Use of imaging and clinical data to screen for cardiovascular disease in asymptomatic diabetics.

BACKGROUND: There is increasing evidence to suggest that not all individuals with type 2 diabetes mellitus (T2DM) have equal risk for developing cardiovascular disease. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches. METHODS: 98 asymptomatic individuals with T2DM without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA). RESULTS: Of 98 subjects (average age 55 ± 6, 64 % female), 43 (44 %) had coronary plaque detectable on CTA, and 38 (39 %) had CAC score >0. By CTA, 16 (16 %) had coronary stenosis ≥50 %, including three subjects with CAC = 0. Subjects with coronary plaque had greater prevalence of carotid plaque (58 % vs. 38 %, p = 0.01) and greater carotid intima media thickness (0.80 ± 0.20 mm vs. 0.70 ± 0.11 mm, p = 0.02). Notably, 18 of 55 subjects (33 %) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom five had ≥ 50 % coronary stenosis, two had <50 % stenosis, and one had no CAD. Among these tests, CAC scoring had the highest sensitivity and specificity for prediction of CAD. CONCLUSION: Among asymptomatic subjects with T2DM, a majority (56 %) had no CAD by CTA. When compared to CTA, CAC was the most accurate screening modality for detection of CAD, while ETT and carotid ultrasound were less sensitive and specific. However, 33 % of subjects with normal coronary CTA had carotid plaque, suggesting that screening for carotid plaque might better characterize stroke risk in such patients.

Role of Trimetazidine in Ischemic Preconditioning in Patients With Symptomatic Coronary Artery Disease.

Ischemic preconditioning (IP) is a powerful cardioprotective cellular mechanism that has been related to the "warm-up phenomenon" or "walk-through" angina, and has been documented through the use of sequential exercise tests (ETs). It is known that several drugs, for example, cromokalim, pinacidil, adenosine, and nicorandil, can interfere with the cellular pathways of IP. The purpose of this article is to report the effect of the anti-ischemic agent trimetazidine (TMZ) on IP in symptomatic coronary artery disease (CAD) patients.We conducted a prospective study evaluating IP by the analysis of ischemic parameters in 2 sequential ETs. In phase I, without TMZ, patients underwent ET1 and ET2 with a 30-minute interval between them. In phase II, after 1 week of TMZ 35 mg twice daily, all patients underwent 2 consecutive ETs (ET3 and ET4). IP was considered present when the time to 1.0-mm segment ST on electrocardiogram deviation (T-1.0 mm) and rate pressure product (RPP) were greater in the second of 2 tests. The improvement in T-1.0 mm and RPP were compared in the 2 phases: without TMZ and after 1-week TMZ to assess the action of such drug in myocardial protective mechanisms. ETs were analyzed by 2 independent cardiologists.From 135 CAD patients screened, 96 met inclusion criteria and 62 completed the study protocol. Forty patients manifested IP by demonstrating an improvement in T-1.0 mm in ET2 compared with ET1, without the use of any drugs (phase I). In phase II, after 1-week TMZ, 26 patients (65%) did not show any incremental result in ischemic parameters in ET4 compared with ET3. Furthermore, of these patients, 8 (20%) had IP blockage.In this study, TMZ did not add any benefit to IP in patients with stable symptomatic CAD.

Avaliação prognóstica da doença coronária estável através de um novo escore / New prognostic score for stable coronary disease evaluation / Evaluación pronóstica de la enfermedad coronaria estable a través de un nuevo score

FUNDAMENTO: A necessidade de melhorar a acurácia do teste de esforço, determinou o desenvolvimento de escores, cuja aplicabilidade já foi amplamente reconhecida. OBJETIVO: Avaliação prognóstica do coronariopata estável através de um novo escore simplificado. MÉTODOS: Um novo escore foi aplicado em 372 coronariopatas multiarteriais e função ventricular preservada, 71,8 por cento homens, idade média 59,5 (± 9,07) anos, randomizados para angioplastia, revascularização cirúrgica e tratamento clínico, acompanhados por 5 anos. Óbito cardiovascular foi o desfecho primário. Infarto do miocárdio não-fatal, óbito e re-intervenção formaram o desfecho combinado secundário. O escore baseou-se numa equação previamente validada resultante da soma de 1 ponto para: sexo masculino, história de infarto, angina, diabete, uso de insulina e ainda 1 ponto para cada década de vida a partir dos 40 anos. Teste positivo adicionou 1 ponto. RESULTADOS: Ocorreram 36 óbitos (10 no grupo angioplastia, 15 no grupo revascularização e 11 no grupo clínico), p = 0,61. Observou-se 93 eventos combinados: 37 no grupo angioplastia, 23 no grupo revascularização e 33 no grupo clínico (p = 0,058). 247 pacientes apresentaram escore clínico > 5 pontos e 216 > 6 pontos. O valor de corte > 5 ou > 6 pontos identificou maior risco, com p = 0,015 e p = 0,012, respectivamente. A curva de sobrevida mostrou uma incidência de óbito após a randomização diferente naqueles com escore > 6 pontos (p = 0,07), e uma incidência de eventos combinados diferente entre pacientes com escore < 6 e > 6 pontos (p = 0,02). CONCLUSÃO: O novo escore demonstrou consistência na avaliação prognóstica do coronariopata estável multiarterial.

BACKGROUND: The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE: Prognostic evaluation of stable coronary disease through a new simplified score. METHODS: A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8 percent male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS: Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score > 5 points and 216 > 6 points. The cutoff point > 5 or > 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and > 6 points (p = 0.02). CONCLUSION: The new score was consistent for multiarterial stable coronary disease risk stratification.

FUNDAMENTO: La necesidad de mejorar la exactitud de las pruebas de estrés, determinó el desarrollo de los puntajes, cuya aplicación fue ampliamente reconocida. OBJETIVO: La evaluación pronóstica del coronariópata estable a través de un nuevo score simplificado. MÉTODOS: Un nuevo score se aplicó en 372 coronariópatas multiarteriales y función ventricular preservada, el 71,8 por ciento varones, edad media de 59,5 (± 9,07) años, randomizados para angioplastia, revascularización quirúrgica y tratamiento clínico, seguidos de cinco años. Muerte cardiovascular fue el resultado primario. El infarto de miocardio no fatal, la muerte y la re-intervención formaron el desenlace combinado secundario. El score se basó en una ecuación previamente validada resultante de la suma de 1 punto a: sexo masculino, antecedentes de infarto, angina, diabetes, uso de insulina y todavía un punto por cada década de vida después de 40 años. Prueba positiva añadida 1 punto. RESULTADOS: Hubo 36 muertes (10 en el grupo de angioplastia, 15 en el grupo de revascularización y 11 en el grupo clínico), p = 0,61. Se observó 93 eventos combinados: 37 en el grupo angioplastia, 23 en el grupo revascularización y 33 en el grupo clínico (p = 0,058). Presentaron score clínico > 5 puntos y 216 > 6 puntos 247 pacientes. El valor de corte > 5 o > 6 puntos identificó un mayor riesgo, con p = 0,015 y p = 0,012, respectivamente. La curva de sobrevida mostró una incidencia de muerte después de la aleatorización que aquellos con score > 6 puntos (p = 0,07), y una incidencia de eventos combinados diferentes entre los pacientes con score < 6 y > 6 puntos (p = 0,02). CONCLUSIÓN: El nuevo score demostró consistencia en la evaluación pronóstica del coronariópata estable multiarterial. (Arq Bras Cardiol 2011;96(5):411-419).

New prognostic score for stable coronary disease evaluation.

BACKGROUND: The need to improve the exercise testing accuracy, pushed the development of scores, whose applicability was already broadly recognized. OBJECTIVE: Prognostic evaluation of stable coronary disease through a new simplified score. METHODS: A new score was applied in 372 multivessel coronary patients with preserved ventricular function, 71.8% male, age: 59.5 (± 9.07) years old, randomized to medical treatment, surgery (CABG) or angioplasty (PTCA), with 5 years of follow-up. Cardiovascular death was considered the primary endpoint. Non-fatal myocardial infarction, death and re-intervention were considered for a combined secondary endpoint. The score was based on an equation previously validated, resulting from a sum of one point for: male gender, infarction history, angina, diabetes, insulin use and one point for each decade of life after 40 years old. Positive exercise testing summed one additional point. RESULTS: Thirty six deaths was observed (10 in group PTCA, 15 in CABG and 11 in the clinical group), p = 0.61. We observed 93 combined events: 37 in PTCA group, 23 in CABG and 33 in the clinical group (p = 0.058). 247 patients presented clinical score ≥ 5 points and 216 ≥ 6 points. The cutoff point ≥ 5 or ≥ 6 points identified higher risk, p = 0.015 and p = 0.012, respectively. The survival curve showed a different death incidence after the randomization when score reached 06 points or more (p = 0.07), and a distinct incidence of combined events between the patients with score < 6 and ≥ 6 points (p = 0.02). CONCLUSION: The new score was consistent for multiarterial stable coronary disease risk stratification.

Head-to-head comparison of dobutamine and adenosine stress real-time myocardial perfusion echocardiography for the detection of coronary artery disease.

We sought to determine the value of dobutamine versus adenosine real-time myocardial perfusion (MP) echocardiography for detecting coronary artery disease and the value of quantitative analysis of MP over electrocardiography, wall motion, and qualitative MP. We studied 54 patients by real-time MP echocardiography and coronary angiography. Replenishment velocity (beta) and an index of myocardial blood flow (A(n)xbeta) were derived from quantitative MP. During dobutamine stress, beta (1.7 +/- 0.7 vs 2.7 +/- 1.2; P < .001) and A(n)xbeta (2.2 +/- 1.0 vs 3.5 +/- 1.6; P < .001) reserves were lower in patients with coronary artery disease. The same was observed with adenosine for beta (1.7 +/- 0.8 vs 2.5 +/- 1.1; P < .001) and A(n)xbeta (1.9 +/- 0.7 vs 3.2 +/- 1.4; P < .001) reserves. Accuracy of electrocardiography, wall motion, qualitative MP, and quantitative MP were 61%, 76%, 76%, and 80% for dobutamine and 70%, 70%, 76%, and 80% for adenosine, respectively. Quantitative MP had incremental diagnostic value over other variables during dobutamine (chi(2) 23.7-38.4; P < .001) and adenosine (chi(2) 26.7-59.4; P < .001). In conclusion, dobutamine and adenosine real-time MP echocardiography hold similar accuracy for detecting coronary artery disease. Quantitative MP provides incremental diagnostic information over other variables.

Atualização nos principais exames complementares para diagnóstico das bradi e taquiarritmias / Update in diagnostic methods for brady and tachyarrhythmias evaluation

Distúrbios do ritmo cardíaco podem ser diagnosticados utilizando-se uma grande variedade de métodos, e suas indicações dependem do tipo de arritmia que se suspeita, das possíveis causas envolvidas, da periodicidade, dos fatores precipitantes e das respostas terapêuticas.O eletrocardiograma é o exame mais comumente solicitado. Monitorização pelo Holter 24 horas, monitores de eventos externos ou implantáveis (monitorização trans-telefônica), teste de inclinação, teste ergométrico e microalternância de onda T podem ser utilizados quando o eletrocardiograma de repouso não documenta ou elucida a arritmia.Variabilidade da freqüência cardíaca, sensibilidade de barorreflexo, eletrocardiograma de alta resolução e dispersão do QT são outras modalidades utilizadas para fornecer informações diagnósticas não invasivas específicas, mas ainda não demosntraram sua real utilidade na prática clínicaOutros testes diagnósticos devem ser indicados para avaliar problemas estruturais, funcionais (disfunção ventricular, valvopatias, doença coronária) ou doenças genéticas, permitindo melhor entendimento e caracterização das bases eletromoleculares e genéticas dos distúrbios do ritmo cardíaco

Teste ergométrico e microalternância de onda T / T wave alternaans and exercise testing

A alternância da onda T representa uma variação morfológica da onda T, batimento a batimento, num padrão A-B, A-B. Desde seu primeiro relato por Herring, em 1909, tal condição tem sido relacionada a uma série de condições clínicas, que incluem síndrome do QT longo, isquemia miocárdica aguda e distúrbios hidroeletrolíticos, e está frequentemente associada a arritmias ventriculares fatais e pior prognóstico. entretanto, a documentação visual da alternância da onda T é um achado eletrocardiográfico raro, perdendo relevância como ferramenta clínica de estratificação de risco. Estudos recentes, têm demonstrado que a medida da alternância da onda T, em microvolts (muito prwurna para ser visualizada ao eletrocardiograma), com a frequência cardíaca elevada a 110 bpm, por meio de estimulação cardíaca artificial, fármacos ou exercício, é altamente preditiva de taquiarristmias ventriculares e morte súbita cardíaca. Nesses estudos, essa técnica não-invasiva mostrou valor preditivo comparável ao do estudo eletrofisiológico, e mostrou-se superior aos outros marcadores não-invasivos de risco para arritmias fatais.

Quando interromper, na sala de emergência, as manobras de ressuscitação cardiopulmonar na parada cardiorrespiratória sem atendimento pré-hospitalar? / When Should we Stop Cardiopulmonary Resuscitation in Patients Brought to the Emergency Room in Cardiac Arrest with no Out-ofHospital Care

PURPOSE: The decision of stopping cardiopulmonary resuscitation (CPR) in patients brought to emergency room in arrest remains a challenge. Such decision is even more difficult when someone is brought by bystanders, after an acute loss of consciousness without any out-of-hospital care. To evaluate the probability of survival of these patients we reviewed retrospectively charts in our institution, during a period of five years. METHODS: One hundred and one patients that fulfilled these characteristics came to our emergency in arrest. The time to arrival since symptoms started, cardiac rhythm at first electrocardiogram (EKG), age, gender, initial CPR success, late outcomes and previous diseases were obtained. Patients were divided in two groups regarding which cardiac rhythms they had at first EKG: A-patients arriving in asystole; and VF-patients arriving in ventricular fibrillation. To evaluate time to arrival, we arbitrarily choose 15 min as a reference point. RESULTS: In these 101 subjects the mean age was 62 +/- 13.7 years and 63 (62.3) were men. Previous heart disease was documented in 74 [dilated cardiomyopathy in 22 (21.7), coronary heart disease in 41 (40.6), arterial hypertension in 25 (24.7) and others in 6 (5.6)]. In 66 episodes we were sure of the time patients spent before arrival (mean 2.5 +/- 11 min). Only in 63 subjects we had no doubts about the rhythm at entrance: VF in 37 (58.7), A in 22 (34.9) and an accelerated idioventricular rhythm (AIR) in four (6.3). Time to arrival was 18.6 +/- 10.6 in VF vs 32.5 +/- 11.7 min in A (p = 0.012). Fourteen (13.8) subjects resumed a supraventricular rhythm with systolic pressure > or = 90 mmHg after CPR and all of them were in VF (13) or AIR (one). Nine patients (8.9) evolved in coma. Only five (4.9) were discharged from the hospital without any neurological disturbance and their time to arrival ranged from one to 15 (9 +/- 5.8) min. CONCLUSION: Delayed arrival to the emergency room (> 15 min) associated with asystole were predictors of unsuccessful CPR, and both data are helpful in deciding when to stop CPR in subjects arriving at the emergency department with no out-of-hospital care.

Objetivo - Avaliar a chance de sobrevivência dos pacientes trazidos à emergência em parada cardiorrespiratória, sem atendimento pré-hospitalar, situação de difícil decisão quanto a se interromper as manobras de ressuscitação cardiopulmonar (RCP). Métodos - Retrospectivamente, analisamos os prontuários de 101 indivíduos trazidos à emergência em parada cardiorrespiratória (PCR) de janeiro/89 a dezembro/93. Avaliamos o tempo em minutos do início do sintomas até a chegada, o ritmo cardíaco ao eletrocardiograma (ECG), idade, sexo, taxa de sucesso inicial da RCP, evolução tardia e doenças pregressas. Dividimos os pacientes em 2 grupos, de acordo com o ritmo inicial: A - assistolia e FV -fibrilação ventricular. Na avaliação do tempo de chegada, consideramos arbitrariamente 15min como referência.Para avaliar diferenças entre os grupos realizamos os testes de Student e do X2 Resultados - A idade média foi de 62±13,7 anos e 63 (62,3%) eram homens. Pôde-se confirmar a existência de doença prévia em 74 casos [cardiomiopatia dilatada em 22 (21,7%), doença coronária em 41 (40,6%), hipertensão arterial em 25 (24,7%) e outras em seis (5,6%)]. Em 66 episódios tivemos certeza do tempo decorrido até a chegada à emergência (média de 22,5± 11 min.). Em 63 casos tivemos certeza do ritmo de chegada: FV em 37 (58,7%), A em 22 (34,9%) e ritmo idioventricular acelerado em quatro (6,3%). O tempo para a chegada foi de 18,6±10,6 no grupo FV vs 32,5±11,7min. no grupo A (p= 0,012). Quatorze (13,8%) indivíduos, nenhum do grupo A, reassumiram ritmo supraventricular com pressão arterial sistólica>90mmHg após a RCP. Desses, nove (8,9%) evoluíram em coma e somente cinco (4,9%) tiveram alta hospitalar, todos sem distúrbios neurológicos e do grupo FV. O tempo de chegada nesses cinco sobreviventes variou de 1 a 15 (9±5,8)min.Conclusão - Um tempo de chegada >15min associado a assistolia pode ajudar na decisão de se terminar os esforços de RCP em indivíduos que chegam à emergência sem atendimento pré-hospitalar