Cardiovascular Prognosis of Subclinical Chronic Obstructive Pulmonary Disease in Patients with Suspected or Confirmed Coronary Artery Disease.

Background: Chronic obstructive pulmonary disease (COPD) worsens prognosis in patients with coronary artery disease (CAD). However, the cardiovascular prognosis in patients with stable or mildly symptomatic COPD remains unclear. Here, we sought to determine the long-term cardiovascular events in patients with subclinical or early-stage COPD with concomitant CAD. Methods: This was a longitudinal analytical study involving 117 patients with suspected or established CAD who underwent assessment of pulmonary function by spirometry and who were followed up for six years (March 2015-January 2021). The patients were divided into two groups, one comprising COPD (n=44) and the other non-COPD (n=73) patients. Cox regression was used to evaluate the association between COPD and cardiovascular events, with adjustment for the established CAD risk factors, and the effect size was measured by the Cohen test. Results: COPD patients were older (p=0.028), had a greater frequency of diabetes (p=0.026), were more likely to be smokers (p<0.001), and had higher modified Medical Research Council scores (p<0.001). There was no difference between the groups regarding gender, body mass index, hypertension, dyslipidemia, family history of CAD, and type of angina. CAD frequency and the proportion of patients with severe and multivessel CAD were significantly higher among COPD than among non-COPD patients (all p<0.001). At six-year follow-up, patients with COPD were more likely to have experienced adverse cardiovascular events than those without COPD (p<0.001; effect size, 0.720). After adjusting for established CAD risk factors, COPD occurrence remained an independent predictor for long-term adverse cardiovascular events (OR: 5.13; 95% CI: 2.29-11.50; p<0.0001). Conclusion: COPD was associated with increased severity of coronary lesions and a greater number of adverse cardiovascular events in patients with suspected or confirmed CAD. COPD remained a predictor of long-term cardiovascular events in stable patients with subclinical or early-stage of COPD, independently of the established CAD risk factors.

Força muscular, distância percorrida e capacidade pulmonar na Doença Pulmonar Obstrutiva Crônica / Muscle strength, distance traveled and lung capacity in Chronic Obstructive Pulmonary Disease

Objetivo: Avaliar a força do músculo quadríceps e sua relação com a capacidade pulmonar em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC). Assim como a capacidade funcional destes pacientes e sua repercussão sobre a funcionalidade desses indivíduos. Métodos: Quarenta voluntários sendo vinte com diagnóstico de DPOC (grupo 1) e vinte saudáveis (grupo 2). Foi mensurado o pico de força (PF) do músculo quadríceps através do dinamômetro portátil MicroFETâ 2 (Hoggan Health Industries, West Jordan, UT, EUA), modo High Threshold. A capacidade pulmonar foi avaliada através do Teste de Caminhada de 6 minutos (TC6m). Resultados: Os pacientes com DPOC classificaram-se em média (61%) como GOLD II de acordo com os valores de VEF1/CVF. A idade média da amostra foi de 61±7 anos e IMC de 25±4 kg.m-2. Apenas 10% do grupo 1 pratica atividade física, e consequentemente obtiveram valores menor de PF (106±33)N comparado com o grupo 2 (163±45)N (p<0,05). O mesmo se repetiu na distância percorrida do TC6m, onde o grupo 1 percorreu uma média de 356±58m e o grupo 2 380±106m (p<0,05). Conclusões: Os pacientes com DPOC apresentam fraqueza muscular do quadríceps desde estágios iniciais da doença (GOLD II). Assim como percorreram uma distância menor do que os participantes saudáveis no TC6m, o que demonstra uma capacidade pulmonar limitada com declínio funcional e baixa tolerância ao exercício.

Força muscular, funcionalidade e distância percorrida em pacientes com doença pulmonar obstrutiva crônica / Muscle strength, functionality and distance traveled in patients with chronic obstructive pulmonary disease

O status funcional do indivíduo com Doença Pulmonar Obstrutiva Crônica (DPOC), considerado um indicador preditivo de agravo do quadro clínico e qualidade de vida dessa população. OBJETIVO: Analisar a força muscular, morbidade, qualidade de vida e distância percorrida em pacientes com DPOC e comparar com o grupo não DPOC. MÉTODOS: Foram avaliados 58 voluntários, 29 do grupo DPOC, classificados em GOLD II e 29 o grupo não DPOC, com os seguintes parâmetros mensurados: função pulmonar; variáveis antropométricas; força muscular; morbidade mediante o índice Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE); qualidade de vida com o questionário do Saint George's Respiratory Questionnaire (SGRQ); capacidade pulmonar através da distância percorrida no teste de caminhada de seis minutos. Para análise estatística, realizado o teste de Shapiro Wilk e os testes de Mann-Whitney ou t de Student, assim como o teste de correlação de Pearson, para valores de p < 0,05. RESULTADOS: A idade média total foi de 61±7 anos, a força de extensores de joelho (p:0,0004), com valores de força menores para o grupo DPOC 110,61±41,69; em comparação com do grupo não DPOC 156,31±44,09, destaca-se ainda a força de flexores de cotovelo (p 0,004), com 96,34±26,15 para grupo DPOC, em comparação ao grupo não DPOC 118,19±34,71. Na distância percorrida do TC6M o grupo DPOC percorreu uma média de 274± 107,86 e o grupo não DPOC 384,98±100,47 (p<0,05). O BODE apresentou correlação de (r = -0,79) com a distância percorrida no TC6M e de (r =0,72) com o Saint George total. CONCLUSÕES: Os pacientes com DPOC apresentaram redução da força muscular de membros superiores, extensores de joelho e da distância percorrida, ao comparar com o grupo não DPOC.

The functional status of individuals with Chronic Obstructive Pulmonary Disease (COPD), considered a predictive indicator of clinical condition and quality of life of this population. OBJECTIVE: To analyze muscle strength, morbidity, quality of life and distance traveled in patients with COPD and compare compare them with the group non-COPD. METHODS: Fifty-eight volunteers were, 29 from the COPD group, classified as GOLD II and 29 in the non-COPD group, with the following parameters measured: pulmonary function; anthropometric variables; muscle strength; morbidity through Body mass index, airway Obstruction, Dyspnea, and Exercise (BODE); quality of life with the Saint George's Respiratory Questionnaire (SGRQ); lung capacity through the distance covered in the six-minute walk test. For statistical analysis, the Shapiro Wilk test and the Mann-Whitney or Student t tests were performed, as well as the Pearson correlation test, for p values < 0,05. RESULTS: The mean total age was 61±7 years, the strength of knee extensors (p 0.0004), with lower strength (N) values for the COPD group 110,61±41,69; compared to the non-COPD group 156,31±44,09, the strength of elbow flexors (p 0,004) stands out, with 96,34±26,15 for the COPD group, compared to the non-COPD group 118,19±34,71. In the distance covered in the 6MWT, the COPD group covered an average of 274± 107,86 and the non-COPD group 384,98±100,47 (p<0,05). The BODE presented a correlation between (r = -0,79) and the distance covered in the 6MWT and (r =0,72) with the total Saint George. CONCLUSIONS: Patients with COPD presented a reduction in muscle strength of the upper limbs, knee extensors and the distance covered, when compared with the non-COPD group

Avaliação do limiar anaeróbio pela variabilidade da frequência cardíaca em diabéticos tipo 2 / Evaluation of anaerobic threshold by heart rate variability in type 2 diabetics

A diabetes é um problema de saúde pública devido a sua alta prevalência, morbidade e mortalidade. O tipo 2 é mais prevalente e representa de 90 a 95% dos casos, sendo as complicações mais comuns o acúmulo de gordura no músculo esquelético e a resistência à insulina. O exercício físico regular contribui para regulação da glicemia, destacando-se o limiar anaeróbio como importante marcador para prescrição de exercícios físicos. OBJETIVO: Avaliar o limiar anaeróbio de indivíduos com diabetes tipo 2 através da variabilidade da frequência cardíaca. MATERIAIS E MÉTODOS: Estudo de caráter transversal, recrutou 18 participantes de ambos os sexos em uma unidade básica de saúde do município de Lagarto-SE, esse foram divididos em 2 grupos de 9 indivíduos. Na análise estatística utilizou-se o teste de Shapiro-Wilk para avaliação da normalidade e posteriormente Anova com pós teste de Tukey para comparação dos grupos. O grupo 1 composto de indivíduos diabéticos tipo 2 e o grupo 2 de indivíduos saudáveis. Também foi avaliada a média da frequência cardíaca em repouso e após o teste de esforço progressivo. RESULTADOS: As características de idade foram homogêneas sendo o grupo 1 com média de 62,1 (±13,9) anos e grupo 2 de 62,0 (±7,0) anos. A média da frequência de repouso foi de 79,8 bpm do grupo diabéticos e 78 bpm do grupo comparação, no limiar anaeróbio foi de 111,5 no grupo 1 e 119 no grupo 2. O tempo para atingir o L.A foi similar entre os grupos, 9,5 min no grupo experimental e 8 min no grupo comparação. CONCLUSÃO: Os valores do limiar anaeróbio de ambos os grupos foram considerados de baixo condicionamento físico, estes não apresentaram diferença estatística.

Diabetes is a public health problem due to its high prevalence, morbidity and mortality. Type 2 is more prevalent and accounts for 90 to 95% of cases, with the most common complications being the accumulation of fat in skeletal muscle and insulin resistance. Regular physical exercise contributes to glycemic regulation, highlighting the anaerobic threshold as an important marker for prescribing physical exercises. OBJECTIVE: To assess the anaerobic threshold of individuals with type 2 diabetes through heart rate variability. MATERIALS AND METHODS: A cross-sectional study, recruited 18 participants of both sexes in a basic health unit in the municipality of Lagarto-SE, which were divided into 2 groups of 9 individuals. In the statistical analysis, the Shapiro-Wilk test was used to assess normality and subsequently Anova with Tukey's post-test to compare the groups. Group 1 consisted of type 2 diabetic individuals and group 2 of healthy individuals. The mean heart rate at rest and after the progressive exercise test was also evaluated. RESULTS: Age characteristics were homogeneous, with group 1 averaging 62.1 years (± 13.9) and group 2 62.0 years (± 7.0). The mean resting frequency was 79.8 bpm in the diabetic group and 78 bpm in the comparison group, at the anaerobic threshold it was 111.5 in group 1 and 119 in group 2. The time to reach the LA was similar between groups , 9.5 min in the experimental group and 8 min in the comparison group. CONCLUSION: The values of the anaerobic threshold of both groups were considered of low physical conditioning, these did not present statistical difference.

Coronary lesions in patients with COPD (Global Initiative for Obstructive Lung Disease stages I-III) and suspected or confirmed coronary arterial disease.

Background: Systemic inflammation is the pathophysiological link between coronary artery disease (CAD) and COPD. However, the influence of subclinical COPD on patients with suspected or diagnosed CAD is largely unknown. Thus, this study was designed to evaluate the degree of coronary involvement in patients with COPD and suspected or confirmed CAD. Methods: In this cross-sectional study, carried out between March 2015 and June 2017, 210 outpatients with suspected or confirmed CAD were examined by both spirometry and coronary angiography or multidetector computed tomography. These patients were divided into two groups: with and without COPD. Size, site, extent, and calcification of the coronary lesions, and the severity of COPD were analyzed. Results: COPD patients (n = 101) presented with a higher frequency of obstructive coronary lesions ≥50% (n = 72, 71.3%), multivessels (n = 29, 28.7%), more lesions of the left coronary trunk (n = 18, 17.8%), and more calcified atherosclerotic plaques and higher Agatston coronary calcium score than the patients without COPD (P < 0.0001). The more severe the COPD in the Global Initiative for Obstructive Lung Disease stages, the more severe the CAD and the more calcified coronary plaques (P < 0.0001). However, there was no difference between the two groups with respect to the main risk factors for CAD. In the univariate analysis, COPD was an independent predictor of obstructive CAD (odds ratio [OR] 4.78; 95% confidence interval: 2.21-10.34; P < 0.001). Conclusion: In patients with suspected CAD, comorbid COPD was associated with increased severity and extent of coronary lesions, calcific plaques, and elevated calcium score independent of the established risk factors for CAD. In addition, the more severe the COPD, the greater the severity of coronary lesions and calcification present.

Consumo leve a moderado de álcool e isquemia miocárdica à ecocardiografia sob estresse físico / Low to moderate alcohol consuption and myocardial ischemia on exercise stress echocardiography

Fundamento: O impacto do consumo de álcool na evolução da isquemia miocárdica permanece incerto. Os estudos divergem quanto a um eventual efeito cardioprotetor ou a um fator de risco cardiovascular desse consumo de maneira leve a moderada. Objetivo: Estudar a relação do consumo leve a moderado de álcool com a isquemia miocárdica à ecocardiografia sob estresse físico (EEF). Métodos: Estudo transversal composto por 6632 pacientes submetidos à EEF, de janeiro de 2000 a dezembro de 2015. Dividiram-se dois grupos: G1 - composto por 2130 (32,1%) pacientes com relato de consumo médio igual ou inferior a 1 dose de bebida alcoólica por dia para mulheres ou de 2 doses para homens; e G2 - formado por 4502 (67,9%) indivíduos que negaram consumo de álcool. A comparação entre os grupos foi feita mediante teste t de Student para variáveis quantitativas, e teste qui-quadrado ou teste de Fisher para as variáveis categóricas. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica. Resultados: G1 apresentou maior frequência de indivíduos do sexo masculino (77,1%; p < 0,001), menor idade média (54,8 ± 10,3 anos; p < 0,001) e maior frequência de isquemia miocárdica à EEF (p = 0,014). Idade, sexo masculino, dislipidemia, hipertensão arterial sistêmica, diabete melito, tabagismo e história familiar positiva apresentaram-se independentemente associados à presença de isquemia miocárdica à EEF. Não foi observada associação independente entre etilismo leve a moderado e isquemia miocárdica (OR 0,96; IC 95%: 0,83-1,11). No entanto, observou-se associação entre idade, sexo masculino, tabagismo e dislipidemia com o consumo de álcool. Conclusão: Etilismo leve a moderado não se apresentou como preditor independente de presença de isquemia miocárdica à EEF. Observou-se, no grupo dos etilistas, um predomínio de homens, dislipidêmicos e tabagistas, importantes variáveis preditoras de isquemia miocárdica

Background: The impact of alcohol consumption on the development of myocardial ischemia remains uncertain. Studies diverge whether low to moderate alcohol consumption provides cardioprotection or whether it is a risk factor for myocardial ischemia. Objective: To study the relationship between low to moderate alcohol consumption and myocardial ischemia on exercise stress echocardiography (ESE). Methods: Cross-sectional study with 6632 patients with known or suspected coronary artery disease undergoing ESE between January/2000 and December/2015. The patients were divided into two groups: G1, composed of 2130 (32.1%) patients whose report showed maximal consumption of 1 drink per day on average for women or of 2 drinks per day for men; G2, composed of individuals denying any alcohol consumption. For comparing between the groups, Student t test was used for quantitative variables, and chi-square test or Fisher exact test, for categorical variables. The significance level adopted was p < 0.05. Logistic regression was also used to evaluate independent risk factors for myocardial ischemia. Results: G1 had a higher number of men (77.1%; p < 0.001), lower mean age (54.8 ± 10.3 years old; p < 0.001) and higher frequency of myocardial ischemia on ESE (p = 0.014). Age, male sex, dyslipidemia, systemic arterial hypertension, diabetes mellitus, smoking and family history were independently associated with myocardial ischemia on ESE. Independent association between low to moderate alcohol consumption and myocardial ischemia on ESE (OR 0.96; 95%CI: 0.83 to 1.11) was not observed. However, age, male sex, smoking and dyslipidemia were associated with alcohol consumption. Conclusion: Low to moderate alcohol consumption was not an independent predictor of myocardial ischemia on ESE. Nevertheless, we observed a predominance of the male sex, dyslipidemia and smoking habit, important predictors of myocardial ischemia, in the group of alcohol consumers

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography.

BACKGROUND: In view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. OBJECTIVE: To evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA). METHODS: This is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted. RESULTS: The frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable. CONCLUSIONS: The frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Atherosclerotic Plaque in Patients with Zero Calcium Score at Coronary Computed Tomography Angiography / Placa Aterosclerótica à Angiotomografia de Coronárias em Pacientes com Escore de Cálcio Zero

Abstract Background: In view of the high mortality for cardiovascular diseases, it has become necessary to stratify the main risk factors and to choose the correct diagnostic modality. Studies have demonstrated that a zero calcium score (CS) is characteristic of a low risk for cardiovascular events. However, the prevalence of individuals with coronary atherosclerotic plaques and zero CS is conflicting in the specialized literature. Objective: To evaluate the frequency of patients with coronary atherosclerotic plaques, their degree of obstruction and associated factors in patients with zero CS and indication for coronary computed tomography angiography (CCTA). Methods: This is a cross-sectional, prospective study with 367 volunteers with zero CS at CCTA in four diagnostic imaging centers in the period from 2011 to 2016. A significance level of 5% and 95% confidence interval were adopted. Results: The frequency of atherosclerotic plaque in the coronary arteries in 367 patients with zero CS was 9.3% (34 individuals). In this subgroup, mean age was 52 ± 10 years, 18 (52.9%) were women and 16 (47%) had significant coronary obstructions (> 50%), with involvement of two or more segments in 4 (25%) patients. The frequency of non-obese individuals (90.6% vs 73.9%, p = 0.037) and alcohol drinkers (55.9% vs 34.8%, p = 0.015) was significantly higher in patients with atherosclerotic plaques, with an odds ratio of 3.4 for each of this variable. Conclusions: The frequency of atherosclerotic plaque with zero CS was relatively high, indicating that the absence of calcification does not exclude the presence of plaques, many of which obstructive, especially in non-obese subjects and alcohol drinkers.

Resumo Fundamento: Diante da alta mortalidade por doenças cardiovasculares, faz-se necessária a estratificação dos principais fatores de riscos e escolha correta da modalidade diagnóstica. Estudos demonstraram que escore de cálcio (EC) zero caracteriza baixo risco de eventos cardiovasculares. No entanto, a frequência de portadores de placa aterosclerótica coronária com EC zero é conflitante na literatura especializada. Objetivo: Avaliar a frequência de pacientes com placa aterosclerótica coronária, seu grau de obstrução e fatores associados em pacientes com EC zero e indicação para angiotomografia computadorizada de coronárias (ATCC). Métodos: Trata-se de estudo transversal, prospectivo, com 367 voluntários portadores de EC zero, mediante a ATCC, no período de 2011-16, em quatro centros de diagnóstico por imagem. Foi assumido nível de significância 5% e intervalo de confiança de 95%. Resultados: A frequência de placa aterosclerótica nas artérias coronárias dos 367 pacientes com EC zero foi de 9,3% (34 indivíduos); neste subgrupo, a média de idade foi 52 ± 10 anos, 18 (52,9%) eram mulheres e 16 (47%) exibiam obstruções coronarianas significativas (> 50%), dos quais 4 (25%) apresentaram placas em pelo menos dois segmentos. A frequência de não obesos (90,6% vs. 73,9%; p = 0,037) e de etilistas (55,9% vs. 34,8%; p = 0,015) foi significativamente maior nos portadores de placa, apresentando, cada variável, odds ratio de 3,4 para o desenvolvimento das referidas placas. Conclusões: A frequência de placa aterosclerótica com EC zero foi considerável, evidenciando, portanto, que a ausência de calcificação não exclui placa, muitas das quais obstrutivas, principalmente nos não obesos e etilistas.

Visão geral com meta-análise de revis~es sistemáticas sobre o valor diagnóstico e prognóstico da angiotomografia de coronárias na emergência / Overview with meta-analysis of systematic reviews of the diagnostic and prognostic value of coronary computed tomography angiography in the emergency department

Fundamento: A alta prevalência de DAC, bem como seu impacto sobre as despesas de saúde e as várias opções de tratamento para reduzir a morbidade e mortalidade relacionados a DAC, vem desenvolver uma ferramenta de diagnóstico precisa e com resultados importantes no departamento de emergência. Objetivo: Fornecer visão geral com meta-análise para compilar evidência a partir de múltiplas revisões sistemáticas (RS) sobre o valor diagnóstico e prognóstico da angiotomografia computadorizada de artérias coronárias (ATCC) na avaliação da dor torácica aguda no setor de emergência (SE). Métodos: Incluímos RS de estudos primários avaliando o valor diagnóstico e prognóstico da ATCC ≥ 64 canais no SE. Os estudos foram conduzidos em pacientes de risco baixo e intermediário para doença arterial coronariana (DAC). Realizou-se avaliação qualitativa usando PRISMA, e aquelas que pontuaram ≥ 80% foram aprovadas. Dois autores extraíram dados independentemente usando um formulário padrão. Os testes de correlação de Spearman, do qui-quadrado, Q de Cochran ou a estatística I 2 de Higgins e Thompson foram usados, assim como o pacote estatístico "mada" (R Core Team, 2015) para meta-análise. Adotou-se o nível de significância de 95%. Resultados: Quatro RS foram elegíveis para inclusão neste estudo, resultando em 13 artigos após aplicação dos critérios de exclusão, sendo apenas 10 usados para a meta-análise, num total de 4831 pacientes (idade média, 54 ± 6 anos; 51% homens), dos quais 46% tinham hipertensão, 32% dislipidemia, 13% diabetes e 26% história familiar de DAC prematura. Na meta-análise, 9 estudos definiram ATCC positiva na presença de lesões luminais ≥ 50%, enquanto 1 estudo definiu ATCC positiva na presença de lesões luminais ≥ 70%. A sensibilidade variou de 77% a 98%, e a especificidade, de 73% a 100%. A análise univariada mostrou homogeneidade do odds ratio diagnóstico (DOR) [Q = 8,5 (df = 9), p = 0,48 and I 2 = 0%]. A estimativa sumária da DOR para ATCC nas análises primárias foi de 4,33 (IC95%: 3,47 ­ 5,18). A área sob a curva foi 0,982 (IC95%: 0,967 ­ 0,999). Houve 29 (0.6%) infartos, 92 (1,9%) revascularizações, 312 (6,4%) angiografias coronarianas invasivas e nenhuma morte. Síndrome coronariana aguda foi diagnosticada em 7,3% dos 1655 pacientes incluídos na meta-análise. Conclusões: O uso de ATCC como ferramenta para estratificação de pacientes de risco cardiovascular baixo e intermediário, que procuraram o SE com dor torácica, tem alta acurácia e segurança, reduz a permanência no hospital e provavelmente os custos, produzindo diagnóstico precoce e uma tomada de decisão mais efetiva

Background: The high prevalence of CAD, as well as your impact on health expenditure and the various treatment options to reduce morbidity and mortality related to CAD, comes to develop a diagnostic tool precis and with important findings in the Emergency Department. Objetive: To conduct an overview with meta-analysis to compile evidence from multiple systematic reviews (SR) on the diagnostic and prognostic value of coronary computed tomography angiography (CCTA) to assess acute chest pain in the emergency department (ED). Methods: We included SR of primary studies that evaluated the diagnostic and prognostic value of CCTA ≥ 64 channels in the ED. The studies were conducted in patients at low and intermediate risk for coronary artery disease (CAD). Quality assessment was performed using PRISMA and approved reviews that scored ≥ 80%. Two authors independently extracted data using a standardized form. Spearman correlation test, Chi-square test, Cochran's Q test or Higgins and Thompson statistical I 2 were used. For meta-analysis, "mada" package statistical software R Core Team, 2015, was used. The significance level adopted was 95%. Results: Four reviews were eligible for inclusion in this overview, resulting in 13 articles after applying the exclusion criteria, and only 10 of these were used for meta-analysis, adding up to a total of 4831 patients (mean age, 54 ± 6 years; 51% male), of whom 46% were hypertensive, 32% had dyslipidemia, 13% had diabetes and 26% had a family history of premature CAD. In the meta-analysis, 9 studies defined CCTA positive in the presence of luminal lesions ≥ 50%, while 1 study defined it as luminal lesions ≥ 70%. Sensitivity ranged from 77% to 98%, and specificity, from 73% to 100%. The univariate analysis showed homogeneity of diagnostic odds ratio (DOR) [Q = 8.5 (df = 9), p = 0.48 and I 2 = 0%]. The pooled mean DOR for CCTA in primary analyses was 4.33 (95% CI: 3.47 - 5.18). The area under the curve (AUC) was 0.982 (95% CI: 0.967 - 0.999). There was no death, 29 (0.6%) infarcts, 92 (1.9%) revascularizations and 312 (6.4%) invasive coronary angiographies. The diagnosis of acute coronary syndrome occurred in 7.3% of the 1655 patients included in the meta-analysis. Conclusions: The use of CCTA as a tool for stratification of patients at low or intermediate cardiovascular risk, who are in the ED with chest pain, has high accuracy, safety, reduces length of hospital stay and probably the costs, producing an early diagnosis and more effective decision making

Preditores de Placa Aterosclerótica em Assintomáticos Isquêmicos à Ecocardiografia sob Estresse Físico / Predictors of Atherosclerotic Plaque in Individuals with Asymptomatic Ischemia on Physical Stress Echocardiography

A isquemia miocárdica pode ocorrer em pacientes assintomáticos e sem história de doença arterial coronariana (DAC). A ecocardiografia sob estresse físico (EEF) é um método de boa acurácia diagnóstica, enquanto a cineangiocoronariografia (CATE) é o método padrão-ouro para detecção de DAC obstrutiva. Todavia, muitos portadores de isquemia em testes funcionais apresentam lesões não obstrutivas à CATE. Objetivo: Identificar a presença de preditores de placas ateroscleróticas obstrutivas à CATE em indivíduos assintomáticos com EEF positiva para isquemia miocárdica. Métodos: Estudo transversal com 278 pacientes assintomáticos submetidos à EEF e à CATE, divididos em grupo G1 (lesões ateroscleróticas obstrutivas ≥ 50%) e G2 (placas inferiores a 50% ou inexistentes). Variáveis quantitativas foram comparadas com os testes t de Student ou Mann-Whitney para grupos independentes, segundo a normalidade da amostra. Para variáveis categóricas, utilizou-se os testes do qui-quadrado ou exato de Fisher, quando apropriado. Para identificação de preditores independentes de lesão aterosclerótica, foi utilizada regressão logística. Resultados: O número de pacientes nos grupos G1 e G2 foi de 233 (83,3%) e 45 (16,2%), respectivamente. A média de idade foi maior no G1 (60,9 ± 9,56 anos versus 51,8 ± 10,05 anos, respectivamente, p < 0,001). O G1 em comparação ao G2 apresentou mais pacientes hipertensos (65,2% versus 48,9%, p = 0,03) e dislipidêmicos (77,3% versus 57,8%, respectivamente, p = 0,006). O G2 em comparação ao G1 apresentou maior frequência de obesidade leve (33,3% versus 14,2%, respectivamente, p = 0,002), que demonstrou ser um fator protetor para lesão aterosclerótica. Conclusão: Os preditores de placa aterosclerótica em assintomáticos isquêmicos à EEF foram idade, gênero masculino e isquemia do tipo fixa.

Myocardial ischemia may occur in asymptomatic patients without a history of coronary artery disease (CAD). Stress echocardiography (SE) is a method with good diagnostic accuracy, while coronary cineangiography (CCA) is the gold standard method to detect obstructive CAD. However, many patients with ischemia on functional tests show nonobstructive lesions on CCA. Objective: To assess the presence of predictors of obstructive atherosclerotic plaques in asymptomatic individuals with an SE positive for myocardial ischemia. Methods: Cross-sectional study with 278 asymptomatic individuals who underwent SE and CCA, divided into groups G1 (obstructive atherosclerotic lesions ≥ 50%) and G2 (plaques below 50% or nonexistent). Quantitative variables were compared with Student's t test or Mann-Whitney test for independent groups, according to the normality of the sample. For categorical variables, we used the chi-square test or Fisher's exact test, as appropriate. Logistic regression was used to identify independent predictors of atherosclerotic lesions. Results: The numbers of patients in G1 and G2 were 233 (83.3%) and 45 (16.2%), respectively. The mean age was higher in G1 (60.9 ± 9.56 years versus 51.8 ± 10.05 years, p < 0.001). G1, when compared with G2, had more patients with hypertension (65.2% versus 48.9%, respectively, p = 0.03) and dyslipidemia (77.3% versus 57.8%, respectively, p = 0.006). G2, when compared with G1, had a higher frequency of mild obesity (33.3% versus 14.2%, respectively, p = 0.002), which emerged as a protective factor for atherosclerotic lesions. Conclusion: The predictors of atherosclerotic plaques in asymptomatic patients with ischemia on SE were age, male gender, and fixed ischemia.

Low Prevalance of Major Events Adverse to Exercise Stress Echocardiography / Baixa Prevalência de Eventos Adversos Maiores à Ecocardiografia sob Estresse Físico

Abstract Background: Stress echocardiography is well validated for diagnosis and risk stratification of coronary artery disease. Exercise stress echocardiography (ESE) has been shown to be the most physiological among the modalities of stress, but its safety is not well established. Objective: To study the complications related to ESE and clinical and echocardiographic variables most commonly associated with their occurrence. Methods: Cross-sectional study consisting of 10250 patients submitted to ESE for convenience, from January 2000 to June 2014. Cardiac Arrhythmias (CA) were the most frequent complications observed during the examination. The volunteers were divided into two groups according to the occurrence of CA during ESE: G1 group, composed of patients who have CA, and G2 formed by individuals who did not show such complication. Results: Group G1, consisting of 2843 patients (27.7%), and Group G2 consisting of 7407 patients (72.3%). There was no death, acute myocardial infarction, ventricular fibrillation or asystole. Predominant CAs were: supraventricular extrasystoles (13.7%), and ventricular extrasystoles (11.5%). G1 group had a higher mean age, higher frequency of hypertension and smoking, larger aortic roots and left atrium (LA) and lower ejection fraction than G2. G1 group also had more ischemic changes (p < 0.001). The predictor variables were age (RR 1.04; [CI] 95% from 1.038 to 1.049) and LA (RR 1.64; [CI] 95% from 1.448 to 1.872). Conclusion: ESE proved to be a safe modality of stress, with non-fatal complications only. Advanced age and enlargement of the left atrium are predictive of cardiac arrhythmias.

Resumo Fundamento: A ecocardiografia sob estresse constitui metodologia validada para diagnóstico e estratificação de risco da doença arterial coronária. A ecocardiografia sob estresse físico (EEF) tem se destacado como a mais fisiológica dentre as modalidades de estresse, todavia sua segurança não está bem estabelecida. Objetivo: Estudar as complicações relacionadas à EEF e as variáveis clínicas e ecocardiográficas preditoras dessas ocorrências. Método: Estudo transversal composto por 10250 pacientes submetidos à EEF por conveniência, de janeiro de 2000 a junho de 2014. As arritmias cardíacas (AC) foram as complicações mais frequentemente encontradas durante o exame. Os voluntários foramdivididos em dois grupos, de acordo com a ocorrência de AC à EEF: grupo G1 - composto por pacientes que apresentaram AC e grupo G2 - formado por indivíduos que não exibiram tal complicação. Resultados: O grupo G1 com 2843 (27,7%) pacientes, e grupo G2 formado por 7407 (72,3%). Não foram registrados óbitos, infarto agudo do miocárdio, assistolia ou fibrilação ventricular. As extrassístoles supraventriculares (13,7%) e as ventriculares (11,5%) foram as AC predominantes. O grupo G1 apresentou idade média mais elevada, maior frequência de hipertensão arterial sistêmica e tabagismo, maiores dimensões da raiz da aorta e do átrio esquerdo (AE) e menor fração de ejeção do ventrículo esquerdo que o G2. O grupo G1 exibiu também, mais alterações isquêmicas (p < 0,001). As variáveis preditoras foram idade (RR 1,04; [IC] 95% 1,038 - 1,049) e AE (RR 1,64; [IC] 95% 1,448 - 1,872). Conclusão: A presente investigação demonstrou que a EEF é uma modalidade segura, ocorrendo apenas complicações não-fatais. Idade avançada e aumento da dimensão do AE são preditores da presença de arritmias cardíacas.

Low Prevalance of Major Events Adverse to Exercise Stress Echocardiography.

BACKGROUND: Stress echocardiography is well validated for diagnosis and risk stratification of coronary artery disease. Exercise stress echocardiography (ESE) has been shown to be the most physiological among the modalities of stress, but its safety is not well established. OBJECTIVE: To study the complications related to ESE and clinical and echocardiographic variables most commonly associated with their occurrence. METHODS: Cross-sectional study consisting of 10250 patients submitted to ESE for convenience, from January 2000 to June 2014. Cardiac Arrhythmias (CA) were the most frequent complications observed during the examination. The volunteers were divided into two groups according to the occurrence of CA during ESE: G1 group, composed of patients who have CA, and G2 formed by individuals who did not show such complication. RESULTS: Group G1, consisting of 2843 patients (27.7%), and Group G2 consisting of 7407 patients (72.3%). There was no death, acute myocardial infarction, ventricular fibrillation or asystole. Predominant CAs were: supraventricular extrasystoles (13.7%), and ventricular extrasystoles (11.5%). G1 group had a higher mean age, higher frequency of hypertension and smoking, larger aortic roots and left atrium (LA) and lower ejection fraction than G2. G1 group also had more ischemic changes (p < 0.001). The predictor variables were age (RR 1.04; [CI] 95% from 1.038 to 1.049) and LA (RR 1.64; [CI] 95% from 1.448 to 1.872). CONCLUSION: ESE proved to be a safe modality of stress, with non-fatal complications only. Advanced age and enlargement of the left atrium are predictive of cardiac arrhythmias.