Implementation of a Telecardiology Service in a Health Unit in the City of Porto Alegre, Brazil: A Pilot Study

Abstract Background: The implementation of Telecardiology in primary care in the city of Porto Alegre, Brazil, is a viable and promising strategy. It would decrease the distance between patient and specialized professional services by reducing unnecessary referrals and improving the quality of primary care and satisfaction of patients and health professionals. Objective: To implement a Telecardiology service and assess user satisfaction using the CARDIOSATIS scale. Methods: This was a pilot study developed by a partnership between the Institute of Cardiology and the Telehealth Center of Rio Grande do Sul. The study was carried out at Eri Flores-Vila Vargas health center in the city of Porto Alegre, from May to October 2019, and included 21 patients attending the health center. The descriptive analysis of data was performed using the SPSS program (Statistical Package for the Sciences) version 23. Data normality was checked using the Kolmogorov-Smirnov test. Statistical significance was set at 10%. Results: Mean age of participants was 43.8 ± 16.1 years. The most common risk factors in the sample were physical inactivity (81%) and smoking (43%). Most patients had normal electrocardiogram (ECG) readings. The time elapsed from the performance of the ECG test, transmission of the ECG traces to Telehealth, and return of the final ECG report to the health center was 0-7 days. The CARDIOSATIS scale revealed a high prevalence of "very satisfied" users for the general satisfaction domain, and only 14.3% of patients were dissatisfied with their health. Conclusions: Telecardiology reduced the distance between patient and the specialized professional, with a high level of patient and health professional satisfaction. Our study can serve as a basis for the implementation of a telecardiology network in the city of Porto Alegre in the future.

Frequência e características dos respondedores a uma intervenção educacional para redução de testes cardíacos inapropriados: um subestudo do Echo WISELY Trial / Frequency and characteristics of responders to an educational intervention to reduce inappropriate heart testing: a sub-study of the Echo WISELY Trial

Introdução: O Echo WISELY Trial é um estudo controlado, randomizado, multicêntrico, cego pelo investigador, que avaliou uma intervenção educacional com base nos critérios de uso apropriado para ecocardiografia para redução da proporção de ecocardiogramas raramente apropriados realizados ambulatorialmente. Objetivo: Descrever a prevalência e identificar preditores de responsividade de médicos respondedores submetidos à intervenção educacional no Echo WISELY Trial. Métodos: Médicos do grupo intervenção receberam um programa educacional multifacetado. O médico respondedor foi definido como aquele que apresentou redução >2,5% na média proporcional de exames raramente apropriados solicitados entre o primeiro trimestre (linha de base) e qualquer um dos seguintes trimestres (segundo ao sexto). Foram comparadas as características do médico (sexo, tempo de formação, especialidade médica e local de trabalho) com as classificações dos ecocardiogramas (apropriado, talvez apropriado e raramente apropriado) e razões clínicas para ecocardiogramas solicitados utilizando teste do qui-quadrado. A significância estatística foi indicada por p < 0,05 bicaudal. Resultados: Foram analisados 4.605 exames solicitados nos seis hospitais participantes de Ontário e randomizados para o braço intervenção. Dentre os 36 médicos incluídos, 26 (72%) foram classificados como respondedores. Entre as variáveis analisadas, não houve diferença significativa entre médicos respondedores e não respondedores à intervenção educacional. O número de exames raramente apropriados solicitados pelos respondedores foi significativamente menor que o de não respondedores (234; 8,67% versus 261; 13,8%; p < 0,0001). Conclusão: A prevalência de médicos respondedores é alta, porém não foram identificados preditores de responsividade à intervenção educacional entre as variáveis analisadas. Isso pode decorrer de aspectos psicológicos e características pessoais dos médicos, que não foram incluídos nesta pesquisa.(AU)

Introduction: The Echo WISELY Trial is a controlled randomized multicenter investigator-blinded study that evaluated an educational intervention based on the criteria for appropriate use of echocardiography to reduce the proportion of rarely appropriate outpatient echocardiograms performed. Objective: To describe the prevalence and identify predictors of the responsiveness of responding physicians subjected to an educational intervention in the Echo WISELY Trial. Methods: The intervention group physicians received a multifaceted educational program. A responding physician was defined as one who had a >2.5% reduction in the proportional mean of rarely appropriate tests requested between the first trimester (baseline) and any of the following trimesters (second to sixth). Physician characteristics (sex, time since graduation, medical specialty, and workplace) were compared to the echocardiogram ratings (appropriate, maybe appropriate, and rarely appropriate) and clinical reasons for the requested echocardiograms using the chi-square test. Statistical significance was indicated by a two-tailed p < 0.05. Results: A total of 4,605 tests requested at the six participating hospitals in Ontario were analyzed and randomized for the intervention arm Of the 36 included physicians, 26 (72%) were classified as responders. Of the variables analyzed, there was no significant difference in the outcomes of the responders versus non-responders to the educational intervention. The number of rarely appropriate tests requested by the responders was significantly lower than that of the non-responders (234 [8.67%] versus 261 [13.8%]; p < 0.0001). Conclusion: The prevalence of responder physicians was high, but predictors of responsiveness to educational intervention were not identified among the analyzed variables. This may be a result of the psychological aspects and personal characteristics of the physicians, which were not included in this research. (AU)

Evaluación del Compromiso Cardiovascular en niños en diálisis mediante el Índice de Masa Ventricular Izquierdo / Left Ventricular Mass Index and Cardiovascular Compromise in children on dialysis

INTRODUCCIÓN: Existe una estrecha relación entre enfermedad renal crónica (ERC) y enfermedad cardiovascular. Una de sus manifestaciones clínicas es la hipertrofia de ventrículo izquierdo (HVI), expresada como Indice de Masa Ventricular Izquierda (IMVI, gr/m27). En pacientes portadores de ERC con retraso de creci miento, el cálculo de IMVI debería ajustarse corrigiendo la edad para la talla. OBJETIVO: Comparar el IMVI corregido por edad para la talla, con el valor calculado por edad cronológica en niños con ERC en diálisis. PACIENTES Y MÉTODO: Estudio de corte transversal. Se analizan ecocardiografías de pacientes portadores de ERC en diálisis entre 1-18 años, enero de 2016 a julio 2017. Se evalúa IMVI ajustando el valor expresado a gr/m27 al percentil para la edad cronológica del niño, y luego se ajusta el valor a la edad corregida por la talla. Se usa estadística descriptiva y estudio de concordancia para las evaluacio nes de IMVI calculado por edad cronológica y para edad corregida por talla. RESULTADOS: Se incluyeron 26 pacientes, 75 ecocardiogramas. Un 56% presentó HVI usando IMVI calculado por edad cronoló gica vs un 46,6% al corregir la edad para la talla. Al comparar los grupos de percentiles de IMVI-edad cronológica vs IMVI ajustado a la edad para la talla real, se observó que el 18,6% de la muestra cambia de grupo de percentil, el 100% de ellos a un grupo de percentil inferior. La concordancia evaluada en base a coeficiente Kappa fue de 0,72 (concordancia perfecta > 0,8), confirmando diferencias al ajustar el IMVI para la edad corregida por la talla. CONCLUSIÓN: El cálculo de IMVI por edad cronológica so breestima el compromiso cardiovascular en niños con ERC que característicamente tienen un retraso de talla. Los resultados sugieren que el cálculo de IMVI ajustado a la edad corregida por talla otorga mayor precisión al diagnóstico de hipertrofia ventricular izquierda en este grupo de pacientes.

INTRODUCTION: There is a close relationship between chronic kidney disease (CKD) and cardiovascular disease. One of its clinical manifestations is left ventricular hypertrophy (LVH), expressed as Left Ventricular Mass Index (LVMI gr/m27). In CKD patients with growth retardation, the LVMI calculation should be adjusted by correcting age for length/height. OBJECTIVE: To compare the age-corrected LVMI for length/height with the value calculated by chronological age in CKD children on dialysis. PATIENTS AND METHOD: Cross-sectional study. We analyzed echocardiographies of CKD children on dialysis aged between 1 and 18, from January 2016 to July 2017. LVMI was evaluated by adjusting the value expressed in gr/m27 to the percentile for the chronological child's age, and then the value was adjusted to the age-corrected length/height. We used descriptive statistics and concordance study for LVMI assessments calculating by chronological age and for age-corrected length/height. RESULTS: 26 patients were included and 75 echocardiograms. 56% had left ventricular hypertrophy using chronological age versus 46.6% age-corrected LVMI for length/height. When comparing the percentile groups of LVMI-chronological age vs. age-adjusted LVMI for actual length/height, it was observed that 18.6% of the sample changed percentile groups, 100% of them to a lower percentile group. The agreement evaluated based on the Kappa coefficient was 0.72 (perfect agreement > 0.8), confirming differences when adjusting the LVMI for age-corrected length/height. CONCLUSION: Calculating LVMI by chro nological age overestimates the cardiovascular involvement in children with CKD who are charac teristically stunted. The results suggest that the age-adjusted, length/height-corrected calculation of LVMI gives greater accuracy to the diagnosis of left ventricular hypertrophy in this group of patients.

Strain Longitudinal e Acidente Vascular Encefálico Isquêmico na Ausência de Cardiopatia Conhecida / Longitudinal Strain and Ischemic Stroke in the Absence of Known Heart Disease

Fundamento: O acidente vascular encefálico (AVE) é prevalente no mundo. Reconhecimento precoce da doença cardiovascular subclínica pode predizer um primeiro episódio de AVE isquêmico; o speckle tracking associado à ecocardiografia (STE) permite detecção precoce da disfunção miocárdica subclínica. Objetivo: Provar a associação entre deformação miocárdica avaliada pelo STE e primeiro episódio de AVE em indivíduos saudáveis. Método: Incluímos participantes entre 40-80 anos com primeiro episódio de AVE isquêmico sem cardiopatia conhecida, pareados por sexo, idade e hipertensão com grupo controle saudável na proporção 1:2. STE avaliou strain longitudinal (SL) do ventrículo esquerdo (VE), e ecocardiografia tradicional foi realizada. Análises univariada e multivariada avaliaram as relações do AVE com fatores de risco cardiovasculares e parâmetros derivados da ecocardiografia. Resultado: 29 casos e 62 controles foram incluídos. Média etária foi 60 ± 12 anos; 54% eram homens. Tabagismo foi mais prevalente em casos do que em controles (34% vs. 9%; p=0.001). Nenhum outro fator de risco evidenciou diferença estatística. Casos tiveram menor deformação miocárdica comparados aos controles (SL -16.7 ± 3.4% vs. -19.2 ± 2.8%; p < 0.001). Não houve diferença em relação aos parâmetros ecocardiográficos tradicionais. Após ajuste para tabagismo e hiperlipidemia, SL manteve-se independentemente associado com AVE (OR=1.3; 95% CI, 1.1 ­ 1.6; p=0.005). A área abaixo à curva ROC para AVE aumentou significativamente após adicionar SL ao tabagismo (0.65 para 0.78, respectivamente; p=0.009). Conclusão: SL tem independente associação com o primeiro episódio de AVE isquêmico em adultos de média idade com corações geralmente normais. SL pode ser potencial marcador de risco nesta população

Background: Stroke is prevalent worldwide, and early recognition of subclinical cardiovascular (CV) disease could predict a first ischemic stroke (IS) episode. Speckle-tracking echocardiography (STE) allows the detection of early subclinical myocardial dysfunction. Aim: To examine the association between myocardial deformation, evaluated by STE, and first episode of IS in a sample of otherwise healthy patients. Methods: We included individuals between 40­80 years old, with a first incidence of IS, with no known CV disease, matched to healthy controls by sex, age, and hypertension at a 1:2 ratio. STE was used to assess LV global longitudinal strain (GLS), and traditional echocardiography was performed. Univariate and multivariable analyses were performed to assess the relationship among stroke, CV risk factors, and echocardiographyderived parameters. Results: A total of 29 cases and 62 controls were included. The mean age of the patients was 60 ± 12 y/o, and 54% were males. Smoking was more prevalent in cases compared to controls (34% vs. 9%; p = 0.001), and there were no significant differences in the other examined risk factors. Cases had less myocardial deformation compared to controls (GLS: -16.7% ± 3.4% vs. -19.2 ± 2.8%; p < 0.001), and there was no

Analysis of cardiovascular risk and carotid intima-media thickness in patients with psoriasis

Abstract Background: Psoriasis is associated with atherosclerosis and increased cardiovascular risk. Currently, an automated ultrasound, called quantitative intima media thickness, has proven to be a useful method to evaluate subclinical atherosclerosis. Objectives: To compare increased cardiovascular risk in psoriasis patients receiving two types of treatments: Methotrexate and tumor necrosis factor inhibitor and to evaluate the correlation between the Framingham score and quantitative intima media thickness. Methods: Fifty patients with plaque psoriasis were selected from June 2017 to July 2018, divided into two groups, receiving methotrexate and tumor necrosis factor inhibitor. Measurement of abdominal circumference, blood pressure, body mass index and presence of metabolic syndrome were performed. Afterwards, the patients were evaluated for increased cardiovascular risk with the Framingham score and for the quantitative intima media thickness of the carotid arteries. Results: The mean age was 54.8 (±12.5) with a slight male predominance (58%). Overall, 84% of the patients had elevated waist circumference, 82% had a body mass index above ideal, and 50% had a metabolic syndrome. For the correlation between quantitative intima media thickness and Framingham Score, Pearson's linear correlation coefficient was 0.617 (p < 0.001), indicating a moderate to strong positive association. Study limitations: The protective effect of the therapies cited in relation to the increased cardiovascular risk was not evaluated. Conclusions: A moderate to strong positive association was found correlating the Framingham Score values with the quantitative intima media thickness measurement and it is not possible to state which drug has the highest increased cardiovascular risk.

The relation between echocardiographic epicardial fat thickness and cha2ds2-vasc score in patients with sinus rhythm

Abstract Objective: To evaluate the predictive value of epicardial fat thickness (EFT) in CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups. Methods: A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA2DS2-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score. Results: Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA2DS2-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA2DS2-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA2DS2-VASc score. Conclusion: Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Importância da educação para prevenção cardiovascular / Importance of education for cardiovascular disease prevention

As doenças cardiovasculares estão entre as maiores causas de morbidade e mortalidade em todo o mundo e são responsáveis por um elevado custo para os sistemas de saúde. Assim, as medidas de prevenção dessas doenças e o controle de seus fatores de risco tornam-se essenciais. Para isso, temos como alternativa, intervenções educacionais para a população, como maneira de fortalecer o indivíduo para realizar as mudanças necessárias em seu estilo de vida, e medidas de educação profissional, para difundir o manejo de emergências cardiovas-culares, com grande impacto na sobrevida de indivíduos com esses problemas. Neste texto, procuramos descrever as medidas educacionais mais frequentes e efetivas para essa prevenção.

Cardiovascular disease is one of the leading causes of morbidity and mortality worldwide and represents a high cost for health systems. Therefore, measures to prevent these conditions and to control their risk factors are essential. One alternative consists of educational interventions for the population as a means of enabling the individual to make the necessary changes in their lifestyle, as well as professional education measures to disseminate the management of cardiovascular emergencies with considerable impact on the survival of individuals with these problems. In this text, we strive to describe the most common and effective educational measures for this prevention

Acompanhamento do paciente diabético com DAC crônica: otimização do tratamento medicamentoso e momento de intervenção / Follow-up of the diabetic patient with chronic CAD: optimizing drug treatment and moment of intervention

A causa mais comum de mortalidade no paciente diabético é a doença cardiovascular, tendo como um de seus principais representantes a doença arterial coronariana (DAC). Homens acima de 40 anos e mulheres acima de 50 anos com DM tipo um ou tipo dois, geralmente, apresentam risco de eventos coronarianos > 2% ao ano. O risco de eventos cardiovasculares ou óbito será mais elevado quando houver diagnóstico clínico de DAC crônica após infarto do miocárdio, acidente vascular cerebral (AVC) ou ataque isquêmico transitório ou mesmo na presença de angina do peito, dispneia de origem isquêmica (equivalente anginoso), claudicação intermitente ou doença da aorta. Os objetivos fundamentais do tratamento da DAC crônica nos pacientes diabéticos não se diferenciam da população não diabética e incluem: prevenção do infarto do miocárdio e redução da mortalidade; redução dos sintomas e da ocorrência da isquemia miocárdica, proporcionando melhor qualidade de vida. Todos os pacientes diabéticos com doença cardiovascular aterosclerótica estabelecida devem receber terapia farmacológica otimizada, medicamentos que reduzam a incidência de infarto e aumentem a sobrevida e medicamentos que melhorem a qualidade de vida dos pacientes. Dessa forma, é fundamental e de prioridade iniciar o tratamento com medicamentos que reduzam a morbimortalidade e associar, quando necessário, medicamentos que controlem a angina e reduzam a isquemia miocárdica. A intervenção de revascularização na DAC crônica em pacientes diabéticos, seja percutânea ou cirúrgica, não deve ser considerada como alternativa, mas sim, como complementar ao tratamento medicamentoso otimizado. O momento dessas intervenções ainda é motivo de diversas controvérsias dentro da cardiologia, mas deve ser considerado quando houver ineficácia desse tratamento medicamentoso otimizado. Portanto, a decisão quanto a intervenção diagnóstica e terapêutica invasiva vai depender, principalmente, do risco a que o paciente é submetido, dependendo da presença e extensão da isquemia miocárdica e da severidade da sintomatologia da dor ou outro sintoma que possa indicar um equivalente isquêmico (disfunção ventricular e/ou arritmia).

The most common cause of mortality among diabetic patients is cardiovascular disease, one of the main representatives of which is coronary artery disease (CAD). Men aged over 40 years and women over 50 years with type 1 or type 2 DM generally present risk of coronary events of >2% a year. The risk of cardiovascular events or death is higher when there is a clinical diagnosis of chronic CAD following myocardial infarction, cerebrovascular accident (CVA) or transitory ischemic attack, or even in the presence of angina of the chest, dyspnea of ischemic origin (anginal equivalent), intermittent claudication, or aortic disease. The fundamental objectives of treatment of chronic CAD in diabetic patients are no different from those in the non-diabetic population, and include: preventing myocardial infarction and reducing mortality; reducing the symptoms and occurrence of myocardial ischemia, improving quality of life. All diabetic patients with established atherosclerotic cardiovascular disease should receive optimized pharmacological therapy, medications that reduce the incidence of stroke and increase survival, and medications that improve the patients' quality of life. Therefore, it is fundamentally important to begin treatment with medications that reduce morbimortality and toassociate, where necessary, medications that control angina and reduce myocardial ischemia. Revascularization intervention in chronic CAD in diabetic patients, whether percutaneous or surgical, should not be considered as an alternative, but rather, as complementary to optimized drug treatment. The best time to perform these interventions is still a motive of various controversies within cardiology, but should be considered when this optimized drug treatment is ineffective. Therefore, the decision on diagnostic and invasive therapeutic intervention will depend, mainly, on the risk to which the patient is exposed, depending on the presence and extent of the myocardial ischemia and the severity of the pain or other symptoms that may indicate an ischemic equivalent (ventricular dysfunction and/or arrhythmia).

Prevalence of factors related to vascular calcification in patients with chronic kidney disease on dialysis

The main aim of the study was to determine the prevalence of vascular calcifications in patients with chronic kidney disease on dialysis in our population assessed by X-ray. The secondary objectives were to determine the cardiovascular risk factors associated with the presence of vascular calcifications and to evaluate the complementary use of the echocardiogram in a cross-sectional, observational, multicentric study. We included patients with chronic kidney disease on dialysis, age =18 years with at least 3 months of renal replacement therapy in 8 dialysis centres in Argentina. The degree of vascular calcification was determined using Adragao and Kauppila scores. The presence of valvular calcifications was established through a trans-thoracic doppler echocardiogram. Univariate and multivariate analysis were undertaken, considering the degree of vascular calcification as the dependent variable; 443 adult patients were evaluated at 8 centres across 5 provinces in Argentina. The prevalence of vascular calcifications by the X-rays was 63%, while 73% presented calcifications in hands and pelvis, with an Adragao score >3, and 60% presented calcifications in the abdominal aorta with a Kauppila score >4. The prevalence of valvular calcifications: 28%. We have shown a higher rate of vascular calcifications with the use of plain X-rays when compared to the prevalence of valvular calcifications obtained with echocardiograms. In this regard, valvular calcifications were present particularly in those patients with a severe level of radiological vascular calcification.

El objetivo primario del estudio fue determinar la prevalencia de calcificaciones vasculares en pacientes con enfermedad renal crónica (ERC) en diálisis, a través de métodos accesibles y reproducibles. Como objetivo secundario: determinar los factores de riesgo cardiovascular asociados a la presencia de calcificaciones vasculares y evaluar la utilidad complementaria del ecocardiograma. Fue un estudio prospectivo, transversal y multicéntrico sobre pacientes prevalentes con ERC en diálisis. Se les realizaron radiografía de columna lumbar, de manos y panorámica de pelvis, para la determinación de las escalas de Adragao y Kauppila. La presencia de calcificaciones valvulares fue establecida por ecocardiograma doppler color transtorácico. Se obtuvieron los datos de 30 variables determinadas para el análisis uni y multivariado (regresión logística) de los factores de riesgo asociados. Se evaluaron 443 pacientes adultos de 8 centros de 5 provincias de la Argentina. La prevalencia de calcificaciones vasculares, determinada por las radiografías, fue 63%. La prevalencia de calcificaciones valvulares fue 28%. Las calcificaciones valvulares estuvieron presentes en aquellos pacientes con graves calcificaciones radiológicas. Las calcificaciones estuvieron asociadas a la edad (>55 años), sexo masculino, diabetes, tiempo de diálisis, tabaquismo y la presencia de enfermedad vascular periférica. Este es el estudio con mayor número de pacientes evaluados en Latinoamérica. Se encuentra alta prevalencia de calcificaciones vasculares en Argentina, fácilmente medibles con técnicas no invasivas como la radiografía simple, que resulta más sensible que el ecocardiograma. Ambos estudios deben ser utilizados de manera complementaria.