Valor da Ressonância Magnética Cardíaca no Diagnóstico e no Prognóstico de Pacientes com Infarto Agudo do Miocárdio sem Doença Arterial Coronariana Obstrutiva (MINOCA) / Value of Cardiac Magnetic Resonance in the Diagnosis and Prognosis of Patients with Acute Myocardial Infarction with Nonobstructive Coronary Artery Disease (MINOCA)

Fundamento: O infarto do miocárdio é uma das principais causas de morbimortalidade no mundo, e 13,2% dos pacientes com síndrome coronariana aguda apresentam coronárias sem obstrução significativa, denominada MINOCA (do inglês Myocardial Infarction with Non-Obstructive Coronary Artery, Infarto do Miocárdio sem Doença Coronariana Obstrutiva). Apesar do MINOCA ter evolução mais favorável que o infarto do miocárdio por obstrução coronariana, seu prognóstico não é benigno. A ressonância magnética cardíaca é o exame que apresenta importância no diagnóstico das diversas causas de MINOCA, e seu valor prognóstico não está completamente elucidado. Objetivo: Avaliar o valor prognóstico da ressonância magnética cardíaca na detecção de eventos adversos maiores em pacientes com MINOCA. Métodos: Coorte prospectiva por meio de coleta de dados de pacientes admitidos na urgência de pacientes com hospital terciário, diagnosticados com MINOCA, no período de 2012 a 2019. Resultados: Foram avaliados 179 pacientes com seguimento médio de 45 ± 21 meses, sendo 52% do sexo masculino, com idade média de 57,3 ± 15,5 anos. Observou-se incidência de eventos adversos maiores de 17,9%. A taxa de mortalidade ao final do acompanhamento foi de 3,8%. Na análise multivariada, apenas a ressonância magnética cardíaca com resultado normal se mostrou como preditor independente de bom prognóstico (hazard ratio: 0,09; intervalo de confiança de 95% 0,01- 0,88; p = 0,04), com curva de Kaplan-Meier apresentando diferença significativa (log-rank x2 = 9,83; p = 0,02) na predição de eventos adversos maiores. Conclusão: A ressonância magnética cardíaca normal mostrou-se como variável independente de bom prognóstico nessa população, podendo ser útil na estratificação de risco de pacientes com MINOCA.

Background: Myocardial infarction is one of the major causes of morbidity and mortality worldwide and 13.2% of patients with acute coronary syndrome have normal or unobstructed coronary arteries, called MINOCA (Myocardial Infarction with Non-Obstructive Coronary Artery). Cardiac magnetic resonance (CMR) is the gold standard for investigating the etiology of acute coronary syndrome. Although MINOCA has a more benign evolution than myocardial infarction due to coronary obstruction, its prognostic factors are not completely elucidated. Objective: To evaluate prognosis, predictive factors and describe the incidence of major adverse cardiovascular events in patients with MINOCA. Methods: Prospective cohort through data collection of patients admitted to the emergency department of a tertiary hospital, diagnosed with MINOCA from 2012 to 2019. The mean follow-up was 45 months, the outcomes considered were: death, rehospitalization due to cardiac causes, recurrence of chest pain, myocardial revascularization (MACE).

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)

Posicionamento de ultrassonografia vascular do departamento de imagem cardiovascular da Sociedade Brasileira de Cardiologia ­ 2019 / Vascular Ultrasound Positioning of the Department of Cardiovascular Imaging of the Society Brazilian Cardiology - 2019

Posicionamento de Ultrassonografia Vascular do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia ­ 2019. (AU)

Value of speckle-tracking echocardiography changes in monitoring myocardial dysfunction during treatment of sepsis: potential prognostic implications.

Speckle-tracking echocardiography (STE) has been increasingly used for detection of sepsis-related myocardial dysfunction. However, the impact of strain changes during sepsis treatment has not been defined. This study assessed STE at admission and during the treatment of patients with sepsis to evaluate its changes as a potential factor for predicting in-hospital outcome. This study included 26 patients with sepsis who underwent STE echocardiography on day 1 and 7 during treatment. Myocardial deformation of both ventricles was assessed using global longitudinal strain. The endpoint was in-hospital mortality. The mean age was 51.4 ± 18.3 years, and 54% were female. The average SOFA score at T0 was 8.6 ± 3.8 points and at day 7 was 4.9 ± 4.7 points. The left ventricular (LV) ejection fraction at baseline was 65.6 ± 9.1%, without changes in echocardiographic parameters during treatment. LV and RV longitudinal strain increased significantly in the patients who survived (- 18.8 ± 3.6 at D1 vs - 20.8 ± 2.5 at D7; p = 0.003; and - 21.3 ± 4.9 at D1 vs - 24.3 ± 5.8 at D7; p = 0.035, respectively), whereas strain values remained unchanged in those who died. After adjustment for the SOFA score, RV longitudinal strain at admission was associated with in-hospital mortality [adjusted odds ratio (OR) 0.760; 95% confidence interval (CI) 0.591-0.977; p - 0.033]. STE improved significantly after the first week of treatment in patients with sepsis who survived compared with those patients who died during hospitalization. RV strain at admission predicted in-hospital mortality. An improvement in STE during sepsis treatment appears to be a useful tool for predicting in-hospital outcome.

Associação entre insuficiência de perfurante anterior do joelho e insuficiência de veia safena magna em pacientes com varizes primárias dos membros inferiores / Association between insufficiency of anterior perforator vein of the knee and great saphenous vein insufficiency in patients with primary varicose veins of the lower limbs

A correta identificação dos pontos de refluxo no estudo das varizes primárias dos membros inferiores é importante na abordagem terapêutica desses pacientes. Objetivo: Avaliar a associação entre a insuficiência de veias perfurantes anteriores do joelho e a insuficiência de veia safena magna em pacientes com varizes primárias de membros inferiores. Métodos: Foram avaliados 886 pacientes, correspondendo a 1.772 membros inferiores, em pacientes acima de 18 anos, de ambos os sexos, submetidos ao mapeamento venoso superficial pela ecografia vascular. Resultados: Os pacientes apresentaram idade média de 46,1 ± 14,5 anos, sendo 81,7% do sexo feminino. A insuficiência de veia safena magna foi encontrada em 38,8% dos casos. A insuficiência da perfurante anterior do joelho foi encontrada em 146 membros inferiores (8,2%), com diâmetro médio de 1,7 ± 0,15 mm, sendo predominante a localização infrapatelar (86,4%). A tributária anterior da veia safena magna originou o refluxo na perna em 34%, com relação direta desta tributária com a perfurante anterior do joelho em 79,4%. Observou-se associação entre a presença de perfurante anterior do joelho e insuficiência de veia safena magna (p = 0,0001) e sexo masculino (p = 0,001). Conclusão: Houve associação entre insuficiência de perfurante anterior do joelho e insuficiência de veia safena magna em pacientes com varizes primárias dos membros inferiores submetidos à ecografia vascular, sendo que a correta identificação desta perfurante pode ser importante na abordagem terapêutica desses pacientes

The accurate identification of reflux points in the study of primary varicose veins of the lower limbs is important in the therapeutic approach of these patients. Objective: To evaluate the association between insufficiency of the anterior perforator vein of the knee and great saphenous vein insufficiency in patients with primary varicose veins of the lower limbs. Methods: The study included 886 patients, corresponding to 1,772 lower limbs, in patients older than 18, of both sexes, undergoing superficial venous mapping using vascular ultrasound. Results: The mean age of the patients was 46.1 ± 14.5 and 81.7% were females. Great saphenous vein insufficiency was found in 38.8% of the cases. Insufficiency of the anterior perforator vein of the knee was found in 146 lower limbs (8.2%), with a mean diameter of 1.7 ± 0.15 mm, prevailing in the infrapatellar area (86.4%). The anterior tributary vein of the great saphenous vein originated leg reflux in 34%, with a direct relation of this tributary vein with the anterior perforator vein of the knee in 79.4%. An association between the presence of anterior perforator vein of the knee and great saphenous vein insufficiency (p = 0.0001) and male gender (p = 0.001). Conclusion: There was an association between insufficiency of the anterior perforator vein of the knee and great saphenous vein insufficiency in patients with primary varicose veins of the lower limbs at vascular ultrasound, and the accurate identification of this perforator vein may be important in the therapeutic approach of these patients

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.

Left Ventricular Regional Wall Motion Abnormality is a Strong Predictor of Cardiotoxicity in Breast Cancer Patients Undergoing Chemotherapy.

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.

Associação entre variação anatômica da veia safena magna e insuficiência venosa em pacientes à ultrassonografia vascular dos membros inferiores / Association between anatomical variation of the great saphenous vein and venous failure in patients undergoing vascular ultrasound of the lower limbs

97 Artigo Original Associação entre Variação Anatômica da Veia Safena Magna e Insuficiência Venosa em Pacientes Submetidos à Ultrassonografia Vascular dos Membros Inferiores Association between Anatomical Variation of the Great Saphenous Vein and Venous Failure in Patients Undergoing Vascular Ultrasound of the Lower Limbs Ana Cristina Lopes Albricker, 2,3 Ane Graziela Ferreira Andrade, 1 Danila Simões Almeida, 1 Gisely Simões Almeida, 1 Jaider Matheus Monteiro de Andrade, 1 Paola Souza dos Santos, 1 Marcio Vinícius Lins Barros 1,3 Faculdade de Saúde e Ecologia Humana, 1 Vespasiano, MG; Faculdade de Ciências Médicas de Minas Gerais; 2 Centro Especializado em Ultrassonografia, 3 Belo Horizonte, MG - Brasil Resumo Introdução: A anatomia venosa pode apresentar significativa variabilidade, com ampla incidência de afluentes venosos, veias duplicadas, tributárias ou acessórias relacionadas às veias safenas. O reconhecimento e a identificação destas variações são importantes no manejo terapêutico destes pacientes, sendo que a ultrassonografia vascular é o método de escolha na avaliação do sistema venoso periférico. Objetivos: avaliar a associação entre variação anatômica da veia safena magna (VSM) e insuficiência venosa dos membros inferiores em pacientes com varizes primárias dos membros inferiores. Métodos: Foram avaliados consecutivamente pacientes com clínica de varizes de membros inferiores no período de 2014 a 2015, excluindo pacientes com história de cirurgia prévia e trombose venosa profunda. A ecografia vascular foi realizada para exame do sistema venoso superficial, em especial ao estudo da VSM, determinando os diversos padrões de variação anatômica deste vaso e sua associação com a presença de insuficiência venosa e classificação CEAP. Resultados: foram examinados 422 membros inferiores de 211 pacientes, com idade entre 21 e 86 anos, média de 45,7 anos, sendo 81% do sexo feminino, com predomínio de CEAP 1 (43,8%) e 2 (46,2%). Refluxo na VSM foi encontrado em 35,1%. A presença de variação anatômica foi encontrada em 8,8% dos pacientes sendo mais frequente em terço distal da coxa e proximal da perna (27,3%), não sendo observado associação entre a variação anatômica da VSM e CEAP (p = 0,25). Observou-se associação estatisticamente significativa entre ausência de variação anatômica e de insuficiência de VSM (p = 0,03). Conclusão: no presente estudo observou-se variação anatômica da veia safena magna em cerca de 9% dos pacientes, com associação significativa entre insuficiência de veia safena magna e ausência de variação anatômica

ntroduction: Venous anatomy may present significant variability, with a wide incidence of venous tributaries, duplicate or accessory veins related to saphenous veins. The recognition and identification of these variations are important in the therapeutic management of these patients, and vascular ultrasonography is the method of choice in the evaluation of the peripheral venous system. Objectives: To evaluate the association between anatomic variance of the great saphenous vein (VSM) and venous insufficiency of the lower limbs in patients with primary varicose veins of the lower limbs. Methods: Patients with varicose veins were consecutively evaluated in the period from 2014 to 2015, excluding patients with a history of previous surgery and deep venous thrombosis. Vascular ultrasound was performed to examine the superficial venous system, in particular to the VSM study, determining the different patterns of anatomical variation of this vessel and its association with the presence of venous insufficiency and CEAP classification. Results: 422 lower limbs of 211 patients, aged between 21 and 86 years, mean age of 45.7 years, 81% female, with a predominance of APC 1 (43.8%) and 2 (46.2% %). Reflux in the VSM was found in 35.1%. The presence of anatomical variation was found in 8.8% of the patients, being more frequent in the distal third of the thigh and proximal of the leg (27.3%). No association was found between the anatomical variation of MSV and CEAP (p = 0.25). There was a statistically significant association between no anatomic variation and the presence of VSM insufficiency (p = 0.03). Conclusion: in the present study, anatomic variation of the great saphenous vein was observed in about 9% of the patients, with a significant association between insufficiency of the great saphenous vein and no anatomical variation

Valor do Strain Bidimensional no Diagnóstico da Miocardite Aguda: Comparação com a Ressonância Cardíaca / The Value of Two-dimensional Strain in the Diagnosis of Acute Myocarditis: Comparison with Cardiac Magnetic Resonance Imaging

Fundamento: A miocardite aguda é uma das principais causas de morte súbita em pacientes jovens. A ressonância magnética cardíaca (RMC) é um método sensível e não invasivo para detecção de miocardite, mas de alto custo e indisponível na maioria dos centros médicos. O strain bidimensional representa uma nova técnica ecocardiográfica que possibilita a avaliação da deformação miocárdica permitindo a análise da função miocárdica global e regional. Objetivo: Avaliar o valor do strain bidimensional em pacientes com diagnóstico de miocardite. Materiais e métodos: Foram estudados prospectivamente pacientes com quadro de miocardite aguda e contratilidade cardíaca normal pela RMC e submetidos à ecocardiografia convencional e strain bidimensional. O miocárdio ventricular foi dividido em 16 segmentos e esses segmentos divididos em dois grupos. Grupo 0: segmento miocárdico normal pela RMC. Grupo 1: segmento miocárdico compatível com miocardite pela RMC. Resultados: Foram avaliados 28 pacientes sendo 82,1% do sexo masculino, com idade de 35,6 ± 8,9 anos. Dos 448 segmentos miocárdicos avaliados, 316 segmentos foram normais (grupo 0) e 132 segmentos (grupo 1) apresentaram diagnóstico de miocardite pela técnica de realce tardio à RMC. A análise do strain bidimensional mostrou diferença significativa entre os grupos (19,6 ± 2,9 versus 15,4 ± 2,8 p = 0,001), com sensibilidade 75% e especificidade 79% e AUC de 0,86 (IC 95% 0,82 a 0,89). Conclusão: O strain bidimensional pode ser útil na avaliação propedêutica de pacientes com miocardite e contratilidade normal pela RMC e ecocardiografia convencional

Background: Acute myocarditis is one of the most important causes of sudden death in young people. Cardiac magnetic resonance (CMR) is a sensitive and non-invasive method in myocarditis diagnosis, but it is expensive and unavailable in most medical centers. Speckle tracking strain echocardiography is a new echocardiographic technique that enables the evaluation of myocardial deformation allowing analysis of global and regional myocardial function. Objective: To evaluate the value of speckle tracking strain echocardiography in patients with acute myocarditis and normal wall motion contraction. Materials and Methods: We prospectively studied patients with acute myocarditis and normal cardiac contractility by CMR and underwent conventional echocardiography and speckle tracking strain echocardiography. The ventricular myocardium was divided into 16 segments by CMR and echocardiography and separated into two groups: Normal myocardial segment (group 1) myocardial segment compatible with myocarditis (group 1). Results: We evaluated 28 patients (82.1% male), aged 35.6 ± 8.9 years. Of the 448 myocardial segments evaluated, 316 segments were normal (group 0) and 132 segments (group 1) were diagnosed with myocarditis by RMC. Speckle tracking strain echocardiography showed a significant difference between groups (-19.6 ± 2.9 versus -15.4 ± 2.8 p = 0.001), with sensitivity of 75% and specificity of 79% with AUC of 0.86 (95% CI 0.82 to 0.89). Conclusion: Speckle tracking strain echocardiography can be useful in the diagnosis evaluation of patients with myocarditis and normal contractility by CMR and conventional echocardiography