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1.
J Am Coll Cardiol ; 74(18): 2278-2291, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672185

RESUMO

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.

3.
Cardiovasc Ultrasound ; 16(1): 20, 2018 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-30249305

RESUMO

BACKGROUND: The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE: To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS: 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS: All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS: Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.


Assuntos
Ecocardiografia sob Estresse/normas , Pulmão/diagnóstico por imagem , Edema Pulmonar/diagnóstico , Controle de Qualidade , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade
4.
J Cardiovasc Med (Hagerstown) ; 10(4): 336-9, 2009 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-19430345

RESUMO

Late complications after pharmacological stress echocardiography are infrequent but potentially dreadful events. We report the case of a 80-year-old woman admitted to hospital for rest chest pain with trivial troponin increase, normal left ventricular function and no significant ECG changes. A dobutamine stress echocardiography was performed for diagnostic purpose, with a negative result. About 30 min after the end of dobutamine infusion, she developed ST-segment elevation in inferior leads associated with chest pain and left ventricular dyssynergy, promptly resolved by sublingual nitrates. Subsequently, angiography documented the absence of significant coronary stenoses. The following clinical course was uneventful. Transient myocardial ischemia was likely due to dobutamine-induced coronary spasm. The case emphasizes the utility of routine, long-lasting monitoring of patients after stress echocardiography, even if negative, to counteract possible late life-threatening complications.


Assuntos
Angina Pectoris/diagnóstico , Vasoespasmo Coronário/etiologia , Ecocardiografia sob Estresse/efeitos adversos , Isquemia Miocárdica/etiologia , Administração Sublingual , Idoso de 80 Anos ou mais , Angina Pectoris/tratamento farmacológico , Angina Pectoris/etiologia , Angina Pectoris/fisiopatologia , Biomarcadores/sangue , Angiografia Coronária , Vasoespasmo Coronário/tratamento farmacológico , Vasoespasmo Coronário/fisiopatologia , Eletrocardiografia , Feminino , Humanos , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/fisiopatologia , Nitroglicerina/administração & dosagem , Resultado do Tratamento , Troponina/sangue , Vasodilatadores/administração & dosagem , Função Ventricular Esquerda
5.
Eur J Echocardiogr ; 10(4): 562-6, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19252188

RESUMO

AIMS: The aim of this study was to assess the prognostic value of tissue Doppler imaging (TDI) in patients with chronic systolic heart failure (HF) with or without restrictive mitral flow (RMF). METHODS AND RESULTS: Echocardiograms were obtained in 378 patients with chronic systolic HF [ejection fraction (EF) < or = 45%] in sinus rhythm. Restrictive mitral flow was defined by an E wave deceleration time (EDT) < or = 140 ms. Tissue Doppler imaging early (Em) diastolic and systolic (Sm) velocities were measured at the mitral annulus. Patients were followed-up for a median of 32 months. Endpoints were all-cause mortality and the combination of death or HF hospitalization. Mean left ventricular EF was 32 +/- 8%. Restrictive mitral flow and TDI annular velocities were all univariate predictors of the endpoints. Ejection fraction <25% was the only multivariate predictor of all-cause mortality. E wave deceleration time and Em < 8 cm/s were independently associated with the combined endpoint of death or HF hospitalization. At 48 months, survival was 61% in patients with RMF and 82% in patients with non-RMF (log-rank: 21.6; P < 0.0001). When patients were stratified according to Em at or above 8 cm/s or below 8 cm/s, those with RMF and Em < 8 cm/s exhibited the worst survival (log-rank: 27.16; P < 0.0001). Patients with Sm < or = 6 cm/s had a 58% survival rate, whereas it was 82% in patients with Sm > 6 cm/s (log-rank: 12.73; P = 0.0004). CONCLUSION: Doppler annular velocities provided useful information for prognostication of patients with systolic HF. Particularly, categorization of patients according to Em velocities allowed us to further stratify patients with RMF and non-RMF.


Assuntos
Ecocardiografia Doppler/métodos , Insuficiência Cardíaca Sistólica/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Idoso , Velocidade do Fluxo Sanguíneo , Distribuição de Qui-Quadrado , Doença Crônica , Feminino , Insuficiência Cardíaca Sistólica/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Valva Mitral/fisiopatologia , Análise Multivariada , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos , Fatores de Risco , Estatísticas não Paramétricas
7.
J Cardiovasc Med (Hagerstown) ; 8(4): 277-80, 2007 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-17413305

RESUMO

Non-obstructive prosthetic valve thrombosis is a rare and underestimated complication in patients with left-sided mechanical heart valves. Systemic embolisation, mainly involving the cerebral circulation, often represents the first clinical manifestation. We report a case of multiple, successive embolizations in the coronary and cerebral circulation, presenting with an acute myocardial infarction and stroke in a patient with latent, non-obstructive thrombosis of a mechanical bileaflet aortic valve. Because of scheduled urological surgery, chronic vitamin K antagonist treatment had previously been discontinued and replaced with low-molecular-weight heparin, at inadequate dosage. Following coronary arteriography, brain computed tomography scan and transoesophageal echocardiography, thrombolysis was performed successfully. This case emphasises the utility of performing transoesophageal echocardiography routinely in the presence of ischaemic signs in patients with mechanical heart valves. In patients requiring discontinuation of oral anticoagulant therapy, accurate management and continuous monitoring of alternative medications are needed in order to avoid severe thromboembolic complications.


Assuntos
Anticoagulantes/administração & dosagem , Valva Aórtica/cirurgia , Embolia/complicações , Implante de Prótese de Valva Cardíaca/efeitos adversos , Heparina de Baixo Peso Molecular/administração & dosagem , Erros Médicos , Infarto do Miocárdio/etiologia , Acidente Vascular Cerebral/etiologia , Trombose/complicações , Idoso , Esquema de Medicação , Ecocardiografia Doppler , Eletrocardiografia , Embolia/diagnóstico por imagem , Embolia/etiologia , Embolia/prevenção & controle , Humanos , Masculino , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/prevenção & controle , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/prevenção & controle , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/prevenção & controle , Varfarina/administração & dosagem
8.
J Cardiovasc Med (Hagerstown) ; 7(3): 203-9, 2006 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-16645387

RESUMO

OBJECTIVE: Chest pain is a frequent cause of medical admission to the emergency department and the main differential diagnosis is between coronary and non-coronary chest pain. We elaborated a computer protocol for the management of patients with chest pain. METHODS: The computer protocol was made of three sections according to clinical, electrocardiographic and biochemical data. Each section was coded by a letter indicating the probability of coronary chest pain for each section. The combination of the three letters formed a score string used to assign patients to four subgroups of overall probability of coronary chest pain (low, medium-low, medium-high, and high). Low-probability patients were discharged from the emergency department, whereas high-probability patients were admitted to the coronary care unit. The medium-probability patients underwent further evaluation by means of a stress test and were re-classified as having a final low probability (negative test) or high probability (positive test). RESULTS: We evaluated 472 patients (mean age 64 years, range 18-97 years; 47% female). The incidence of coronary events in patients with low, medium-low, medium-high and high overall probability was 1.9, 12.8,13.5 and 68.0%, respectively (P < 0.05). The positive and negative predictive values of the protocol were 64.7 and 97.1%, respectively. CONCLUSIONS: Our computer protocol represents a reliable method for the management of patients with chest pain and a non-diagnostic electrocardiogram.


Assuntos
Dor no Peito/etiologia , Doença das Coronárias/diagnóstico , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Dor no Peito/diagnóstico , Protocolos Clínicos , Unidades de Cuidados Coronarianos , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Alta do Paciente , Probabilidade
9.
Ital Heart J Suppl ; 4(4): 332-6, 2003 Apr.
Artigo em Italiano | MEDLINE | ID: mdl-12784768

RESUMO

BACKGROUND: Mass screening for occult abdominal aortic aneurysm is not realistic for the low prevalence of this condition in the general population. Screening in a high-risk population, especially during standard echocardiographic examination, could be more cost-effective than a separate screening program. The aim of this study was to evaluate the feasibility and accuracy of a rapid evaluation (examination arbitrary time-limit of 2 min) of the abdominal aorta at the end of a routine transthoracic echocardiographic examination. METHODS: One hundred and eighty-one male patients (average age 61 years, range 45-79 years) were studied. A subgroup of 83 patients was also blindly examined by a radiologist for diagnostic accuracy evaluation. RESULTS: Abdominal aortic aneurysm was defined as an aortic diameter enlargement > or = 3.0 cm. Sixteen patients were excluded due to suboptimal aortic wall imaging or to examination lasting > 2 min (feasibility 91%). An occult aneurysm was found in 7 patients (3.8%). As regards the presence/absence of aneurysms in the subgroup of patients undergoing double examination, sensitivity and specificity were 80 and 100% respectively. CONCLUSIONS: Rapid evaluation of the abdominal aorta for aortic screening during routine echocardiography is highly feasible and accurate without any significant prolongation of the examination time and should therefore be routinely performed during standard examination.


Assuntos
Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ecocardiografia , Programas de Rastreamento/métodos , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/patologia , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade
10.
Ital Heart J Suppl ; 3(6): 613-8, 2002 Jun.
Artigo em Italiano | MEDLINE | ID: mdl-12116810

RESUMO

BACKGROUND: We evaluated the appropriateness of indications to echocardiography for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 2848 prescriptions (patients: 1450 males, 1398 females; mean age 62 years, range 15-90 years). The indications to test were of class I (appropriate) in 43.6%, of class II (of doubtfully appropriateness) in 36.8% and of class III (inappropriate) in 19.6% of the cases. In 60.8% of the cases the exam was considered abnormal. In particular, an abnormal result was found in 83.8% of class I, in 56.6% of class II and in 17.8% of class III exams (p < 0.05). The exam was considered useful in 51.1% of the cases. In particular, a useful result was found in 78.9% of class I, in 39% of class II and in 12.1% of class III exams (p < 0.05). Cardiologists prescribed 856/2848 tests (30%). Their indications were of class I in 58.8%, of class II in 29.8% and of class III in 11.4% of the cases vs 37, 39.9 and 23.1% of non-cardiologists' prescriptions (p < 0.05). Abnormal findings were found in 74.3% of cardiologist- vs 55% of non-cardiologist-prescribed examinations (odds ratio 2.45, 95% confidence interval 2.04-2.92; p < 0.05); similarly, clinically useful information could be derived from 63.1% of cardiologist- vs 46% of non-cardiologist-prescribed examinations (odds ratio 2.07, 95% confidence interval 1.75-2.45; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, about half of the prescriptions for echocardiography can be considered inappropriate; appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.


Assuntos
Cardiologia/normas , Ecocardiografia/estatística & dados numéricos , Ecocardiografia/normas , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/normas , Cardiologia/estatística & dados numéricos , Estudos de Avaliação como Assunto , Feminino , Humanos , Itália , Masculino , Medicina/normas , Medicina/estatística & dados numéricos , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Especialização , Revisão da Utilização de Recursos de Saúde
11.
Echocardiography ; 13(1): 9-20, 1996 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-11442899

RESUMO

BACKGROUND: Myocardial reflectivity is abnormally increased in patients with thalassemia major under transfusion treatment, probably due to myocardial iron deposits and/or secondary structural changes. Such increased reflectivity has been detected by both qualitative and subjective analysis of two-dimensional echocardiographic (2-D echo) images and quantitative assessment of integrated backscatter amplitude with noncommercially available ultrasound prototypes. The purpose of this study was to assess the acoustic properties of myocardium in patients with beta-thalassemia major and iron overload by means of quantitative computerized offline textural analysis of conventionally recorded 2-D echo images, and to compare textural data with other qualitative (visual assessment) and quantitative (ultrasound backscatter analysis) approaches for myocardial ultrasound tissue characterization simultaneously applied to these patients. METHODS AND RESULTS: Thirty-five young patients with thalassemia major, without clinical signs of cardiac failure, and 20 age and sex matched normal controls were studied by echocardiography. Each patient was receiving blood transfusion every 2-3 weeks. Two-dimensional echo images, obtained with a commercially available echocardiograph using the parasternal long-axis view, were digitized off line and analyzed by first and second order texture algorithms applied to regions of interest in the myocardium (septal and posterior wall). The mean gray level value was higher in thalassemic patients than in controls on both the septum (110 +/- 25 vs 57 +/- 13, arbitrary units on a 0-255 scale; P < 0.01) and posterior wall (91 +/- 25 vs 67 +/- 18; P < 0.01). Among second order statistical parameters, contrast and angular second moment significantly (P < 0.01) differentiated septal and posterior walls of patients and controls. In thalassemic patients, no consistent correlation was found between wall texture parameters and hematologic (years of transfusions and chelation, number of transfusions), 2-D echo (posterior wall thickness, left ventricular end-diastolic diameter), and Doppler (transmitral E/A waves ratio) parameters. Myocardial walls with visually assessed increased echo reflectivity showed a trend toward higher values of mean gray level when compared with myocardial segments with qualitatively assessed normal reflectivity (septum: 121 +/- 26 vs 106 +/- 24; posterior wall: 105 +/- 23 vs 87 +/- 23). Although radiofrequency integrated backscatter has been demonstrated to be capable of identifying thalassemic patients, no significant correlation was found between mean gray level (by texture analysis) and radiofrequency data (septum: r = 0.03; posterior wall: r = 0.09; P = NS for both). CONCLUSIONS: Myocardial walls affected by hemochromatosis show ultrasound image texture alterations that may be quantified with digital image analysis techniques and appear mostly unrelated to hematologic and conventional, as well as radiofrequency-based, echocardiographic parameters. These changes in quantitatively evaluated echo reflectivity are present even before the development of clinical and echocardiographic signs of cardiac dysfunction. (ECHOCARDIOGRAPHY, Volume 13, January 1996)

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