Valor Prognóstico de Rigidez Aórtica usando Ressonância Magnética Cardiovascular em Idosos com Suspeita ou Confirmação de Doença Arterial Coronariana / Prognostic Value of Aortic Stiffness using Cardiovascular Magnetic Resonance in The Elderly with Known or Suspected Coronary Artery Disease

Resumo Fundamento A rigidez aórtica é considerada um marcador de doença cardiovascular. A ressonância magnética cardiovascular (RMC) permite realizar uma avaliação abrangente da rigidez aórtica e da isquemia miocárdica em um único exame. Entretanto, dados prognósticos relacionados à rigidez aórtica em pacientes idosos permanecem limitados. Objetivo Determinar o valor prognóstico da rigidez aórtica usando a velocidade da onda de pulso (VOP) baseada em RMC em pacientes idosos com doença arterial coronariana (DAC). Métodos Foram cadastrados pacientes consecutivos com idade >70 com indicação para RMC com perfusão de estresse com adenosina incluindo VOP, entre 2010 e 2014. Os pacientes foram acompanhados para verificar a ocorrência de eventos cardíacos adversos maiores (MACE), incluindo mortalidade cardíaca, infarto do miocárdio não fatal, hospitalização por insuficiência cardíaca, revascularização tardia (>180 dias após a RMC), e acidente vascular isquêmico. Foram realizadas análises univariadas e multivariadas para determinar os preditores de MACE. Um p-valor <0,05 foi considerado estatisticamente significativo. Resultados A VOP média foi 13,98±9,00 m/s. Depois de um período mediano de acompanhamento de 59,6 meses em 263 pacientes (55% do sexo feminino, 77±5 anos), ocorreram 61 MACE. Pacientes com VOP elevada (>13,98 m/s) tiveram índices de MACE significativamente mais altos (FC 1,75; IC 95% 1,05-2,94; p=0,03) que os dos pacientes com VOP não elevada (<13,98 m/s). A análise multivariada demonstrou que pressão arterial diastólica, fração de ejeção ventricular esquerda (FEVE), isquemia miocárdica, e VOP elevada são preditores independentes de MACE (p<0,05 para todos). A VOP apresentou um valor prognóstico incremental em relação a dados clínicos, FEVE e isquemia (qui-quadrado global aumentado = 7,25, p=0,01). Conclusão A rigidez aórtica, usando-se a RMC, é um preditor independente forte de eventos cardiovasculares em pacientes idosos com suspeita de DAC ou DAC confirmada.

Abstract Background Aortic stiffness is established as a marker of cardiovascular disease. Cardiovascular magnetic resonance (CMR) provides a comprehensive assessment of aortic stiffness and myocardial ischemia in a single examination. However, prognostic data concerning aortic stiffness in elderly patients remain limited. Objective To determine the prognostic value of aortic stiffness using CMR-based pulse wave velocity (PWV) in elderly patients with known or suspected coronary artery disease (CAD). Methods This study enrolled consecutive patients aged >70 referred for adenosine stress perfusion CMR including PWV between 2010 and 2014. Patients were followed up for occurrence of major adverse cardiovascular events (MACE), including cardiac mortality, nonfatal myocardial infarction, hospitalization for heart failure, late revascularization (>180 days after CMR), and ischemic stroke. Univariable and multivariable analyses were performed to determine the predictors of MACE. A p-value of <0.05 is considered statistically significant. Results Mean PWV was 13.98±9.00 m/s. After a median follow-up period of 59.6 months in 263 patients (55% female, 77±5 years), 61 MACE occurred. Patients with elevated PWV (>13.98 m/s) had significantly higher rates of MACE (HR 1.75; 95% CI 1.05-2.94; p=0.03) than those with non-elevated PWV (<13.98 m/s). Multivariate analysis demonstrated diastolic blood pressure, left ventricular ejection fraction (LVEF), myocardial ischemia, and elevated PWV as independent predictors for MACE (p<0.05 for all). PWV provided an incremental prognostic value over clinical data, LVEF, and ischemia (increased global chi-square=7.25, p=0.01). Conclusion Aortic stiffness using CMR is a strong and independent predictor of cardiovascular events in elderly patients with known or suspected CAD.

Valor Prognóstico da Imagem de Ressonância Magnética Cardíaca de Perfusão em Estresse com Adenosina em Idosos com Doença Arterial Coronariana Conhecida ou Suspeita / Prognostic Value of Adenosine Stress Perfusion Cardiac Magnetic Resonance Imaging in Older Adults with Known or Suspected Coronary Artery Disease

Resumo Fundamento: Há dados limitados sobre o valor prognóstico da ressonância magnética cardíaca (RMC) em estresse em pacientes idosos. Objetivo: Determinar o valor prognóstico da RMC em estresse com adenosina em idosos com doença arterial coronariana (DAC) conhecida ou suspeita. Métodos: Entre 2010 e 2015, pacientes consecutivos com 65 anos ou mais encaminhados para RMC em estresse com adenosina foram acompanhados para a ocorrência de eventos cardíacos graves (morte cardíaca e infarto do miocárdio não-fatal) e eventos cardiovasculares adversos maiores (ECAM) que também incluíram hospitalização por insuficiência cardíaca e acidente vascular cerebral isquêmico. As análises univariadas e multivariadas foram realizadas para determinar o valor prognóstico da isquemia miocárdica, com valor de p <0,05 considerado estatisticamente significante. Resultados: Após um período médio de seguimento de 50,4 meses em 324 pacientes (48% do sexo masculino, 73±7 anos), ocorreram 21 eventos cardíacos graves e 52 ECAM. Pacientes com isquemia miocárdica (n=99) apresentaram taxas significantemente maiores de eventos cardíacos graves (HR 5,25 [IC 95% 2,11-13,04], p<0,001) e ECAM (HR 3,01 [IC 95% 1,75-5,20], p<0,001) do que aqueles sem isquemia. A análise multivariada determinou a isquemia como preditor independente de eventos cardíacos graves (HR 3,14 [IC 95% 1,22-8,07], p=0,02) e ECAM (HR 1,91 [IC 95% 1,02-3,59], p=0,04). A isquemia forneceu um valor prognóstico incremental sobre fatores clínicos e fração de ejeção do ventrículo esquerdo para predizer eventos cardíacos graves e ECAM (p<0,01 para ambos). Nenhum evento adverso grave ocorreu durante ou imediatamente após os exames de RMC. Conclusão: A RMC em estresse com adenosina é segura e demonstra valor prognóstico em idosos com DAC conhecida ou suspeita.

Abstract Background: There is limited data on the prognostic value of stress cardiac magnetic resonance (CMR) in older adults. Objective: To determine the prognostic value of adenosine stress CMR in older individuals with known or suspected coronary artery disease (CAD). Methods: Between 2010 and 2015, consecutive patients aged 65 years or older referred for adenosine stress CMR were followed for the occurrence of severe cardiac events (cardiac death and nonfatal myocardial infarction) and major adverse cardiovascular events (MACE) that also included hospitalization for heart failure and ischemic stroke. Univariate and multivariate analyses were performed to determine the prognostic value of myocardial ischemia, with p-value <0.05 considered statistically significant. Results: After a mean follow-up period of 50.4 months in 324 patients (48% male, 73±7 years), 21 severe cardiac events and 52 MACE occurred. Patients with myocardial ischemia (n=99) had significantly higher rates of severe cardiac events (HR 5.25 [95% CI 2.11-13.04], p<0.001) and MACE (HR 3.01 [95% CI 1.75-5.20], p<0.001) than those without ischemia. Multivariable analysis determined ischemia as an independent predictor of severe cardiac events (HR 3.14 [95% CI 1.22-8.07], p=0.02) and MACE (HR 1.91 [95%CI 1.02-3.59], p=0.04). Ischemia provided an incremental prognostic value over clinical factors and left ventricular ejection fraction for predicting severe cardiac events and MACE (p<0.01 for both). No severe adverse events occurred during or immediately after CMR examinations. Conclusion: Adenosine stress CMR is safe and has prognostic value in older adults with known or suspected CAD.

Clinical and echocardiographic parameters and score for the left atrial thrombus formation prediction in the patients with mitral stenosis.

BACKGROUND: Rheumatic mitral stenosis is one of the important health problems, especially in Thailand. Thromboembolic complications from this disease remain the major problem in these patients. These complications are usually related to the left atrial thrombus formation. OBJECTIVE: To determine the parameters that can predict the presence of left atrial thrombus in these patients. MATERIAL AND METHOD: Two hundred and sixty Thai patients with mitral stenosis from Siriraj Hospital were prospectively recruited in the study. The baseline clinical characteristics of these patients which were related to thrombus formation were properly collected. All patients underwent the transthoracic and transesophageal echocardiography with the standard technique to detect the mitral valve area, mitral valve score, left atrial size, LV ejection fraction, right ventricular systolic pressure, spontaneous echo contrast (SEC) and associated valvular lesions. Transesophageal echocardiography was used as the gold standard for evaluation of left atrial thrombus. These parameters were analyzed to demonstrate association with the presence of left atrial thrombus by univariate and multiple logistic regression analysis. Equation with score for prediction of left atrial thrombus was also purposed. RESULTS: There were 77 men and 183 women in the present study. Left atrial thrombus was detected in 26% and previous thromboembolic complications occurred in 16.5%. Atrial fibrillation presented in 52.5%. From univariate analysis, atrial fibrillation (81.2% vs. 42.9%, p < 0.001), male sex (37.7% vs 25.6%, p < 0.050), left atrial enlargement by electrocardiogram (45.5% vs 15.4%, p < 0.001), left atrial diameter (7.26 vs 6.97 cm, p < 0.030), left atrial volume (132. 7 vs. 113.5 cm2, p < 0.001), EFby Teich method (58.9 vs 62.5%, p < 0.011), EF by MOD-bp (60.7 vs. 64.6%, p < 0.005), tricuspid regurgitation (46.4% vs. 28.8%, p < 0.008), mitral regurgitation (10.1 vs. 3.1%, p < 0.022), and RVSP (57.0 vs. 49.7 mmHg, p < 0.005) can predict the presence of left atrial thrombus formation with statistical significance. Using multiple logistic regression model, only atrial fibrillation (OR 5.95, 95% CI 1.21-29.3, p < 0.02) and RVSP (OR 1.02, 95%CI 1.01-1.04, p < 0.04) were independent predictors. The authors proposed score for predicting probability of left atrial thrombus formation that equal to -3.61 + 1.79 AF + 0.03 RVSP with AUC of 0.764. The best cut-off point for this score was -1.49, which gave a sensitivity of 91%, specificity of 56%, PPV of 48%, and NPV of 90%. CONCLUSION: Prevalence of thromboembolic complications and thrombus formation is high in patients with mitral stenosis in Thailand. From the present study, the predictors for left atrial thrombus formation in the patients with mitral stenosis were atrial fibrillation and RVSP The model for predicting left trial thrombus formation was also proposed with high sensitivity and NPV.

Accuracy of visual assessment in the detection and quantification of myocardial scar by delayed enhancement magnetic resonance imaging.

BACKGROUND: Delayed-enhancement magnetic resonance imaging (DE-MRI) is now a standard for the detection of myocardial scar and viability. Standard analysis needs expensive software. OBJECTIVE: To determine the accuracy of visual assessment in the detection and quantification of myocardial scar by DE-MRI technique. MATERIAL AND METHOD: The authors enrolled 32 patients with coronary artery disease (CAD) as documented by coronary angiography (CAG) and left ventricular dysfunction. All patients underwent cardiac magnetic resonance imaging for the assessment of global and regional myocardial function and DE-MRI. The presence and amount of scar in each myocardial segment was assessed by standard method. Visual assessment was performed by two methods: 1) visual drawing of the boundary of the hyperenhancement region and calculation of percentages of scar in an individual segment; 2) visual estimation of grading of hyperenhancement area from 0 (no scar) to 4 (> 75% scar). The agreement for scar detection and correlation of scar quantification for individual segments were evaluated. RESULTS: Thirty-one of 32 patients in the present study had myocardial scar. One thousand four hundred and thirty two myocardial segments were analyzed. Visual detection of myocardial scar has an excellent level of agreement with standard method of scar (Kappa = 0.963 and 0.952, p<0.001 for visual method I and II). Visual method I and II has an accuracy of 98.2% and 97.6% respectively in the detection of myocardial scar compared to standard method. Percentages of myocardial scar in each myocardial segment by visual method I correlate very well with standard method (Intraclass Correlation Coefficient = 0.885). Visual grading of amount of myocardial scar also has an excellent correlation with standard method (Spearman rank correlation coefficient = 0.934). CONCLUSION: Visual assessment of myocardial scar is accurate for the detection and quantification of scar.