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J Am Coll Cardiol ; 74(18): 2278-2291, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672185


BACKGROUND: The assessment of coronary flow velocity reserve (CFVR) in left anterior descending coronary artery (LAD) expands the risk stratification potential of stress echocardiography (SE) based on stress-induced regional wall motion abnormalities (RWMA). OBJECTIVES: The purpose of this study was to assess the feasibility and functional correlates of CFVR. METHODS: This prospective, observational, multicenter study initially screened 3,410 patients (2,061 [60%] male; age 63 ± 11 years; ejection fraction 61 ± 9%) with known or suspected coronary artery disease and/or heart failure. All patients underwent SE (exercise, n = 1,288; vasodilator, n = 1,860; dobutamine, n = 262) based on new or worsening RWMA in 20 accredited laboratories of 8 countries. CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed-Doppler assessment of LAD flow. A subset of 1,867 patients was followed up. RESULTS: The success rate for CFVR on LAD was 3,002 of 3,410 (feasibility = 88%). Reduced (≤2.0) CFVR was found in 896 of 3,002 (30%) patients. At multivariable logistic regression analysis, inducible RWMA (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 4.9 to 8.5; p < 0.01), abnormal left ventricular contractile reserve (OR: 3.4; 95% CI: 2.7 to 4.2; p < 0.01), and B-lines (OR: 1.5; 95% CI: 1.1 to 1.9; p = 0.01) were associated with reduced CFVR. During a median follow-up time of 16 months, 218 events occurred. RWMA (hazard ratio: 3.8; 95% CI: 2.3 to 6.3; p < 0.001) and reduced CFVR (hazard ratio: 1.5; 95% CI: 1.1 to 2.2; p = 0.009) were independently associated with adverse outcome. CONCLUSIONS: CFVR is feasible with all SE protocols. Reduced CFVR is often accompanied by RWMA, abnormal LVCR, and pulmonary congestion during stress, and shows independent value over RWMA in predicting an adverse outcome.

Int J Cardiovasc Imaging ; 35(6): 1019-1026, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30977036


The peak stress/rest ratio of left ventricular (LV) elastance, or LV force, is a load-independent index of left ventricular contractile reserve (LVCR) with stress echo (SE). To assess the accuracy of LVCR calculated during SE with approaches of different complexity. Two-hundred-forty patients were referred to SE for known or suspected coronary artery disease or heart failure and, of those, 200 patients, age 61 ± 15, 99 females, with interpretable volumetric SE were enrolled. All readers had passed the upstream quality control reading for regional wall motion abnormality (RWMA) and end-systolic volume (ESV) measurement. The employed stress was dipyridamole (0.84 mg, 6 min) in 86 (43%) and dobutamine (up to 40 mcg/kg/min) in 114 (57%) patients. All underwent SE with evaluation of RWMA and simultaneous LVCR assessment with stress/rest ratio of LV force (systolic blood pressure by cuff sphygmomanometer/ESV). ESV was calculated in each patient by two of three methods: biplane Simpson rule (S, in 100 patients), single plane area-length (AL, apical four-chamber area and length, in 100 patients), and Teichholz rule (T, from parasternal long axis and/or short axis view, in 200 patients). RMWA were observed in 54 patients. Success rate for ESV measurement was 76% (100/131) for S, 92% (100/109) for AL, and 100% (240/240) for T. There were 100 paired measurements (rest and stress) with S versus T, and 100 with AL versus T. The analysis time was the shortest for T (33 ± 8 s at rest, 34 ± 7 s at stress), intermediate for AL (70 ± 22 s at rest 67 ± 21 s at stress), and the longest for S (136 ± 24 at rest 129 ± 27 s at stress, p < 0.05 vs. T and AL). ESV absolute values were moderately correlated: T versus S (r rest = 0.746, p < 0.01, n = 100; r stress = 0.794, p < 0.01, n = 100); T vs. AL (r = 0.603 p < 0.01, n = 100, at rest and r = 0.820 p < 0.01 n = 100 at peak stress). LVCR values were tightly correlated independently of the method employed: T versus S (r = 0.899, p < 0.01, n = 100), and T versus AL (r = 0.845, p < 0.01, n = 100). LVCR can be accurately determined with all three methods used to extract the raw values of ESV necessary to generate the calculation of Force. Although S is known to be more precise in determining absolute ESV values, the relative (rest-stress) changes can be assessed, with comparable accuracy, with simpler and more feasible T and AL methods, characterized by higher success rate, shorter imaging and analysis time.

Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Volume Sistólico , Função Ventricular Esquerda , Agonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Idoso , Doença da Artéria Coronariana/fisiopatologia , Dipiridamol/administração & dosagem , Dobutamina/administração & dosagem , Estudos de Viabilidade , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Sístole , Vasodilatadores/administração & dosagem
Int J Cardiol ; 249: 479-485, 2017 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-28986062


BACKGROUND: The trial "Stress Echo (SE) 2020" evaluates novel applications of SE beyond coronary artery disease. The aim of the study was control quality and harmonize reading criteria. METHODS: One reader from 78 centers of the SE 2020 network asked for credentials to read a set of 20 SE video-clips selected by the core lab. All aspiring centers met the pre-requisite of high-volume and the years of experience in SE ranged from 5 to 31years (mean value 18years). The diagnostic gold standard was a reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%). RESULTS: Of the initial 78 who started, 57 completed the first attempt: individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor correlation between years of experience and the reader's score on first attempt (r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it again after the web-based session and their accuracy improved (74% vs. 96%, p<0.001). The kappa inter-observer agreement before and after web-based training was 0.59 on first attempt and rose to 0.91 on the last attempt. CONCLUSIONS: In SE reading, the volume of activity or years of experience is not synonymous with diagnostic quality. Qualitative analysis and operator-dependence can become a limiting weakness in clinical practice, in the absence of strict pathways of learning, credentialing and audit.

Cardiologistas/normas , Competência Clínica/normas , Doença das Coronárias/diagnóstico por imagem , Ecocardiografia sob Estresse/normas , Controle de Qualidade , Doença das Coronárias/epidemiologia , Ecocardiografia sob Estresse/métodos , Humanos , Internacionalidade , Reprodutibilidade dos Testes
Acta Cardiol ; 63(4): 507-13, 2008 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-18795590


INTRODUCTION: The added value of routine echocardiography, in respect to clinical examination and ECG, has received little attention. We sought to evaluate the contribution of two-dimensional echocardiography, in respect to clinical examination and ECG, in detecting left ventricular (LV) dilatation and systolic dysfunction. METHOD: A group of 100 patients, scheduled for cardiac magnetic resonance imaging (MRI), was prospectively studied. RESULTS: Clinical examination identified moderate-to-severe LV dysfunction, defined as a LV ejection fraction (EF) < 45% at MRI, with a sensitivity of 62% and a specificity of 68%. After ECG, sensitivity and specificity slightly improved (71 and 70%, respectively). After the echocardiographic report, sensitivity reached 84% and specificity 90%. LV EF by echocardiography (routine studies) was closely related with that by MRI (r = 0.84). LV function was scored as undefined in 17% of patients after clinical examination, in 5% of patients after ECG and in no patient after echocardiography (P < 0.0001). Clinical examination identified patients with LV dilatation (LV end-diastolic volume > or = 110 ml/m2) with a poor sensitivity (33%) but a good specificity (88%). After ECG, sensitivity was 39% and specificity 87%; after echocardiography, sensitivity reached 53% and specificity 92%. CONCLUSION: Echocardiography provides information on LV function and dimensions that vastly exceeds that obtained by clinical examination and ECG. This study supports the use of echocardiography to improve patient diagnosis and management after history and physical examination.

Ecocardiografia , Ventrículos do Coração/patologia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Área Sob a Curva , Diástole , Ventrículos do Coração/diagnóstico por imagem , Humanos , Modelos Logísticos , Imagem por Ressonância Magnética , Estudos Prospectivos , Curva ROC , Sensibilidade e Especificidade , Volume Sistólico , Sístole , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda
Eur J Heart Fail ; 9(6-7): 723-9, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17347039


BACKGROUND: The diagnostic process has become increasingly dependent on instrumental and laboratory investigation. AIM: To evaluate the accuracy of symptoms and signs in identifying left ventricular (LV) dilatation and/or systolic dysfunction. METHODS: A group of 100 patients in stable clinical condition and scheduled for cardiac magnetic resonance imaging was prospectively examined by two cardiologists, who were unaware of the individual patient's condition. Patients were interviewed and underwent physical examination. RESULTS: Several symptoms and signs were associated with LV dilatation and systolic dysfunction at univariate analysis. Using multiple logistic regression, a mitral systolic murmur, a laterally displaced LV impulse, orthopnoea and hepatomegaly were all independent predictors of LV dilatation (end-diastolic volume >or=110 ml/m(2)) (p<0.0001) and LV dysfunction (ejection fraction <45%) (p<0.0001). The combination of the above variables correctly identified 79% of patients with LV dilatation (sensitivity 51%, specificity 92%), and 82% of patients with LV dysfunction (sensitivity 68%, specificity 90%). Considering LV dilatation and dysfunction, 77% of patients were correctly identified after history alone (kappa=0.13), 84% after LV impulse examination (kappa=0.55) and 86% after cardiac auscultation (kappa=0.58). CONCLUSION: Symptoms and signs predict LV dilatation and/or dysfunction with fair sensitivity and excellent specificity.

Baixo Débito Cardíaco/diagnóstico , Insuficiência Cardíaca/diagnóstico , Hipertrofia Ventricular Esquerda/diagnóstico , Imagem por Ressonância Magnética , Disfunção Ventricular Esquerda/diagnóstico , Atividades Cotidianas/classificação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Volume Cardíaco , Diástole , Eletrocardiografia , Feminino , Auscultação Cardíaca , Insuficiência Cardíaca/etiologia , Humanos , Modelos Logísticos , Masculino , Anamnese , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Variações Dependentes do Observador , Exame Físico , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Sensibilidade e Especificidade , Sístole