Chronic Obstructive Pulmonary Disease: The Role of Myocardial Deformation Indices and Right Ventricle Three-Dimensional Echocardiography

Abstract Background: Right ventricular dysfunction is a major complication in chronic obstructive pulmonary disease (COPD) and, despite its prognostic implications, is rarely considered in routine clinical analysis. Objectives: To compare RV function variables with standard and advanced echocardiographic techniques in patients with stable COPD and controls. Methods: Twenty COPD patients classified as GOLD ≥ II (13 men aged 68.4 ± 8.3 years) and 20 matched controls were compared. Myocardial strain/strain rate indices were obtained by tissue Doppler and two-dimensional speckle tracking echocardiography. Right ventricular ejection fraction was obtained with three-dimensional software. Free wall myocardial thickness (FWMT) and tricuspid annular systolic excursion (TAPSE) were also measured. Numerical variables were compared between groups with Student's t-test or the Mann-Whitney test. Associations between categorical variables were determined with Fisher's exact test. P-values < 0.05 were considered statistically significant. Results: All myocardial deformation indices, particularly global longitudinal strain (-17.2 ± 4.4 vs -21.2: ± 4.4 = 0.001) and 3D right ventricular ejection fraction (40.8 ± 9.3% vs 51.1 ± 6.4% p <0.001) were reduced in COPD patients. These patients presented higher right ventricular FWMT and lower TAPSE values than controls. Conclusion: Myocardial deformation indices, either tissue Doppler or speckle tracking echocardiography and 3D right ventricular ejection fraction, are robust markers of right ventricular dysfunction in patients with stable COPD. Assessing global longitudinal strain by speckle tracking echocardiography is a more practical and reproducible method.

Spectral Analysis Related to Bare-Metal and Drug-Eluting Coronary Stent Implantation / Análise Espectral Relacionada ao Implante de Stent Coronariano Convencional e Farmacológico

Background: The autonomic nervous system plays a central role in cardiovascular regulation; sympathetic activation occurs during myocardial ischemia. Objective: To assess the spectral analysis of heart rate variability during stent implantation, comparing the types of stent. Methods: This study assessed 61 patients (mean age, 64.0 years; 35 men) with ischemic heart disease and indication for stenting. Stent implantation was performed under Holter monitoring to record the spectral analysis of heart rate variability (Fourier transform), measuring the low-frequency (LF) and high-frequency (HF) components, and the LF/HF ratio before and during the procedure. Results: Bare-metal stent was implanted in 34 patients, while the others received drug-eluting stents. The right coronary artery was approached in 21 patients, the left anterior descending, in 28, and the circumflex, in 9. As compared with the pre-stenting period, all patients showed an increase in LF and HF during stent implantation (658 versus 185 ms2, p = 0.00; 322 versus 121, p = 0.00, respectively), with no change in LF/HF. During stent implantation, LF was 864 ms2 in patients with bare-metal stents, and 398 ms2 in those with drug-eluting stents (p = 0.00). The spectral analysis of heart rate variability showed no association with diabetes mellitus, family history, clinical presentation, beta-blockers, age, and vessel or its segment. Conclusions: Stent implantation resulted in concomitant sympathetic and vagal activations. Diabetes mellitus, use of beta-blockers, and the vessel approached showed no influence on the spectral analysis of heart rate variability. Sympathetic activation was lower during the implantation of drug-eluting stents. .

Fundamento: O sistema nervoso autônomo tem papel central na regulação cardiovascular, ocorrendo uma ativação simpática durante a isquemia miocárdica. Objetivo: Avaliar a análise espectral da frequência cardíaca (AE) durante o implante de stent, comparando os tipos de stent. Métodos: Foram estudados 61 pacientes (idade média de 64 anos), 35 homens, com cardiopatia isquêmica e indicação de implante de stent. O implante foi feito sob monitoramento pelo Holter para o registro da AE (transformação de Fourier), com medidas dos componentes LF (baixa frequência), HF (alta frequência) e relação LF/HF, antes e durante o procedimento. Resultados: Implante de stent convencional feito em 34 pacientes; nos demais, farmacológico. A coronária abordada foi a direita em 21 pacientes, a descendente anterior em 28, a circunflexa em nove. Houve aumento do LF e do HF durante o implante em todos os pacientes, comparando-se com o período antes do implante (658 versus 185 ms2, p = 0,00, para LF; 322 versus 121 ms2, p = 0,00, para HF, respectivamente), sem alteração da LF/HF. LF durante o implante foi de 864 ms2 nos pacientes com stent convencional e de 398 com farmacológico (p = 0,00). Não houve associação entre a AE e a presença de diabetes, história familiar, apresentação clínica, uso de betabloqueador (BB), idade, vaso ou seu segmento. Conclusões: O implante de stent resultou em ativação simpática e concomitante ativação vagal. Não houve influência do quadro de diabetes, uso de BB e vaso sobre a AE. Houve menor ativação simpática durante o implante de stent farmacológico. .

Dispersão da onda P e índice de volume do átrio esquerdo como preditores na insuficiência cardíaca / P-wave dispersion and left atrial volume index as predictors in heart failure

FUNDAMENTO: Estudos demonstram que a dispersão da onda P (DP) e o índice de volume do átrio esquerdo (Aesc) são preditores de eventos cardiovasculares (EC). OBJETIVO: Verificar o valor prognóstico da dispersão da onda P e do Aesc para a ocorrência de EC em pacientes com insuficiência cardíaca. MÉTODOS: Estudo longitudinal e prospectivo com 78 pacientes consecutivos com idade média de 47,2 anos, sendo 52 homens, estáveis com insuficiência cardíaca, submetidos à avaliação clínica, aos exames de eletrocardiograma e ao ecocardiograma, com seguimento de 26,5 meses. RESULTADOS: As médias das variáveis foram: 50 ms DP e 35,5 ml/m² Aesc. Considerando-se DP > 40 ms e como referência Aesc > 28 ml/m², o valor preditivo positivo da DP foi de 87,5% e o negativo de 76,9%. Durante o seguimento, 21 pacientes apresentaram EC. Houve associação entre as medidas do átrio esquerdo, os volumes do ventrículo esquerdo e a fração de ejeção e EC. Não houve associação entre a DP e EC. Pela análise multivariada, o átrio esquerdo e o Aesc foram preditores de eventos (p = 0,00 e 0,02). Pela curva de operação característica para a variável estável EC, foram obtidas as áreas de 0,80 e 0,69 para Aesc (p = 0,00) e Aesc > 28 ml/m² (p = 0,01). As curvas de sobrevida (Kaplan-Meier) livre daqueles eventos para Aesc > 28 ml/m² e para a etiologia chagásica demonstraram razão de chance de 14,4 (p = 0,00) e de 3,2 (p = 0,03). Não houve diferença de evolução entre pacientes com insuficiência cardíaca isquêmica e não isquêmica. CONCLUSÃO: DP não esteve correlacionada a EC. Aesc foi um preditor independente de EC e os chagásicos apresentaram pior evolução.

BACKGROUND: Studies have shown that P-wave dispersion (PWD) and left atrial volume index (LAVi) are predictors of cardiovascular events (CE). OBJECTIVE: To verify the prognostic value of PWD and LAVi for the occurrence of CE in patients with heart failure (HF). METHODS: This was a longitudinal prospective study of 78 consecutive patients with a mean age of 47.2 years, of which 52 were males. Patients had stable HF and underwent clinical evaluation, electrocardiogram and echocardiogram assessments, with a follow-up of 26.5 months. RESULTS: The means of the variables were: 50 ms for PWD and 35.5 mL/m² for LAVi. Considering PWD > 40 ms and, as reference, LAVi > 28 mL/m², the positive predictive value of PWD was 87.5% and the negative predictive value was 76.9%. During follow-up, 21 patients had CE. There was an association between left atrial measurements, left ventricular volumes, ejection fraction and CE. There was no association between PWD and CE. At the multivariate analysis, the left atrium and LAVi were predictors of events (p = 0.00 and 0.02). Through the operating characteristic curve for the variable stable CE, areas of 0.80 and 0.69 were obtained for LAVi (p = 0.00) and LAVi > 28 mL/m² (p = 0.01). Survival curves (Kaplan-Meier) free of those events for LAVi > 28 mL/m² and for Chagas disease etiology showed an odds ratio of 14.4 (p = 0.00) and 3.2 (p = 0.03). There was no difference in outcome between patients with ischemic and nonischemic heart failure. CONCLUSION: PWD was not correlated to CE. LAVi was an independent predictor of CE, and chagasic patients showed worse outcomes.