Integral Velocidade-Tempo da Insuficiência Aórtica: Um Novo Marcador Ecocardiográfico na Avaliação da Gravidade da Insuficiência Aórtica / Velocity-Time Integral of Aortic Regurgitation: A Novel Echocardiographic Marker in the Evaluation of Aortic Regurgitation Severity

Resumo Fundamento A ecocardiografia é essencial para o diagnóstico e a quantificação da insuficiência aórtica (IA). A integral velocidade-tempo (IVT) do fluxo da IA pode estar relacionada à gravidade da IA. Objetivo Este estudo tem por objetivo avaliar se a IVT é um marcador ecocardiográfico de gravidade da IA. Métodos Foram incluídos todos os pacientes com IA nativa moderada ou grave e ritmo sinusal que visitaram o nosso laboratório de imagem entre janeiro e outubro de 2016. Todos os indivíduos foram submetidos a um ecocardiograma completo com medição da IVT da IA. A associação entre a IVT e a gravidade da IA foi analisada por regressão logística e modelos de regressão multivariada. Valores p<0,05 foram considerados estatisticamente significativos. Resultados Entre os 62 pacientes incluídos (68,5±14,9 anos; 64,5%: IA moderada; 35,5%: IA grave), a IVT foi maior em indivíduos com IA moderada em comparação àqueles com IA grave (2,2±0,5 m versus 1,9±0,5 m, p=0,01). Pacientes com IA grave apresentaram valores maiores de diâmetro diastólico final do ventrículo esquerdo (DDFVE) (56,1±7,1 mm versus 47,3±9,6 mm, p=0,001), volume diastólico final do ventrículo esquerdo (VDFVE) (171±36,5 mL versus 106±46,6 mL, p<0,001), orifício regurgitante efetivo (0,44±0,1 cm2 versus 0,18±0,1 cm2, p=0,002) e volume regurgitante (71,3±25,7 mL versus 42,5±10,9 mL, p=0,05), assim como menor fração de ejeção do ventrículo esquerdo (FEVE) (54,1±11,2% versus 63,2±13,3%, p=0,012). A IVT mostrou ser um marcador de gravidade da IA, independentemente do DDFVE, VDFVE e FEVE ( odds ratio 0,160, p=0,032) e da frequência cardíaca e pressão arterial diastólica (PAD) ( odds ratio 0,232, p=0,044). Conclusões A IVT do fluxo da IA apresentou associação inversa com a gravidade da IA, independentemente do diâmetro e volume do ventrículo esquerdo, frequência cardíaca, PAD e FEVE. A IVT pode ser um marcador de gravidade da IA em pacientes com IA nativa e ritmo sinusal. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Echocardiography is essential for the diagnosis and quantification of aortic regurgitation (AR). Velocity-time integral (VTI) of AR flow could be related to AR severity. Objective This study aims to assess whether VTI is an echocardiographic marker of AR severity. Methods We included all patients with moderate or severe native AR and sinus rhythm who visited our imaging laboratory from January to October 2016. All individuals underwent a complete echocardiogram with AR VTI measurement. The association between VTI and AR severity was analyzed by logistic regression and multivariate regression models. A p-value<0,05 was considered statistically significant. Results Among the 62 patients included (68.5±14.9 years old; 64.5%: moderate AR; 35.5%: severe AR), VTI was higher in individuals with moderate AR compared to those with severe AR (2.2±0.5 m vs. 1.9±0.5 m, p=0.01). Patients with severe AR presented greater values of left ventricular end-diastolic diameter (LVEDD) (56.1±7.1 mm vs. 47.3±9.6 mm, p=0.001), left ventricular end-diastolic volume (LVEDV) (171±36.5 mL vs. 106±46.6 mL, p<0.001), effective regurgitant orifice (0.44±0.1 cm2vs. 0.18±0.1 cm2, p=0.002), and regurgitant volume (71.3±25.7 mL vs. 42.5±10.9 mL, p=0.05), as well as lower left ventricular ejection fraction (LVEF) (54.1±11.2% vs. 63.2±13.3%, p=0.012). The VTI proved to be a marker of AR severity, irrespective of LVEDD, LVEDV, and LVEF (odds ratio 0.160, p=0.032) and of heart rate and diastolic blood pressure (DBP) (odds ratio 0.232, p=0.044). Conclusions The VTI of AR flow was inversely associated with AR severity regardless of left ventricular diameter and volume, heart rate, DBP, and LVEF. VTI could be a marker of AR severity in patients with native AR and sinus rhythm. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Velocity-Time Integral of Aortic Regurgitation: A Novel Echocardiographic Marker in the Evaluation of Aortic Regurgitation Severity. / Integral Velocidade-Tempo da Insuficiência Aórtica: Um Novo Marcador Ecocardiográfico na Avaliação da Gravidade da Insuficiência Aórtica.

BACKGROUND: Echocardiography is essential for the diagnosis and quantification of aortic regurgitation (AR). Velocity-time integral (VTI) of AR flow could be related to AR severity. OBJECTIVE: This study aims to assess whether VTI is an echocardiographic marker of AR severity. METHODS: We included all patients with moderate or severe native AR and sinus rhythm who visited our imaging laboratory from January to October 2016. All individuals underwent a complete echocardiogram with AR VTI measurement. The association between VTI and AR severity was analyzed by logistic regression and multivariate regression models. A p-value<0,05 was considered statistically significant. RESULTS: Among the 62 patients included (68.5±14.9 years old; 64.5%: moderate AR; 35.5%: severe AR), VTI was higher in individuals with moderate AR compared to those with severe AR (2.2±0.5 m vs. 1.9±0.5 m, p=0.01). Patients with severe AR presented greater values of left ventricular end-diastolic diameter (LVEDD) (56.1±7.1 mm vs. 47.3±9.6 mm, p=0.001), left ventricular end-diastolic volume (LVEDV) (171±36.5 mL vs. 106±46.6 mL, p<0.001), effective regurgitant orifice (0.44±0.1 cm2vs. 0.18±0.1 cm2, p=0.002), and regurgitant volume (71.3±25.7 mL vs. 42.5±10.9 mL, p=0.05), as well as lower left ventricular ejection fraction (LVEF) (54.1±11.2% vs. 63.2±13.3%, p=0.012). The VTI proved to be a marker of AR severity, irrespective of LVEDD, LVEDV, and LVEF (odds ratio 0.160, p=0.032) and of heart rate and diastolic blood pressure (DBP) (odds ratio 0.232, p=0.044). CONCLUSIONS: The VTI of AR flow was inversely associated with AR severity regardless of left ventricular diameter and volume, heart rate, DBP, and LVEF. VTI could be a marker of AR severity in patients with native AR and sinus rhythm. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

FUNDAMENTO: A ecocardiografia é essencial para o diagnóstico e a quantificação da insuficiência aórtica (IA). A integral velocidade-tempo (IVT) do fluxo da IA pode estar relacionada à gravidade da IA. OBJETIVO: Este estudo tem por objetivo avaliar se a IVT é um marcador ecocardiográfico de gravidade da IA. MÉTODOS: Foram incluídos todos os pacientes com IA nativa moderada ou grave e ritmo sinusal que visitaram o nosso laboratório de imagem entre janeiro e outubro de 2016. Todos os indivíduos foram submetidos a um ecocardiograma completo com medição da IVT da IA. A associação entre a IVT e a gravidade da IA foi analisada por regressão logística e modelos de regressão multivariada. Valores p<0,05 foram considerados estatisticamente significativos. RESULTADOS: Entre os 62 pacientes incluídos (68,5±14,9 anos; 64,5%: IA moderada; 35,5%: IA grave), a IVT foi maior em indivíduos com IA moderada em comparação àqueles com IA grave (2,2±0,5 m versus 1,9±0,5 m, p=0,01). Pacientes com IA grave apresentaram valores maiores de diâmetro diastólico final do ventrículo esquerdo (DDFVE) (56,1±7,1 mm versus 47,3±9,6 mm, p=0,001), volume diastólico final do ventrículo esquerdo (VDFVE) (171±36,5 mL versus 106±46,6 mL, p<0,001), orifício regurgitante efetivo (0,44±0,1 cm2 versus 0,18±0,1 cm2, p=0,002) e volume regurgitante (71,3±25,7 mL versus 42,5±10,9 mL, p=0,05), assim como menor fração de ejeção do ventrículo esquerdo (FEVE) (54,1±11,2% versus 63,2±13,3%, p=0,012). A IVT mostrou ser um marcador de gravidade da IA, independentemente do DDFVE, VDFVE e FEVE ( odds ratio 0,160, p=0,032) e da frequência cardíaca e pressão arterial diastólica (PAD) ( odds ratio 0,232, p=0,044). CONCLUSÕES: A IVT do fluxo da IA apresentou associação inversa com a gravidade da IA, independentemente do diâmetro e volume do ventrículo esquerdo, frequência cardíaca, PAD e FEVE. A IVT pode ser um marcador de gravidade da IA em pacientes com IA nativa e ritmo sinusal. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Trombo sobre la red de Chiari: Thrombus on Chiari Network

El descubrimiento de una masa en la aurícula derecha obliga a realizar un amplio diagnóstico diferencial que incluye tumores, vegetaciones, trombo, válvula de Eustaquio o red de Chiari. Tradicionalmente, estas posibilidades etiológicas se han considerado excluyentes. En esta presentación se describe el caso de un varón con cuadro catarral, dolorimiento generalizado y febrícula, con diagnóstico de fibrilación auricular y, mediante ecocardiograma, de una masa alargada muy móvil en la aurícula derecha. Se plantearon diferentes entidades etiológicas y finalmente se inició tratamiento con heparina, con lo que se produjo la resolución de dicha masa, con persistencia de una estructura filamentosa compatible con la red de Chiari.

The presence of a mass in the right atrium requires a broad differential diagnosis including tumors, vegetations, thrombus, Eustachian valve, or Chiari network. Traditionally, these etiological possibilities have been considered exclusive. This report describes the case of a male patient with catarrh, generalized tenderness and low-grade fever, diagnosed with atrial fibrillation. An echocardiography revealed a mobile, elongated mass in the right atrium. Different etiological entities were posed, and finally heparin treatment was started which resolved the mass, with a persistent filamentous structure compatible with Chiari network.

Trombo sobre la red de Chiari: Thrombus on Chiari Network

El descubrimiento de una masa en la aurícula derecha obliga a realizar un amplio diagnóstico diferencial que incluye tumores, vegetaciones, trombo, válvula de Eustaquio o red de Chiari. Tradicionalmente, estas posibilidades etiológicas se han considerado excluyentes. En esta presentación se describe el caso de un varón con cuadro catarral, dolorimiento generalizado y febrícula, con diagnóstico de fibrilación auricular y, mediante ecocardiograma, de una masa alargada muy móvil en la aurícula derecha. Se plantearon diferentes entidades etiológicas y finalmente se inició tratamiento con heparina, con lo que se produjo la resolución de dicha masa, con persistencia de una estructura filamentosa compatible con la red de Chiari.(AU)

The presence of a mass in the right atrium requires a broad differential diagnosis including tumors, vegetations, thrombus, Eustachian valve, or Chiari network. Traditionally, these etiological possibilities have been considered exclusive. This report describes the case of a male patient with catarrh, generalized tenderness and low-grade fever, diagnosed with atrial fibrillation. An echocardiography revealed a mobile, elongated mass in the right atrium. Different etiological entities were posed, and finally heparin treatment was started which resolved the mass, with a persistent filamentous structure compatible with Chiari network.(AU)

[Usefulness of clinical profiling and exercise testing in the prognostic assessment of patients admitted with chest pain but without high-risk criteria]. / Utilidad del perfil clínico y la ergometría en la valoración del pronóstico de los pacientes ingresados por dolor torácico sin criterios de alto riesgo.

INTRODUCTION AND OBJECTIVES: Few data are available on the outcome of patients admitted to hospital with suspected acute coronary syndrome who have no high-risk factors and who undergo exercise testing before discharge. Our objectives were to investigate outcomes in this group of patients and to determine whether clinical history-taking or exercise testing can help to predict outcome. PATIENTS AND METHOD: The study population comprised 449 patients admitted to hospital with chest pain suggestive of acute coronary syndrome. All were judged to be at a low risk of subsequent events (i.e., none had ischemic ECG changes or an elevation in troponin level). They underwent treadmill exercise testing before discharge, after an observation period of at least 12 hours. Exercise testing was performed after clinical evaluation based on an algorithm involving troponin-T level and resting ECG. The median follow-up duration was 479 days. The single combined endpoint was defined as cardiac death, or hospital admission for nonfatal acute myocardial infarction or unstable angina. RESULTS: Adverse events occurred in 44 (10%) of the 449 patients. A high event rate was associated with four clinical features (i.e., age > or =65 years, diabetes, previous acute myocardial infarction, and typical chest pain) and with a positive result on exercise testing. CONCLUSIONS: Adverse events after discharge are not infrequent in patients admitted to hospital with suspected acute coronary syndrome and a low risk profile. Both the patient's clinical characteristics and exercise test results should be taken into account in accurately determining prognosis.

Utilidad del perfil clínico y la ergometría en la valoración del pronóstico de los pacientes ingresados por dolor torácico sin criterios de alto riesgo / Usefulness of clinical profiling and exercise testing in the prognostic assessment of patients admitted with chest pain but without high-risk criteria

Introducción y objetivos. Hay escasa información sobre la evolución de los pacientes hospitalizados por dolor torácico que no presentan criterios de alto riesgo tras su evaluación inicial, a los que se realiza una prueba de esfuerzo para su valoración antes del alta. Nuestro objetivo fue evaluar el pronóstico de este grupo de pacientes y averiguar si hay factores clínicos y derivados de la prueba de esfuerzo que permitan predecir su evolución. Pacientes y método. La población estaba constituida por 449 pacientes hospitalizados por dolor torácico de posible origen isquémico, sin criterios de alto riesgo (sin alteraciones isquémicas en el electrocardiograma ni elevación de la troponina), a los que se realizó una prueba de esfuerzo previa al alta, tras un período de observación de al menos 12 h. La mediana de seguimiento fue 479 días. Se consideraron acontecimientos adversos la muerte cardíaca o el reingreso por infarto agudo de miocardio (IAM) no mortal o angina inestable. Resultados. De los 449 pacientes, 44 (10%) presentaron algún suceso. En el análisis de regresión de Cox se identificaron como predictores independientes de evolución desfavorable cuatro variables clínicas (edad ≥ 65 años, diabetes, IAM previo y carácter típico del dolor torácico) y una prueba de esfuerzo positiva. Conclusiones. Los pacientes hospitalizados por dolor torácico sin criterios de alto riesgo tras su evaluación inicial, a los que se efectúa una prueba de esfuerzo, no están exentos de sucesos adversos tras el alta. El perfil clínico contribuye, junto con el resultado de la ergometría, a la valoración del riesgo de estos pacientes

Introduction and objectives. Few data are available on the outcome of patients admitted to hospital with suspected acute coronary syndrome who have no high-risk factors and who undergo exercise testing before discharge. Our objectives were to investigate outcomes in this group of patients and to determine whether clinical history-taking or exercise testing can help to predict outcome. Patients and method. The study population comprised 449 patients admitted to hospital with chest pain suggestive of acute coronary syndrome. All were judged to be at a low risk of subsequent events (i.e., none had ischemic ECG changes or an elevation in troponin level). They underwent treadmill exercise testing before discharge, after an observation period of at least 12 hours. Exercise testing was performed after clinical evaluation based on an algorithm involving troponin-T level and resting ECG. The median follow-up duration was 479 days. The single combined endpoint was defined as cardiac death, or hospital admission for nonfatal acute myocardial infarction or unstable angina. Results. Adverse events occurred in 44 (10%) of the 449 patients. A high event rate was associated with four clinical features (i.e., age ≥65 years, diabetes, previous acute myocardial infarction, and typical chest pain) and with a positive result on exercise testing. Conclusions. Adverse events after discharge are not infrequent in patients admitted to hospital with suspected acute coronary syndrome and a low risk profile. Both the patient's clinical characteristics and exercise test results should be taken into account in accurately determining prog

Prognosis of patients with unstable angina and low-risk exercise test: significance of ST-segment depression on the admission ECG.

The presence of ST-segment depression on the admission electrocardiogram (ECG) is an important predictor of poor outcome in patients with unstable angina. On the other hand, patients with unstable angina who undergo a low-risk exercise test are supposed to have a favorable prognosis. The objective of the study was to determine the prognostic significance of ST-segment depression on the admission ECG in patients with unstable angina who undergo an exercise test that indicates a low risk of events. An interpretable exercise test was performed in 257 patients with primary unstable angina. A low-risk exercise test was completed by 156 (60%) patients and medical therapy was planned for all these patients. A multivariate analysis was performed in order to determine the independent predictors of events (cardiac death, nonfatal acute myocardial infarction, or admission for unstable angina) during a 12-month follow-up. Among patients with a low-risk exercise test, there were no significant differences between patients with and without ST-segment depression on the presenting ECG with regard to event rate (34 vs. 29%, P=NS). In multivariate analysis, ST-segment depression was not related to a higher incidence of events. Our findings appear to indicate that the presence of ST-segment depression on the admission ECG loses its prognostic significance in patients with primary unstable angina if they complete a low-risk exercise test.

Prueba de esfuerzo de bajo riesgo en pacientes con angina inestable: ¿implica un pronóstico favorable? / Low risk exercise treadmill test in patients with unstable angina: does it mean a good prognosis?

Introducción y objetivos. La prueba de esfuerzo de bajo riesgo se relaciona con un buen pronóstico en los pacientes con cardiopatía isquémica crónica. Sin embargo, apenas existen estudios que hayan evaluado prospectivamente el pronóstico de los pacientes con angina inestable controlada con tratamiento médico y que realizan una prueba de esfuerzo de bajo riesgo. Nuestro objetivo fue determinar el pronóstico de esta población específica y si existen variables clínicas o derivadas de la ergometría predictoras de eventos. Métodos. Se diseñó un protocolo de estudio prospectivo, según el cual se evaluaron 175 pacientes con diagnóstico de angina inestable, a los que se realizó una prueba de esfuerzo para la valoración pronostica antes del alta hospitalaria durante un período de dos años. La población de estudio estaba constituida por los 93 pacientes (un 82 por ciento de varones; edad: 60 ñ 9 años) que no presentaron criterios de alto riesgo previamente definidos en la prueba de esfuerzo y fueron dados de alta con tratamiento farmacológico. Resultados. Tras un período de seguimiento medio de 13 ñ 6 meses, 30 pacientes (32 por ciento) padecieron algún evento: 2 muertes (2 por ciento); 6 infarto agudo de miocardio no mortal (6 por ciento); 18 angina inestable (19 por ciento) y 4 revascularización (4 por ciento). En el análisis multivariado, sólo la angina durante la prueba de esfuerzo fue un predictor independiente de eventos ( odds ratio: 2,35; intervalo de confianza del 95 por ciento: 1,22-4,50; p = 0,01). Conclusiones. Los pacientes con angina inestable que realizan una ergometría de bajo riesgo y son dados de alta con tratamiento médico tienen una incidencia de eventos relativamente elevada durante el primer año. En esta población específica, la presencia de angina durante la ergometría se asocia a una evolución desfavorable (AU)