Semiologia Cardiovascular: As Personalidades por Detrás dos Epônimos / Cardiovascular Semiotics: The Personalities Behind the Eponyms

Desde seus primórdios, a medicina sempre se baseou na observação de sinais e achados específicos de pacientes doentes. A semiologia é, portanto, um estudo milenar. A semiologia cardíaca, apesar de mais recente, é mais complexa no seu aprendizado devido à dificuldade na interpretação dos achados auscultatórios. Austin Flint, Rivero Carvallo, Antonio Valsalva e Adolf Kussmaul foram alguns dos diversos médicos que se dedicaram ao estudo acadêmico da semiologia cardíaca e se eternizaram na área médica através de epônimos na cardiologia. Uma seleção dos principais e mais icônicos epônimos em cardiologia se faz necessária para complementar e destacar a importância do conhecimento do exame físico cardiovascular à beira do leito e a interpretação de seus possíveis achados, principalmente em uma era da medicina envolvida com tantas inovações tecnológicas na área de imagem. O objetivo deste artigo de revisão é abordar aspectos históricos de epônimos cardiológicos selecionados e a importância desses epônimos na prática médica atual, especialmente para aqueles em treinamento que desejam se aprofundar no estudo da semiotécnica cardiovascular

Comparison between users of a new methodology for heart sound auscultation.

Auscultation is a routine exam and the first line of screening in heart pathologies. The objective of this study was to assess if using a new data collection system, the DigiScope Collector, with a guided and automatic annotation of heart auscultation, different levels of expertise/experience users could collect similar digital auscultations. Data were collected within the Heart Caravan Initiative (Paraíba, Brasil). Patients were divided into two study groups: Group 1 evaluated by a third year medical student (User 1), and an experienced nurse (User 2); Group 2 evaluated by User 2 and an Information Technology professional (User 3). Patients were auscultated sequentially by the two users, according to the randomization. Features extracted from each data set included the length (HR) of the audio files, the number of repetitions per auscultation area, heart rate, first (S1) and second (S2) heart sound amplitudes, S2/S1, and aortic (A2) and pulmonary (P2) components of the second heart sound and relative amplitudes (P2/A2). Features extracted were compared between users using paired-sample test Wilcoxon test, and Spearman correlations (P<;0.05 considered significant). Twenty-seven patients were included in the study (13 Group 1, and 14 Group 2). No statistical significant differences were found between groups, except in the time of auscultation (User 2 consistently presented longer auscultation time). Correlation analysis showed significant correlations between extracted features from both groups: S2/S1 in Group 1, and S1, S2, A2, P2, P2/A2 amplitudes, and HR in Group 2. Using the DigiScope Collector, we were able to collect similar digital auscultations, according to the features evaluated. This may indicate that in sites with limited access to specialized clinical care, auscultation files may be acquired and used in telemedicine for an expert evaluation.

[Auscultation of the heart: an art on the road to extinction]. / La auscultación del corazón, un arte en vías de extinción.

Auscultation of the heart is a clinical art that allows the doctor to make accurate diagnoses with the skills after formal training. The technology efficiently complements the clinical diagnosis, so that the latter is insufficient without a clinical approach; on the other hand, when the clinical practice is replaced by technology, diagnosis and treatment is equally ineffective. The cult of technology has led to the gradual/ass of the ability of cardiac auscultation, and the doctor has lost a powerful tool with diagnostic potential.

Aferição da pressão arterial durante exercícios resistidos pelo método auscultatório: [revisão] / Measuring blood pressure through auscultation method during resistance exercises: [review]

A medida da pressão arterial pelo método indireto auscultatório vem sendo utilizada durante exercícios resistidos. Com o objetivo de avaliar, em diferentes estudos, a metodologia de aferição da pressão arterial pelo método auscultatório durante exercícios resistidos, foram analisados quinze estudos que atenderam aos critérios de inclusão, quanto a: 1) Exercícios observados; 2) Descrição da confiabilidade intra e interavaliadores; 3) Respeito àsrecomendações existentes para a medida da pressão arterial durante exercícios resistidos; 4) Manômetros utilizados; 5)Coleta no sistema duplo-cego. Os resultados encontrados indicam que 80 dos estudos observaram indivíduos jovens(26±5 anos) e 20 idosos (70±7 anos) saudáveis. Quase todos(93) os estudos mediram a pressão arterial durante exercícios resistidos para membros inferiores. Apenas 20 dos estudos verificaram a reprodutibilidade da medida da pressão arterial (correlação intraclasse). Recomendações específicas para a medida da pressão arterial durante os exercícios resistidos foram seguidas por 73 dos estudos, mas muitos aplicaram-nas de forma incompleta ou incorreta. Apenas 7 dos estudos adotaram abordagem duplo-cega. Conclui-se que a qualidade metodológica dos estudos que se valeram do método auscultatório para medida da pressão arterial em exercícios resistidos é questionável, principalmente no tocante à reprodutibilidade da medida e margem de erro. São necessários estudos adicionais para a definição de protocolos de medida padronizados para comparar diferentes situações de exercícios resistidos em populações diversas.

Estimación auscultatoria de la presiónsistólica de arteria pulmonar: ¿Es factible?. Correlación con determinación ecocardiográfica / Heart auscultatory assessment of pulmonary artery systolic pressure

The clinical assessment of pulmonary artery systolic pressure (PASP) by means of heart auscultation may be comparable to the measures obtained by Doppler echocardiography. Aim: To compare PASP estimated by heart auscultation and echocardiography. Material and Methods: Thirty consecutive patients aged 70 ± 16 years (68 percent women) were evaluated prospectively, all of whom had an echocardiogram requested by their attending physician. Echocardiographic evaluation of PASP was made by tricuspid regurgitation velocity plus right a trial pressure estimate. Two trained clinicians, blinded for the clinical history and rest of physical examination, auscultated the patients. PASP was estimated from the auscultatory intensity of the pulmonary component in comparison to the aortic component of the second heart sound and its propagation towards the apex, in accordance to a pre-established algorithm. Correlation between auscultatory and echocardiographic measures of PASP was made by Pearson test. Variability between both methods and among observers was evaluated with Bland-Altman analysis. Results: Fifty two per cent of patients were hypertensive and 20 percent diabetic. Admission diagnoses were heart failure in 50 percent of cases, exacerbation of chronic obstructive pulmonary disease in 20 percent, pulmonary thromboembolism in 10 percent and other clinical entities in 20 percent. A significant correlation was found between auscultatory and echocardiographic estimation of PASP (r = 0.64, p = 0, 01). Bland-Altman analysis showed a mean difference between both determinations of 7.6 ± 7.6 mmHg. Bland-Altman analysis between both operators showed an average difference of 5.4 ± 8.4 mm Hg. Conclusions: Heart auscultatory evaluation allows a precise and reproducible estimation of PASP and compares favorably with echocardiographic assessment.

[Heart auscultatory assessment of pulmonary artery systolic pressure]. / Estimación auscultatoria de la presiónsistólica de arteria pulmonar: ¿Es factible?. Correlación con determinación ecocardiográfica.

BACKGROUND: The clinical assessment of pulmonary artery systolic pressure (PASP) by means of heart auscultation may be comparable to the measures obtained by Doppler echocardiography. AIM: To compare PASP estimated by heart auscultation and echocardiography. MATERIAL AND METHODS: Thirty consecutive patients aged 70 ± 16 years (68% women) were evaluated prospectively, all of whom had an echocardiogram requested by their attending physician. Echocardiographic evaluation of PASP was made by tricuspid regurgitation velocity plus right a trial pressure estimate. Two trained clinicians, blinded for the clinical history and rest of physical examination, auscultated the patients. PASP was estimated from the auscultatory intensity of the pulmonary component in comparison to the aortic component of the second heart sound and its propagation towards the apex, in accordance to a pre-established algorithm. Correlation between auscultatory and echocardiographic measures of PASP was made by Pearson test. Variability between both methods and among observers was evaluated with Bland-Altman analysis. RESULTS: Fifty two per cent of patients were hypertensive and 20% diabetic. Admission diagnoses were heart failure in 50% of cases, exacerbation of chronic obstructive pulmonary disease in 20%, pulmonary thromboembolism in 10% and other clinical entities in 20%. A significant correlation was found between auscultatory and echocardiographic estimation of PASP (r = 0.64, p = 0, 01). Bland-Altman analysis showed a mean difference between both determinations of 7.6 ± 7.6 mmHg. Bland-Altman analysis between both operators showed an average difference of 5.4 ± 8.4 mm Hg. CONCLUSIONS: Heart auscultatory evaluation allows a precise and reproducible estimation of PASP and compares favorably with echocardiographic assessment.

Avaliação de um modelo de parâmetros distribuídos aplicado à estimação da geometria arterial na hipertensão / Evaluation of a distributed parameter model applied to arterial geometry estimation in hypertension

A hipertensão arterial provoca adaptações estruturais nas artérias, principalmente pelos processos de hipertrofia e remodelagem, as quais antecedem lesões de órgãos-alvo. A determinação de variáveis mecânicas e geométricas associadas ao sistema arterial possibilita ao clínico identificar precocemente as adaptações que decorrem da hipertensão arterial sistêmica no paciente, permitindo a intervenção terapêutica mais adequada. Este trabalho apresenta a avaliação de um modelo eletro-hidráulico e seu método associado para a determinaçãodos parâmetros geométricos do segmento arterial do antebraço. O método proposto requer somente a aquisição não-invasiva de ondas de pulso em dois sítios distintos. Séries de ondas de pulso da artéria radial foram simuladas a partir de ondas de pulso reais da artéria braquial, empregandoum modelo de parâmetros distribuídos simplificado das artérias do antebraço. O modelo é composto por três seções,representando os segmentos arteriais braquial, radial e a mão. As artérias braquial e radial foram representadas por componentes resistivos (atrito local), indutivos (massa do sangue) e capacitivos (complacência arterial), enquanto a mão foi representada por elementos resistivos (resistências de pequenos vasos da mão e periféricos) e capacitivos (complacência de pequenos vasos). Os resultados mostram um erro médio de estimação que pode ser considerado pequeno (3,7%) quando comparado aos valores de adaptação arterial in vivo (alterações de até 15%), indicando a utilização deste procedimento para estimar o processo de remodelagem das artérias de médio calibre observado na hipertensão arterial sistêmica.

Arterial hypertension leads to structural adaptation of arteries, mainly hypertrophy or remodeling, which precedes target-organ injuries. Determination of both mechanical and geometrical variables related to arterial system allows physicians to identify early arterial adaptation derived from systemic hypertension and to propose therapeutics. This work presents the evaluation of an electric-hydraulic model, and associated method, for determination of geometrical and mechanical parameters of forearm arteries. The proposed method requires only noninvasive acquisition of two pressure pulses at distinct sites. Series of pressure pulses from radial artery were simulated using acquired brachial artery pulses and a simplified distributed-model of the forearm arteries. The model presents three sections, representing brachial, radial, and hand vasculature. Brachial and radial arteries were represented with resistive (friction), inductive (blood mass), and capacitive (arterial compliance) elements. The hand was modeled with resistive (small vessels and capillaries) and capacitive elements (small vessels compliance). The results show that an average estimation error of 3.7% is small compared to “in vivo” findings (changes up to 15%), indicatingthat the procedure can be used to assess the remodeling of medium-sized arteries on primary systemic arterial hypertension.

Analysis of simulated heart sounds by intrinsic mode functions.

The mechanisms involved in the generation of heart sounds have always been of interest, mainly for diagnosis purposes. As a result, mathematical models have been proposed for first (S1) and second (S2) heart sounds and different efforts have been made to select the best signal processing tool to analyze them. Different frequency analysis techniques have been used to relate cardiac structure to the vibration they emit. In this work, we applied the empirical mode decomposition (EMD), a recently developed technique, for time-frequency (TF) analysis of heart sounds. EMD has shown interesting properties for biomedical signals related to nonlinear and non-stationary analysis. EMD is an adaptive decomposition since the extracted information is obtained directly from the signal without the use of kernels or mother waveforms. In this paper, EMD is first investigated in simulated scenarios through mathematical models for SI and S2 to validate its performance. Later, a real heart sound acquired over the thoracic surface of a healthy subject is analyzed. The work points out the advantage of EMD for this task.

Heart sounds interference cancellation in lung sounds.

Several attempts have been made to achieve a quantitative analysis of lung sounds mainly for two purposes: a) an understanding of their genesis, and b) an insight of their changes with pathologies for medical diagnosis. Early studies involved the collection of acoustic information at several positions on the thoracic surface or at the extra-thoracic trachea with one up to four microphones, but with a non-simultaneous acquisition. However, an increment for simultaneous acquisition points has been suggested; for example, as a consequence of multichannel acquisition acoustic visualization through computerized interpolation has emerged being helpful to analyze lung sounds (LS) origin, distribution, and relation to ventilation. Nevertheless, quantitative analysis of lung sounds requires eliminating interference signals prior to the extraction of relevant features. The acquired signals not only contain LS but also heart sounds (HS) among other interferences. HS are unavoidable and sometimes represent severe disturbing interference. This paper proposes a HS cancellation scheme as an extension of a previous effort using the Empirical Mode Decomposition (EMD) and a combination of time warping with linear adaptive FIR filtering. Simulated signals are used to evaluate the performance of the proposed scheme under known and controlled scenarios.

Ausculta cardíaca: bases fisiológicas - fisiopatológicas / Cardiac auscultation: physiological and physiopathological mechanisms

São revistos os mecanismos básicos, determinantes dos sons cardíacos, normais e anormais, com ênfase nas suas implicações para a ausculta cardíaca à beira do leito

Ausculta cardíaca versus ecocardiografia na detecçäo de valvulopatias / Cardiac auscultation versus echocardiography in the diagnosis of valvulopathies

Este trabalho tem como objetivo estabelecer a sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo da ausculta cardíaca por cardiologistas e acadêmicos de medicina para a detecçäo de sopros cardíacos, comparando-os com a ecocardiografia. Foram examinados 41 pacientes por acadêmicos, cardiologistas e, após, esses pacientes foram submetidos à ecocardiografia. A sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo da ausculta cardíaca obtidos pelo cardiologista foram 60 por cento, 67 por cento, 91 por cento e 22 por cento, respectivamente. A sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo obtidos pelos acadêmicos foram 48 por cento, 83 por cento, 95 por cento e 22 por cento, respectivamente. Na associaçäo dos achados obtidos pelos cardiologistas mais acadêmicos, os valores passaram a 68 por cento, 67 por cento, 92 por cento e 27 por cento, respectivamente. A prevalência de pelo menos uma valvulopatia com fluxo de intensidade moderada ou maior (grau III ou maior) ocorreu em nove pacientes (21,9 por cento), com sensibilidades, pelos cardiologistas e acadêmicos, de, respectivavamente, 67 por cento e 77 por cento

Soplos cardíacos funcionales en niños: ¿usted está capacitado para distinguir un soplo funcional de uno patológico? / Functional heart murmurs in children: you is trained for differentiate a functional murmur of a pathologic murmur?

Cerca del 70 por ciento de los soplos cardíacos detectados en la edad pediátrica son soplos originados en estructuras cardíacas normales. La incorrecta catalogación de un soplo cardíaco como soplo anormal genera gran inquietud en la familia y muchas veces también en el mismo niño, por lo tanto el pediatra debe poder definir los soplos funcionales. Este artículo es una guía para ayudar en dicho pronóstico

Semiologia da 2§ bulha / Semiology of the 2nd sound

Descreve-se a gense da segunda bulha cardíaca bem como seus componentes, sua valorizaçäo hemodinâmica e melhores condiçÖes de ausculta, tanto no coracao normal como nas diversas patologias que alteram suas características de intensidade e desdobramento.

Ausculta cardíaca: bases fisiológicas / Cardiac auscultation: physiological mechanisms

Sao revistos os mecanismos básicos determinantes dos sons cardíacos normais e anormais com ênfase nas suas implicaçoes para a ausculta cardíaca à beira do leito.