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1.
Br J Anaesth ; 123(4): 408-420, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31320115

RESUMO

Preoperative cardiac function is an important predictor of postoperative outcomes. Patients with heart failure are at higher risk of perioperative morbidity and mortality. Left ventricular ejection fraction, derived by standard echocardiography, is most frequently used to assess cardiac function in the intraoperative and postoperative periods. Myocardial strain analysis, a measurement of myocardial deformation, can provide additional information to left venricular eject fraction estimation. Here, we provide an overview of myocardial strain and different methods used to evaluate strain, including speckle tracking echocardiography. Speckle tracking echocardiography is an imaging modality that can analyse and track small segments of the myocardium, which provides greater detail for assessing global and regional cardiac motion and function. We further review the literature to illustrate the value of speckle tracking echocardiography-derived myocardial strain in describing cardiac function and its association with adverse surgical outcomes in the perioperative period, including low cardiac output states, need for inotropic support, postoperative arrhythmias, subclinical myocardial ischaemia, and length of hospital stay.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Coração/diagnóstico por imagem , Assistência Perioperatória/métodos , Ecocardiografia , Testes de Função Cardíaca , Humanos , Interpretação de Imagem Assistida por Computador , Miocárdio , Volume Sistólico
2.
J Am Soc Echocardiogr ; 32(2): 267-276, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30459123

RESUMO

BACKGROUND: Cardio-oncology is a recently established discipline that focuses on the management of patients with cancer who are at risk for developing cardiovascular complications as a result of their underlying oncologic treatment. In metastatic colorectal cancer (mCRC) and metastatic renal cell carcinoma (mRCC), vascular endothelial growth factor inhibitor (VEGF-i) therapy is commonly used to improve overall survival. Although these novel anticancer drugs may lead to the development of cardiotoxicity, whether early detection of cardiac dysfunction using serial echocardiography could potentially prevent the development of heart failure in this patient population requires further study. The aim of this study was to investigate the role of two-dimensional speckle-tracking echocardiography in the detection of cardiotoxicity due to VEGF-i therapy in patients with mCRC or mRCC. METHODS: Patients with mRCC or mCRC were evaluated using serial echocardiography at baseline and 1, 3, and 6 months following VEGF-i treatment. RESULTS: A total of 40 patients (34 men; mean age, 63 ± 9 years) receiving VEGF-i therapy were prospectively recruited at two academic centers: 26 (65%) were receiving sunitinib, eight (20%) pazopanib, and six (15%) bevacizumab. The following observations were made: (1) 8% of patients developed clinically asymptomatic cancer therapeutics-related cardiac dysfunction; (2) 30% of patients developed clinically significant decreases in global longitudinal strain, a marker for early subclinical cardiac dysfunction; (3) baseline abnormalities in global longitudinal strain may identify a subset of patients at higher risk for developing cancer therapeutics-related cardiac dysfunction; and (4) new or worsening hypertension was the most common adverse cardiovascular event, afflicting nearly one third of the study population. CONCLUSIONS: Cardiac dysfunction defined by serial changes in myocardial strain assessed using two-dimensional speckle-tracking echocardiography occurs in patients undergoing treatment with VEGF-i for mCRC or mRCC, which may provide an opportunity for preventive interventions.

3.
J Womens Health (Larchmt) ; 27(5): 542-551, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29672210

RESUMO

BACKGROUND: In women with low to intermediate risk of coronary artery disease (CAD), prognostic detection strategies have been controversial. We present the follow-up data of the SMART trial in peri/postmenopausal women at low to intermediate risk of CAD. OBJECTIVES: To determine the value of contrast stress echocardiography (CSE), stress electrocardiogram (sECG), and serum biomarkers for prediction of cardiovascular events (CE) in peri/postmenopausal women at low to intermediate risk of CAD. MATERIALS AND METHODS: From January 2004 to August 2007, 400 peri/postmenopausal women were prospectively enrolled. All women had detailed risk factor assessment, and underwent simultaneous CSE (Definity®, Lantheus Medical Imaging) and sECG. Laboratories included brain natriuretic peptide (BNP), atrial natriuretic peptide, endothelin, and high sensitivity C-reactive protein. Wall motion score index was based on a 16-segment model. Abnormal CSE was defined as new or worsening wall motion abnormality at stress, while abnormal sECG was ≥1 mm horizontal/downsloping ST segment depression/elevation (80 mseconds duration). Self-reported outcome data were collected from a mailed Women's Heart Clinic Questionnaire. CE outcomes included all-cause mortality, nonfatal myocardial infarction (MI), heart failure, chest pain hospitalization or development of typical angina (CP), and revascularization (REVASC). Adjusted Cox proportional hazard ratios (HR; 95% confidence intervals) were reported. RESULTS: A total of 366 women (54.4 ± 5.5 years, Framingham risk 6.5% ± 4.4%) completed simultaneous CSE and sECG. Forty-two (11.5%) had abnormal CSE, while sECG was abnormal in 22 (6%) women. Follow-up (4.4 ± 1.2 years) was available in 315/366 (86%) women (78% exercise-CSE, 22% dobutamine-CSE). In those who completed follow-up, CSE was abnormal in 33 women (10.5%) and sECG was abnormal in 21 (6.7%). In 33 women with abnormal CSE, sECG was abnormal in 7 (21.2%) and normal in 26 (79%), p = 0.0004. CE occurred in 27 (8.6%) women: 8 all-cause mortality, 2 nonfatal MI, 13 CP, and 4 REVASC. CE occurred in 21% versus 7% of women with abnormal versus normal CSE, p = 0.014 and 38% versus 6% of women with abnormal versus normal sECG, p < 0.0001. Rest BNP was higher in women with CE versus those without (p = 0.018). Abnormal sECG and abnormal CSE were associated with CE, while only abnormal sECG was an independent predictor of CE (adjusted HR 10.3 [1.9-61.4], p = 0.007). Of the laboratory results, only BNP was associated with CE (adjusted HR 2.9 [1.1-7.3], p = 0.028). CONCLUSIONS: sECG and rest BNP were independent predictors of subsequent CE within 5 years in peri/postmenopausal women at low to intermediate risk of CAD.


Assuntos
Biomarcadores/sangue , Dor no Peito/etiologia , Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/estatística & dados numéricos , Eletrocardiografia , Menopausa , Prognóstico , Adulto , Idoso , Angina Pectoris/epidemiologia , Arizona/epidemiologia , Índice de Massa Corporal , Ecocardiografia sob Estresse/métodos , Teste de Esforço , Feminino , Florida/epidemiologia , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio/epidemiologia , Estudos Prospectivos , Medição de Risco , Fatores de Risco
5.
Asian Pac J Cancer Prev ; 18(9): 2395-2401, 2017 09 27.
Artigo em Inglês | MEDLINE | ID: mdl-28950684

RESUMO

Background: MicroRNA deregulation may occur during hepatocellular carcinoma (HCC) genesis and progression stages. MicroRNA-34a (miR-34a) functions as a tumor suppressor and is down-regulated or silenced in a variety of human cancers, while heat shock proteins (Hsps) play important roles in assisting protein folding and preventing both protein aggregation and transport across membranes. The present study aimed to evaluating serum expression of miR-34a and its target Hsp70 for early detection of HCC in patients with liver cirrhosis (LC), focusing on correlations with clinicopathological features. Methods: A total of 180 patients were included: 120 with HCC on top of LC (60 with either early or late HCC) and 60 patients with HCV-related LC. In addition, 60 healthy individuals were considered as controls. Real-time polymerase chain reactions were performed for expression profiling of serum miR-34a and Hsp70 and for allelic discrimination of the promotor variant (rs2763979, C/T). In addition, in silico analysis was carried out. Results: All participants were heterozygote for the promotor polymorphism. miR-34a serum levels were significantly under-expressed in LC and especially HCC patients as compared to controls. Associations with a high Child-Turcotte- Pugh (CTP) score, advanced cancer stage, and number of masses were noted. In contrast the target Hsp70 was significantly overexpressed in cancer patients but not in LC group and inversely correlated with miR-34a levels. Conclusion: Utility of circulating miRNAs as biomarkers for early detection of HCC was raised. Future large-scale studies are warranted to confirm the current findings.

7.
Circ Heart Fail ; 10(2)2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28159826

RESUMO

BACKGROUND: Afterload reduction is a cornerstone in the management of patients with heart failure (HF) and reduced ejection fraction. However, arterial load and the effect of HF therapies on afterload might vary between individuals. Tailoring vasoactive medicines to patients with HF based upon better understanding of arterial afterload may enable better individualization of therapy. METHODS AND RESULTS: Subjects with HF and reduced ejection fraction underwent aggressive titration of vasoactive HF therapies with assessment of central aortic waveforms analyzed using pulse wave, wave separation, and arterial reservoir models. Clinical response to treatment was assessed using the 6-minute walk test distance, which increased in 25 subjects and decreased or remained unchanged in 13. Subjects with improvement on therapy displayed higher aortic pressure wave pulsatility (central pulse pressure [PP], reflected pressure wave, and reservoir pressure) at study entry compared with subjects without improvement (all P<0.05). Parameters derived by the arterial analysis methods were strongly correlated with one another and displayed similar ability to predict improvement. Aortic pressure pulsatility significantly decreased in subjects with functional improvement, whereas no change was observed in patients without functional improvement (P for interaction <0.05). These differences in arterial load at baseline and on therapy were not apparent from conventional brachial artery cuff pressure assessments. CONCLUSIONS: Increased aortic pressure wave pulsatility and greater decrease in pulsatility on treatment are associated with functional improvement in patients with HF and reduced ejection fraction receiving aggressive vasodilator titration. These differences are not identifiable using brachial cuff pressures. Central aortic waveform analysis may enable better individualization of vasoactive therapies in chronic HF and reduced ejection fraction. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00588692.


Assuntos
Aorta/efeitos dos fármacos , Pressão Arterial/efeitos dos fármacos , Insuficiência Cardíaca/tratamento farmacológico , Fluxo Pulsátil/efeitos dos fármacos , Rigidez Vascular/efeitos dos fármacos , Vasodilatadores/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Aorta/fisiopatologia , Doença Crônica , Teste de Esforço , Tolerância ao Exercício/efeitos dos fármacos , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota , Projetos Piloto , Análise de Onda de Pulso , Recuperação de Função Fisiológica , Método Simples-Cego , Volume Sistólico/efeitos dos fármacos , Fatores de Tempo , Resultado do Tratamento , Vasodilatadores/efeitos adversos , Função Ventricular Esquerda/efeitos dos fármacos , Caminhada
8.
Mayo Clin Proc ; 91(11): 1535-1544, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27720456

RESUMO

OBJECTIVE: To evaluate the impact of screening stress testing for coronary artery disease in asymptomatic patients with diabetes in a community-based population. PATIENTS AND METHODS: This observational study included 3146 patients from Olmsted County, Minnesota, with no history of coronary artery disease or cardiac symptoms in whom diabetes was newly diagnosed from January 1, 1992, through December 31, 2008. With combined all-cause mortality and myocardial infarction as the primary outcome, weighted Cox proportional hazards regression was performed with screening stress testing within 2 years of diabetes diagnosis as the time-dependent covariate. For descriptive analysis, participants were classified by their clinical experience during the first 2 years postdiagnosis as screened (asymptomatic, underwent stress test), unscreened (asymptomatic, no stress test), or symptomatic (experienced symptoms or event). RESULTS: Among the screened and unscreened participants, 54% (1358 of 2538) were men; the mean (SD) age at diabetes diagnosis was 55 years (13.8 years), and 97% (2442 of 2520) had type 2 diabetes. In event-free survival analysis, 292 patients comprised the screened cohort and 2246 patients comprised the unscreened cohort. Death or myocardial infarction occurred in 454 patients (32 patients in the screened cohort and 422 in the unscreened cohort [5-year rate, 1.9% and 5.3%, respectively]) during median (interquartile range) follow-up of 9.1 years (5.3-12.5 years). Screening stress testing was associated with improved event-free survival (hazard ratio, 0.61; P=.004), independent of cardiac risk factors. However, while stress test results were abnormal in 47 of the 292 screened patients (16%), only 6 (2%) underwent coronary revascularization. CONCLUSION: Although screening cardiac stress testing in asymptomatic patients with diabetes in this community-based population was associated with improvement in long-term event-free survival, this result does not appear to occur by coronary revascularization alone.


Assuntos
Doenças Assintomáticas , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Diabetes Mellitus Tipo 2/epidemiologia , Teste de Esforço , Estudos de Coortes , Ponte de Artéria Coronária/estatística & dados numéricos , Diagnóstico Precoce , Ecocardiografia sob Estresse , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio/epidemiologia , Imagem de Perfusão do Miocárdio , Intervenção Coronária Percutânea/estatística & dados numéricos , Modelos de Riscos Proporcionais
9.
Echocardiography ; 33(10): 1539-1545, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27546353

RESUMO

PURPOSE: Infarct mass as assessed by myocardial-delayed enhancement imaging on cardiac magnetic resonance (CMR) and myocardial blood flow as assessed by real time myocardial perfusion echocardiography (RT-MPE) have been shown to predict adverse events following ST elevation myocardial infarction (STEMI). There has been no published comparison of quantitative assessment using these modalities as predictors of clinical outcomes to date. We compared RT-MPE with CMR for prediction of cardiac events in reperfused STEMI patients. MATERIALS AND METHODS: Consecutive STEMI patients with early reperfusion were studied. RT-MPE and CMR were performed. Perfusion score indices (PSIRT-MPE and PSICMR ) were calculated [sum of segmental perfusion scores/number of segments]. CMR infarct mass (g) and RT-MPE myocardial blood flow (MBF dB/s) were quantified. Patients were followed for cardiac events (death, nonfatal MI, revascularization, angina, and heart failure). RESULTS: All 27 patients (age 62±14; follow-up 3.5±2.6 years) had thrombolysis in myocardial infarction (TIMI) grade 3 flow of infarct vessel. Cardiac events occurred in 17 (63%). Cardiac event patients had higher PSIRT-MPE , PSICMR , infarct mass, and lower MBF. PSIRT-MPE cutoff of 0.3 had an AUC of 0.856 (82% sensitivity, 70% specificity), while a PSICMR cutoff of 0.2 had an AUC of 0.765 (76% sensitivity, 60% specificity). Infarct mass and MBF were independent predictors of cardiac events after adjusting for risk factors (hazard ratios: 20.9 [95% CI 1.8-256] P=.02 and 8.1 [95% CI 1.5-78] P=.01, respectively). CONCLUSIONS: Quantitative RT-MPE performed comparably to CMR for prediction of MACE in STEMI patients supporting a prognostic role for this noninvasive, bedside imaging method.


Assuntos
Ecocardiografia/métodos , Imagem Cinética por Ressonância Magnética/métodos , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/cirurgia , Imagem de Perfusão do Miocárdio/métodos , Revascularização Miocárdica/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio/mortalidade , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Resultado do Tratamento
10.
J Womens Health (Larchmt) ; 25(10): 1014-1020, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27258570

RESUMO

INTRODUCTION: We aim to describe changes in exercise habits and barriers to physical activity over 5 years in menopausal women at low-intermediate risk for cardiovascular disease. MATERIALS AND METHODS: Women in the Stress Echocardiography in Menopausal Women at Risk for Coronary Artery Disease trial were prospectively enrolled in a multisite study from 2004 to 2007. Inclusion criteria were as follows: peri- and postmenopausal women with symptoms and/or risk factors for cardiovascular disease resulting in referral for stress echocardiography. A questionnaire, which assessed details of medical history, physical activity, and body mass index (BMI), was administered at baseline and 5 years. RESULTS: 216 menopausal women (62.5% hypertensive, 15.3% diabetic, 52.3% prior or current smokers) were studied. At baseline, age was 54.9 ± 4.8 years, BMI was 30.7 ± 6.4 kg/m2, and Framingham risk score was 4.05% ± 3.76%. One hundred women (46.3%) were obese, 79 (36.6%) overweight, and 37 (17.1%) had a normal BMI. Women changed their self-reported aerobic exercise patterns in similar patterns regardless of their BMI at baseline. There was low participation in strength training among all women. Mean BMI decreased by 0.12 kg/m2 in obese women and increased by 1.63 kg/m2 in normal BMI women at 5 years (p < 0.0001). CONCLUSION: These data suggest that women can increase their level of physical activity regardless of BMI and that overweight or obese status is not a barrier to initiating an aerobic, nonaerobic, or strength training exercise routine.


Assuntos
Ecocardiografia sob Estresse/métodos , Teste de Esforço , Exercício , Menopausa , Pós-Menopausa , Adulto , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/etiologia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade , Obesidade/complicações , Sobrepeso/complicações , Estudos Prospectivos , Fatores de Risco , Inquéritos e Questionários
11.
Artigo em Inglês | MEDLINE | ID: mdl-27313280

RESUMO

BACKGROUND: The CoreValve US High-Risk Clinical Study compared clinical outcomes and serial echocardiographic findings in patients with severe aortic valve stenosis after transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis or surgical aortic valve replacement (SAVR). METHODS AND RESULTS: Eligible patients were randomly assigned 1:1 to TAVR with a self-expanding bioprosthesis or SAVR (N=747). Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, and 1 year after the procedure and were analyzed at a central core laboratory. Compared with SAVR patients (N=357), TAVR patients (N=390) had a lower mean aortic valve gradient, larger valve area, and less patient-prosthesis mismatch (all P<0.001), but more paravalvular regurgitation at discharge, which decreased at 1 year. SAVR patients experienced significant right ventricular systolic dysfunction at discharge and 1 month with normal right ventricular function at 1 year. One-year all-cause mortality was 14.2% for TAVR and 19.1% for SAVR patients. Preimplantation aortic regurgitation ≥mild was associated with reduced mortality hazard for both the TAVR (hazard ratio 0.48, 95% confidence interval 0.27-0.85; P=0.01) and the SAVR groups (hazard ratio 0.53, 95% confidence interval 0.32-0.87; P=0.01). Aortic regurgitation ≥mild after TAVR was associated with increased risk for all-cause mortality (hazard ratio 1.95, 95% confidence interval 1.08-3.53; P=0.03). CONCLUSIONS: In patients with severe aortic stenosis at increased surgical risk, TAVR was associated with better systolic valve performance, similar left ventricular remodeling, more paravalvular regurgitation, and less right ventricular systolic dysfunction compared with SAVR. Despite an overall mortality reduction for the TAVR group, ≥mild aortic valve regurgitation after TAVR was associated with an increased mortality hazard. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240902.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Ecocardiografia Doppler , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Desenho de Prótese , Substituição da Valva Aórtica Transcateter/instrumentação , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemodinâmica , Humanos , Masculino , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos , Função Ventricular Esquerda , Função Ventricular Direita , Remodelação Ventricular
12.
J Am Soc Echocardiogr ; 29(6): 491-502, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27038513

RESUMO

BACKGROUND: Intraplaque neovascularization is considered an important indicator of plaque vulnerability. Contrast-enhanced ultrasound (CEUS) of carotid arteries improves imaging of carotid intima-media thickness and permits real-time visualization of neovascularization of the atherosclerotic plaque. The authors conducted a systematic review and meta-analysis to evaluate the accuracy of CEUS-detected carotid atherosclerotic plaque. METHODS: A systematic search was performed to identify studies published in the MEDLINE, Embase, Scopus, and Web of Science databases from 2004 to June 2015. Studies evaluating the accuracy of quantitative analysis and qualitative analysis (visual interpretation) for the diagnosis of intraplaque neovascularization compared with histologic specimens and/or clinical diagnosis of symptomatic plaque were included. Parameters evaluated were plaque quantitative CEUS intensity and the visual grading of plaque CEUS. A random-effects meta-analysis was used to pool the likelihood ratios (LRs), diagnostic odds ratios, and summary receiver operating characteristic curves. Corresponding areas under the curves were calculated. RESULTS: The literature search identified 203 studies, 20 of which were selected for systematic review; the final meta-analysis included seven studies. For qualitative CEUS, pooled sensitivity was 0.80 (95% CI, 0.72-0.87), pooled specificity was 0.83 (95% CI, 0.76-0.89), the pooled positive LR was 3.22 (95% CI, 1.67-6.18), the pooled negative LR was 0.24 (95% CI, 0.09-0.64), the pooled diagnostic odds ratio was 15.57 (95% CI, 4.94-49.03), and area under the curve was 0.894. For quantitative CEUS, pooled sensitivity was 0.77 (95% CI, 0.71-0.83), pooled specificity was 0.68 (95% CI, 0.62-0.73), the pooled positive LR was 2.34 (95% CI, 1.69-3.23), the pooled negative LR was 0.34 (95% CI, 0.25-0.47), the pooled diagnostic odds ratio was 7.06 (95% CI, 3.6-13.82), and area under the curve was 0.888. CONCLUSIONS: CEUS is a promising noninvasive diagnostic modality for detecting intraplaque neovascularization. Standardization of quantitative analysis and visual grading classification is needed to increase reliability and reduce technical heterogeneity.


Assuntos
Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/epidemiologia , Espessura Intima-Media Carotídea/estatística & dados numéricos , Meios de Contraste , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Modelos Estatísticos , Prevalência , Reprodutibilidade dos Testes , Medição de Risco , Sensibilidade e Especificidade , Revisão da Utilização de Recursos de Saúde
13.
JACC Cardiovasc Imaging ; 8(12): 1364-1375, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26508386

RESUMO

OBJECTIVES: The aim of this study was to describe the natural history and clinical importance of paravalvular aortic regurgitation (PVAR) after CoreValve transcatheter aortic valve replacement (TAVR) and to relate these findings to the structural and hemodynamic changes documented by serial echocardiographic analysis. BACKGROUND: PVAR after TAVR with the self-expanding CoreValve bioprosthesis has been shown to regress over time, but the time course and the mechanism of PVAR regression has not been completely characterized. METHODS: Patients with severe aortic stenosis who underwent CoreValve TAVR and followed up to 1 year in the multicenter CoreValve U.S. Pivotal Trial (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement) were studied. Serial echocardiography studies were analyzed by an echocardiographic core laboratory. Annular sizing ratio was calculated from computed tomography measurements. Paired, as well as total, data were compared. RESULTS: The CoreValve was implanted in 634 patients with a mean age of 82.7 ± 8.4 years. After a marked improvement noted at discharge, aortic valve velocity, mean gradient, and effective orifice area further improved significantly at 1 month (2.08 ± 0.45 m/s vs. 1.99 ± 0.46 m/s, p < 0.0001, 9.7 ± 4.4 mm Hg vs. 8.9 ± 4.6 mm Hg, p < 0.0001, and 1.78 ± 0.51 cm(2) vs. 1.85 ± 0.58 cm(2), p = 0.03, respectively). The improvement was sustained through 1 year. PVAR was moderate or severe in 9.9%, and of 36 patients with moderate PVAR at discharge and paired data, 30 (83%) improved at least 1 grade of regurgitation at 1 year. Annular sizing ratio was significantly associated with the degree of PVAR. CONCLUSIONS: There was further improvement in aortic prosthetic valve hemodynamics and regression of PVAR up to 1 year compared with discharge after TAVR with CoreValve. These changes are possibly due to remodeling and outward expansion of the self-expandable CoreValve with nitinol frame. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902).


Assuntos
Insuficiência da Valva Aórtica/etiologia , Estenose da Valva Aórtica/terapia , Bioprótese , Causas de Morte , Falha de Prótese , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Ecocardiografia/métodos , Feminino , Seguimentos , Próteses Valvulares Cardíacas , Hemodinâmica/fisiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Remissão Espontânea , Medição de Risco , Estatísticas não Paramétricas , Taxa de Sobrevida , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/métodos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos
14.
J Am Soc Echocardiogr ; 28(12): 1393-400, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26416199

RESUMO

BACKGROUND: The aim of this study was to compare the efficacy of myocardial perfusion (MP) and wall motion (WM) analysis obtained with real-time myocardial contrast echocardiography (RTMCE) and two widely used contrast agents in detecting coronary artery disease after injection of the vasodilator regadenoson. METHODS: One hundred fifty patients were studied at two academic centers using regadenoson (400-µg intravenous bolus) vasodilator stress RTMCE (7.5% Optison infusion [n = 50] or 1.5% Definity infusion [n = 100]). Both MP and WM with RTMCE were analyzed at rest and after regadenoson bolus. Comparisons of WM and MP sensitivity, specificity, and accuracy were made. Quantitative angiography was performed in all patients within 1 month of the regadenoson stress study (>50% and >70% diameter stenosis was considered significant). Reviewers were blinded to all clinical and quantitative angiographic data. RESULTS: Rate-pressure product after regadenoson was higher in Optison than Definity patients (P = .004). Using a 50% diameter stenosis on quantitative angiography as a reference standard, overall sensitivity, specificity, and accuracy for combined WM and MP analysis were not different for both agents (Optison, 77%, 64%, and 73%; Definity, 80%, 74%, and 78%; P = NS). The sensitivity, specificity, and accuracy of WM analysis alone for Optison were 68%, 71%, and 69% compared with 60%, 72%, and 66% for Definity (P = NS). Adding MP analysis improved the sensitivity and accuracy of Definity for detecting both >50% and >70% stenoses (P < .001 vs WM), while MP analysis did not improve the sensitivity of Optison for detecting either >50 or >70% stenoses. CONCLUSIONS: RTMCE during regadenoson stress using either Optison or Definity is a rapid and effective method for the detection of coronary artery disease. The ability of MP imaging to improve WM accuracy may depend on the rate-pressure product achieved.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Imagem de Perfusão do Miocárdio/métodos , Purinas/administração & dosagem , Pirazóis/administração & dosagem , Agonistas do Receptor A2 de Adenosina/administração & dosagem , Meios de Contraste/administração & dosagem , Angiografia Coronária , Estudos de Viabilidade , Feminino , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
15.
J Womens Health (Larchmt) ; 24(3): 174-81, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25761214

RESUMO

BACKGROUND: A women-based formula for calculation of age-predicted maximum heart rate [age-predicted maximum heart rate=206-(0.88×age)] was established in asymptomatic volunteer women undergoing treadmill exercise tolerance testing (ETT). We sought to perform a comparison of the performance of this women-based formula for prediction of peak heart rate to the traditional formula [220-age] and our own database-generated prediction formula in a large database of women undergoing ETT. METHODS: We performed a retrospective analysis of all consecutive women who underwent symptom-limited Bruce protocol ETT at the Mayo Clinic from 1994 to 2010. Women with known cardiovascular disease or those using beta blockers, calcium channel blockers, or digitalis were excluded. Separate analyses were performed according to symptomatic status. RESULTS: The study included 11,029 women (89.4% Caucasian) with a mean age 52±12 years; 3,632 (33%) were referred specifically for evaluation of symptoms. Age-predicted maximum heart rate calculated by the traditional formula was achieved by 49.7% of women versus 69.9% by the women-based formula with most of the underestimation observed in older women. Average absolute deviation between achieved and predicted peak heart rate (HR) was 10.85±9.18 bpm for traditional versus 11.98±9.00 for women-based formulas (dependent t=-16.64, p<0.0001). The linear regression line calculated from our population [HR=201-(0.67×age)] was closer to the women-based formula, both in terms of intercept and slope than the traditional formula. Peak HR was shown to be slightly affected (-2.5 bpm) by symptom status at referral, whereas smoking and diabetes more significantly reduced achieved peak HR. CONCLUSIONS: The women-based formula underestimated peak HR, especially in older women, but was observed to be closer in both intercept and slope to the regression line determined from our study in this large population of female patients. These sex-unique observations should be taken into account when determining adequacy and targets for ETT in women.


Assuntos
Exercício/fisiologia , Frequência Cardíaca/fisiologia , Modelos Cardiovasculares , Adolescente , Adulto , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Teste de Esforço , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
16.
Expert Rev Cardiovasc Ther ; 13(4): 445-53, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25695762

RESUMO

Type 2 diabetes mellitus patients are at increased risk for macrovascular and microvascular complications. Both in vivo and in vitro studies of small arteries and arterioles of diabetic subjects demonstrate impaired endothelial function without anatomic lesions. Coronary flow reserve (CFR) is a surrogate marker of coronary microcirculatory endothelial function in diabetic patients without significant stenosis of the associated epicardial coronary artery. Glycosylated hemoglobin A1c is related to likelihood of occurrence of microvascular events. The objective of this article is to report on recent developments in multiple noninvasive techniques to assess CFR and their use in aiding the understanding of the relationship of CFR, glycemic control and cardiovascular outcomes.


Assuntos
Circulação Coronária , Vasos Coronários/diagnóstico por imagem , Diabetes Mellitus Tipo 2/metabolismo , Angiopatias Diabéticas/diagnóstico , Hemoglobina A Glicada/metabolismo , Coração/diagnóstico por imagem , Microcirculação , Microvasos/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Diabetes Mellitus Tipo 2/complicações , Angiopatias Diabéticas/etiologia , Angiopatias Diabéticas/fisiopatologia , Ecocardiografia Doppler , Humanos , Microvasos/fisiopatologia , Imagem de Perfusão do Miocárdio , Tomografia por Emissão de Pósitrons , Tomografia Computadorizada de Emissão de Fóton Único
17.
Eur J Prev Cardiol ; 22(5): 636-44, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-24821732

RESUMO

BACKGROUND: a negative peak supine bicycle exercise stress echocardiography (ESE) was shown to have a long-term favourable prognostic value. Data on the long-term prognosis of ischaemic electrocardiographic (ISECG) changes in the setting of a negative peak supine bicycle ESE are lacking. DESIGN: we evaluated the prognostic value of negative peak supine bicycle ESE with or without concomitant ISECG changes in a referral population evaluated for chest pain after an inconclusive first-line work-up including clinical evaluation and exercise ECG stress. METHODS: from 2003 to 2010, patients who underwent a peak supine bicycle ESE and were deemed to be negative were evaluated. Two groups based on concomitant stress ECG tracing were analysed - those with normal stress ECG and those with ISECG changes. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations. RESULTS: a total of 371 patients (mean age 59.1 ± 12.1 years, 49.9% women) were studied. Of those, 141 (38.0%) had concomitant ISECG changes. Mean follow-up was 3.46 ± 1.76 years. The primary endpoint occurred in 3.0% of patients, (2.2% in those with normal stress ECG, and in 4.3% with ISECG changes, p = 0.251); with unadjusted hazard ratio for primary endpoint of 2.04 (95%CI 0.62-6.69, p = 0.239) in patients with ISECG changes compared to those with normal stress ECG. CONCLUSIONS: in an outpatient population without known CAD evaluated for chest pain after inconclusive first-line work-up, a negative peak supine bicycle ESE confers an excellent prognosis regardless of the nature of concomitant stress ECG abnormalities.


Assuntos
Dor no Peito/diagnóstico por imagem , Eletrocardiografia , Teste de Esforço/métodos , Decúbito Dorsal/fisiologia , Idoso , Dor no Peito/mortalidade , Ecocardiografia sob Estresse , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Medição de Risco
18.
Heart Vessels ; 30(1): 45-55, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24408670

RESUMO

Successful restoration of patency of the infarct-related artery is important in management of acute ST-segment elevation myocardial infarction (STEMI); however, it does not necessarily translate into the restoration of perfusion at the tissue level. In this study, we evaluate the prognostic role of qualitative and quantitative myocardial contrast echocardiography (MCE) in predicting cardiac events (after adjustment for cardiovascular risk factors) in STEMI patients undergoing reperfusion. Bedside resting real-time MCE using continuous infusion of diluted contrast agent (Definity) was performed within a median of 21.4 h from revascularization in STEMI. Myocardial perfusion on qualitative MCE was graded 1 = homogenous; 2 = partial/patchy; and 3 = absent. Perfusion score index (PSI) was calculated by adding the perfusion score in all segments divided by the total number of evaluable segments. Quantitative perfusion parameters [A, dB; ß, sec(-1); and Aß] were analyzed using a 17-segment model. Patients were followed for cardiac events including death; nonfatal myocardial infarction (MI); hospitalization for cardiac symptoms; coronary revascularization; or heart failure. Thirty-seven reperfused STEMI patients with a mean age of 64 years (range, 40-86 years) were enrolled and followed for a median of 1.4 years. Cardiac events occurred in 22 patients. Patients with cardiac events had a higher perfusion score index (PSI), and lower A, ß and Aß parameters compared to patients without events [1.84 ± 0.36 vs 1.39 ± 0.17 for PSI, P < 0.001; 0.57 ± 0.24 vs 0.85 ± 0.30 for A, P = 0.03; 0.34 ± 0.15 vs. 0.53 ± 0.17 for ß, P = 0.002; and 0.21 ± 0.12 vs. 0.49 ± 0.32, for Aß, P = 0.003; respectively]. A PSI value of 1.58 provided an area under the curve (AUC) of 0.873, while ß of 0.423 and Aß of 0.323 provided an AUC of 0.858 and 0.842, respectively. PSI and Aß were independent predictors of cardiac events with an adjusted hazard ratio of 3.41 (1.19-12.27); and 4.19 (1.3-19.09), respectively. No contrast-related side effects were reported. Evaluation of perfusion in reperfused STEMI patients by qualitative and quantitative MCE (myocardial blood flow, Aß) provides independent prediction of cardiac events.


Assuntos
Síndrome Coronariana Aguda/diagnóstico por imagem , Ecocardiografia , Fluorcarbonetos , Infarto do Miocárdio/diagnóstico por imagem , Intervenção Coronária Percutânea , Idoso , Meios de Contraste , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Reperfusão Miocárdica , Prognóstico , Análise de Regressão , Fatores de Risco , Sensibilidade e Especificidade
19.
Mayo Clin Proc ; 89(12): 1664-72, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25441400

RESUMO

OBJECTIVE: To analyze a large cohort of patients who underwent exercise testing and also report sex differences in other exercise heart rate (HR) parameters to determine whether separate sex-based equations to predict peak HR are indicated. PATIENTS AND METHODS: Patients aged 40 to 89 years who performed treadmill exercise tests (Bruce protocol) from September 21, 1993, to December 20, 2010, were included. Patients with cardiovascular disease or taking HR-attenuating drugs were excluded. After analyses on preliminary cohort, peak HR-modifying factors were eliminated to obtain a pure data set. Analysis of variance was used to test difference in HR responses by sex with age adjustment. RESULTS: A total of 37,010 patients (67.3% men) were included in the preliminary cohort. Men had higher peak HR (166±17 vs 163±16 beats/min [bpm]; P<.001), HR reserve (90±19 vs 84±17 bpm; P<.001), and HR recovery (19±8 vs 18±9 bpm; P<.03). Poor exercise capacity, current smoking, diabetes, and obesity had significant peak HR-lowering effects (all P<.001). In a pure cohort of 19,013 patients (51.3% of full cohort) without these factors, regression lines approximated more closely the traditional line of 220 - age. For men, the regression line in our final cohort was peak HR = 220 - 0.95 × age. For women, both slope (0.79 bpm/y) and intercept (210 bpm) were still substantially different from those obtained with the traditional formula. CONCLUSION: The HR responses to exercise are different in men and women. The HR response of men was close to that obtained with the traditional formula, but peak HR in women had a lower intercept and decreased more slowly with age. A separate formula for peak HR in women appears to be appropriate.


Assuntos
Exercício/fisiologia , Frequência Cardíaca/fisiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Eletrocardiografia , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais
20.
J Diabetes Res ; 2014: 243518, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25097860

RESUMO

To study the relationship between glycosylated hemoglobin (HgbA1c) and myocardial perfusion in type 2 diabetes mellitus (T2DM) patients, we prospectively enrolled 24 patients with known or suspected coronary artery disease (CAD) who underwent adenosine stress by real-time myocardial perfusion echocardiography (RTMPE). HgbA1c was measured at time of RTMPE. Microbubble velocity (ß min(-1)), myocardial blood flow (MBF, mL/min/g), and myocardial blood flow reserve (MBFR) were quantified. Quantitative MCE analysis was feasible in all patients (272/384 segments, 71%). Those with HgbA1c > 7.1% had significantly lower ßreserve and MBFR than those with HgbA1c ≤ 7.1% (P < 0.05). In patients with suspected CAD, there was a significant inverse correlation between MBFR and HgbA1c (r = -0.279, P = 0.01); however, in those with known CAD, this relationship was not significant (r = -0.117, P = 0.129). Using a MBFR cutoff value > 2 as normal, HgbA1c > 7.1% significantly increased the risk for abnormal MBFR, (adjusted odds ratio: 1.92, 95% CI: 1.12-3.35, P = 0.02). Optimal glycemic control is associated with preservation of MBFR as determined by RTMPE, in T2DM patients at risk for CAD.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Diabetes Mellitus Tipo 2/sangue , Angiopatias Diabéticas/diagnóstico por imagem , Ecocardiografia sob Estresse , Reserva Fracionada de Fluxo Miocárdico , Hemoglobina A Glicada/análise , Imagem de Perfusão do Miocárdio/métodos , Adenosina , Idoso , Biomarcadores/sangue , Velocidade do Fluxo Sanguíneo , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/fisiopatologia , Diabetes Mellitus Tipo 2/complicações , Angiopatias Diabéticas/etiologia , Angiopatias Diabéticas/fisiopatologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Prospectivos , Fluxo Sanguíneo Regional , Fatores de Risco , Vasodilatadores/uso terapêutico
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