Position statement on indications of echocardiography in adults ­ 2019

In accordance with the "Standards for the Elaboration of Guidelines, Positions and Normations" sanctioned by the Brazilian Society of Cardiology, this document was written to update the "Echocardiography Indication Guidelines" of 2009. The new document is not intended to be a comprehensive review of echocardiography, but rather an indispensable basic guide to support the rational clinical decision-making of the physician requesting the exam for adult patients. Although it considers the recent technological advances of echocardiography, its purpose is not to describe in detail echocardiography methods, but to summarize in a clear and concise way the main situations in which echocardiography brings benefit to the diagnosis and/or therapeutic orientation of the individual. This manuscript chose to highlight the class of recommendation, as described below: Class I: conditions for which there is conclusive evidence or, in the absence thereof, general agreement that the examination procedure is useful and safe. Class II: conditions for which there is conflicting evidence and/or divergence of opinion on the utility and/or safety of the examination. Class-IIa: evidence or opinions favorable to the examination. Most experts approve. Class IIb: utility and/or safety less well established, with divergent opinions. Class III: conditions for which there is evidence or consensus that the examination is not useful and, in some cases, may even be harmful. In addition, the level of evidence was also described, as follows: A: several concordant randomized clinical trials or robust meta-analyses; B: less robust meta-analysis data or single randomized clinical study or observational studies; C: expert opinion.(AU)

Left Ventricular Regional Wall Motion Abnormality is a Strong Predictor of Cardiotoxicity in Breast Cancer Patients Undergoing Chemotherapy / Alteração Contrátil Segmentar Ventricular Esquerda é Preditor Independente de Cardiotoxicidade em Pacientes com Câncer de Mama em Tratamento Quimioterápico

Abstract Background: Chemotherapeutic agents of anthracyclines class and humanized monoclonal antibodies are effective treatments for breast cancer, however, they present a potential risk of cardiotoxicity. Several predictors have been recognized as predictors in the development of cardiac toxicity, and the evaluation of left ventricular segmental wall motion abnormalities (LVSWMA) has not been studied. Objective: To analyze prospectively the role of LVSWMA among echocardiographic parameters in the prediction of development of cardiotoxicity in breast cancer patients undergoing treatment with chemotherapy. Methods: Prospective cohort of patients diagnosed with breast cancer and in chemotherapy treatment with potential cardiotoxicity medications including doxorubicin and trastuzumab. Transthoracic echocardiograms including speckle tracking strain echocardiography were performed at standard times before, during and after the treatment to assess the presence (or lack thereof) of cardiotoxicity. Cardiotoxicity was defined by a 10% decrease in the left ventricular ejection fraction, on at least one echocardiogram. Multivariate logistic regression models were used to verify the predictors related to the occurrence of cardiotoxicity over time. Results: Of the 112 patients selected (mean age 51,3 ± 12,9 years), 18 participants (16.1%) had cardiotoxicity. In the multivariate analysis using the logistic regression model, those with LVWMA (OR = 6.25 [CI 95%: 1.03; 37.95], p < 0,05), LV systolic dimension (1.34 [CI 95%: 1.01; 1.79], p < 0,05) and global longitudinal strain by speckle tracking (1.48 [CI 95%: 1.02; 2.12], p < 0,05) were strongly associated with cardiotoxicity. Conclusion: In the present study, we showed that LVWMA, in addition to global longitudinal strains, were strong predictors of cardiotoxicity and could be useful in the risk stratification of these patients.

Resumo Fundamento: Os agentes quimioterápicos da classe das antraciclinas e dos anticorpos monoclonais humanizados são tratamentos eficazes para o câncer de mama, entretanto, apresentam alto risco de cardiotoxicidade. Diversos parâmetros têm sido reconhecidos como preditores no desenvolvimento de toxicidade cardíaca, sendo que a avaliação da alteração contrátil segmentar ventricular esquerda (ACSVE) ainda não foi estudada. Objetivo: Analisar a associação entre o surgimento de ACSVE e o desenvolvimento de cardiotoxicidade em pacientes com câncer de mama em tratamento com quimioterapia. Métodos: Coorte prospectiva de pacientes diagnosticados com câncer de mama e em tratamento quimioterápico com doxorrubicina e/ou trastuzumab. Foram realizados ecocardiogramas transtorácicos antes, durante e depois do tratamento para avaliar a presença ou não de cardiotoxicidade. A cardiotoxicidade foi definida por um decréscimo de 10% na fração de ejeção do ventrículo esquerdo, em pelo menos um ecocardiograma. Modelos de regressão logística multivariada foram utilizados para verificar os fatores preditores na ocorrência de cardiotoxicidade ao longo do tempo. Resultados: Dos 112 pacientes selecionados (idade média = 51,3 ± 12,9 anos), 18 (16,1%) apresentaram cardiotoxicidade. Na análise multivariada os pacientes com ACSVE (OR = 6,25 [IC 95%: 1,03; 37,95], p < 0,05), diâmetro sistólico do VE (OR = 1,34 [IC 95%:1,01; 1,79], p < 0,05) e strain longitudinal global pela técnica de speckle tracking (OR = 1,48 [IC 95%: 1,02; 2,12], p < 0,05) foram preditores significativos e independentes na predição de cardiotoxidade. Conclusão: Mostramos que ACSVE, bem como a redução do strain longitudinal global foram preditores independentes para cardiotoxicidade, podendo ser úteis na estratificação de risco destes pacientes.

Incremental value of hormonal therapy for deep vein thrombosis prediction: an adjusted Wells score for women.

Deep venous thrombosis (DVT) management includes prediction rule evaluation to define standard pretest DVT probabilities in symptomatic patients. The aim of this study was to evaluate the incremental usefulness of hormonal therapy to the Wells prediction rules for DVT in women. We studied women undertaking compressive ultrasound scanning for suspected DVT. We adjusted the Wells score for DVT, taking into account the ß-coefficients of the logistic regression model. Data discrimination was evaluated by the receiver operating characteristic (ROC) curve. The adjusted score calibration was assessed graphically and by the Hosmer-Lemeshow test. Reclassification tables and the net reclassification index were used for the adjusted score comparison with the Wells score for DVT. We observed 461 women including 103 DVT events. The mean age was 56 years (±21 years). The adjusted logistic regression model included hormonal therapy and six Wells prediction rules for DVT. The adjusted score weights ranged from -4 to 4. Hosmer-Lemeshow test showed a nonsignificant P value (0.69) and the calibration graph showed no differences between the expected and the observed values. The area under the ROC curve was 0.92 [95% confidence interval (CI) 0.90-0.95] for the adjusted model and 0.87 (95% CI 0.84-0.91) for the Wells score for DVT (Delong test, P value < 0.01). Net reclassification index for the adjusted score was 0.22 (95% CI 0.11-0.33, P value < 0.01). Our results suggest an incremental usefulness of hormonal therapy as an independent DVT prediction rule in women compared with the Wells score for DVT. The adjusted score must be evaluated in different populations before clinical use.

Indicadores de processo e de resultados da disciplina de Trabalho de Conclusão de Curso em escola médica privada / Assessment of a discipline supporting final graduation papers in a private medical school

Introdução: os Trabalhos de Conclusão de Curso (TCCs) sistematizam a atividade acadêmica discente, abordando temas profissionais com orientação docente. O objetivo deste estudo foi avaliar a implantação do TCC no curso de Medicina de instituição de ensino superiorprivada. Método: estudo descritivo abordando TCC da graduação de Medicina entre 2009 e 2014. As avaliações das disciplinas e do processo de aquisição de habilidades científicas foram feitas por questionário. Avaliações institucionais do processo de TCC finalizado e indicadores padronizados foram desenvolvidos. Resultados: nos últimos sete semestres, 80 TCCs envolveram 315 alunos. Na fase de projetos, médias da autoavaliação dos discentes (n=65) em dois semestres consecutivos foram 9 e 8,7 (desvios-padrão 1,5 e 1,3). A maioria dos discentes reconhece a contribuição da disciplina (53/65, 81,5%) para formar pesquisadores, mas metade não considera aplicar conhecimentos adquiridos em outras áreas (32/65, 49,3%) e imaginam resolver dúvidas profissionais avaliando trabalhos científicos (41/65, 63,1%). A mediana da avaliação institucional dos discentes para o TCC finalizado, entre 2011 e 2013 (n=257), foi 7 com desvio-padrão entre 2,2 e 4,9. A taxa de entrega do TCC nos prazos foi 78/80 (97,5%) e de trabalhos publicados em revistas indexadas, 12/80 (15%). Em 2013, houve 30 projetos indicados para o Comitê de Ética em Pesquisa, com 24 aprovações à primeira submissão (80%). Conclusão: o processo de TCC apresenta avaliação regular pelos discentes e bons indicadores de processo e resultados. Estratégias para a compreensão da metodologia científica na qualificação e atualização do conhecimento médico devem ser incentivadas.

Introduction: Disciplines supporting graduation papers (TCC) are suggested by Brazilian graduation authorities. We evaluated the introduction of TCC disciplines in a Brazilian private medical school. Method: This study describes the introduction of TCC disciplines in a private medical school in Brazil from 2009 and 2014. We evaluated scientific knowledge and skills acquisition by medical students throughout the course and during the TCC disciplines. Institutional evaluation of the TCC process and specific outcome measures were developed. Results: During the previous seven medical terms (6-month periods), 80 studies were concluded including315 medical students. A total of 65 students performed self-evaluations in project-phase of TCC, showing average results of 9 and 8.7 (standard deviation 1.5 and 1.3). Most (53/65, 81.5%) students recognized the discipline value as research training but many (32/65, 49.2%) do notexpect to use their acquired knowledge on other medical disciplines. They recognize however that future medical problems will be evaluated by scrutinizing medical papers (41/65, 63,1%). Institutional evaluation of the TCC process by near-graduation students between 2011 and 2013 showed median of 7 out of 10 (n=257, standard deviation between 2.2 and 4.9). The proportion of studies delivered on time was 78/80 (97,5%) and 12 studies were published in Brazilian peer-reviewed journals. A total of 24/30 studies were approved by the Ethical Committee on first submission (80%) in 2013. Conclusion: TCC disciplines were introduced in a medical school with fair assessment by the students. Strategies to increase medical student awareness of methodological skills importance should be developed.