Telemedicina como instrumento de consulta cardiológica durante la pandemia COVID-19 / Telemedicine as an instrument for cardiological consultation during the COVID-19 pandemic

Resumen La telemedicina es una herramienta subutilizada en nuestros sistemas de atención sanitaria. Se trata de un recurso tecnológico que optimiza los servicios de salud, ahorra recursos, expande la capacidad de atención especializada a lugares remotos, descongestiona servicios médicos tradicionales y es un instrumento invaluable de enseñanza e investigación. La pandemia por COVID-19 nos obliga a extender su uso y supone una oportunidad para diseñar una adecuada implementación.

Abstract Telemedicine is an underused instrument along our healthcare systems. It´s a technological tool that optimizes resources, save money, expands our capacities, decongests our traditional medical services and is an invaluable help for teaching and research. The COVID-19 pandemic is forcing us to expand its use and it gives us the opportunity to design an appropriate implementation.

Assessment of the vertebral heart scale and cardiothoracic ratio to standardize the heart size of collared peccaries (Tayassu tajacu Linnaeus, 1758) restrained with ketamine and midazolam / Avaliação do vertebral heart scale e índice cardiotorácico na padronização do tamanho cardíaco de cateto (Tayassu tajacu Linnaeus, 1758) contidos com cetamina e midazolam

Wild species, especially those threatened with extinction, are increasingly being investigated to obtain information that can be useful for their preservation. The objective of the present study was to standardize the vertebral heart scale (VHS) and cardiothoracic ratio (CTR) of the collared peccary (Tayassu tajacu Linnaeus, 1758) sedated with ketamine and midazolam. Fourteen clinically healthy collared peccaries were examined in the two-year age group weighing 15-22kg. The animals were submitted to digital radiography of the thorax in lateral and dorsal ventral projections to calculate the VHS and CTR. The VHS mean values for males and females was 8.88±0.51v for right recumbency and 8.84±0.39v for left decubitus, and there were no significant between-gender differences regarding recumbency (p>0.05). The CTR showed mean values of 0.50±0.05 (males) and 0.45±0.04 (females), but the gender-differences were not significant (p>0.05). A positive correlation was shown between VHS and CTR (r=0.98, right decubitus; r=0.96, left decubitus). Establishing reference values for heart measurements in collared peccaries using digital radiography of the thorax permitted standardization of the VHS and CTR values for this wild species. In the studied wild animal model, the VHS and CTR heart assessment indexes were shown to be essential diagnostic tools for investigations of alterations in the size of the cardiac silhouette.(AU)

Espécies silvestres têm sido cada vez mais exploradas como forma de obter informações que favoreçam sua conservação, especialmente aquelas ameaçadas de extinção. Este trabalho teve por objetivo a padronização dos valores de VHS (vertebral heart scale) e índice cardiotorácico (ICT) de catetos (Tayassu tajacu Linnaeus, 1758) contidos com Cetamina e Midazolam. Foram avaliados 14 catetos clinicamente saudáveis, com faixa etária de 2 anos e variação média de peso entre 15 a 22Kg. Os animais foram submetidos a radiografia digital de tórax em projeções laterolaterais e dorsoventrais para o cálculo do vertebral heart scale (VHS) e Índice Cardiotorácico (ICT). O VHS evidenciou valores médios entre machos e fêmeas de 8,88±0,51v para decúbito direito e 8,84±0,39v para decúbito esquerdo, não ocorrendo diferença estatística entre os decúbitos (p>0,05). O ICT revelou valores médios de 0,50±0,05 (machos) e de 0,45±0,04 (fêmeas), não sendo verificada diferença estatística significativa entre os sexos (p>0,05). Verificou-se correlação positiva entre VHS e o ICT (r=0,98, decúbito direito, r= 0,96, decúbito esquerdo). O estabelecimento dos valores de referência para mensurações cardíacas em catetos, a partir de radiografias digitais do tórax, permitiu a padronização do VHS e ICT para esta espécie silvestre. No modelo animal silvestre estudado, os índices de avaliação cardíaca VHS e ICT mostraram-se como uma ferramenta diagnóstica imprescindível para investigações sobre as alterações do tamanho da silhueta cardíaca.(AU)

Reperfusion therapy of myocardial infarction in Mexico: A challenge for modern cardiology / La reperfusión en el infarto del miocardio en México: un reto para la cardiología moderna

Abstract: Mexico has been positioned as the country with the highest mortality attributed to myocardial infarction among the members of the Organization for Economic Cooperation and Development. This rate responds to multiple factors, including a low rate of reperfusion therapy and the absence of a coordinated system of care. Primary angioplasty is the reperfusion method recommended by the guidelines, but requires multiple conditions that are not reached at all times. Early pharmacological reperfusion of the culprit coronary artery and early coronary angiography (pharmacoinvasive strategy) can be the solution to the logistical problem that primary angioplasty rises. Several studies have demonstrated pharmacoinvasive strategy as effective and safe as primary angioplasty ST-elevation myocardial infarction, which is postulated as the choice to follow in communities where access to PPCI is limited. The Mexico City Government together with the National Institute of Cardiology have developed a pharmaco-invasive reperfusion treatment program to ensure effective and timely reperfusion in STEMI. The model comprises a network of care at all three levels of health, including a system for early pharmacological reperfusion in primary care centers, a digital telemedicine system, an inter-hospital transport network to ensure primary angioplasty or early percutaneous coronary intervention after fibrinolysis and a training program with certification of the health care personal. This program intends to reduce morbidity and mortality associated with myocardial infarction.

Resumen: México se ha posicionado como el país con mayor mortalidad atribuible al infarto del miocardio entre los países de la Organización de Cooperación y Desarrollo Económico. Esta tasa responde a múltiples factores, incluyendo una baja tasa de reperfusión y la ausencia de un sistema único y coordinado para la atención del infarto. Aun cuando la angioplastia es el método de reperfusión recomendado, requiere un sistema coordinado con personal entrenado y recursos materiales, condiciones que no siempre pueden ser alcanzadas. La reperfusión farmacológica temprana, seguida de angiografía coronaria temprana (estrategia farmacoinvasiva) es la solución al problema logístico que representa la angioplastia primaria. Múltiples estudios han demostrado que la estrategia farmacoinvasiva es tan segura y efectiva como la angioplastia primaria en el infarto agudo del miocardio con elevación del segmento ST, y se plantea como la estrategia de elección en comunidades donde el acceso a angioplastia está limitado por factores económicos, geográficos o socioculturales. El gobierno de la Ciudad de México en conjunto con el Instituto Nacional de Cardiología ha desarrollado un programa de estrategia farmacoinvasiva para asegurar la reperfusión temprana en el infarto del miocardio. El modelo comprende una red de atención en los 3 niveles, incluyendo un sistema de reperfusión farmacológica en centros de primer contacto, transferencia de electrocardiogramas mediante telemedicina entre el primer nivel y el Instituto Nacional de Cardiología, una red de transporte interhospitalario y un programa de entrenamiento y educación continua. El objetivo de este programa es reducir la morbilidad y la mortalidad asociadas al infarto del miocardio.

Recomendaciones para mejorar la seguridad radiológica durante los procedimientos de intervencionismo cardiológico / Recommendations to improve radiation safety during invasive cardiovascular procedures

El objetivo de este articulo fue entregar una guia con recomendaciones para mejorar la Seguridad Radiológica durante los procedimientos de intervencionismo cardiológico. Se describe la clasificación de los efectos causados por las radiaciones ionizantes a los pacientes y personal médico. Se recomienda la aplicación de un programa de Garatia de Calidad, el cual implicará tantos gastos, como mayores beneficios. Como parte de este programa, se sugiere la implementación de un programa de Protección Radiológica, que incluya al personal, monitoreo de la radiación, blindajes y entrenamiento del personal. Se deben establecer acciones permanentes en cada laboratorio de hemodinamia para gestionar de la mejor forma posible las dosis de radiación antes, durante y después de la intervención. Finalmente, para avanzar en la implementación de estas recomendaciones, creemos que un paso fundamental es la revisión de nuestro marco juridico en el ámbito de la Seguridad Radiológica, donde resultan imprescindibles aspectos como la implementación de programas de Garantia de Calidad y Protección Radiológica, junto al establecimiento de Niveles Referenciales de dosis para pacientes.

In this paper we present guidelines aimed to improve radiation safety during invasive cardiovascular procedures. Unwanted effects upon patients and medical personnel are conventionally classified. A program of Quality Assurance is proposed, an aspect of which is a program for radiologic protection, including operator protection, radiation monitoring, shielding and personnel training. Permanent and specific actions should be taken at every cardiovascular lab, before, during and after interventions. In order to implement these guidelines and actions, a fundamental step is a review of current legislation. Specific programs for quality control and radiologic protection along with a definition of acceptable radiation exposure doses are required.

Marcación de un derivado de glucosa con 99mTc mediante la formación de un complejo Tc(V)-nitruro: estudios preliminares / Labelling of a glucose derivative with 99mTc through the formation of a Tc(V)-nitride symmetrical complex: preliminary studies

La preparación de derivados de glucosa marcados con 99mTc reviste gran interés para la evaluación del consumo de glucosa in vivo en oncología y cardiología nuclear. Este trabajo presenta la marcación de un análogo de glucosa (GLU-DTC) mediante la formación de un complejo Tc(V)-nitruro simétrico. Para ello se incorporó a la biomolécula un grupo ditiocarbamato capaz de coordinar al metal. La marcación fue realizada mediante sustitución de ligandos, obteniéndose una única especie con pureza radioquímica superior al 90 por cientp, la que se mantuvo durante al menos 4 hs. La caracterización fisicoquímica y biológica muestra que el complejo 99mTc(V)-nitruro(GLU-DTC)2 es un compuesto estable y altamente hidrofílico, aunque su unión a proteínas plasmáticas es mayor a la esperada, hecho que justificaría la alta actividad retenida en sangre y en hígado durante la evaluación biológica en ratones CD1 normales. Estos resultados indican que la marcación con 99mTc de este derivado de glucosa produce una alteración significativa de su comportamiento biológico.

The preparation of 99mTc-labeled glucose derivatives is of great interest to evaluate the in vivo glucose uptake in nuclear oncology and cardiology. This paper presents the labelling of a glucose analogue (GLU-DTC) through the formation of a Tc(V)-nitride symmetrical complex. For this purpose, a dithiocarbamate group was incorporated to the biomolecule, in order to coordinate the metal. The labelling reaction was carried out by substitution yielding a single complex with radiochemical purity above 90 percent. This complex was stable for at least 4 hours. The physicochemical and biological characterization shows that the 99mTc(V)-nitride(GLU-DTC)2 complex is a stable and highly hydrophilic compound, although its plasma protein binding is greater than expected, a fact which justifies the high activity retained in blood and liver during the biological evaluation in normal CD1 mice. These results indicate that 99mTc labelling of this glucose derivate alters significantly its biological behaviour.

Evaluation of left ventricular rotation and twist using speckle tracking imaging in patients with atrial septal defect / 华中科技大学学报（医学）（英德文版）

Speckle tracking imaging (STI) was employed to investigate the effect of right ventricular (RV) volume and pressure overload on left ventricular (LV) rotation and twist in 35 patients with atrial septal defect (ASD), 18 of which with pulmonary hypertension, and 21 healthy subjects serving as controls. The peak rotations of 6 segments at the basal and apical short-axises and the average peak rotation and interval time of the 6 segments in the opposite direction during early systolic phase were measured respectively. LV twist versus time profile was drawn and the peak twist and time to peak twist were calculated. LV ejection fraction (EF) was measured by Biplane Simpson. Compared to ASD patients without pulmonary hypertension and healthy subjects, the peak rotations of posterior, inferior and postsept walls at the basal level were lower (P<0.05), and the average counterclockwise peak rotation of 6 segments at the basal level during early systolic phase was higher (P<0.05), and the average interval time was delayed (P<0.05). LV peak twist was also lower (P<0.05), and had a significant negative correlation with pulmonary arterial systolic pressure (r=-0.57, P=0.001). No significant differences were found in LVEF among the three groups. It was suggested that although RV volume overload due to ASD has no significant effects on LV rotation and twist, LV peak twist is lower in ASD patients with pulmonary hypertension. Thus LV twist may serve as a new indicator of the presence of pulmonary hypertension in ASD patients.

Assessment of left ventricular global twist in essential hypertensive heart by speckle tracking imaging / 华中科技大学学报（医学）（英德文版）

The left ventricular twist was evaluated by 2-dimensional ultrasound speckle-tracking imaging (STI) in 50 patients with hypertension with normal geometric left ventricle (LV) and 45 normal subjects as control group. The mean value of LV rotation was obtained at each plane using STI. LV twist and twist velocity were defined as apical rotation/rotation rate relative to the base respectively. To adjust the intersubject differences in heart rates, the time sequence were normalized. The results showed that peak twist developed near the end of systole. Peak LV twist was significantly higher in patients with hypertension than normal controls (P<0.001). The diastolic untwisting mainly occurred in early diastole ( approximately 38%). Compared with normal controls, untwisting rate (Untw R) in patients with hypertension was significantly reduced (P<0.001), and untwisting half-time (UHT) was significantly delayed (P<0.05). This study demonstrated that STI has a potential ability to evaluate the early change of heart function in patients with hypertension by measuring the twist of LV.

Qualidade de vida em cardiologia: [revisão] / Quality of life in cardiology: [review]

A busca de qualidade de vida vem assumindo um papel importante dentro da área da saúde e é uma das metas dentro da cardiologia preventiva e terapêutica. Este artigo teve como propósito realizar uma revisão da literatura na qualidade de vida em cardiologia, enfocando as principais concepções, métodos de mensuração e mudanças clínicas significativas. Observa-se a necessidade de mais pesquisas dentro desta área através de mensurações cuidadosamente selecionadas, sendo de grande relevância para o paciente e para o profissional responsável pela saúde do mesmo.

Quality of life has been playing an important role in public health and is one of the goals in preventive and therapeutic interventions in cardiology. This paper aims at performing a review of the literature concerning quality of life in cardiology, focusing on the main conceptions, measurement methods, and significant clinical changes. More research using carefully selected measurements should be performed, since it is of great relevance for the patient and for the health professional responsible for providing care.

Considerações referentes à influência do posicionamento dos membros superiores sobre o resultado da cintilografia de perfusão do miocárdio / Considerations about the influence of upper arms positioning on myocardial perfusion scintigraphy results

INTRODUÇÃO: Na cintilografia de perfusão do miocárdio, contrariamente ao desenvolvimento tecnológico ao longo do tempo, manteve-se desde o princípio a mesma forma, por vezes desconfortável ou mesmo inviável, de posicionamento na aquisição das imagens: decúbito dorsal com os braços elevados. OBJETIVOS: O objetivo da pesquisa foi o de avaliar se na aquisição da cintilografia de perfusão do miocárdio o posicionamento com os membros superiores abaixados(T) apresenta os mesmos resultados que os obtidos com os membros superiores elevados(C), tanto em termos de alterações perfusionais como em relação aos parâmetros funcionais. . MÉTODOS: Foram estudados 120 pacientes, 83 (69%) do sexo masculino, com idade 59,4 ± 11,4 anos e peso 72,8 ± 14 kg. Foi realizada primeiramente a aquisição C e na seqüência a aquisição T, utilizando protocolo de um dia de repouso-estresse (dose 370 MBq e 1110 MBq de sestamibi-99mTc), com estresse sincronizado ao eletrocardiograma (gated- SPECT). Três modelos distintos de equipamentos de dois detectores foram utilizados no estudo. Os estudos foram processados usando reconstrução iterativa (OSEM). Na interpretação foi utilizado o modelo de segmentação miocárdica de 17 segmentos, pontuados de 0 a 4 (normal a ausente) segundo o grau de captação. Baseada na análise de um observador dentre um grupo de sete, foi realizada a comparação da totalidade dos segmentos e também segmento a segmento das aquisições C e T nas etapas de estresse e de repouso. Foi comparada também a somatória das pontuações das etapas de estresse(SSS) e repouso(SRS). Os pacientes foram divididos segundo dois critérios: primeiramente, normais (SSS=0) e anormais (SSS>1) e posteriormente, em de baixo risco (SSS3) e de maior risco (SSS>3) A comparação dos parâmetros funcionais de fração de ejeção do ventrículo esquerdo (FEVE), volume diastólico final (VDF), volume sistólico final(VSF), somatória dos escores de motilidade (SMS) e somatória dos escores de espessamento (STS)...

Contrary to the advances in imaging technology for nuclear cardiology applications, we keep using the same often uncomfortable and sometimes impracticable patient position- supine with arms raised above the head (C). We tested another position modality: supine with arms down at the sides of the trunk (T). The purpose of this study was to verify if the functional and perfusion results of the acquisition T are equivalent to those of the acquisition mode C. We studied 120 patients (pts), 83 (69%) male, aged 59.4±11.4 years and weighting 72.8±14 kg. We performed a one-day protocol (rest gated/stress), using 99mTc-sestamibi (370 MBq and 1110 MBq). In both times (rest and stress), we first performed acquisition in C and in sequence the acquisition in T. The studies were performed in three types of dual detector SPECT systems. T mode was executed successfully in all pts. Images were processed by the iterative reconstruction method (OSEM). Each study was independently interpreted by one nuclear medicine specialist from a group of seven physicians using the 17-segment model. The segments were scored using a 5-point model ranging from 0 (normal uptake) to 4 (uptake absent). The total score of the left ventricle at stress is referred to as the summed stress score (SSS) and at rest as the summed rest score (SRS). The patients were categorized in subgroups by two criteria: normal (SSS=0) or abnormal (SSS1) and low risk (SSS3) or risk (SSS>3). The values of the functional parameters of left ventricular ejection fraction (LVEF), end diastolic volume (EDV), end systolic volume (ESV), stress motion score (SMS) and stress thickening score (STS) for both C and T were automatically obtained by the quantitative gated SPECT (QGS) program and results were compared. Shoulder and/or back pain occurred in 23.3% of C patients and in 5% of T patients. There was no agreement between the 2040 segmental scores of both rest and stress in C and T modes (p<0.05)...

Recent landmark trials in cardiology.

This section outlines various recent ongoing /completed trials on use of amiodarone, beta blockers, clopidogrel antiplatelet agents, cardiac resynchronization therapy and drug-eluting stents in management of cardiac complications and morbidity.