heart disease in echo (OR=3.9, 95% CI 2.1 to 7.2, p<0.001). Compared with 12-lead ECG, the AFSD had sensitivity of 90.2% (95% CI 77.0% to 97.3%) and specificity of 84.0% (95% CI 79.3% to 88.0%) for AF detection. CONCLUSION: AFSD demonstrated high sensitivity for AF detection in primary care patients referred for echo. AF prevalence was substantial and independently associated with structural or functional heart disease, suggesting that AFSD screening could be a useful primary care tool to stratify risk and prioritise echo.

Ischemic cerebrovascular events in patients with Chagas cardiomyopathy: a prospective follow-up study.

BACKGROUND: Chagas disease cardiomyopathy is a common form of dilated cardiomyopathy worldwide, and an important cause of stroke in Latin America. The long-term cumulative risk of ischemic cerebrovascular event (ICE) and its relation to left ventricular (LV) dysfunction have not been determined. The aims of this study were to describe the incidence and to evaluate the effect of LV ejection fraction on the risk for ICE in patients with Chagas cardiomyopathy. METHODS: A total of 213 consecutive patients with Chagas disease and LV systolic dysfunction, 131 males, mean age 48+/-12 years, were prospectively enrolled. The use of anticoagulation was based on clinical indications. The end point was ICE, which included fatal or nonfatal stroke and transient ischemic attack. Risk factors for events were assessed by Cox proportional-hazards analysis. RESULTS: Mean follow-up was 36 months; 69 patients died and seven underwent cardiac transplantation. The overall incidence of ICE was 2.67 events per 100 patient/years. Independent risk factors for ICE included LV ejection fraction (HR 0.95, 95% CI 0.91 to 0.99, p=0.009) and left atrial volume corrected for body surface area (HR 1.04, 95% CI 1.01 to 1.07, p=0.007), which persisted after adjustment for anticoagulation use. Patients with ejection fractions