Non-Targeted Self-Measured Blood Pressure and Hypertension Control in Public and Private Health Systems in Brazil

Abstract Background: It is estimated that more than 30% of the Brazilian population has systemic arterial hypertension (SAH), and mostly as an uncontrolled disease. The most recent Brazilian Guideline of Hypertension recommends the practice of self-measurement of blood pressure (BP) as one of the strategies for a better control of SAH, but there is no consensus about the efficiency of this tool. Objective: To assess the control of SAH and the practice of non-targeted self-measured BP (SMBP) among hypertensive users of the Unified Health System (SUS) and the Supplementary Network (SN). Methods: This is a cross-sectional, observational, analytical study, with a stratified probability sample. One thousand volunteers were investigated, being 500 from SUS and 500 from the SN. Uni and multivariate analyses were performed considering a 5% significance level. Results: Patients from SUS presented inferior sociodemographic data (schooling, social status) in relation to those of the SN (p < 0.001), and showed lower control of SAH (p = 0.014), as well as more visits to the emergency room in the past year due to hypertension (p = 0.002), and fewer regular appointments with the cardiologist (p = 0.004). SMBP was equally present in both assessed groups (p = 0.567), even though users of the SN have been more advised to not conduct such a practice (p = 0.002). SMBP (p < 0.001) was an independent factor for uncontrolled SAH both in SUS (OR = 3.424) and in the SN (OR = 3.474). Conclusion: Patients in SUS presented lower SAH control. The practice of SMBP, mostly practiced with an uncalibrated digital device, was equally present in both groups and became an independent factor of uncontrolled SAH.

Religiosity and Spirituality: The Relationship Between Psychosocial Factors and Cardiovascular Health

Abstract Background: Religiosity and Spirituality (R/S), despite being different entities, are multidimensional constructs, whose influence on cardiovascular health has been increasingly studied in recent decades. Objectives: To discriminate patients into subgroups according to R/S levels, in order to compare them regarding the distribution of cardiovascular comorbidities and clinical events. Methods: This is an observational, cross-sectional, analytical study. Two R/S scales were applied to a sample of patients seen at cardiology outpatient clinics. A cluster analysis was used to discriminate individuals into subgroups regarding R/S levels, which were subsequently compared regarding the frequencies of clinical variables related to cardiovascular health. A significance level of 5% was set for the statistical tests. Results: The sample included 237 patients with a mean age of 60.8 years (±10.7), of which 132 were female (55.7%). Cluster analysis (C) distinguished two groups: C1, with lower levels of R/S, and C2, with higher levels of R/S (p<0.001). C2 had a lower frequency of alcohol consumption (29.5% vs. 76.0%; p<0.001), smoking (12.9% vs. 51.0%; p<0.001), systemic arterial hypertension (SAH — 65.5% vs. 82.3%; p=0.005), dyslipidemia (58.3% vs. 77.1%; p=0.003), chronic coronary syndrome (36.7% vs. 58.3%; p=0.001), and prior cardiovascular events (15.8% vs. 36.5%; p<0.001) when compared to C1. There was also a higher frequency of females in C2 (82.0% vs. 17.7%; p<0.001). Conclusions: A better cardiovascular morbidity profile was observed in the group of patients with higher R/S levels, suggesting a probable positive relationship between R/S and cardiovascular health.

Resposta Exagerada da Pressão Arterial Sistólica ao Exercício e Isquemia Miocárdica à Ecocardiografia sob Estresse Físico / Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Resumo Fundamento A associação entre resposta exagerada da pressão arterial sistólica ao exercício (REPASE) e isquemia miocárdica é controversa e pouco estudada em indivíduos com síndrome coronariana crônica estabelecida ou suspeita. Objetivo Verificar a relação entre isquemia miocárdica e REPASE em indivíduos submetidos à ecocardiografia sob estresse físico (EEF). Métodos Trata-se de estudo transversal com 14.367 indivíduos submetidos à EEF, de janeiro de 2000 a janeiro de 2022, divididos em dois grupos: G1 - composto por pacientes cuja pressão sistólica de pico apresentou incremento ≥ 90 mmHg (valor correspondente ao percentil 95 da população estudada) -, e G2 - formado por indivíduos que não apresentaram resposta hipertensiva exagerada. Os grupos foram comparados mediante os testes t de Student e qui-quadrado. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica, REPASE, queixa de precordialgia típica prévia ao exame e angina durante o teste. Resultados Dos 14.367 pacientes, 1.500 (10,4%) desenvolveram REPASE e 7.471 (52,0%) eram do sexo feminino. Os percentuais de queixa prévia de precordialgia típica, angina durante o teste e isquemia miocárdica dos pacientes com REPASE foram de 5,8%, 2,4% e 18,1% contra 7,4%, 3,9% e 24,2%, em indivíduos sem REPASE, respectivamente (p = 0,021, p = 0,004, p < 0,001). Na análise multivariada, a REPASE foi associada, independentemente, a uma menor probabilidade de isquemia miocárdica (odds ratio: 0,73; intervalo de confiança de 95%: 0,58 a 0,93; p = 0,009). Conclusão O incremento exagerado da pressão arterial sistólica durante a EEF pode ser um marcador de exclusão de isquemia miocárdica.

Abstract Background The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. Objective To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). Methods This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. Results Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). Conclusion Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Subclinical Systolic Dysfunction during Chemotherapy for Breast Cancer

Abstract Background Cardiotoxicity is the main complication related to cancer therapy. Studies indicate that global longitudinal strain is an early detector of subclinical dysfunction of the left ventricle, preceding the decline in ejection fraction (EF). However, the reproducibility of such methodology has not been tested outside specialized centers. Objectives To assess the frequency of subclinical cardiotoxicity and to compare global longitudinal strain and EF measurements during the clinical course of patients undergoing chemotherapy for breast cancer. Methods This was an observational prospective study of 78 adult women who underwent serial echocardiograms (baseline and 1, 3, and 6 months after the beginning of chemotherapy), to evaluate biplane and 3D EF and global longitudinal strain. Cardiotoxicity and subclinical dysfunction were defined according to American Society of Echocardiography/European Association of Cardiovascular Imaging criteria. Statistical significance was set at p < 0.05. Results The mean age of the patients was 50.1 ± 11.48 years. The frequency of subclinical cardiotoxicity (defined by global longitudinal strain) was 14.9% after 30 days of chemotherapy, 16.7% after 3 months, and 19.7% after 6 months, compared to 4.5%, 3%, and 6.6%, respectively, when clinical cardiotoxicity was determined according to EF. The group that developed subclinical cardiotoxicity by 30 days (group A) had a higher frequency of clinical cardiotoxicity at 3 months (p=0.028) and a lower mean biplane EF after 30 days (p= 0.036) than the group that showed no evidence of subclinical cardiotoxicity (group B). Conclusion Subclinical cardiotoxicity was frequent and began early, being associated with a drop in EF during the clinical course.

Bariatric Surgery: Late Outcomes in Patients Who Reduced Comorbidities at Early Follow-Up.

Backgroundand Objectives: In severe obesity, a relevant weight loss can promote the reduction of comorbidities, such as systemic arterial hypertension (SAH), dyslipidemia, and diabetes mellitus (DM2). Bariatric surgery (BS) has been an essential resource in the therapy of this disease with a short-term reduction of cardiometabolic risk (CR). This study aimed to evaluate the reduction of factors associated with the CR in patients undergoing BS at a 5-year follow-up. Materials and Methods: This is a longitudinal, retrospective study carried out with patients undergoing BS by the Brazilian Public Healthcare System (PHS). Anthropometric and clinical parameters related to the CR (DM2, dyslipidemia, and SAH), quantified by the Assessment of Obesity-Related Comorbidities (AORC) score, were evaluated at the following moments: admission and preoperative and postoperative returns (3 months, 6 months, 1 to 5 years). Results: The sample had a mean age of 44.69 ± 9.49 years and were predominantly in the age group 20-29 years (34.80%) and women (72.46%). At admission to the service, 42.3% had DM2, 50.7% dyslipidemia, and 78.9% SAH. Regarding BS, the gastric bypass technique was used in 92.86% of the sample, and the waiting time for the procedure was 28.3 ± 24.4 months. In the pre- and postoperative period of 3 months, there was a significant reduction in the frequency of DM2 (p < 0.003), dyslipidemia (p < 0.000), and SAH (p < 0.000). However, at postoperative follow-up from 6 months to 5 years, there was no significant reduction in the comorbidities studied. After five years, 35.7% had total remission of DM2 and 2.9% partial remission of DM2, 44.2% had control and remission of dyslipidemia, and 19.6% of SAH (AORC score ≤ 2 for the comorbidities). Conclusion: BS promoted a reduction of the CR in the first three months after BS in severely obese PHS users.

Minimally invasive supratentorial neurosurgical approaches guided by Smartphone app and compass.

The precise location in the scalp of specifically planned points can help to achieve less invasive approaches. This study aims to develop a smartphone app, evaluate the precision and accuracy of the developed tool, and describe a series of cases using the referred technique. The application was developed with the React Native framework for Android and iOS. A phantom was printed based on the patient's CT scan, which was used for the calculation of accuracy and precision of the method. The points of interest were marked with an "x" on the patient's head, with the aid of the app and a compass attached to a skin marker pen. Then, two experienced neurosurgeons checked the plausibility of the demarcations based on the anatomical references. Both evaluators marked the frontal, temporal and parietal targets with a difference of less than 5 mm from the corresponding intended point, in all cases. The overall average accuracy observed was 1.6 ± 1.0 mm. The app was used in the surgical planning of trepanations for ventriculoperitoneal (VP) shunts and for drainage of abscesses, and in the definition of craniotomies for meningiomas, gliomas, brain metastases, intracranial hematomas, cavernomas, and arteriovenous malformation. The sample consisted of 88 volunteers who exhibited the following pathologies: 41 (46.6%) had brain tumors, 17 (19.3%) had traumatic brain injuries, 16 (18.2%) had spontaneous intracerebral hemorrhages, 2 (2.3%) had cavernomas, 1 (1.1%) had arteriovenous malformation (AVM), 4 (4.5%) had brain abscesses, and 7 (7.9%) had a VP shunt placement. In cases approached by craniotomy, with the exception of AVM, straight incisions and minicraniotomy were performed. Surgical planning with the aid of the NeuroKeypoint app is feasible and reliable. It has enabled neurological surgeries by craniotomy and trepanation in an accurate, precise, and less invasive manner.

Disfunção diastólica precoce em pacientes com câncer de mama submetidas à quimioterapia / Early diastolic dysfunction in breast cancer patients undergoing chemotherapy

Fundamento: A quimioterapia para o câncer de mama está associada a complicações cardiovasculares graves, como a insuficiência cardíaca. A fração de ejeção do ventrículo esquerdo é o principal parâmetro para avaliar a função sistólica nessas pacientes. Todavia, a ocorrência de disfunção diastólica pode preceder à disfunção sistólica. Objetivos: Avaliar as funções diastólica e sistólica do ventrículo esquerdo de portadoras de câncer de mama em tratamento quimioterápico com antraciclinas. Métodos: Trata-se de estudo observacional, longitudinal, analítico e prospectivo. Estudaram-se 62 mulheres com câncer de mama, com idades de 21 a 75 anos, que realizaram ecocardiogramas basais e após 3 meses de tratamento. Avaliaram-se parâmetros de função diastólica, e as pacientes foram classificadas em disfunção diastólica tipos:1, 2 ou 3. Definiu-se a disfunção sistólica como fração de ejeção do ventrículo esquerdo ≤ 53%. Resultados: Decorridos 3 meses de tratamento, 35 pacientes (56,4%) apresentavam disfunção diastólica tipo 1, e apenas uma (1,6%) do tipo 2. A disfunção diastólica ocorreu em 26 pacientes já na etapa basal e surgiu em dez indivíduos no decurso do tratamento. Os parâmetros de função diastólica velocidade de onda E e relação E/A diminuíram significativamente (p < 0,05) com a quimioterapia, todavia, os demais não tiveram variação significativa. Apenas três pacientes apresentaram disfunção sistólica, porém verificou-se maior redução da fração de ejeção do ventrículo esquerdo no grupo que desenvolveu disfunção diastólica durante o tratamento comparativamente ao grupo que apresentava já disfunção diastólica no período basal (p = 0,04). Conclusão: A disfunção diastólica ocorre precocemente em portadoras de câncer de mama submetidas à quimioterapia. O surgimento de disfunção diastólica no decurso do tratamento se associa à redução significativa da fração de ejeção do ventrículo esquerdo. (AU)

Background: Chemotherapy for breast cancer is associated with serious cardiovascular complications such as heart failure. The left ventricular ejection fraction is the main parameter used to assess systolic function in these patients. However, the occurrence of diastolic dysfunction may precede that of systolic dysfunction. Objectives: To evaluate left ventricle diastolic and systolic functions in women with breast cancer undergoing chemotherapy using anthracyclines. Methods: This observational, longitudinal, analytical, and prospective study included 62 women with breast cancer aged 21­75 years old who underwent echocardiography at baseline and after three months of treatment. Diastolic function parameters were evaluated, and the patients were classified as diastolic dysfunction type 1, 2, or 3. Systolic dysfunction was defined as a left ventricular ejection fraction ≤ 53%. Results: After three months of treatment, 35 patients (56.4%) had type 1 diastolic dysfunction, while one (1.6%) had type 2. Diastolic dysfunction was identified in 26 patients at baseline and developed in 10 patients during treatment. Diastolic function parameters, E wave velocity, and E/A ratio decreased significantly (p < 0.05) with chemotherapy; however, the others showed no significant variations. Only three patients had systolic dysfunction, but there was a greater reduction in left ventricular ejection fraction in the group that developed diastolic dysfunction during treatment versus the group with diastolic dysfunction at baseline (p = 0.04). Conclusion: Diastolic dysfunction occurs early in women with breast cancer undergoing chemotherapy. Its onset during the course of treatment is associated with a significantly reduced left ventricular ejection fraction. (AU)

Ecoestresse físico na cardiomiopatia hipertrófica: como, quando e por quê? / Exercise stress echocardiography in hypertrophic cardiomyopathy: how, when and why?

Resumo Historicamente, o papel do ecocardiograma de estresse físico no manejo da cardiomiopatia hipertrófica tem sido negligenciado na prática clínica, de acordo com a análise das diretrizes do American College of Cardiology/ American Heart Association de 2002, que recomendavam cautela no uso dessa metodologia, em portadores de cardiomiopatia hipertrófica, devido ao risco de possível ocorrência tanto de arritmia cardíaca, como de colapso hemodinâmico no esforço. Atualmente, o estresse físico na cardiomiopatia hipertrófica integra a avaliação rotineira de pacientes sintomáticos com ou sem gradiente da via de saída do ventrículo esquerdo < 50 mmHg, em repouso. Para este grupo, é um método seguro e confiável para medir o gradiente da via de saída do ventrículo esquerdo durante o esforço e sólido diferenciador de pacientes com cardiomiopatia hipertrófica não obstrutivos (gradiente ausente, tanto em repouso quanto no esforço) daqueles com gradientes lábeis (gradiente ausente no repouso e presente no esforço). Portanto, na avaliação da cardiomiopatia hipertrófica, o estresse físico é igualmente útil na quantificação do grau de regurgitação mitral, nas alterações da contratilidade segmentar do ventrículo esquerdo e na avaliação da função diastólica do ventrículo esquerdo, diante do esforço, sendo capaz de predizer o futuro desenvolvimento de sintomas de insuficiência cardíaca. O método é também importante na determinação das diferentes estratégias de tratamento para cada paciente, desde a miomectomia cirúrgica ou a ablação septal alcoólica, para aqueles com gradiente lábil, com sintomas limitantes e refratários ao tratamento medicamentoso versus transplante cardíaco para aqueles sem gradiente.(AU)

Consumo leve a moderado de álcool e isquemia miocárdica à ecocardiografia sob estresse físico / Low to moderate alcohol consuption and myocardial ischemia on exercise stress echocardiography

Fundamento: O impacto do consumo de álcool na evolução da isquemia miocárdica permanece incerto. Os estudos divergem quanto a um eventual efeito cardioprotetor ou a um fator de risco cardiovascular desse consumo de maneira leve a moderada. Objetivo: Estudar a relação do consumo leve a moderado de álcool com a isquemia miocárdica à ecocardiografia sob estresse físico (EEF). Métodos: Estudo transversal composto por 6632 pacientes submetidos à EEF, de janeiro de 2000 a dezembro de 2015. Dividiram-se dois grupos: G1 - composto por 2130 (32,1%) pacientes com relato de consumo médio igual ou inferior a 1 dose de bebida alcoólica por dia para mulheres ou de 2 doses para homens; e G2 - formado por 4502 (67,9%) indivíduos que negaram consumo de álcool. A comparação entre os grupos foi feita mediante teste t de Student para variáveis quantitativas, e teste qui-quadrado ou teste de Fisher para as variáveis categóricas. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica. Resultados: G1 apresentou maior frequência de indivíduos do sexo masculino (77,1%; p < 0,001), menor idade média (54,8 ± 10,3 anos; p < 0,001) e maior frequência de isquemia miocárdica à EEF (p = 0,014). Idade, sexo masculino, dislipidemia, hipertensão arterial sistêmica, diabete melito, tabagismo e história familiar positiva apresentaram-se independentemente associados à presença de isquemia miocárdica à EEF. Não foi observada associação independente entre etilismo leve a moderado e isquemia miocárdica (OR 0,96; IC 95%: 0,83-1,11). No entanto, observou-se associação entre idade, sexo masculino, tabagismo e dislipidemia com o consumo de álcool. Conclusão: Etilismo leve a moderado não se apresentou como preditor independente de presença de isquemia miocárdica à EEF. Observou-se, no grupo dos etilistas, um predomínio de homens, dislipidêmicos e tabagistas, importantes variáveis preditoras de isquemia miocárdica

Background: The impact of alcohol consumption on the development of myocardial ischemia remains uncertain. Studies diverge whether low to moderate alcohol consumption provides cardioprotection or whether it is a risk factor for myocardial ischemia. Objective: To study the relationship between low to moderate alcohol consumption and myocardial ischemia on exercise stress echocardiography (ESE). Methods: Cross-sectional study with 6632 patients with known or suspected coronary artery disease undergoing ESE between January/2000 and December/2015. The patients were divided into two groups: G1, composed of 2130 (32.1%) patients whose report showed maximal consumption of 1 drink per day on average for women or of 2 drinks per day for men; G2, composed of individuals denying any alcohol consumption. For comparing between the groups, Student t test was used for quantitative variables, and chi-square test or Fisher exact test, for categorical variables. The significance level adopted was p < 0.05. Logistic regression was also used to evaluate independent risk factors for myocardial ischemia. Results: G1 had a higher number of men (77.1%; p < 0.001), lower mean age (54.8 ± 10.3 years old; p < 0.001) and higher frequency of myocardial ischemia on ESE (p = 0.014). Age, male sex, dyslipidemia, systemic arterial hypertension, diabetes mellitus, smoking and family history were independently associated with myocardial ischemia on ESE. Independent association between low to moderate alcohol consumption and myocardial ischemia on ESE (OR 0.96; 95%CI: 0.83 to 1.11) was not observed. However, age, male sex, smoking and dyslipidemia were associated with alcohol consumption. Conclusion: Low to moderate alcohol consumption was not an independent predictor of myocardial ischemia on ESE. Nevertheless, we observed a predominance of the male sex, dyslipidemia and smoking habit, important predictors of myocardial ischemia, in the group of alcohol consumers

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography / Placa Aterosclerótica à Angiotomografia de Coronárias em Pacientes com Escore de Cálcio Zero

Abstract Background: In view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. Objective: To evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA). Methods: This is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted. Results: The frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable. Conclusions: The frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Resumo Fundamento: Diante da alta mortalidade por doenças cardiovasculares, faz-se necessária a estratificação dos principais fatores de riscos e escolha correta da modalidade diagnóstica. Estudos demonstraram que escore de cálcio (EC) zero caracteriza baixo risco de eventos cardiovasculares. No entanto, a frequência de portadores de placa aterosclerótica coronária com EC zero é conflitante na literatura especializada. Objetivo: Avaliar a frequência de pacientes com placa aterosclerótica coronária, seu grau de obstrução e fatores associados em pacientes com EC zero e indicação para angiotomografia computadorizada de coronárias (ATCC). Métodos: Trata-se de estudo transversal, prospectivo, com 367 voluntários portadores de EC zero, mediante a ATCC, no período de 2011-16, em quatro centros de diagnóstico por imagem. Foi assumido nível de significância 5% e intervalo de confiança de 95%. Resultados: A frequência de placa aterosclerótica nas artérias coronárias dos 367 pacientes com EC zero foi de 9,3% (34 indivíduos); neste subgrupo, a média de idade foi 52 ± 10 anos, 18 (52,9%) eram mulheres e 16 (47%) exibiam obstruções coronarianas significativas (> 50%), dos quais 4 (25%) apresentaram placas em pelo menos dois segmentos. A frequência de não obesos (90,6% vs. 73,9%; p = 0,037) e de etilistas (55,9% vs. 34,8%; p = 0,015) foi significativamente maior nos portadores de placa, apresentando, cada variável, odds ratio de 3,4 para o desenvolvimento das referidas placas. Conclusões: A frequência de placa aterosclerótica com EC zero foi considerável, evidenciando, portanto, que a ausência de calcificação não exclui placa, muitas das quais obstrutivas, principalmente nos não obesos e etilistas.

Visão geral com meta-análise de revis~es sistemáticas sobre o valor diagnóstico e prognóstico da angiotomografia de coronárias na emergência / Overview with meta-analysis of systematic reviews of the diagnostic and prognostic value of coronary computed tomography angiography in the emergency department

Fundamento: A alta prevalência de DAC, bem como seu impacto sobre as despesas de saúde e as várias opções de tratamento para reduzir a morbidade e mortalidade relacionados a DAC, vem desenvolver uma ferramenta de diagnóstico precisa e com resultados importantes no departamento de emergência. Objetivo: Fornecer visão geral com meta-análise para compilar evidência a partir de múltiplas revisões sistemáticas (RS) sobre o valor diagnóstico e prognóstico da angiotomografia computadorizada de artérias coronárias (ATCC) na avaliação da dor torácica aguda no setor de emergência (SE). Métodos: Incluímos RS de estudos primários avaliando o valor diagnóstico e prognóstico da ATCC ≥ 64 canais no SE. Os estudos foram conduzidos em pacientes de risco baixo e intermediário para doença arterial coronariana (DAC). Realizou-se avaliação qualitativa usando PRISMA, e aquelas que pontuaram ≥ 80% foram aprovadas. Dois autores extraíram dados independentemente usando um formulário padrão. Os testes de correlação de Spearman, do qui-quadrado, Q de Cochran ou a estatística I 2 de Higgins e Thompson foram usados, assim como o pacote estatístico "mada" (R Core Team, 2015) para meta-análise. Adotou-se o nível de significância de 95%. Resultados: Quatro RS foram elegíveis para inclusão neste estudo, resultando em 13 artigos após aplicação dos critérios de exclusão, sendo apenas 10 usados para a meta-análise, num total de 4831 pacientes (idade média, 54 ± 6 anos; 51% homens), dos quais 46% tinham hipertensão, 32% dislipidemia, 13% diabetes e 26% história familiar de DAC prematura. Na meta-análise, 9 estudos definiram ATCC positiva na presença de lesões luminais ≥ 50%, enquanto 1 estudo definiu ATCC positiva na presença de lesões luminais ≥ 70%. A sensibilidade variou de 77% a 98%, e a especificidade, de 73% a 100%. A análise univariada mostrou homogeneidade do odds ratio diagnóstico (DOR) [Q = 8,5 (df = 9), p = 0,48 and I 2 = 0%]. A estimativa sumária da DOR para ATCC nas análises primárias foi de 4,33 (IC95%: 3,47 ­ 5,18). A área sob a curva foi 0,982 (IC95%: 0,967 ­ 0,999). Houve 29 (0.6%) infartos, 92 (1,9%) revascularizações, 312 (6,4%) angiografias coronarianas invasivas e nenhuma morte. Síndrome coronariana aguda foi diagnosticada em 7,3% dos 1655 pacientes incluídos na meta-análise. Conclusões: O uso de ATCC como ferramenta para estratificação de pacientes de risco cardiovascular baixo e intermediário, que procuraram o SE com dor torácica, tem alta acurácia e segurança, reduz a permanência no hospital e provavelmente os custos, produzindo diagnóstico precoce e uma tomada de decisão mais efetiva

Background: The high prevalence of CAD, as well as your impact on health expenditure and the various treatment options to reduce morbidity and mortality related to CAD, comes to develop a diagnostic tool precis and with important findings in the Emergency Department. Objetive: To conduct an overview with meta-analysis to compile evidence from multiple systematic reviews (SR) on the diagnostic and prognostic value of coronary computed tomography angiography (CCTA) to assess acute chest pain in the emergency department (ED). Methods: We included SR of primary studies that evaluated the diagnostic and prognostic value of CCTA ≥ 64 channels in the ED. The studies were conducted in patients at low and intermediate risk for coronary artery disease (CAD). Quality assessment was performed using PRISMA and approved reviews that scored ≥ 80%. Two authors independently extracted data using a standardized form. Spearman correlation test, Chi-square test, Cochran's Q test or Higgins and Thompson statistical I 2 were used. For meta-analysis, "mada" package statistical software R Core Team, 2015, was used. The significance level adopted was 95%. Results: Four reviews were eligible for inclusion in this overview, resulting in 13 articles after applying the exclusion criteria, and only 10 of these were used for meta-analysis, adding up to a total of 4831 patients (mean age, 54 ± 6 years; 51% male), of whom 46% were hypertensive, 32% had dyslipidemia, 13% had diabetes and 26% had a family history of premature CAD. In the meta-analysis, 9 studies defined CCTA positive in the presence of luminal lesions ≥ 50%, while 1 study defined it as luminal lesions ≥ 70%. Sensitivity ranged from 77% to 98%, and specificity, from 73% to 100%. The univariate analysis showed homogeneity of diagnostic odds ratio (DOR) [Q = 8.5 (df = 9), p = 0.48 and I 2 = 0%]. The pooled mean DOR for CCTA in primary analyses was 4.33 (95% CI: 3.47 - 5.18). The area under the curve (AUC) was 0.982 (95% CI: 0.967 - 0.999). There was no death, 29 (0.6%) infarcts, 92 (1.9%) revascularizations and 312 (6.4%) invasive coronary angiographies. The diagnosis of acute coronary syndrome occurred in 7.3% of the 1655 patients included in the meta-analysis. Conclusions: The use of CCTA as a tool for stratification of patients at low or intermediate cardiovascular risk, who are in the ED with chest pain, has high accuracy, safety, reduces length of hospital stay and probably the costs, producing an early diagnosis and more effective decision making

Cardiopulmonary exercise testing in patients with left bundle branch block and preserved ejection fraction / Teste de Esforço cardiopulmonar em portadores de bloqueio do ramo esquerdo e fração de ejeção preservada

BACKGROUND: Left bundle branch block (LBBB) has prognostic significance in patients with congestive heart failure. However, its influence is not well established in patients with preserved systolic ventricular function. OBJECTIVE: To evaluate the implications of LBBB presence in the cardiovascular performance of patients with preserved left ventricular systolic function (LVEF). METHODS: 26 LBBB patients (61.3 ± 8.2 years of age) and 23 healthy individuals (58 ± 6.8 years of age) with LVEF > 0.5 underwent cardiopulmonary exercise testing (CPET). RESULTS: CPET analysis revealed: peak oxygen consumption (VO2 ) predicted in the LBBB group was 87.2 ± 15.0% versus 105.0 ± 15.6% (p < 0.0001); peak oxygen pulse predicted in LBBB group was 98.6 ± 18.6% vs 109.9 ± 13.5% (p = 0.02); VO2 predicted anaerobic threshold in LBBB group was 67.9 ± 13.6% vs 70.2 ± 12.8% (p = 0.55); ΔVO2 /Δload in the LBBB group was 15.5 ± 5.51 versus 20.7 ± 7.3 ml.min-1.watts-1 (p = 0.006); ventilation / carbon dioxide production (VE/VCO2 slope) in LBBB group was 29.8 ± 2.9 versus 26.2 ± 2.9 (p = 0.0001) and VO2 recovery time in the LBBB group was 85.2 ± 11.8 vs. 71.5 ± 11.0 seconds (p = 0.0001). LBBB was an independent marker for VE/VCO2 slope increase. CONCLUSION: LBBB presence in individuals with preserved LVEF did not affect cardiovascular performance, but there was an increase of the VE/VCO2 slope in comparison to the control group.

FUNDAMENTO: O bloqueio do ramo esquerdo (BRE) tem importância prognóstica em portadores de insuficiência cardíaca congestiva. Todavia, a sua influência não está bem estabelecida em pacientes com função ventricular sistólica preservada. OBJETIVO: Avaliar as implicações da presença do BRE no desempenho cardiovascular em pacientes com função sistólica do ventrículo esquerdo (FEVE) preservada. MÉTODOS: Foram submetidos ao teste de esforço cardiopulmonar (TECP), 26 portadores de BRE (61,3 ± 8,2 anos) e 23 indivíduos saudáveis (58 ± 6,8 anos), com FEVE > 0,5. RESULTADOS: A análise do TECP revelou: consumo de oxigênio (VO2 ) pico predito no grupo BRE foi de 87,2 ± 15,0% versus 105,0 ± 15,6% (p < 0,0001); pulso de oxigênio pico predito no grupo BRE foi de 98,6 ± 18,6% versus 109,9 ± 13,5%, (p = 0,02); VO2 predito limiar anaeróbico no grupo BRE foi de 67,9 ± 13,6 % versus 70,2 ± 12,8% (p = 0,55); ∆VO2 /∆carga no grupo BRE foi de 15,5 ± 5,51 versus 20,7 ± 7,3 ml.min-1.watts-1 (p = 0,006); relação ventilação/produção de dióxido de carbono (VE/VCO2 slope) no grupo BRE foi de 29,8 ± 2,9 versus 26,2 ± 2,9 (p = 0,0001) e tempo de recuperação do VO2 no grupo BRE foi de 85,2 ± 11,8 versus 71,5 ± 11,0 segundos (p = 0,0001). O BRE foi marcador independente para o aumento do VE/VCO2 slope. CONCLUSÃO: A presença de BRE em indivíduos com FEVE preservada não comprometeu o desempenho cardiovascular, mas houve aumento do VE/VCO2 slope em relação ao grupo controle.

Preditores de Placa Aterosclerótica em Assintomáticos Isquêmicos à Ecocardiografia sob Estresse Físico / Predictors of Atherosclerotic Plaque in Individuals with Asymptomatic Ischemia on Physical Stress Echocardiography

A isquemia miocárdica pode ocorrer em pacientes assintomáticos e sem história de doença arterial coronariana (DAC). A ecocardiografia sob estresse físico (EEF) é um método de boa acurácia diagnóstica, enquanto a cineangiocoronariografia (CATE) é o método padrão-ouro para detecção de DAC obstrutiva. Todavia, muitos portadores de isquemia em testes funcionais apresentam lesões não obstrutivas à CATE. Objetivo: Identificar a presença de preditores de placas ateroscleróticas obstrutivas à CATE em indivíduos assintomáticos com EEF positiva para isquemia miocárdica. Métodos: Estudo transversal com 278 pacientes assintomáticos submetidos à EEF e à CATE, divididos em grupo G1 (lesões ateroscleróticas obstrutivas ≥ 50%) e G2 (placas inferiores a 50% ou inexistentes). Variáveis quantitativas foram comparadas com os testes t de Student ou Mann-Whitney para grupos independentes, segundo a normalidade da amostra. Para variáveis categóricas, utilizou-se os testes do qui-quadrado ou exato de Fisher, quando apropriado. Para identificação de preditores independentes de lesão aterosclerótica, foi utilizada regressão logística. Resultados: O número de pacientes nos grupos G1 e G2 foi de 233 (83,3%) e 45 (16,2%), respectivamente. A média de idade foi maior no G1 (60,9 ± 9,56 anos versus 51,8 ± 10,05 anos, respectivamente, p < 0,001). O G1 em comparação ao G2 apresentou mais pacientes hipertensos (65,2% versus 48,9%, p = 0,03) e dislipidêmicos (77,3% versus 57,8%, respectivamente, p = 0,006). O G2 em comparação ao G1 apresentou maior frequência de obesidade leve (33,3% versus 14,2%, respectivamente, p = 0,002), que demonstrou ser um fator protetor para lesão aterosclerótica. Conclusão: Os preditores de placa aterosclerótica em assintomáticos isquêmicos à EEF foram idade, gênero masculino e isquemia do tipo fixa.

Myocardial ischemia may occur in asymptomatic patients without a history of coronary artery disease (CAD). Stress echocardiography (SE) is a method with good diagnostic accuracy, while coronary cineangiography (CCA) is the gold standard method to detect obstructive CAD. However, many patients with ischemia on functional tests show nonobstructive lesions on CCA. Objective: To assess the presence of predictors of obstructive atherosclerotic plaques in asymptomatic individuals with an SE positive for myocardial ischemia. Methods: Cross-sectional study with 278 asymptomatic individuals who underwent SE and CCA, divided into groups G1 (obstructive atherosclerotic lesions ≥ 50%) and G2 (plaques below 50% or nonexistent). Quantitative variables were compared with Student's t test or Mann-Whitney test for independent groups, according to the normality of the sample. For categorical variables, we used the chi-square test or Fisher's exact test, as appropriate. Logistic regression was used to identify independent predictors of atherosclerotic lesions. Results: The numbers of patients in G1 and G2 were 233 (83.3%) and 45 (16.2%), respectively. The mean age was higher in G1 (60.9 ± 9.56 years versus 51.8 ± 10.05 years, p < 0.001). G1, when compared with G2, had more patients with hypertension (65.2% versus 48.9%, respectively, p = 0.03) and dyslipidemia (77.3% versus 57.8%, respectively, p = 0.006). G2, when compared with G1, had a higher frequency of mild obesity (33.3% versus 14.2%, respectively, p = 0.002), which emerged as a protective factor for atherosclerotic lesions. Conclusion: The predictors of atherosclerotic plaques in asymptomatic patients with ischemia on SE were age, male gender, and fixed ischemia.

Ressonância magnética cardíaca na avaliação do ventrículo direito e suas patologias / Cardiovascular magnetic resonance imaging in the evaluation of the right ventricle and its pathologies

A ressonância magnética cardíaca (RMC) constitui método não invasivo e tridimensional que permite a avaliaçãomorfológica e funcional de todas as câmaras do coração. Esse método tem ganhado importância na identificaçãoe caracterização de cardiopatias primárias que envolvem o ventrículo direito (VD), além de doenças secundárias que levam à disfunção das câmaras direitas. Dessa forma, este trabalho objetiva elucidar a melhor metodologia no diagnóstico dessas doenças mediante a RMC.

Angiotomografia de Coronárias e Proteína C Reativa na Avaliação da Doença Arterial Coronariana / Coronary Computed Tomography Angiography and C-Reactive Protein in the Evaluation of Coronary Artery Disease

Fundamento: A doença arterial coronariana (DAC) constitui a principal causa de morte nos países desenvolvidos. No Brasil, gasta-se aproximadamente 1,74% do Produto Interno Bruto com doenças cardiovasculares. Testes de isquemia possuem baixa acurácia diagnóstica em indivíduos com risco intermediário de DAC e a angiotomografia computadorizada de múltiplos detectores (ATCMD) pode contribuir para esclarecer o diagnóstico desses pacientes, não obstante o custo deste procedimento que ainda é elevado para o nosso padrão. A proteína C reativa (PCR) eleva-se no caso de inflamação sistêmica e tem sido utilizada como marcador de DAC. Objetivo: Avaliar a correlação da PCR com a presença de placas ateroscleróticas identificadas pela angiotomografia. Métodos: Trata-se de um estudo de corte transversal, no qual foram incluídos 118 pacientes com risco intermediário para DAC, que realizaram ATCMD das artérias coronárias e dosagem de PCR de setembro de 2011 a janeiro de 2013 em um hospital de referência cardiológica. Resultados: Cerca de 55% da amostra foi representada pelo gênero masculino. A DAC, HAS e obesidade foram identificadas em 68,6%, 76,3% e 31,8% dos indivíduos, respectivamente. Observou-se que os pacientes com concentrações elevadas de PCR tiveram uma chance 2,9 maior de apresentarem DAC diagnosticada por ATCMD (p = 0,016). Conclusão: Indivíduos com PCR alterada têm maior chance de apresentarem DAC diagnosticada à ATCMD e possuem valores de PCR mais elevados que pacientes sem DAC. A PCR, junto a outros fatores de risco, pode representar um elemento preditivo relevante para o diagnóstico de DAC na ATCMD, ou em situações quando a realização da ATCMD não é possível

Background: Coronary artery disease (CAD) is the leading cause of death in developed countries. In Brazil, approximately 1.74% of the gross domestic product is spent on cardiovascular diseases. Ischemia tests have a low diagnostic accuracy for patients with intermediate CAD risk, and multidetector computed tomography angiography (MDCTA) may help establish the diagnosis of these patients, despite the cost of this procedure, which is still high for our standards. C-reactive protein (CRP) is increased in cases of systemic inflammation and has been used as a CAD marker. Objective: To evaluate the correlation of CRP with the presence of atherosclerotic plaques identified on CT angiography. Methods: Cross-sectional study including 118 patients with intermediate risk of CAD, who underwent coronary MDCTA and CRP measurement from September 2011 to January 2013 in a referral cardiology hospital. Results: Males comprised about 55% of the sample. CAD, hypertension, and obesity were identified in 68.6%, 76.3%, and 31.8% of the subjects, respectively. We observed that patients with increased CRP levels had a 2.9-fold higher chance of presenting CAD on MDCTA (p = 0.016). Conclusion: Individuals with altered CRP are more likely to present CAD diagnosed by MDCTA and have higher CRP values than patients without CAD. CRP, along with other risk factors, may represent a relevant predictive element in the diagnosis of CAD in MDCTA, or in situations in which MDCTA is not feasible

Low Prevalance of Major Events Adverse to Exercise Stress Echocardiography / Baixa Prevalência de Eventos Adversos Maiores à Ecocardiografia sob Estresse Físico

Abstract Background: Stress echocardiography is well validated for diagnosis and risk stratification of coronary artery disease. Exercise stress echocardiography (ESE) has been shown to be the most physiological among the modalities of stress, but its safety is not well established. Objective: To study the complications related to ESE and clinical and echocardiographic variables most commonly associated with their occurrence. Methods: Cross-sectional study consisting of 10250 patients submitted to ESE for convenience, from January 2000 to June 2014. Cardiac Arrhythmias (CA) were the most frequent complications observed during the examination. The volunteers were divided into two groups according to the occurrence of CA during ESE: G1 group, composed of patients who have CA, and G2 formed by individuals who did not show such complication. Results: Group G1, consisting of 2843 patients (27.7%), and Group G2 consisting of 7407 patients (72.3%). There was no death, acute myocardial infarction, ventricular fibrillation or asystole. Predominant CAs were: supraventricular extrasystoles (13.7%), and ventricular extrasystoles (11.5%). G1 group had a higher mean age, higher frequency of hypertension and smoking, larger aortic roots and left atrium (LA) and lower ejection fraction than G2. G1 group also had more ischemic changes (p < 0.001). The predictor variables were age (RR 1.04; [CI] 95% from 1.038 to 1.049) and LA (RR 1.64; [CI] 95% from 1.448 to 1.872). Conclusion: ESE proved to be a safe modality of stress, with non-fatal complications only. Advanced age and enlargement of the left atrium are predictive of cardiac arrhythmias.

Resumo Fundamento: A ecocardiografia sob estresse constitui metodologia validada para diagnóstico e estratificação de risco da doença arterial coronária. A ecocardiografia sob estresse físico (EEF) tem se destacado como a mais fisiológica dentre as modalidades de estresse, todavia sua segurança não está bem estabelecida. Objetivo: Estudar as complicações relacionadas à EEF e as variáveis clínicas e ecocardiográficas preditoras dessas ocorrências. Método: Estudo transversal composto por 10250 pacientes submetidos à EEF por conveniência, de janeiro de 2000 a junho de 2014. As arritmias cardíacas (AC) foram as complicações mais frequentemente encontradas durante o exame. Os voluntários foramdivididos em dois grupos, de acordo com a ocorrência de AC à EEF: grupo G1 - composto por pacientes que apresentaram AC e grupo G2 - formado por indivíduos que não exibiram tal complicação. Resultados: O grupo G1 com 2843 (27,7%) pacientes, e grupo G2 formado por 7407 (72,3%). Não foram registrados óbitos, infarto agudo do miocárdio, assistolia ou fibrilação ventricular. As extrassístoles supraventriculares (13,7%) e as ventriculares (11,5%) foram as AC predominantes. O grupo G1 apresentou idade média mais elevada, maior frequência de hipertensão arterial sistêmica e tabagismo, maiores dimensões da raiz da aorta e do átrio esquerdo (AE) e menor fração de ejeção do ventrículo esquerdo que o G2. O grupo G1 exibiu também, mais alterações isquêmicas (p < 0,001). As variáveis preditoras foram idade (RR 1,04; [IC] 95% 1,038 - 1,049) e AE (RR 1,64; [IC] 95% 1,448 - 1,872). Conclusão: A presente investigação demonstrou que a EEF é uma modalidade segura, ocorrendo apenas complicações não-fatais. Idade avançada e aumento da dimensão do AE são preditores da presença de arritmias cardíacas.

Low Prevalance of Major Events Adverse to Exercise Stress Echocardiography.

BACKGROUND: Stress echocardiography is well validated for diagnosis and risk stratification of coronary artery disease. Exercise stress echocardiography (ESE) has been shown to be the most physiological among the modalities of stress, but its safety is not well established. OBJECTIVE: To study the complications related to ESE and clinical and echocardiographic variables most commonly associated with their occurrence. METHODS: Cross-sectional study consisting of 10250 patients submitted to ESE for convenience, from January 2000 to June 2014. Cardiac Arrhythmias (CA) were the most frequent complications observed during the examination. The volunteers were divided into two groups according to the occurrence of CA during ESE: G1 group, composed of patients who have CA, and G2 formed by individuals who did not show such complication. RESULTS: Group G1, consisting of 2843 patients (27.7%), and Group G2 consisting of 7407 patients (72.3%). There was no death, acute myocardial infarction, ventricular fibrillation or asystole. Predominant CAs were: supraventricular extrasystoles (13.7%), and ventricular extrasystoles (11.5%). G1 group had a higher mean age, higher frequency of hypertension and smoking, larger aortic roots and left atrium (LA) and lower ejection fraction than G2. G1 group also had more ischemic changes (p < 0.001). The predictor variables were age (RR 1.04; [CI] 95% from 1.038 to 1.049) and LA (RR 1.64; [CI] 95% from 1.448 to 1.872). CONCLUSION: ESE proved to be a safe modality of stress, with non-fatal complications only. Advanced age and enlargement of the left atrium are predictive of cardiac arrhythmias.