Como eu faço no Coração de Atleta: avaliação dos diferentes tipos de adaptação ao exercício / My approach to "Athlete'S Heart": evaluation of the different types of adaptation to exercise

A prática regular de esportes pode induzir adaptações no coração, sendo essa condição comumente chamada de "coração de atleta". As alterações observadas incluem dilatação das câmaras cardíacas, aumento da espessura miocárdica, melhora do enchimento ventricular, aumento da trabeculação do ventrículo esquerdo (VE), dilatação da veia cava inferior, entre outras. Essas alterações também podem ser observadas em algumas doenças cardíacas, como cardiomiopatia (CMP) dilatada, hipertrófica e outras. Dessa forma, os exames de imagem cardíaca são fundamentais na identificação dessas alterações e na diferenciação entre o "coração de atleta" e uma possível cardiopatia.(AU)

Exercise-induced adaptation may occur in amateur and professional athletes. This condition is commonly named "athlete's heart". The alterations observed include dilation of the heart chambers, increased myocardial thickness, improved ventricular filling, increased left ventricular trabeculation, dilation of the inferior vena cava, among others. These changes can also be observed in some heart diseases, such as dilated, hypertrophic and other cardiomyopathies (CMP). Thus, cardiac imaging tests are fundamental in identifying these alterations and in differentiating between "athlete's heart" and possible heart disease. (AU)

Risk of Obstructive Sleep Apnea and Echocardiographic Parameters / Correlação entre Risco de Apneia Obstrutiva do Sono e Parâmetros do Ecocardiograma

Abstract Background: Obstructive sleep apnea (OSA) is a chronic progressive disorder with high mortality and morbidity rate, associated with cardiovascular diseases (CVD), especially heart failure (HF). The pathophysiological changes related to OSA can directly affect the diastolic function of the left ventricle. Objectives: To assess the association of the risk of OSA, evaluated by the Berlin Questionnaire (BQ), and echocardiographic (ECHO) parameters related to diastolic dysfunction in individuals without HF assisted in primary care. Methods: A cross-sectional study that included 354 individuals (51% women) aged 45 years or older. All individuals selected were submitted to an evaluation that included the following procedures: consultation, filling out the BQ, clinical examination, laboratory examination and transthoracic Doppler echocardiography (TDE). Continuous data are presented as medians and interquartile intervals, and categoric variables in absolute and relative frequencies. The variables associated with risk of OSA and at the 0.05 level integrated the gamma regression models with a log link function. A value of p < 0.05 was considered an indicator of statistical significance. Exclusion criteria were presence of HF, to fill out the BQ and patients with hypertension and obesity not classified as high risk for OSA by other criteria. All individuals were evaluated on a single day with the following procedures: medical appointment, BQ, laboratory tests and ECHO. Results: Of the 354 individuals assessed, 63% were classified as having high risk for OSA. The patients with high risk for OSA present significantly abnormal diastolic function parameters. High risk for OSA confirmed positive and statistically significant association, after adjustments, with indicators of diastolic function, such as indexed left atrium volume LAV-i (p = 0.02); E'/A' (p < 0.01), A (p = 0.02), E/A (p < 0.01). Conclusion: Our data show that patients at high risk for OSA present worsened diastolic function parameters measured by TDE.

Resumo Fundamento: A apneia obstrutiva do sono (AOS) é um transtorno crônico, progressivo, com alta morbimortalidade e associado às doenças cardiovasculares (DCV), entre elas a insuficiência cardíaca (IC). As alterações fisiopatológicas relacionadas com a AOS podem impactar diretamente a função diastólica do ventrículo esquerdo. Objetivo: Estimar a associação entre risco de AOS, avaliada pelo Questionário de Berlim (QB), e parâmetros do ecocardiograma, relacionados com a função diastólica, em indivíduos sem IC na atenção primária. Métodos: Estudo transversal que incluiu 354 indivíduos (51% mulheres) com idade igual ou superior a 45 anos. Todos os indivíduos selecionados foram submetidos a uma avaliação que constou dos seguintes procedimentos: consulta, preenchimento do QB e exame clínico, realização de exames laboratoriais e ecocardiograma Doppler transtorácico (EDT). Os dados contínuos são apresentados em medianas e intervalos interquartílicos e os categóricos em frequências absolutas e relativas. As variáveis que apresentaram associação ao risco de AOS em nível de 0,05 integraram os modelos de regressão gama com função de ligação log link. Análise bruta: Um valor de p < 0,05 foi considerado como indicador de significância estatística. Resultados: Dos 354 indivíduos analisados, 63% foram classificados como tendo alto risco para AOS. Os pacientes com alto risco para AOS apresentam alterações significativas dos parâmetros que avaliam a função diastólica. Alto risco para AOS confirmou sua associação positiva e estatisticamente significativa, após ajuste, a indicadores de disfunção diastólica - VAE-i (p = 0,02); E'/A' (p < 0,01); A (p = 0,02); E/A (p < 0,01). Conclusão: Nossos dados mostram que pacientes com alto risco de AOS apresentam piora dos parâmetros de função diastólica medidos pelo EDT.

Prevalencia de septal pouch en una cohorte derivada para ecocardiograma transesofágico / Prevalence of septal pouch in a cohort derived for transesophageal echocardiography / Prevalência da bolsa septal em uma coorte derivada para ecocardiografia transesofágica

Resumen: Introducción: los defectos del septum interauricular (SIA) son frecuentes. En los últimos años se ha identificado una nueva entidad conocida comoseptal pouch (SP). Los datos sobre su prevalencia son escasos, estimándose entre 30%-50% en la población general. El rol como fuente de cardioembolia es discutido. Objetivos: el objetivo primario es determinar la prevalencia y caracterizar el SP; en forma secundaria, definir la variabilidad interobservador para su diagnóstico. Material y método: estudio observacional, descriptivo y analítico. Se reclutaron en forma prospectiva pacientes consecutivos derivados para ecocardiograma transesofágico (ETE) entre el 20 de abril de 2018 y el 30 de agosto de 2018. Se registraron datos patronímicos, antecedentes personales de accidente cerebrovascular (ACV), ritmo cardíaco y motivo del estudio. Se evaluó la presencia de SP y se caracterizó como left-sided septal pouch (LSSP) o rigth-sided septal pouch (RSSP); se midió profundidad, presencia de trombo en su interior y se completó el estudio ecocardiográfico. Las imágenes fueron evaluadas por dos ecocardiografistas ciegos entre sí. Las variables cualitativas se presentan en frecuencia relativa (FR); las cuantitativas en mediana e intervalo intercuartilo. Se realizó test de chi cuadrado para evaluar la asociación entre la presencia de SP y la presencia de ACV o de FA. La reproducibilidad del diagnóstico de SP fue evaluada por índice Kappa. Resultados: se incluyeron 50 sujetos. La prevalencia de SP fue de 0,5 (FR), 0,46 LSSP y 0,04 RSSP. El índice Kappa interobservador para el diagnóstico fue 0,68, error estándar 0,14, con 84% de acuerdo. Catorce sujetos tenían antecedente de ACV, en nueve de ellos se diagnosticó SP (chi cuadrado p=0,21); 18 pacientes tenían fibrilación auricular/flutter, la mitad de ellos tenía SP (chi cuadrado p=1). Conclusión: la prevalencia de SP fue de la mitad de la población, predominando ampliamente el LSSP, con buena reproducibilidad en su diagnóstico. Se trata de un hallazgo subdiagnosticado; interesa continuar investigando su posible asociación con ACV.

Summary: Introduction: the interatrial septum defects are frequent. A new entity has recently been identified, known as septal pouch. Prevalence data in general population is scarce, and is estimated between 30%-50%. The role as a source of cardioembolism is unclear. Objectives: the primary objective is to determine the prevalence and characterize the septal pouch; secondarily to define the interobserver variability for the diagnosis. Material and methods: observational, descriptive and analytical study. Consecutive patients were recruited for transesophageal echocardiography between 4/20/2018 and 8/30/2018. We recorded patronymic data, personal history of stroke, heart rate, and the reason for the study. The presence of septal pouch was defined and characterized as left-sided septal pouch or rigth-sided septal pouch; depth was measured, presence of thrombus inside and echocardiographic study measures were completed. The images were evaluated by two blind echocardiographers. The qualitative variables are presented in relative frequency (RF), the quantitative variables in median and interquartile interval. Chi square test was carried out. The reproducibility of the diagnosis of septal pouch was evaluated by Kappa index. Results: 50 subjects were included. The prevalence of septal pouch was 0.5 (RF), 0.46 left-sided septal pouch and 0.04 rigth-sided septal pouch. The interobserver Kappa index for diagnosis is 0.68, standard error 0.14, with 84% agreement. 14 subjects had stroke, in 9 of them septal pouch was diagnosed (chi square p=0.21); 18 patients had atrial fibrillation or flutter, half of them had septal pouch (chi square p=1). Conclusion: the prevalence of septal pouch was half of the population, predominantly the left-sided septal pouch, with good reproducibility in diagnosis. It is an underdiagnosed finding; further investigation is necessary to assess its relation to stroke.

Resumo: Introdução: os defeitos do septo interatrial são freqüentes. Nos últimos anos, uma nova entidade conhecida como bolsa septal foi identificada. Dados sobre prevalência são escassos, estimados em 30%-50% na população geral. O papel como fonte de cardioembolismo é discutido. Objetivos: o objetivo primário é determinar a prevalência e caracterizar a bolsa septal; secundariamente definir a variabilidade interobservador para o seu diagnóstico. Material e métodos: estudo observacional, descritivo e analítico. Consecutivos pacientes foram recrutados para ecocardiograma transesofágico entre 20/4/2018 e 30/08/2018. Registramos dados patronímicos, histórico pessoal de acidente vascular cerebral, frequência cardíaca e o motivo do estudo. A presença de bolsa septal foi definida e caracterizada como bolsa septal esquerda ou bolsa septal direita; a profundidade foi medida, a presença de trombo no interior e o estudo ecocardiográfico foram concluídos. As imagens foram avaliadas por dois ecocardiografistas cegos. As variáveis qualitativas são apresentadas em frequência relativa (FR); os quantitativos em mediana e interquartil intervalo. O teste do qui quadrado foi realizado. A reprodutibilidade do diagnóstico de bolsa septal foi avaliada pelo índice Kappa. Resultados: 50 sujeitos foram incluídos. A prevalência de bolsa septal foi de 0,5 (FR), 0,46 bolsa septal esquerda e 0,04 bolsa septal direita. O índice Kappa interobservador para diagnóstico é 0,68, erro padrão 0,14, com 84% de concordância. 14 sujeitos apresentaram acidente vascular cerebral, em 9 deles foi diagnosticada bolsa septal (qui-quadrado p=0,21); 18 pacientes apresentaram fibrilhação auricular / flutter, metade deles com bolsa septal (qui quadrado p=1). Conclusão: a prevalência de bolsa septal foi metade da população, predominantemente a bolsa septal esquerda, com boa reprodutibilidade em seu diagnóstico. É um achado subdiagnosticado; é interessante para continuar investigando sua possível associação com acidente vascular cerebral.

Heart Failure with Mid-Range Ejection Fraction - State of the Art / Insuficiência Cardíaca com Fração de Ejeção Intermediária - Estado da Arte

Abstract In 2016, the European Society of Cardiology (ESC) recognized heart failure (HF) with ejection fraction between 40 and 49% as a new HF phenotype, HF with mid-range ejection fraction (HFmrEF), with the main purpose of encouraging studies on this new category. In 2018, the Brazilian Society of Cardiology adhered to this classification and introduced HFmrEF in Brazil. This paper presents a narrative review of what the literature has described about HFmrEF. The prevalence of patients with HFmrEF ranged from 13 to 24% of patients with HF. Analyzing the clinical characteristics, HFmrEF shows intermediate characteristics or is either similar to HF with preserved ejection fraction (HFpEF) or to HF with reduced fraction (HFrEF). Regarding the prognosis, HFmrEF's all-cause mortality is similar to HFpEF's and lower than HFrEF's. Studies that analyzed cardiac mortality concluded that there was no significant difference between HFmrEF and HFrEF, both of which were lower than HFpEF. Despite the significant increase of publications on HFmrEF, there is a great scarcity of prospective studies and clinical trials that allow delineating specific therapies for this new phenotype. To better treat HFmrEF patients, it is fundamental that cardiologists and internists understand the differences and similarities of this new phenotype.

Resumo Em 2016, a Sociedade Europeia de Cardiologia (ESC) reconheceu a insuficiência cardíaca (IC) com fração de ejeção do ventrículo esquerdo entre 40% e 49% como um novo fenótipo de IC, a IC com fração de ejeção intermediária (ICFEI), tendo como principal intuito, incentivar estudos sobre essa nova categoria. Em 2018, a Sociedade Brasileira de Cardiologia aderiu a essa classificação e introduziu a ICFEI no Brasil. O presente trabalho traz uma revisão narrativa sobre o que a literatura descreve até o momento sobre ICFEI. A prevalência de pacientes com ICFEI variou de 13-24% dos pacientes com IC. Quando avaliadas as características clínicas, a ICFEI apresenta um caráter intermediário ou se assemelha algumas vezes com a IC de fração de ejeção preservada (ICFEP) e outras com a IC de fração reduzida (ICFER). Quanto ao prognóstico, a ICFEI apresenta mortalidade por todas as causas semelhante a ICFEP e menor que a ICFER. Os estudos que analisaram a mortalidade por causa cardíaca concluíram que não houve diferença significativa entre ICFEI e ICFER, sendo ambas menores que a ICFEP. Apesar do considerável aumento de publicações sobre a ICFEI, ainda existe uma grande carência de estudos prospectivos e ensaios clínicos que possibilitem delinear terapias específicas para esse novo fenótipo. O conhecimento das particularidades da ICFEI por cardiologistas e internistas é fundamental para o melhor manejo desses pacientes.

Cardiovascular risk in children and adolescents with end stage renal disease

OBJECTIVES: To evaluate cardiovascular involvement in children and adolescents with End Stage Renal Disease (ESRD) and to characterize the main risk factors associated with this outcome. METHODS: Cross-sectional study of 69 children and adolescents at renal transplantation and 33 healthy individuals matched by age and gender. The study outcomes were left ventricular mass z-score (LVMZ) and carotid artery intima-media thickness (CIMT). The potential risk factors considered were age, gender, CKD etiology, use of oral vitamin D and calcium-based phosphate binders, systolic and diastolic blood pressure, body mass index z-score, time since diagnosis, dialysis duration, serum levels of ionic calcium, phosphorus, parathyroid hormone, fibroblast growth factor (FGF 23), uric acid, homocysteine, cholesterol, triglycerides, C-reactive protein (CRP), vitamin D and hemoglobin. RESULTS: In the multivariate analysis, the factors associated with LVMZ were dialysis duration, age, systolic blood pressure, serum hemoglobin and HDL cholesterol levels. Regarding CIMT, in the multivariate analysis, systolic blood pressure was the only factor associated with the outcome. CONCLUSION: Children exhibited important cardiovascular involvement at the time of the renal transplantation. Both of the studied outcomes were independently associated with systolic blood pressure. For this reason, controlling blood pressure seems to be the main therapy to minimize cardiovascular involvement in children with ESRD.

Trombosis sobre válvula protésica biológica. Reporte de caso / Thrombosis on biological prosthetic valve. Case report

Resumen: El siguiente artículo reporta el caso clínico de una paciente portadora de trombosis valvular bioprotésica en posición aórtica. La trombosis sobre válvula bioprotésica es una patología de baja prevalencia pero que puede conducir a un aumento en la tasa de accidentes cerebrovasculares, así como a largo plazo ser un factor coadyuvante de degeneración bioprotésica. Actualmente, el diagnóstico de la misma se realiza mediante ecocardiografía por el hallazgo de un incremento del gradiente medio transvalvular mayor a 50%, engrosamiento de los velos o movimiento anormal de los mismos, con una especificidad de 93%. El tratamiento con warfarina mostró ser efectivo en 83% de los pacientes, según un estudio prospectivo, así como en el caso de nuestra paciente que luego del tratamiento presenta una clara mejoría sintomática con disminución de los gradientes transvalvulares.

Summary: The following article reports a clinical case of a patient with bioprosthetic valvular thrombosis in aortic position. Bioprothesis valve thrombosis is a pathology of low prevalence but it can result in an increase in the rate of stroke as well as in the long term, a factor promoting bioprosthetic degeneration. Currently the diagnosis of the bioprothesis valve thrombosis is made by echocardiography by the finding of an increase in the mean transvalvular gradient greater than 50%, thickening of the cups and / or an abnormal movement of them with a specificity of 93%. Treatment with warfarin has shown to be effective in 83% of patients according to a prospective study, as well as in the case of our patient, with a clear symptomatic improvement as well as a decrease in mean transvalvular gradient after treatment.

Reanimación cardiopulmonar: manejo de las H y las T / Cardiopulmonary resuscitation, approach of "H & T" / Ressucitação cardiopulmonar: tratamento das H e T

Resumen: Existen distintas opciones de programas de entrenamiento en las que se enseñan a los profesionales de la salud las destrezas necesarias para llevar a cabo reanimación cardiopulmonar avanzada; uno de los más conocidos es el curso ACLS, impartido por la Asociación Americana del Corazón. Uno de los temas abordados en este programa es el manejo de las causas que pueden desencadenar un paro cardiorrespiratorio (particularmente en ritmos no desfibrilables) y la importancia de iniciar un manejo simultáneo durante las maniobras de reanimación cardiopulmonar. El objetivo del presente artículo es hacer una revisión minuciosa acerca de cuándo sospechar, cómo diagnosticar y cómo tratar cada una de las causas de asistolia y actividad eléctrica sin pulso (AESP). Se abordará el análisis que se debe realizar antes, durante y después de un paro cardiorrespiratorio. Además, se hará mención de la utilidad de la ultrasonografía o ecocardiografía de emergencia en el entorno de esta emergencia.

Abstract: There are different training programs that teach health professionals the skills needed to perform advanced cardiopulmonary resuscitation; one of the best known is the ACLS course, taught by the American Heart Association. One of the topics in this course is the handling of the causes that can trigger a cardiac arrest (particularly in non-shockable rhythms), and the importance of initiating simultaneous management during cardiopulmonary resuscitation. The aim of this article is to review thoroughly when to suspect, how to diagnose and how to treat each of the causes of asystole and pulseless electrical activity. We will tackle the analysis that has to be performed before, during and after cardiac arrest. In addition, we will review the usefulness of emergency ultrasound or echocardiography in this emergency scenario.

Resumo: Existem diversas opções de programas de treinamento que ensinam os profissionais da saúde as habilidades necessárias para executar a ressuscitação cardiopulmonar avançada, entre eles um dos mais conhecidos é o curso ACLS ensinado pela American Heart Association. Um dos temas abordados neste programa é o tratamento das causas que podem provocar uma parada cardíaca (particularmente em ritmos não chocáveis) e a importância de iniciar um tratamento simultâneo durante a ressuscitação cardiopulmonar. O objetivo deste artigo é fazer uma revisão completa sobre quando suspeitar, como diagnosticar e como tratar cada uma das causas de assistolia e atividade elétrica sem pulso. Se abordará a análise que deve ser feita dos acontecimentos antes, durante e depois da parada cardíaca. Além disso, será feita menção sobre a utilidade da ultra-sonografia ou ecocardiografia neste ambiente de emergência.

Clinical implication of real-time three-dimensional transesophageal echocardiography in percutaneous transcatheter left atrial appendage closure with Amplatzer Cardiac Plug(ACP) device for non-valvular atrial fibrillation patients / 中华超声影像学杂志

Objective To evaluate the application value of real-time three-dimensional echocardiography (RT-3D TEE) in nonvalvular atrial fibrillation patients after transcatheter left atrial appendage closure (LAAC) with the Amplatzer Cardiac Plug (ACP).Methods The two-dimensional transesophageal echocardiography (2D TEE) and RT-3D TEE were performed in selected patients to measure the diameter of left atrial appendage ostium and landing zone,to observe left atrial appendage morphology and lobular distribution.These were also performed to guide the whole process of transcatheter LAAC with ACP,which included the atrial septal puncture,sheathing canal cruise,occluder device implantation,and verifying the stability of occluder device and releasing the device.It involved observing ACP occluder morphology,location,stability,surrounding residual shunt,whether influencing the mitral valve and left superior pulmonary vein flow,and pericardial effusion.Results A total of 15 patients (100％) successfully underwent LAAC with the ACP.The maximum diameter of left atrial appendage ostium by 2D-TEE measurement during operation was (20.5 ± 2.9)mm,located at 135°.The diameter of left atrial appendage landing zone was (17.1 ± 2.8) mm,located at 45°;(18.0 ± 4.0) mm,located at 90°;(22.1 ± 4.7)mm,located at 135°,respectively.The left atrial appendage morphology:2 had one leaf and 13 had two leaves or more,including 2 cases of bifoliate short neck shape.In 15 patients,6 cases of cauliflower type,2 cases of wind sock type,3 cases of chicken wing type,2 cases of cactus type and 2 cases of complex type.The proximal left atrial appendage morphology:3 cases of boot type,2 cases of wide mouth type,6 cases of narrow mouth type,2 cases of straight tube type,and 2 cases of bifoliate short neck type.There was no obvious residual shunt in all the patients at immediately post-operation.Conclusions In the transcatheter LAAC with the ACP,RT-3D TEE has important application value in the preoperative selection of patients,the choice of appropriate occluder,guidance of full-process monitoring during operation,the postoperative effect evaluation and so on.

Evaluación de la función ventricular y auricular derecha con ecocardiografía 3D en tromboembolia pulmonar aguda / Assessment of right ventricular and atrial function with 3D echocardiography in acute pulmonary embolism

Introducción: La tromboembolia pulmonar aguda (TEP) es un padecimiento grave. La ecocardiografía tridimensional (ECO-3D) es un método accesible, novedoso y preciso para cuantificar la función ventricular y auricular derechas. A la fecha, no existen suficientes estudios que evalúen su papel en esta entidad. Objetivo: Determinar la utilidad del ECO-3D en la evaluación de la función ventricular y auricular derecha, y el riesgo de complicaciones cardiovasculares en pacientes con TEP aguda. Material y métodos: Se analizaron 35 pacientes, admitidos al HC CMN SXXI con TEP por angioTAC, mediante equipo Phillips IE 33, se midieron parámetros bidimensionales (2D) y 3D relacionados con función ventricular y auricular derecha (TomTec y qlab 10). Se evaluaron complicaciones cardiovasculares intrahospitalarias. Resultados: El riesgo relativo de eventos cardiovasculares mayores combinados (ECMC) intrahospitalarios por ECO-3D fue: índice de esfericidad de la aurícula derecha > 1.32; RR 20.3 IC 95% 2.9-13.8; p = 0.0001, FEVD RR 7.3 IC 95% 2.5-20.9; p = 0.0001, VDFVD > 77 mL RR de 7.3 IC 95% 2.56-20.9; p = 0.0001, VSFVD RR 5.5 IC 95% 2.26-13.3; p = 0.0001. El análisis multivariado mostró tres predictores de riesgo independiente: índice de esfericidad de la aurícula derecha > 1.32, TEP masiva y presión arterial media. Conclusiones: La evaluación combinada mediante ecocardiografía 3D de función ventricular y auricular derechas permiten una evaluación cuantitativa, predicción del riesgo para la presentación de complicaciones cardiovasculares y tiempo de estancia intrahospitalarios en pacientes con TEP aguda.

Introduction: Acute pulmonary embolism (PE) is a serious condition. Tridimensional Ecocardiography (3D ECHO) is an accessible, novel and accurate method for determination of right ventricular and atrial function. To date there are insufficient studies to assess their role in this entity. Objective: Determine the usefulness of ECO-3D in evaluating right atrial and ventricular function, and the risk of cardiovascular complications in patients with acute PE. Material and methods: 35 patients were admitted to the HC CMN SXXI with PE by CT angiogram, we analized 2D and 3D parameters by Philips iE33, right atrial and ventricular function (TomTec and QLAB 10). Hospital cardiovascular complications were evaluated. Results: The relative risk of major combined cardiovascular events for 3D ECHO was: right atrial sphericity index > 1.32; RR 20.3 95% CI 2.9-13.8; p = 0.0001, RVEF RR 7.3 95% CI 2.5-20.9; p = 0.0001, RVEDV> 77 mL RR 2.56 95% CI 7.3-20.9, p = 0.0001, RR 5.5 RVESV 95% CI 2.26-13.3; p = 0.0001. Multivariate analysis showed three independent risk predictors: right atrial sphericity index > 1.32, massive PE and mean arterial pressure. Conclusions: The combined assessment by 3D echocardiography right ventricular and atrial function allow a quantitative assessment, risk prediction for cardiovascular complications and presentation of time-hospital stay in patients with acute PE.

Hormone therapy with tamoxifen reduces plasma levels of NT-B-type natriuretic peptide but does not change ventricular ejection fraction after chemotherapy in women with breast cancer

The objective of this study was to evaluate the effect of tamoxifen on the plasma concentration of NT-pro-B-type natriuretic peptide (NT-proBNP) in women undergoing chemotherapy for breast cancer and to correlate changes in NT-proBNP with the left ventricular ejection fraction (LVEF). Over a period of 12 months, we followed 60 women with a diagnosis of breast cancer. The patients were separated into a group that received only chemotherapy (n=23), a group that received chemotherapy + tamoxifen (n=21), and a group that received only tamoxifen (n=16). Plasma levels of NT-proBNP were assessed at 0 (T0), 6 (T6), and 12 (T12) months of treatment, and echocardiography data were assessed at T0 and T12. Plasma NT-proBNP levels were increased in the chemotherapy-only group at T6 and T12, whereas elevated NT-proBNP levels were only found at T6 in the chemotherapy + tamoxifen group. At T12, the chemotherapy + tamoxifen group exhibited a significant reduction in the peptide to levels similar to the group that received tamoxifen alone. The chemotherapy-only group exhibited a significant decrease in LVEF at T12, whereas the chemotherapy + tamoxifen and tamoxifen-only groups maintained levels similar to those at the beginning of treatment. Treatment with tamoxifen for 6 months after chemotherapy significantly reduced the plasma levels of NT-proBNP and did not change LVEF in women with breast cancer.

Efeitos respiratórios e hemodinâmicos da prova de volume em pacientes com choque e síndrome do desconforto respiratório agudo: um estudo observacional utilizando o ultrassom pulmonar / Respiratory and hemodynamic effects of fluid loading in patients with shock and acute respiratory distress syndrome: a lung ultrasound observational study

Introdução: Este estudo foi desenhado para avaliar o impacto da reposição de fluidos na aeração pulmonar, oxigenação e hemodinâmica pacientes com diagnóstico de choque séptico e síndrome do desconforto respiratório agudo (SDRA). Métodos: Durante o período de 1 ano, um estudo prospectivo observacional foi realizado com 32 pacientes com diagnóstico de choque séptico e SDRA. Os parâmetros cardiorrespiratórios foram mensurados utilizando um cateter de Swan-Ganz (n = 29) ou um cateter de PICCO (n = 3). A aeração pulmonar e o fluxo sanguíneo regional pulmonar foram avaliados pelo exame de ultrassom pulmonar à beira-leito. As medidas foram realizadas antes (T0), ao final (T1) e 40 minutos após (T2) a infusão de fluidos, consistindo em um litro de solução salina administrado em 30 minutos nas primeiras 48 horas do início do choque séptico e SDRA. Resultados: O escore de ultrassom pulmonar aumentou em 23% em T2, de 13 no tempo basal a 16 (p < 0,001). O índice cardíaco e as pressões de enchimento cardíaco aumentaram significativamente em T1 (p < 0,001) e retornaram aos valores de base em T2. O aumento no escore de ultrassom pulmonar secundário à infusão de fluidos foi estatisticamente correlacionado com o aumento do índice cardíaco e não foi associado ao aumento do "shunt" pulmonar ou ao aumento do fluxo sanguíneo regional pulmonar. Em T1, PaO2/FiO2 aumentou significativamente (p < 0,005) de 144 (123 - 198) a 165 (128 - 226) e retornou aos valores de base em T2, e o escore de ultrassom pulmonar continuou a aumentar. Conclusão: A reposição de fluidos precoce melhora transitoriamente a hemodinâmica e deteriora a aeração pulmonar. As mudanças na aeração podem ser observadas à beiraleito com o auxílio do ultrassom pulmonar e podem ser úteis como medida protetora contra a reposição excessiva de fluidos...

Introduction: The study was designed to assess the impact of fluid loading on lung aeration, oxygenation and hemodynamics in patients with septic shock and acute respiratory distress syndrome (ARDS). Methods: During a 1-year period, a prospective observational study was performed in 32 patients with septic shock and ARDS. Cardiorespiratory parameters were measured using Swan Ganz (n=29) or PiCCO catheters (n=3). Lung aeration and regional pulmonary blood flows were measured using bedside transthoracic ultrasound. Measurements were performed before (T0), at the end of volume expansion (T1) and 40 minutes later (T2), consisting of 1-L of saline over 30 minutes during the first 48h following onset of septic shock and ARDS. Results: Lung ultrasound score increased by 23 % at T2, from 13 at baseline to 16 (p < 0.001). Cardiac index and cardiac filling pressures increased significantly at T1 (p < 0.001) and returned to control values at T2. The increase in lung ultrasound score was statistically correlated with fluid loading-induced increase in cardiac index and was not associated with increase in pulmonary shunt or regional pulmonary blood flow. At T1, PaO2/FiO2 significantly increased (p < 0.005) from 144 (123 to 198) to 165 (128 to 226) and returned to control values at T2 whereas lung ultrasound score continued to increase. Conclusions: Early fluid loading transitorily improves hemodynamics and oxygenation and worsens lung aeration. Aeration changes can be detected at the bedside by transthoracic lung ultrasound which may serve as a safeguard against excessive fluid loading...

Avaliação da estimulação ventricular direita crônica em crianças e adultos jovens com bloqueio atrioventricular congênito isolado / Evaluation of chronic right ventricular pacing in children and young adults with isolated congenital complete atrioventricular block

Introdução: O bloqueio atrioventricular congênito isolado (BAVCi) é raro e tem múltiplas apresentações clínicas. O implante de marca-passo cardíaco permanente (MP) é o tratamento de escolha, resultando em evolução clínica satisfatória para a maioria dos casos, porém, aproximadamente 10% deles apresentam remodelamento ventricular e insuficiência cardíaca grave. Objetivos: Estudar a evolução tardia de crianças e adultos jovens com BAVCi e estimulação crônica do ventrículo direito (VD), visando determinar: a prevalência de sinais clínicos e laboratoriais de insuficiência cardíaca e de remodelamento ventricular; a capacidade funcional; a qualidade de vida e fatores preditores de alterações clínicas, funcionais ou ecocardiográficas. Métodos: Estudo transversal realizado em coorte de portadores de BAVCi e MP implantado antes de 21 anos de idade com estimulação no VD há mais de um ano. Todos os indivíduos foram submetidos a avaliação clínica e laboratorial, da capacidade funcional, da qualidade de vida e a ecocardiograma. Mães e sujeitos da pesquisa foram investigados para doenças reumatológicas. Os dados foram armazenados no sistema REDCap (Research Electronic Data Capture) e analisados pelos programas SAS (Statistical Analysis System), SPSS (Statistical Package for the Social Sciences) e R Studio. A análise dos dados incluiu: análise univariada para pesquisa de associações entre variáveis preditoras e desfechos, coeficiente de correlação de Pearson e modelo de regressão linear multivariado. Resultados: De março/2010 a dezembro/2013, foram avaliados 63 indivíduos, 68% do sexo feminino, com idade de 1 a 40 anos, com MP por 13,4 ± 6,5 anos e estimulação do VD por 10,0 ± 5,4 anos. O modo de estimulação era atrioventricular em 55,6%, o percentual de estimulação de VD de 97,9 ± 4,2% e a duração do complexo QRS estimulado de 152,4 ± 20,1 ms. A maioria (88,9%) era assintomática e não utilizava medicamentos de ação cardiovascular. Maior tempo de MP...

Introduction: Isolated congenital atrioventricular block (iCAVB) is a rare condition with multiple clinical presentations. Permanent cardiac pacing is the most effective therapy for this population resulting in satisfactory long-term outcomes. However, approximately 10% of patients may have ventricular remodeling and severe heart failure. Objectives: To study the long-term effects of chronic right ventricular (RV) pacing in children and young adults with iCAVB in order to determine: prevalence of clinical and laboratory signs of heart failure and ventricular remodeling, functional capacity, quality of life and predictors of clinical, functional or echocardiographic abnormalities. Methods: Cross-sectional study of a cohort of iCAVB patients with <= 21 years old at initial pacemaker (PM) implantation and single or dual-chamber pacing in a unique RV site for a minimum of one year. All subjects underwent clinical and laboratory assessment, functional capacity, quality of life and echocardiogram. Mothers and research subjects were investigated for rheumatic diseases. Data were stored in REDCap (Research Electronic Data Capture) system and analyzed by SAS (Statistical Analysis System), SPSS (Statistical Package for the Social Sciences) and R Studio programs. Data analysis included: univariate analysis for associations between predictor variables and outcomes, Pearson correlation coefficient and linear regression multivariate model. Results: Between March/2010 and December/2013, we evaluated 63 subjects aged 1-40 years old, 68% female, under PM for 13.4 ± 6.5 years and under RV pacing for 10.0 ± 5.4 years. Pacing mode was atrioventricular in 55.6%, percentage of RV pacing was 97.9 ± 4.2% and paced QRS duration was 152.4 ± 20.1 ms. Overall, the majority (88.9%) were asymptomatic and did not use cardiovascular drugs. Longer time under PM (P= 0.013), or even under RV pacing (P= 0.005), higher age at study inclusion (P= 0.032) and lower left ventricular...

Estrategias de tratamiento del paciente con hipertensión arterial esencial: Perfil neurohormonal y geometría ventricular izquierda

La geometría ventricular izquierda, determinada por ecocardiografía bidimensional, proporciona de manera indirecta información sobre el perfil hemodinámico y neurohormonal del paciente hipertenso. En dos estudios pilotos, llevados a cabo en el Instituto de Investigaciones Cardiovasculares de la Universidad de Los Andes hemos utilizado al patrón geométrico como guía para orientar el tratamiento farmacológico del paciente hipertenso. La correspondencia de la estrategia farmacológica con el mecanismo neurohormonal, responsable de la hipertensión arterial, permite un control de la presión arterial con menor número de medicamentos y reduce la incidencia de efectos colaterales y complicaciones. Más aún, el proceso de remodelación cardiaca puede ser influenciado favorable o desfavorablemente, si la estrategia terapéutica empleada se corresponde o no con el mecanismo neurohormonal subyacente. El proceso de remodelación cardiaca, en la transición hacia los dos fenotipos de insuficiencia cardiaca congestiva, se caracteriza por modificaciones opuestas de la geometría y función ventricular. Los pacientes que evolucionan hacia la insuficiencia cardiaca sistólica experimentan una progresiva dilatación de las cavidades cardiacas izquierdas y disminución de la función sistólica. Por el contrario, en los pacientes que evolucionan hacia la insuficiencia cardiaca diastólica, el tamaño de las cavidades cardiacas se reduce y la relajación ventricular se altera.

The neurohormonal and hemodynamic profiles, of uncomplicated hypertensive patients, can be inferred from the left ventricular geometric pattern. We have used the left ventricular geometric pattern to guide the pharmacological treatment of hypertensive patients. Blood pressure control can be achieved with less medications and complications and adverse effects are reduced with a therapeutic strategy aimed at the underlying neurohormonal and hemodynamic profiles. On the contrary, cardiac remodelling is unfavorably influenced by a therapeutic strategy unmatched to the underlying responsable mechanisms. During transition to the two phenotypes of congestive heart failure, cardiac remodelling evolves in opposite directions. Thus, patients with systolic heart failure undergo progressive ventricular dilatation with thinning of its walls, where as, diastolic heart failure patients are characterized by shrinking of their left ventricular cavities with increasing relative wall thickness.

Ecocardiografia de cães da raça Yorkshire Terrier clinicamente normais / Echocardiography of clinically normal Yorkshire Terrier dogs

Determinaram-se os parâmetros ecocardiográficos em modo-M normais de cães da raça Yorkshire Terrier. Foram utilizados 30 cães clinicamente sadios, com peso médio de 2,42±0,64kg e idades entre um e seis anos. O diâmetro do átrio esquerdo e da aorta, a dimensão interna do ventrículo esquerdo na diástole e na sístole, a espessura do septo interventricular na diástole e na sístole, e a espessura da parede posterior do ventrículo esquerdo na diástole e na sístole correlacionaram-se com o peso corporal. As demais variáveis do modo-M não se correlacionaram com peso corporal, sexo ou idade. Os valores ecocardiográficos obtidos neste estudo podem ser utilizados como referência para cães dessa raça.

The aim of this study was to establish the normal echocardiographic parameters in M-mode for Yorkshire Terrier dogs. Thirty clinically normal dogs with mean weight of 2.42±0.64kg and ages varying from one to six years old were studied. The left atrial diameter, the aortic diameter, the left ventricular internal dimension at end - diastole and end - systole, end - diastolic and end - systolic interventricular septal thickness, and end - diastolic and end - systolic left ventricular posterior wall thickness had correlation with body weight. The other M - mode variables showed no linear correlations with body weight, sex or age. The echocardiographic values found in this study can be used as reference for this breed.

Factibilidad de la valoración hemodinámica ecocardiográfica no invasiva en la insuficiencia cardíaca / Feasibility of non invasive ecocardiographic hemodynamic valoration in cronic heart failure

Objetivo: determinar la factibilidad de la estimación por ecocardiografía Doppler del patrón hemodinámico y sus características en una población de pacientes ambulatorios con insuficiencia cardíaca crónica asistidos en el Hospital de Clínicas (Montevideo,Uruguay). Material y método: se reclutaron prospectivamente 30 pacientes consecutivos referidos a la policlínica de insuficiencia cardíaca del Hospital de Clínicas entre octubre de 2003 y julio de 2004, con criterios diagnósticos de Boston positivos o fracción de eyección del ventrículo izquierdo (FEVI) menor de 40%, edad mediana 61[46-90] años, 23 hombres (77%), en ritmo sinusal, clase funcional (CF): CF I: 17 (57%), CF II: 8 (27%), CF III: 5 (16%), tratados según la Task Force AHA/ACC: inhibidores de la enzima de conversión de angiotensina (IECA) en 26 pacientes (87%), beta bloqueantes 18 (60%), diuréticos 22 (73%). Se les realizó ecocardiografía Doppler con equipo ATL CX 200, determinación de FEVI (mediana 31% [16-65]), patrón de llenado del ventrículo izquierdo (VI)[(normal (N), relajación anormal (RA), seudonormal (SN) o restrictivo (R)], índice cardíaco (Ic, l/min/m2), resistencia vascular sistémica (RVS, d.s.cm-5) y resistencia vascular pulmonar (RVP, d.s.cm-5). Resultados: la distribución según patrón de llenado del VI fue N: 1 (3%), RA: 19 (64%), SN: 7 (23%), R: 3 (10%). Todos los pacientes en CF III presentaron patrón R o SN. Se pudo estimar RVS en 97% (29/30), RVP: 27% (8/30), Ic: 100% (30/30). Medianas del patrón: Ic 2,01 l/min/m2 [0,78-2,92], RVS 1,844 d.s.cm-5 [1013-5706], RVP 178 d.s.cm-5 [90-298]. En 83% de los pacientes (25/30) la RVS fue mayor de 1.200 dinas.seg.cm-5 y en 66% (20/30) el Ic fue menor de 2,2 l/min/m2. Conclusiones: es factible estimar el patrón hemodinámico por ecocardiografía Doppler en pacientes ambulatorios con insuficiencia cardíaca crónica, éste se caracteriza por Ic bajo y elevación de RVS. Sin embargo, la determinación de RVP no lo es.

The aim of this trial is to define the feasibility of cardiac echo Doppler to estimate hemodinamic pattern and establish its characteristics in a group of out- hospital patients with chronic heart failure, assisted in Hospital de Clínicas (HC), Montevideo Uruguay. Material and method: thirty consecutive patients sent to be evaluated in the heart failure policlinic of HC were included between October 2003 and July 2004. Positive Boston criterions for the diagnosis of heart failure and/or ejection fraction of left ventricle (EFLV) less or equal to 40% and sinus rhythm were required. Medium age: 61[46-90] years, 23 men(77%), functional class (FC): FC I: 17 (57%), FC II: 8 (27%), FC III: 5 (16%); treated according Task Force of Heart Failure AHA/ACC: angiotensine enzime converter inhibitor in 26 patients (87%), beta blockers 18 (60%), diuretics 22 (73%). Cardiac echo Doppler was performed with ATL CX 2000 equipment, EFLV, left ventricule input pattern (LVIP) [(normal (N), abnormal relaxation (AR), pseudonormal (P) o restrictive (R)], cardiac index (CI, l/min/m2), systemic vascular ressistance (SVR, d.s.cm-5) and pulmonar vascular ressistance (PVR), d.s.cm-5) were determined. LVEF medium 31% [16-65]), LVIP distribution: AR: 19 (64%), P: 7 (23%), R: 3 (10%). All patients FC III had R or P LVIP.Results: SVR was possible to estimate in 97% of cases (29/30), PVR in 27% (8/30), CI in 100% (30/30). Medium CI: 2,01 l/min/m2 [0,78-2,92], medium SVR 1.844 d.s.cm-5 [1.013-5.706], medium PVR 178 d.s.cm-5 [90-298]. In 83% of patients (25/30), SVR was greater than1.200 d.seg.cm-5 and in 66% (20/30), CI was lower than 2,2 l/min/m2. Conclutions: Estimation of hemodinamic pattern of chronic heart failure patients by cardiac echo Doppler is feasible with exception of PVR. It is characterized by low cardiac index and high systemic vascular ressistance.