Avaliação ecocardiográfica do paciente com choque circulatório: uma abordagem contemporânea / Echocardiographic evaluation of a patient in circulatory shock: a contemporary approach

O choque circulatório é caracterizado por um estado de ineficiência da oferta de oxigênio tecidual e disfunção múltipla de órgãos. Necessita de diagnóstico e terapias rápidas e assertivas para redução de sua alta letalidade. O ecocardiograma já se estabeleceu como método fundamental no manejo do paciente com choque circulatório. Auxilia de forma crucial no diagnóstico etiológico, prognóstico, monitorização hemodinâmica e estimativa volêmica desses pacientes, tendo como potenciais vantagens a portabilidade, ausência de contraste ou radiação, baixo custo e avaliação em tempo real e de forma seriada. Em ambiente de UTI, demonstra alta correlação com formas invasivas (cateter de artéria pulmonar) e minimamente invasivas (termodiluição transpulmonar) de monitorização hemodinâmica. Atualmente, outras técnicas, como ultrassom pulmonar e VExUS score, têm se agregado à avaliação ecocardiográfica, tornando o método mais abrangente e acurado. Essas técnicas acrescentam dados relevantes na estimativa da volemia do paciente crítico, influenciando na decisão probabilística de fluidoresponsividade e agregando informações no raciocínio diagnóstico das causas do choque, otimizando o prognóstico desses pacientes. O point of care ultrasound (POCUS) tem como objetivo tornar mais acessível, ao médico não especialista em radiologia, habilidades para se obter informações a beira leito, por meio do ultrassom, que o ajudem na tomada de decisões. Esse artigo aborda as diversas aplicabilidades do ecocardiograma em pacientes com choque circulatório, incluindo avaliação prognóstica e diagnóstico etiológico por meio dos parâmetros encontrados nas principais causas de choque, além da monitorização hemodinâmica, avaliação de fluido-responsividade e utilização prática do ultrassom pulmonar.(AU)

Circulatory shock is characterized by a state of inefficient tissue oxygen supply and multiple organ dysfunction. Patients with circulatory shock require fast and assertive diagnosis and therapies to reduce its high lethality. Echocardiography has already been established as a fundamental method in managing patients with circulatory shock. It provides crucial assistance in etiological diagnosis, prognosis, hemodynamic monitoring, and volume estimation in these patients; its potential advantages include portability, absence of contrast or radiation, low cost, and real-time serial assessment. In the intensive care unit setting, it demonstrates a high correlation with invasive (pulmonary artery catheter) and minimally invasive (transpulmonary thermodilution) forms of hemodynamic monitoring. Currently, other techniques, such as pulmonary ultrasound and VExUS score, have been added to echocardiographic assessment, making the method more comprehensive and accurate. These techniques add relevant data to blood volume estimation in critical patients, influencing the probabilistic decision of fluid responsiveness and providing additional information in the diagnostic reasoning of the causes of shock, thus optimizing these patients' prognosis. Point of care ultrasound (POCUS) aims to make abilities to obtain information at the bedside more accessible to physicians who are not specialists in radiology, by means of ultrasound, which assists them in decision-making. This article addresses the diverse applications of echocardiography in patients with circulatory shock, including prognostic evaluation and etiological diagnosis by means of the parameters found in the main causes of shock, in addition to hemodynamic monitoring, evaluation of fluid responsiveness, and practical use of pulmonary ultrasound.(AU)

Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. / Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023.

Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.

Figura Central : Posicionamento do Departamento de Imagem Cardiovascular da Sociedade Brasileira de Cardiologia sobre o Uso do Strain Miocárdico na Rotina do Cardiologista ­ 2023 Proposta de inclusão do strain no algoritmo integrado de avaliação da função diastólica, adaptado e traduzido de Nagueh et al. 67 AE: átrio esquerdo; Ap: duração da onda A reversa pulmonar; Am: duração da onda A mitral; DD: disfunção diastólica; FEVEr: fração de ejeção do ventrículo esquerdo reduzida; IT: insuficiência tricúspide; SAEr: strain do AE de reservatório; SLGVE: strain longitudinal global do ventrículo esquerdo. Se remodelamento concêntrico, confirmar com SLGVE. Na presença de FEVEr, tempo de desaceleração da onda E mitral (TDE) < 160 ms e onda S < D pulmonar também são parâmetros de pressão de enchimento aumentada. Esse algoritmo não se aplica a pacientes com fibrilação atrial (FA), calcificação do anel mitral ou valvopatia mitral maior que discreta, bloqueio de ramo esquerdo (BRE), ritmo de marca-passo, próteses valvares ou hipertensão pulmonar (HP) primária grave.

2016 Left ventricular diastolic function guideline have better prognostic value than 2009 guideline in patients with acute coronary syndrome

BACKGROUND: Cardiovascular disease is the leading cause of death in Brazil and worldwide. In the context of diastolic dysfunction, echocardiography is the best non-invasive diagnostic method. However, the comparison of the two main guidelines for evaluate left ventricular diastolic function in acute coronary syndrome (ACS) is scarce. OBJECTIVE: To compare the prognostic value of both guidelines of American Society of Echocardiography, from 2009 and 2016, in patients with ACS. METHODS: This is a sub-analysis of a prospective cohort observational study with 109 patients admitted to the emergency with ACS. The follow up was performed within 1 year and combined outcome was cardiovascular death or new heart failure. We used the non-parametric Spearman method to assess the correlation between the categories of diastolic function according to the guideline used. The Cox model and the Log rank test with Kaplan-Meier curves were used to compare the prognostic value of categorizing patients according to the guideline used. The results were expressed as hazard ratio with a confidence interval of 95%. RESULTS: The mean age was 63 years ± 11, most male patients (73.4%) and the predominant color of patients was white (60.4%). Among the main risk factors, the most frequent for coronary artery disease was dyslipidemia (78%), followed by systemic arterial hypertension (77.1%) and sedentary lifestyle (65.9%). The study identified a mean borderline ejection fraction, a high E/E' ratio, and LV diastolic and systolic volumes presented means above normal. The most common electrocardiographic change on admission was T-wave inversion (45%), and NSTEMI was the main clinical diagnosis (74%). The categories in which there was a greater disagreement between the guidelines were grade II diastolic dysfunction and normal function. The correlation between the diagnosis of diastolic dysfunction when compared to the use of the 2009 and 2016 guidelines was weak (R = 0.56 by Spearman's method; p<0.001). By the Kaplan-Meier curves, dividing the groups into with or without LA pressure elevation, the distinction between the evolution of the two groups is significant when performed by the 2016 guideline (Log Rank = 8.17; p = 0.04). CONCLUSION: The current guideline (2016) for the assessment of left ventricular diastolic dysfunction showed a higher prognostic value of combined outcome of cardiovascular death or new heart failure within one year, when compared to the guideline of 2009 in patients.

Left atrial minimum volume is better correlate of left atrial dysfunction by two-dimensional strain

BACKGROUND: The analysis of left atrial (LA) function can add important information to the understanding of cardiovascular diseases. Therefore, to assess its functioning the use of volumetric measurements is adopted. The maximum LA volume is the most echocardiography parameter used, however, some studies demonstrated that minimum LA volume is better to correlate with atrial dysfunction. Purpose: The purpose of this study was compare the accuracy of the phasic volumes of the left atrium in determining LA dysfunction identified by the two-dimensional strain. METHODS: This observational, cross-sectional study admitted 109 participants with diagnosis of acute coronary syndrome non-ST-segment elevation. The exams were performed within 72 hours of admission. LA volume was defined by the mean of measurements performed in the four and two-chamber apical windows using Simpson's method. The phasic volumes of the left atrium were measured using an electrocardiogram synchronized with the device. Reservoir LA strain less than 21% was the cut off to LA dysfunction. RESULTS: The phasic LA volume variables analyzed were maximal (LAVMAX), minimal (LAVMIN) and before atrial contraction (LAVBAC) volume, and each variable indexed for body surface (LAVIMAX, LAVIMIN and LAVIBAC). Therefore, a Roc curve was generated for each volume variable to assess which would be more accurate in predicting left atrial dysfunction. The Youden index was used to determine the cutoff point for each one of them. The areas under the Roc curves were: 0.83 (LAVIMIN), 0.81 (LAVMIN), 0.78 (LAVBAC), 0.76 (LAVIMAX), 0.74 (LAVIBAC) and 0.71 (LAVMAX). CONCLUSION: This study concluded that phasic volumes were good determinants of left atrial dysfunction identified by 2D strain. The minimum left atrial volume was the better correlated with left atrial dysfunction.

Left atrial minimum volume is better correlate of left atrial dysfunction by two-dimensional strain

BACKGROUND: The analysis of left atrial (LA) function can add important information to the understanding of cardiovascular diseases. Therefore, to assess its functioning the use of volumetric measurements is adopted. The maximum LA volume is the most echocardiography parameter used, however some studies demonstrated that minimum LA volume is better to correlate with atrial dysfunction. PURPOSE: The purpose of this study was compare the accuracy of the phasic volumes of the left atrium in determining LA dysfunction identified by the two-dimensional strain. METHODS: This observational, cross-sectional study admitted 109 participants with diagnosis of acute coronary syndrome non-ST-segment elevation. The exams were performed within 72 hours of admission. LA volume was defined by the mean of measurements performed in the four and two-chamber apical windows using Simpson's method. The phasic volumes of the left atrium were measured using an electrocardiogram synchronized with the device. Reservoir LA strain less than 21% was the cut off to LA dysfunction. RESULTS: The phasic LA volume variables analyzed were maximal (LAVMAX), minimal (LAVMIN) and before atrial contraction (LAVBAC) volume, and each variable indexed for body surface (LAVIMAX, LAVIMIN and LAVIBAC). Therefore, a Roc curve was generated for each volume variable to assess which would be more accurate in predicting left atrial dysfunction. The Youden index was used to determine the cutoff point for each one of them. The areas under the Roc curves were: 0.83 (LAVIMIN), 0.81 (LAVMIN), 0.78 (LAVBAC), 0.76 (LAVIMAX), 0.74 (LAVIBAC) and 0.71 (LAVMAX). CONCLUSION: This study concluded that phasic volumes were good determinants of left atrial dysfunction identified by 2D strain. The minimum left atrial volume was the better correlate with left atrial dysfunction.

Association between left atrial strain and left ventricular diastolic function in patients with acute coronary syndrome

BACKGROUND: Left ventricular diastolic function is an important prognostic marker in acute coronary syndrome. However, classification of the dysfunction grade using isolated echocardiographic parameters remains difficult. Therefore, it is necessary to combine multiple data in diagnostic algorithms. The purpose of this study was to evaluate the capacity of left atrial strain (LAS) components to classify left ventricular diastolic dysfunction (DD) grade. METHODS: Cross-sectional speckle-tracking echocardiography. Patients were divided according to the diastolic dysfunction grade for later association with the LAS. RESULTS: The three LAS components showed moderate correlation with most diastolic variables(left atrial volume index, E/e' ratio and e' wave). In addition, there was related reduction of the LAS, which was inversely proportional to the DD grade (p < 0.05). LAS was effective for the identification of patients with DD grade III [area under the curve (AUC) for the reservoir = 0.99; conduit AUC = 0.89; contraction AUC = 0.99) and also those with DD grade II or III (reservoir AUC = 0.94; conduit AUC = 0.92; contraction AUC = 0.80]. CONCLUSIONS: LAS alone presented excellent capacity to classify DD in patients with acute coronary syndrome and may represent an additional tool for this purpose. (AU)

Association between left atrial strain and left ventricular diastolic function in patients with acute coronary syndrome.

BACKGROUND: Left ventricular diastolic function is an important prognostic marker in acute coronary syndrome. However, classification of the dysfunction grade using isolated echocardiographic parameters remains difficult. Therefore, it is necessary to combine multiple data in diagnostic algorithms. The purpose of this study was to evaluate the capacity of left atrial strain (LAS) components to classify left ventricular diastolic dysfunction (DD) grade. METHODS: Cross-sectional study with 109 consecutive patients admitted to the emergency room with acute coronary syndrome. Patients were referred for echocardiographic evaluation within 72 h. Mean values of LAS, corresponding to three phases of atrial function (reservoir, conduit and contraction), were obtained by speckle-tracking echocardiography. Patients were divided according to the diastolic dysfunction grade for later association with the LAS. RESULTS: The three LAS components showed moderate correlation with most diastolic variables (left atrial volume index, E/e' ratio and e' wave). In addition, there was related reduction of the LAS, which was inversely proportional to the DD grade (p < 0.05). LAS was effective for the identification of patients with DD grade III [area under the curve (AUC) for the reservoir = 0.99; conduit AUC = 0.89; contraction AUC = 0.99) and also those with DD grade II or III (reservoir AUC = 0.94; conduit AUC = 0.92; contraction AUC = 0.80]. CONCLUSIONS: LAS alone presented excellent capacity to classify DD in patients with acute coronary syndrome and may represent an additional tool for this purpose.

Association between left atrial strain and left ventricular diastolic function in patients with acute coronary syndrome

BACKGROUND: Left ventricular diastolic function is an important prognostic marker in acute coronary syndrome. However, classifcation of the dysfunction grade using isolated echocardiographic parameters remains difcult. Therefore, it is necessary to combine multiple data in diagnostic algorithms. The purpose of this study was to evaluate the capacity of left atrial strain (LAS) components to classify left ventricular diastolic dysfunction (DD) grade. METHODS: Cross-sectional study with 109 consecutive patients admitted to the emergency room with acute coronary syndrome. Patients were referred for echocardiographic evaluation within 72 h. Mean values of LAS, corresponding to three phases of atrial function (reservoir, conduit and contraction), were obtained by speckle-tracking echocardiography. Patients were divided according to the diastolic dysfunction grade for later association with the LAS. RESULTS: The three LAS components showed moderate correlation with most diastolic variables (left atrial volume index, E/e' ratio and e' wave). In addition, there was related reduction of the LAS, which was inversely proportional to the DD grade (p< 0.05). LAS was efective for the identifcation of patients with DD grade III [area under the curve (AUC) for the reservoir=0.99; conduit AUC=0.89; contraction AUC=0.99) and also those with DD grade II or III (reservoir AUC=0.94; conduit AUC=0.92; contraction AUC=0.80]. CONCLUSIONS: LAS alone presented excellent capacity to classify DD in patients with acute coronary syndrome and may represent an additional tool for this purpose.

Correlação entre o strain bidimensional do átrio esquerdo com os desfechos clínicos da síndrome coronariana aguda sem supradesnivelamento do segmento ST / Correlation between the left atrial strain by two-dimensional speckle tracking and the clinical outcomes in patients with non-ST elevation acute coronary syndrome

Introdução: A disfunção atrial esquerda está associada a pior prognóstico em diversas situações clínicas. O método de strain bidimensional do átrio esquerdo permite avaliar de forma direta todas as fases da função atrial. Pouco se conhece sobre o comportamento das fases da função atrial esquerda em pacientes com síndrome coronariana aguda. O objetivo desse estudo foi correlacionar as funções de reservatório, conduto e contração do átrio esquerdo com desfechos adversos cardiovasculares em pacientes com síndrome coronariana aguda sem supradesnivelamento do segmento ST. Método: Esse estudo recrutou prospectivamente 109 pacientes com diagnóstico de infarto agudo do miocárdio sem elevação do segmento ST e de angina instável de risco moderado ou alto pelo escore GRACE para realização de ecocardiograma nas primeiras 72 horas. A função atrial foi avaliada por parâmetros ecocardiográficos convencionais e pelo strain bidimensional obtido pela média das janelas apicais 2 e 4 câmaras. O desfecho primário foi avaliado em até um ano de seguimento e foi composto pelos seguintes eventos adversos: óbito, insuficiência cardíaca nova, nova internação por síndrome coronariana aguda ou por insuficiência cardíaca, angina estável com necessidade de nova intervenção coronariana, arritmia (fibrilação atrial ou taquicardia ventricular) e acidente vascular cerebral. Os desfechos secundários foram os combinados desses eventos...

Índice Internacional de Função Erétil Simplificado e doença coronariana em pacientes hipertensos / Simplified International Index of Erectile Function (IIEF-5) and coronary artery disease in hypertensive patients

FUNDAMENTO: A Disfunção Erétil (DE) se associa ao risco aumentado de Doença Arterial Coronariana (DAC). OBJETIVO: Avaliar a associação entre DE, determinada pelo Índice Internacional de Função Erétil Simplificado (IIFE-5), e DAC. MÉTODOS: Estudo de corte transversal que avaliou 263 hipertensos (55 [50 - 61] anos). A DE foi avaliada pelo IIEF-5 e a DAC, por meio da história de revascularização miocárdica prévia e/ou por cineangiocoronariografia. RESULTADOS: O IIFE-5 se correlacionou com o clearance de creatinina [ClCr] (Rho = 0,23; p < 0,001) e com a idade (Rho = -0,22; p < 0,001). Quarenta e dois pacientes apresentavam DAC; e o IIFE-5 foi capaz de discriminá-los (área sob a curva ROC = 0,63; p = 0,006). Os pacientes foram divididos em dois grupos: IIFE-5 < 20 (n = 140) e IIFE- 5 > 20 (n = 123); aqueles com menor IIFE-5 tinham idade mais elevada (57 [52 - 61] vs. 54 [45 - 60] anos; p = 0,002), maior prevalência de DAC (22% vs. 9%; p = 0,004), tabagismo (64% vs. 47%; p = 0,009) e do uso de inibidores dos canais de cálcio (65 % vs. 43%; p = 0,001), além de menor ClCr (67,3 [30,8 - 88,6] vs. 82,6 [65,9 - 98,2] ml/min; p < 0,001). O IIFE-5 < 20 se associou ao maior risco de DAC em regressão logística; tanto univariada (RR = 2,89 [IC 95% 1,39 - 6,05]), quanto após ajustes para idade, diabetes, ClCr, tabagismo, pressão arterial média e uso de anti- hipertensivos (RR = 2,59 [IC 95%: 1,01 - 6,61]). CONCLUSÃO: O IIFE-5 se associa ao diagnóstico de DAC e sua utilização pode agregar informação ao estadiamento do risco cardiovascular em pacientes hipertensos.

BACKGROUND: Erectile Dysfunction (ED) is associated with increased risk of coronary artery disease (CAD). OBJECTIVE: To evaluate the association between ED, determined by the Simplified International Index of Erectile Function (IIEF-5) and CAD. METHODS: This was a cross-sectional cohort study that evaluated 263 hypertensive patients (55 [50-61] years). ED was assessed through the IIEF-5 and CAD by the history of previous myocardial revascularization and/or coronary angiography. RESULTS: The IIEF-5 correlated with creatinine clearance [CrCl] (Rho = 0.23, p <0.001) and age (Rho = -0.22, p <0.001). Forty-two patients had CAD, and IIEF-5 was able to discriminate them (area under the ROC curve = 0.63, p = 0.006). Patients were divided into two groups: IIEF-5 < 20 (n = 140) and IIEF-5 > 20 (n = 123); those with lower IIEF-5 scores were older (57 [52-61] vs. 54 [45-60] years, p = 0.002), had higher prevalence of CAD (22% vs. 9%, p = 0.004), smoking (64% vs. 47%, p = 0.009) and use of calcium channel inhibitors (65% vs. 43.%, p = 0.001), as well as lower CrCl (67.3 [30.8 to 88.6] vs. 82.6 [65.9 - 98.2] ml/min, p <0.001). The IIEF-5 < 21 was associated with increased risk of CAD in the logistic regression, both univariate (RR = 2.89 [95%CI: 1.39 - 6.05]), and after adjusting for age, diabetes, CrCl, smoking, mean arterial pressure and use of antihypertensive drugs (RR = 2.59 [95% CI: 1.01 - 6.61]). CONCLUSION: The IIEF-5 is associated with the diagnosis of CAD and its use can add information to cardiovascular risk staging in hypertensive patients.

Simplified International Index of Erectile Function (IIEF-5) and coronary artery disease in hypertensive patients.

BACKGROUND: Erectile Dysfunction (ED) is associated with increased risk of coronary artery disease (CAD). OBJECTIVE: To evaluate the association between ED, determined by the Simplified International Index of Erectile Function (IIEF-5) and CAD. METHODS: This was a cross-sectional cohort study that evaluated 263 hypertensive patients (55 [50-61] years). ED was assessed through the IIEF-5 and CAD by the history of previous myocardial revascularization and/or coronary angiography. RESULTS: The IIEF-5 correlated with creatinine clearance [CrCl] (Rho = 0.23, p <0.001) and age (Rho = -0.22, p <0.001). Forty-two patients had CAD, and IIEF-5 was able to discriminate them (area under the ROC curve = 0.63, p = 0.006). Patients were divided into two groups: IIEF-5 < 20 (n = 140) and IIEF-5 > 20 (n = 123); those with lower IIEF-5 scores were older (57 [52-61] vs. 54 [45-60] years, p = 0.002), had higher prevalence of CAD (22% vs. 9%, p = 0.004), smoking (64% vs. 47%, p = 0.009) and use of calcium channel inhibitors (65% vs. 43.%, p = 0.001), as well as lower CrCl (67.3 [30.8 to 88.6] vs. 82.6 [65.9 - 98.2] ml/min, p <0.001). The IIEF-5 < 21 was associated with increased risk of CAD in the logistic regression, both univariate (RR = 2.89 [95%CI: 1.39 - 6.05]), and after adjusting for age, diabetes, CrCl, smoking, mean arterial pressure and use of antihypertensive drugs (RR = 2.59 [95% CI: 1.01 - 6.61]). CONCLUSION: The IIEF-5 is associated with the diagnosis of CAD and its use can add information to cardiovascular risk staging in hypertensive patients.

Prevenção cardiovascular populacional: estratégiasde redução do risco / Cardiovascular prevention population: estrategiasde risk reduction

Atualmente, as doenças cardiovasculares são as principais causas de morbidade e mortalidade no mundo. Apesar dos avanços no dignóstico e no tratamento, o aspecto mais importante para que haja real diminuição de seu ônus é a prevenção cardiovascular. Dentre as categorias de prevenção, que serão pormenorizados nesta monografia...