Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 396
Filtrar
2.
J Cardiovasc Magn Reson ; 22(1): 74, 2020 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-33040733

RESUMO

AIM: Human Immunodeficiency Virus (HIV) patients commonly experience dyspnea for which an immediate cause may not be always apparent. In this prospective cohort study of HIV patients with exercise limitation, we use cardiopulmonary exercise testing (CPET) coupled with exercise cardiovascular magnetic resonance (CMR) to elucidate etiologies of dyspnea. METHODS AND RESULTS: Thirty-four HIV patients on antiretroviral therapy with dyspnea and exercise limitation (49.7 years, 65% male, mean absolute CD4 count 700) underwent comprehensive evaluation with combined rest and maximal exercise treadmill CMR and CPET. The overall mean oxygen consumption (VO2) peak was reduced at 23.2 ± 6.9 ml/kg/min with 20 patients (58.8% of overall cohort) achieving a respiratory exchange ratio > 1. The ventilatory efficiency (VE)/VCO2 slope was elevated at 36 ± 7.92, while ventilatory reserve (VE: maximal voluntary ventilation (MVV)) was within normal limits. The mean absolute right ventricular (RV) and left ventricular (LV) contractile reserves were preserved at 9.0% ± 11.2 and 9.4% ± 9.4, respectively. The average resting and post-exercise mean average pulmonary artery velocities were 12.2 ± 3.9 cm/s and 18.9 ± 8.3 respectively, which suggested lack of exercise induced pulmonary artery hypertension (PAH). LV but not RV delayed enhancement were identified in five patients. Correlation analysis found no relationship between peak VO2 measures of contractile RV or LV reserve, but LV and RV stroke volume correlated with PET CO2 (p = 0.02, p = 0.03). CONCLUSION: Well treated patients with HIV appear to have conserved RV and LV function, contractile reserve and no evidence of exercise induced PAH. However, we found evidence of impaired ventilation suggesting a non-cardiopulmonary etiology for dyspnea.

3.
Curr Probl Cardiol ; : 100654, 2020 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-32958324

RESUMO

Acute aortic syndrome (AAS) is an emergency and life-threatening condition including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer and iatrogenic-traumatic aortic injury. An integrated multiparametric approach (clinical history and examination, electrocardiogram, biomarkers and imaging techniques) is recommended in order to make timely and accurate diagnosis, delineate the prognosis, choose the most appropriate therapeutic interventions tailored for the individual patient. Nowadays the best imaging strategy for diagnosing AAS and its complications is a combination of transthoracic echocardiography and computed tomography angiography (CTA). Transesophageal echocardiography tends to be carried out in complicated cases prior to surgical or endovascular therapy, often in the operating room and under general anesthesia. In this regard, intravascular ultrasound and intraluminal phase array imaging may be implemented during the endovascular procedures depending on operator expertise and cost issues. On the other hand, owing to its intrinsic characteristics, magnetic resonance imaging is an ideal imaging technique for serial measurements in patients at risk of AAS or with chronic dissection. Among biomarkers, D-dimer is the closest to "golden status" (high sensitivity and low negative likelihood ratio). Interestingly, 18fluorodeoxyglucose positron emission tomography/CT is increasingly being used along with specific serologic biomarkers (white blood cells, C-reactive protein, fibrinogen and D-dimer) to detect and monitor vascular inflammation affecting the aorta and systemic arteries. It is expected, in the near future, the development of serologic and imaging biomarkers able to early detect clinically-silent pathologic changes in the aorta wall before (primary prevention) and after (secondary prevention) the acute index event.

5.
J Card Surg ; 2020 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-32939836

RESUMO

BACKGROUND: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data. METHODS: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am. RESULTS: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference. CONCLUSIONS: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

6.
Artigo em Inglês | MEDLINE | ID: mdl-32858628

RESUMO

: In the last 20 years, a substantial improvement in the efficacy of cancer treatment has induced a progressive increase in cancer survival, with an obvious parallel increase in morbidity and mortality related to the adverse effects of anticancer therapy, in particular, cardiovascular complications. In relation to the peculiar aspects related to cardiac and vascular toxicity, clinical management of patients should be ideally reserved for experts in the field of this novel medical discipline, which has been defined as cardio-oncology. The rationale for this choice corresponds to the aim of identifying patients more prone to developing cardiovascular damage, prevent overt cardiotoxicity and conduct active surveillance of treated patients for early identification of cardiac and vascular involvement during short- and long-term follow-up. Due to the burden of treated cancer patients, the development of dedicated cardio-oncology services has become one of the main goals of contemporary medicine, needed to accomplish the peculiar mission of guiding the patients through the narrow path of cancer survival without the expense of cardiovascular damage. The main purpose of cardio-oncology services is to provide dedicated cardiologic care to cancer patients affected by concomitant (subclinical or overt) cardiovascular diseases, either preexisting the cancer onset or acquired during and after the time course of anticancer therapy. In this article, we describe a possible spoke-hub model of cardio-oncology services, which could be appropriately applied in Italy. Rationale, organization, definition of referral criteria, strategies, interventional programs, long-term surveillance and home assistance of this model are described and discussed.

7.
Chest ; 2020 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-32805242

RESUMO

A right heart catheterization with measurements of pulmonary artery wedge pressure (PAWP) may be necessary for the diagnosis of left heart failure as a cause of pulmonary hypertension or unexplained dyspnea. Diagnostic cutoff values are a PAWP of ≥ 15 mm Hg at rest or a PAWP of ≥ 25 mm Hg during exercise. However, accurate measurement of PAWP can be challenging and heart failure may be occult. Left heart catheterization, with measurement of left ventricular end-diastolic pressure, may also be indecisive. Measurements are then best repeated in stress conditions. Exercise is an option, but the equipment is not universally available, and interpretation can be difficult in patients with wide respiratory pressure swings. An alternative is offered by a fluid challenge. Studies have gathered data supporting infusion of 500 mL or 7 mL/kg saline and a PAWP of 18 mm Hg as a diagnostic cutoff. The procedure is simple and does not take much catheterization laboratory time. Combining echocardiography with invasive measurements may increase the diagnostic accuracy of diastolic dysfunction. Cardiac output after a fluid challenge may be of prognostic relevance.

8.
Echocardiography ; 2020 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-32762102

RESUMO

OBJECTIVES: To analyze left ventricular (LV) myocardial deformation and contractile reserve (CR) in asymptomatic patients with severe aortic regurgitation (AR) at rest and during exercise, and their correlation with functional capacity. BACKGROUND: The natural history of chronic AR is characterized by a prolonged silent phase before onset of symptoms and overt LV dysfunction. Assessment of LV systolic function and contractile reserve has an important role in the decision-making of AR asymptomatic patients. METHODS: Standard echo, lung ultrasound, and LV 2D speckle tracking strain were performed at rest and during exercise in asymptomatic patients with severe AR and in age- and sex-comparable healthy controls. RESULTS: 115 AR patients (male sex 58.2%; 52.3 ± 18.3 years) and 55 controls were enrolled. Baseline LV ejection fraction was comparable between the groups. Resting LV global longitudinal strain (GLS) and myocardial work efficiency (MWE) were significantly reduced in AR (GLS-15.8 ± 2.8 vs -21.4 ± 4.4; P < .001). Patients with AR and CR- showed reduced resting LV GLS and MWE and increased B-lines. MWE was closely related to peak effort watts, VO2 , LV E/e', and B-lines, at a multivariable analysis. Both GLS and MWE were strong independent predictors of CR. A resting LV GLS cutoff of -12% differentiated CR+ and CR- (78% sensitivity and 84% specificity). CONCLUSIONS: The lower resting values of LV GLS and MWE in severe AR asymptomatic patients suggest an early subclinical myocardial damage that seems to be closely associated with lower exercise capacity, greater pulmonary congestion, and blunted LV contractile reserve during stress.

11.
Artigo em Inglês | MEDLINE | ID: mdl-32657562

RESUMO

BACKGROUND: Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV). METHODS: We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638). RESULTS: Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume. CONCLUSIONS: Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

12.
JACC Cardiovasc Imaging ; 13(10): 2085-2095, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32682714

RESUMO

OBJECTIVES: The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE). BACKGROUND: B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE. METHODS: The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up. RESULTS: According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction. CONCLUSIONS: Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).

13.
Eur J Prev Cardiol ; : 2047487320934265, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32615795

RESUMO

AIMS: The purpose of this study was to assess the value of genetic testing in addition to a comprehensive clinical evaluation, as part of the diagnostic work-up of elite and/or amateur Italian athletes referred for suspicion of inherited cardiac disease, following a pre-participation screening programme. METHODS: Between January 2009-December 2018, of 5892 consecutive participants, 61 athletes were investigated: 30 elite and 31 amateur athletes. Elite and amateur athletes were selected, on the basis of clinical suspicion for inherited cardiac disease, from two experienced centres for a comprehensive cardiovascular evaluation. Furthermore, the elite and amateur athletes were investigated for variants at DNA level up to 138 genes suspected to bear predisposition for possible cardiac arrest or even sudden cardiac death. RESULTS: Of these 61 selected subjects, six (10%) had diagnosis made possible by a deeper clinical evaluation, while genetic testing allowed a definite diagnosis in eight (13%). The presence of >3 clinical markers (i.e. family history, electrocardiogram and/or echocardiographic abnormalities, exercise-induced ventricular arrhythmias) was associated with a higher probability of positive genetic diagnosis (75%), compared with the presence of two or one clinical markers (14.2%, 8.1%, respectively, p-value = 0.004). CONCLUSION: A combined clinical and genetic evaluation, based on the subtle evidence of clinical markers for inherited disease, was able to identify an inherited cardiac disease in about one-quarter of the examined athletes.

14.
Eur Heart J ; 41(34): 3255-3268, 2020 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-32484517

RESUMO

AIMS: Takotsubo syndrome (TTS) is an acute heart failure syndrome, which shares many features with acute coronary syndrome (ACS). Although TTS was initially described with angiographically normal coronary arteries, smaller studies recently indicated a potential coexistence of coronary artery disease (CAD) in TTS patients. This study aimed to determine the coexistence, features, and prognostic role of CAD in a large cohort of patients with TTS. METHODS AND RESULTS: Coronary anatomy and CAD were studied in patients diagnosed with TTS. Inclusion criteria were compliance with the International Takotsubo Diagnostic Criteria for TTS, and availability of original coronary angiographies with ventriculography performed during the acute phase. Exclusion criteria were missing views, poor quality of angiography loops, and angiography without ventriculography. A total of 1016 TTS patients were studied. Of those, 23.0% had obstructive CAD, 41.2% had non-obstructive CAD, and 35.7% had angiographically normal coronary arteries. A total of 47 patients (4.6%) underwent percutaneous coronary intervention, and 3 patients had acute and 8 had chronic coronary artery occlusion concomitant with TTS, respectively. The presence of CAD was associated with increased incidence of shock, ventilation, and death from any cause. After adjusting for confounders, the presence of obstructive CAD was associated with mortality at 30 days. Takotsubo syndrome patients with obstructive CAD were at comparable risk for shock and death and nearly at twice the risk for ventilation compared to an age- and sex-matched ACS cohort. CONCLUSIONS: Coronary artery disease frequently coexists in TTS patients, presents with the whole spectrum of coronary pathology including acute coronary occlusion, and is associated with adverse outcome. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT01947621.

15.
Heart Fail Clin ; 16(3): 305-315, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503754

RESUMO

Acute aortic syndromes are life-threatening medical conditions that include classic acute aortic dissection (AAD), aortic intramural hematoma, penetrating aortic ulcer, and even aortic pseudoaneurysm and traumatic aortic injury. The European Society of Cardiology has designed a multiparametric diagnostic algorithm to provide stepwise diagnosis. All patients with AAD should receive aggressive medical therapy to control blood pressure and heart rate. Urgent surgical repair is recommended for type A AAD. Uncomplicated type B AAD requires aggressive medical therapy. In contrast thoracic endovascular repair is recommended for complicated type B. AAD should be considered a lifelong disease that affects the entire aorta.


Assuntos
Doenças da Aorta , Procedimentos Cirúrgicos Cardiovasculares/métodos , Tratamento de Emergência/métodos , Procedimentos Endovasculares/métodos , Algoritmos , Doenças da Aorta/classificação , Doenças da Aorta/diagnóstico , Doenças da Aorta/fisiopatologia , Doenças da Aorta/terapia , Humanos , Imagem Multimodal
16.
Heart Fail Clin ; 16(3): 317-330, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503755

RESUMO

Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.


Assuntos
Embolia Pulmonar , Medição de Risco/métodos , Ecocardiografia/métodos , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemodinâmica , Humanos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/terapia
17.
Heart Fail Clin ; 16(3): 331-346, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503756

RESUMO

Cardiovascular emergencies represent life-threatening conditions requiring a high index of clinical suspicion. In an emergency scenario, a simple stepwise biomarker/imaging diagnostic algorithm may help prompt diagnosis and timely treatment along with related improved outcomes. This article describes several clinical cases of cardiovascular emergencies, such as coronary stent thrombosis-restenosis, takotsubo syndrome, acute myocarditis, massive pulmonary embolism, type A acute aortic dissection, cardiac tamponade, and endocarditis.


Assuntos
Técnicas de Imagem Cardíaca/métodos , Doenças Cardiovasculares , Emergências/classificação , Tratamento de Emergência/métodos , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/terapia , Humanos
19.
Circulation ; 141(24): 2004-2025, 2020 Jun 16.
Artigo em Inglês | MEDLINE | ID: mdl-32539609

RESUMO

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA