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1.
Arq Bras Cardiol ; 2019 Sep 02.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31482986

RESUMO

BACKGROUND: Most cardiovascular abnormalities in patients infected with the human immunodeficiency virus (HIV) have been associated with myocardial damage directly caused by the virus. Some cases, however, may be associated with adverse effects from antiretroviral therapy (ART). New ventricular function assessment techniques are capable of detecting early changes in the cardiac function of HIV-infected patients using or not using ART. The usefulness of these techniques has been little employed in these patients. OBJECTIVES: To investigate the potential influence of antiretroviral therapy (ART) on the occurrence of subclinical left ventricular systolic dysfunction evaluated by myocardial strain rate analysis using two-dimensional speckle tracking echocardiography (2-D Echo) in treated HIV patients compared to untreated patients and healthy individuals. METHODS: Sixty-eight HIV-infected patients with no cardiovascular symptoms, normal left ventricular (LV) ejection fraction (> 0.55 on 2-D Echo) were divided into three groups: 11 patients not using antiretroviral therapy (NT), 24 using protease inhibitor (PI) and 33 using non-nucleoside reverse transcriptase inhibitor (NNRTI). We also studied 30 normal non-HIV infected individuals (Ctrl). Demographic, clinical, biochemical and anthropometric data were collected. Preliminary transthoracic echocardiography included study of myocardial strain using two-dimensional speckle tracking. We studied strain and strain rate in the seventeen left ventricular (LV) myocardial segments in the longitudinal, circumferential and radial axes. Statistical analysis of the data was done with IBM SPSS - version 20 for Windows. Upon analysis of the data, namely the normality of independent variables in the different groups and the homogeneity of the variances between the groups, Kruskal-Wallis' non-parametric test was done, followed by Dunn's multiple comparison tests to test the significance of the differences between the values measured in the study groups. A significance level of 5% was adopted for decision-making on statistical tests. RESULTS: The mean age of HIV patients was 40 ± 8.65 years and the mean age of controls was 50 ± 11.6 years (p < 0.001). Median LV global longitudinal strain (GLS) of NT patients (-17.70%), PI patients (-18.27%) and NNRTIs (-18.47%) were significantly lower than that of the Ctrl group (-20.77%; p = 0.001). There was no significant difference in mean SLG between treated patients (PI, NNRTI) and untreated (NT) patients. No significant differences were observed in mean circumferential and radial strain, nor on circumferential and radial strain rates between the NT, PI, NNRTI and Ctrl groups. CONCLUSION: The data suggest that HIV patients present, on myocardial strain measured by speckle tracking, signs of early LV systolic dysfunction that seem to be unrelated to the presence of ART. The prognostic significance of this condition in these patients deserves further studies.

4.
Can J Cardiol ; 35(8): 1015-1029, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31376903

RESUMO

This review describes the current evidence and controversies for viability imaging to direct revascularization decisions and the impact on patient outcomes. Balancing procedural risks and possible benefit from revascularization is a key question in patients with heart failure of ischemic origin (IHF). Different stages of ischemia induce adaptive changes in myocardial metabolism and function. Viable but dysfunctional myocardium has the potential to recover after restoring blood flow. Modern imaging techniques demonstrate different aspects of viable myocardium; perfusion (single-photon emission computed tomography [SPECT], positron emission tomography [PET], cardiovascular magnetic resonance [CMR]), cell metabolism (PET), cell membrane integrity and mitochondrial function (201Tl and 99mTc-based SPECT), contractile reserve (stress echocardiography, CMR) and scar (CMR). Observational studies suggest that patients with IHF and significant viable myocardium may benefit from revascularization compared with medical treatment alone but that in patients without significant viability, revascularization appears to offer no survival benefit or could even worsen the outcome. This was not supported by 2 randomized trials (Surgical Treatment for Ischemic Heart Failure [STICH] and PET and Recovery Following Revascularization [PARR] -2) although post-hoc analyses suggest that benefit can be achieved if decisions had been strictly based on viability imaging recommendations. Based on current evidence, viability testing should not be the routine for all patients with IHF considered for revascularization but rather integrated with clinical data to guide decisions on revascularization of high-risk patients with comorbidities.

5.
Arq Bras Cardiol ; 2019 Jul 18.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31340238

RESUMO

BACKGROUND: Oxidative stress and inflammation are present in coronary artery disease (CAD) and are linked to the activation of the transcription nuclear factor kappa B (NF-κB). To attenuate these complications, transcription factors like nuclear factor erythroid 2-related factor 2 (Nrf2) and peroxisome proliferator-activated receptor-ß/δ (PPARß/δ) can be activated to inhibit NF-κB. However, the available data on expression of NF-κB, Nrf2 and PPARß/δ in CAD patients are limited. OBJECTIVE: To evaluate the expression of the transcription factors NF-κB and Nrf2 and PPAR𝛽/𝛿 in CAD patients. METHODS: Thirty-five patients (17 men, mean age 62.4 ? 7.55 years) with CAD and twelve patients (5 men, mean age 63.50 ? 11.46 years) without CAD were enrolled. Peripheral blood mononuclear cells (PBMCs) were isolated and processed for mRNA expression of Nrf2, NF-κB, NADPH: quinone oxidoreductase 1 (NQO1) and PPARß/δ mRNAs using quantitative real-time polymerase chain reaction (qPCR). p < 0.05 was considered statistically significant. RESULTS: There was no difference in the mRNA expressions of Nrf2 (1.35 ? 0.57), NF-κB (1.08 ? 0.50) or in the antioxidant enzyme NQO1 (1.05 ? 0.88) in the CAD group compared to the group without CAD (1.16 ? 0.76, 0.95 ? 0.33, 0.81 ? 0.55, respectively). However, PPARß/δ was highest expressed in the CAD group (1.17 ? 0.86 vs. 0.56 ? 0.34, p = 0.008). CONCLUSION: The main finding of this study was the PPARß/δ being more expressed in the PBMC of patients with CAD compared to the control group, whereas no differences were observed in Nrf2 or NF-κB mRNA expressions.

7.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 302-309, May-June 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1002221

RESUMO

Abstract This paper is about the Guideline for Ventilation / Perfusion Scintigraphy. It has been developed by the Brazilian Society of Nuclear Medicine to be a best practices guide used in Nuclear Medicine. Its function is to be an educational tool to help the Nuclear Medicine Services in Brazil to guarantee a quality care to the patients.

10.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 302-309, may.-june. 2019. ilus
Artigo em Inglês | LILACS | ID: biblio-1006185

RESUMO

This paper is about the Guideline for Ventilation / Perfusion Scintigraphy. It has been developed by the Brazilian Society of Nuclear Medicine to be a best practices guide used in Nuclear Medicine. Its function is to be an educational tool to help the Nuclear Medicine Services in Brazil to guarantee a quality care to the patients


Assuntos
Humanos , Masculino , Feminino , Relação Ventilação-Perfusão , Guias como Assunto/normas , Artéria Pulmonar/patologia , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico por imagem , Diagnóstico por Imagem/métodos , Cintilografia/métodos , Medicina Nuclear/normas
14.
Arq. bras. cardiol ; 111(4): 607-615, Oct. 2018. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-973766

RESUMO

Abstract Background: Heart failure (HF) affects more than 5 million individuals in the United States, with more than 1 million hospital admissions per year. Cardiac resynchronization therapy (CRT) can benefit patients with advanced HF and prolonged QRS. A significant percentage of patients, however, does not respond to CRT. Electrical dyssynchrony isolated might not be a good predictor of response, and the last left ventricular (LV) segment to contract can influence the response. Objectives: To assess electromechanical dyssynchrony in CRT with LV lead implantation guided by GATED SPECT. Methods: This study included 15 patients with functional class II-IV HF and clinically optimized, ejection fraction of 35%, sinus rhythm, left bundle-branch block, and QRS ≥ 120 ms. The patients underwent electrocardiography, answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and underwent gated myocardial perfusion SPECT up to 4 weeks before CRT, being reassessed 6 months later. The primary analysis aimed at determining the proportion of patients with a reduction in QRS duration and favorable response to CRT, depending on concordance of the LV lead position, using chi-square test. The pre- and post-CRT variables were analyzed by use of Student t test, adopting the significance level of 5%. Results: We implanted 15 CRT devices, and 2 patients died during follow-up. The durations of the QRS (212 ms vs 136 ms) and the PR interval (179 ms vs 126 ms) were significantly reduced (p < 0.001). In 54% of the patients, the lead position was concordant with the maximal delay site. In the responder group, the lateral position was prevalent. The MLHFQ showed a significant improvement in quality of life (p < 0.0002). Conclusion: CRT determines improvement in the quality of life and in electrical synchronism. Electromechanical synchronism relates to response to CRT. Positioning the LV lead in the maximal delay site has limitations.


Resumo Fundamento: A insuficiência cardíaca (IC) afeta mais de 5 milhões de pessoas nos Estados Unidos, com mais de 1 milhão de internações/ano. A terapia de ressincronização (TRC) pode beneficiar pacientes com IC avançada e QRS alargado; entretanto, percentual significativo de pacientes não respondem à TRC. O dissincronismo elétrico isolado pode não representar um bom preditor de resposta, e o local da última ativação do ventrículo esquerdo (VE) pode influenciar na resposta. Objetivos: Avaliar o dissincronismo eletromecânico na TRC com o implante do eletrodo do VE orientado por GATED SPECT. Métodos: Incluídos 15 pacientes com IC classe funcional II-IV, otimizados clinicamente, com fração de ejeção de 35%, ritmo sinusal, bloqueio de ramo esquerdo, QRS ≥ 120 ms. Realizaram eletrocardiograma, Questionário Minnesota Vivendo com Insuficiência Cardíaca (MLHFQ) e cintilografia GATED SPECT até 4 semanas antes do implante. Reavaliados 6 meses após. Análise primária visou determinar a proporção de pacientes com redução da duração do QRS e resposta favorável à TRC dependendo da concordância ou não na posição do eletrodo, utilizando teste Qui-Quadrado. Análise das variáveis pré e pós TRC foi feita através do teste t de Student, assumindo significância de 5%. Resultados: Realizamos 15 implantes com 2 óbitos no seguimento. As reduções das durações do QRS (212 ms vs 136 ms) e do IPR (179 ms vs 126 ms) foram significativas (p < 0,001). Em 54%, o eletrodo foi concordante com o local de maior atraso. No grupo respondedor, a posição lateral foi prevalente. O MLHFQ mostrou melhora significativa da qualidade de vida (p < 0,0002). Conclusão: A TRC determina melhora da qualidade de vida e do sincronismo elétrico. O sincronismo eletromecânico relaciona-se com a resposta à TRC. O posicionamento do eletrodo de VE no sítio de maior retardo tem limitações.

17.
J Cardiovasc Pharmacol Ther ; : 1074248418799364, 2018 Sep 09.
Artigo em Inglês | MEDLINE | ID: mdl-30198318

RESUMO

BACKGROUND: Heart rate (HR) reduction with ivabradine has been proved to reduce hospitalization and death from heart failure (HF). We sought to investigate whether pyridostigmine would effectively reduce HR in patients with chronic HF as compared with ivabradine. METHODS: Twenty-one patients with HF who were in sinus rhythm with a resting HR over 70 bpm, despite optimal medical treatment, were included in a randomized, double-blind study comparing pyridostigmine versus ivabradine. The initial dose of ivabradine was 5 mg twice daily to reach a target HR between 50 and 60 bpm and could be titrated to a maximum of 7.5 mg twice daily. Pyridostigmine was used in a fixed dose of 30 mg 3 times daily. RESULTS: The baseline HR for ivabradine and pyridostigmine groups was 89.1 (13.5) and 80.1 (7.2) bpm, respectively ( P = .083). After 6 months of treatment, HR was significantly reduced to 64.8 (8.3) bpm in the ivabradine group ( P = .0014) and 63.6 (5.9) bpm in the pyridostigmine group ( P = .0001). The N-terminal pro-B-type natriuretic peptide was reduced in the ivabradine group (median: 1308.4 [interquartile range: 731-1896] vs 755.8 [134.5-1014] pg/mL; P = .027) and in the pyridostigmine group (132.8 [89.9-829] vs 100.7 [38-360] pg/mL; P = .002). Inflammatory markers interleukin-1, interleukin-6, and tumor necrosis factor were reduced in both groups. Exercise capacity was improved in both groups, with increments in volume of oxygen utilization ([Formula: see text]O2; ivabradine: 13.1 vs 15.6, P = .048; pyridostigmine: 13.3 vs 16.7, P = .032). Heart rate recovery in the first minute postexercise was improved with pyridostigmine (11.8 [3.9] vs 18 [6.5]; P = .046), but not with ivabradine (13.3 [6.9] vs 14.1 [8.2]; P = .70). No differences in either group were observed in the myocardial scintigraphy with 123-iodine-metaiodobenzylguanidine. CONCLUSION: Both drugs significantly reduced HR, with improvements in exercise capacity and in neurohormonal and inflammatory profiles.

19.
Arq Bras Cardiol ; 111(4): 607-615, 2018 Oct.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30156606

RESUMO

BACKGROUND: Heart failure (HF) affects more than 5 million individuals in the United States, with more than 1 million hospital admissions per year. Cardiac resynchronization therapy (CRT) can benefit patients with advanced HF and prolonged QRS. A significant percentage of patients, however, does not respond to CRT. Electrical dyssynchrony isolated might not be a good predictor of response, and the last left ventricular (LV) segment to contract can influence the response. OBJECTIVES: To assess electromechanical dyssynchrony in CRT with LV lead implantation guided by GATED SPECT. METHODS: This study included 15 patients with functional class II-IV HF and clinically optimized, ejection fraction of 35%, sinus rhythm, left bundle-branch block, and QRS ≥ 120 ms. The patients underwent electrocardiography, answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and underwent gated myocardial perfusion SPECT up to 4 weeks before CRT, being reassessed 6 months later. The primary analysis aimed at determining the proportion of patients with a reduction in QRS duration and favorable response to CRT, depending on concordance of the LV lead position, using chi-square test. The pre- and post-CRT variables were analyzed by use of Student t test, adopting the significance level of 5%. RESULTS: We implanted 15 CRT devices, and 2 patients died during follow-up. The durations of the QRS (212 ms vs 136 ms) and the PR interval (179 ms vs 126 ms) were significantly reduced (p < 0.001). In 54% of the patients, the lead position was concordant with the maximal delay site. In the responder group, the lateral position was prevalent. The MLHFQ showed a significant improvement in quality of life (p < 0.0002). CONCLUSION: CRT determines improvement in the quality of life and in electrical synchronism. Electromechanical synchronism relates to response to CRT. Positioning the LV lead in the maximal delay site has limitations.

20.
Int. j. cardiovasc. sci. (Impr.) ; 31(3)jul.-ago. 2018. tab, graf
Artigo em Português | LILACS | ID: biblio-908914

RESUMO

Fundamentos: Cerca de 20 a 40% dos pacientes com insuficiência cardíaca não respondem à terapia de ressincronização. Para melhorar a seleção de pacientes, foi desenvolvida a análise de fase pela cintilografia de perfusão miocárdica (GSPECT). Objetivo: Avaliar a resposta clínica e cintilográfica de pacientes com insuficiência cardíaca submetidos à terapia de ressincronização pelo uso do GSPECT. Métodos: Estudo intervencionista, incluindo pacientes consecutivos que foram estudados pelo GSPECT 4 semanas antes da implantação da terapia de ressincronização cardíaca e 6 meses depois do implante. Estes pacientes responderam ao Questionário de Qualidade de Vida de Minnesota. A comparação das variáveis categóricas foi realizada com teste exato de Fisher e teste qui quadrado e, em variáveis numéricas, com o teste t de Student. O nível de significância estatística adotado foi de 5%. As variáveis cintilográficas analisadas foram fração de ejeção do ventrículo esquerdo, volume sistólico final, volume diastólico final, massa do ventrículo esquerdo, desvio padrão e largura de banda, assim como a duração do QRS e o escore do Questionário de Qualidade de Vida de Minnesota. A presença de dissincronismo mecânico foi definida como desvio padrão > 43º.Resultados: Foram incluídos nove pacientes no estudo. Após a terapia de ressincronização cardíaca, houve melhora significativa (p < 0,05) dos parâmetros volume sistólico final (206 ± 80 mL vs. 158 ± 108 mL), QRS (180 ± 18 ms vs. 120 ± 9 ms), massa do ventrículo esquerdo (248 ± 65 g vs. 193 ± 52 g) e Questionário de Qualidade de Vida de Minnesota (63 ± 16 vs. 34 ± 20). Todos os pacientes com critérios cintilográficos de dissincronismo mecânico apresentaram melhora clínica. Dois pacientes apresentavam apenas dissincronismo elétrico e não atingiram melhora clínica significativa, apesar de apresentarem redução da duração do QRS. Conclusão: O GSPECT foi capaz de diferenciar os pacientes com dissincronismo elétrico puro daqueles com dissincronismo mecânico associado, por meio dos parâmetros de dissincronismo intraventricular. A terapia de ressincronização cardíaca está associada à melhora tanto do dissincronismo mecânico quanto do elétrico. O GSPECT pré-implante identificou que os pacientes com dissincronismos elétrico e mecânico associados apresentaram melhor resposta à terapia de ressincronização cardíaca do que aqueles com dissincronismo elétrico puro


Background: Approximately 20 to 40% of patients with heart failure do not respond to cardiac resynchronization therapy (CRT). To improve patient selection, phase analysis by myocardial perfusion scintigraphy (GSPECT) was developed. Objectives: To evaluate the clinical and scintigraphic response of patients with heart failure (HF) submitted to CRT using GSPECT. Method: This was an interventional study that included consecutive patients assessed by GSPECT four weeks prior to CRT implantation and six months after it for comparison. These patients also answered the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The categorical variables were compared using Fisher's exact test and chi-square test, whereas Student's t-test was used for numerical variables. The level of statistical significance was set at 5%. The scintigraphic variables analyzed were left ventricular ejection fraction, end-systolic volume, end-diastolic volume, left ventricular mass, standard deviation and bandwidth, as well as QRS duration and the Minnesota Quality of Life Questionnaire score. The presence of mechanical dyssynchrony was defined as standard deviation > 43º. Results: Nine patients were included in the study. After the cardiac resynchronization therapy, there was a significant improvement (p <0.05) in the end-systolic volume (206 ± 80 mL vs. 158 ± 108 mL), QRS (180 ± 18 ms vs. 120 ± 9 ms), left ventricular mass (248 ± 65 g vs. 193 ± 52 g) and Minnesota Quality of Life Questionnaire score (63 ± 16 vs. 34 ± 20). All patients with scintigraphic criteria of mechanical dyssynchrony showed clinical improvement. Two patients had only electrical dyssynchrony and did not achieve significant clinical improvement, although they showed QRS duration reduction. Conclusion: GSPECT was able to differentiate patients with isolated electrical dyssynchrony from those with associated mechanical dyssynchrony, through the intraventricular dyssynchrony parameters. The cardiac resynchronization therapy is associated with the improvement of both mechanical and electrical dyssynchrony. Pre-implantation GSPECT showed that patients with associated electrical and mechanical dyssynchrony had a better response to cardiac resynchronization therapy than those with isolated electrical dyssynchrony


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Terapia de Ressincronização Cardíaca/métodos , Doença da Artéria Coronariana/terapia , Insuficiência Cardíaca/terapia , Imagem de Perfusão do Miocárdio/métodos , Cintilografia/métodos , Tomografia Computadorizada por Raios X/métodos , Eletrocardiografia/métodos , Infarto do Miocárdio , Valor Preditivo dos Testes , Estudos Prospectivos , Análise Estatística , Volume Sistólico , Inquéritos e Questionários
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