Disección aórtica: verdadero valor diagnóstico de la radiografía de tórax / Aortic dissection: True diagnostic value of thorax X-ray

Resumen Objetivo: Evaluar la capacidad diagnóstica de los signos radiológicos y su aplicabilidad para el diagnóstico de disección aórtica (DA). Establecer un valor de corte para el ensanchamiento mediastínico izquierdo en la DA y determinar su sensibilidad (S) y especificidad (E). Método: Se incluyeron 39 pacientes a los que se realizó angiotomografía de aorta torácica por sospecha clínica de DA, en un instituto cardiovascular de alta complejidad, del 1 de agosto de 2018 al 1 de febrero de 2019. Se realizaron radiografías de tórax de frente a todos los pacientes. Resultados: el 72% de los pacientes eran hombres. El promedio de edad fue de 63 años. La hipertensión arterial fue el factor de riesgo cardiovascular más común. El 43% de los pacientes tuvieron DA, el 76% fueron de tipo B. La media del ancho mediastínico máximo mostró una diferencia de 1,5 cm entre los pacientes con DA y sin DA. En cambio, la diferencia fue de 2 cm para el ancho mediastínico izquierdo. El ensanchamiento mediastínico máximo y del mediastino izquierdo fueron signos estadísticamente significativos; este último con muy buena capacidad diagnóstica (área bajo la curva: 0,84). Se calculó un punto de corte para el ancho mediastínico izquierdo de 5,39 cm (S: 82%; E: 77%). El ensanchamiento del botón aórtico, aorta ascendente/descendente o asimetría entre ambas también fueron signos estadísticamente significativos. Conclusiones: Los signos radiológicos para el diagnóstico de DA fueron validados. Se calculó un punto de corte para el ancho mediastínico izquierdo de 5,39 cm, con buena capacidad diagnóstica.

Abstract Objective: To evaluate the diagnostic capacity of the radiological signs for aortic dissection (AD) and their applicability for the diagnosis, as well as to establish a cut-off value for left mediastinal width in AD and determine its sensitivity (S) and specificity (E). Method: From a high complexity cardiovascular institute, 39 patients were selected and chest X-rays were performed from August 1, 2018 to February 1, 2019. Selection criteria involved those who underwent computed tomography angiography of thoracic aorta for clinical suspicion of AD. Results: Within the sample, 72% were men (mean 63 years old), with hypertension as a most common risk factor. 43% of the patient had AD, 76% were type B. The mean maximum mediastinal width showed a difference of 1.5 cm between patients with AD and those without it. In contrast, the difference was 2 cm for the left mediastinal width. Maximum mediastinal width and left mediastinal width were statistically significant signs. Left mediastinal width presented good diagnostic capacity (area under the curve: 0.84). Cut-off point of 5.39 cm for the left mediastinal width was calculated (S: 82%; E: 77%). Finally, widening of the aortic knob, ascending/descending aorta or asymmetry between both showed to be statistically significant signs. Conclusions: Radiological signs for the diagnosis of AD was validated. Also, a cut-off point for the left mediastinal width of 5.39 cm was found with a very good diagnostic capacity.

Lung ultrasound in acute myocardial infarction. Updating Killip & Kimball.

BACKGROUND: Heart failure complicating acute myocardial infarction marks an ominous prognosis. Killip and Kimball's classification of heart failure remains a useful tool in these patients. Lung ultrasound can detect pulmonary congestion but its usefulness in this scenario is unknown. OBJECTIVE: To investigate the diagnostic accuracy of lung ultrasound to predict heart failure in patients with acute myocardial infarction. METHODS: Patients admitted with acute myocardial infarction and without heart failure were evaluated with a lung ultrasound. The presence of B-lines was recorded and counted. The presence of new heart failure (Killip Class B, C, or D) during hospitalization was evaluated by a cardiologist blinded to the results of lung ultrasound. A ROC curve analysis was done to evaluate the diagnostic accuracy of B-lines to predict heart failure. RESULTS: 200 patients were included. Three patients were diagnosed with cardiogenic shock, 5 with acute pulmonary edema, and 17 with mild heart failure. Patients who develop heart failure had a median of 14 B-lines, however, patients who remained in Killip class A had a median of 2 (p = 0,0001). The area under the ROC curve of the sum of B-lines to predict any form of heart failure was 0,91 (CI95% 86-97). The best cut-off value was 5 B-lines, with a sensitivity of 88% (IC95% 68,8-97,5) and specificity of 81% (IC95% 73,9-86,2). CONCLUSION: Lung ultrasound done at admission can help to predict heart failure In patients with acute myocardial infarction.

Diagnostic ability of Physical Examination in aortic Valve stenosis / La capacidad diagnóstica del examen físico en la estenosis valvular aórtica

background: Physical examination is essential to detect aortic stenosis but there is scarce information currently available. Objectives: The goal of this study is to evaluate the diagnostic yield of physical examination, the interobserver agreement of clinical signs, and to establish a score to identify severe aortic stenosis. Methods: One-hundred patients were included in the study. Before echocardiographic evaluation, two cardiologists independently evaluated the clinical signs of the physical examination in aortic stenosis. Sensitivity, specificity, and inter-observer agreement were calculated, and the area under the curve was analyzed to develop a score for predicting severe aortic stenosis. results: The decreased intensity of the first heart sound and the crescendo-decrescendo shape of the murmur had sensitivity >90% and specificity <70%. The specificities of an absent second sound, a murmur that peaks later in systole and the presence of a parvus et tardus pulse were >95%, but the sensitivities were <50%. Inter-observer agreement was good for most criteria, except for murmur shape and intensity. The best area under the curve was achieved by the score composed of heart sounds of decreased or absent intensity, duration of the holosystolic murmur, parvus et tardus carotid pulse and a grade 3-4 systolic murmur. Conclusions: Physical examination findings have low sensitivity but good specificity. Inter-observer agreement of clinical signs of severity was moderately good. Correct identification of patients with severe aortic stenosis can be achieved using a simple score.

La estimulación septal del ventrículo derecho generaría igual disincronía biventricular que la estimulación apical en pacientes con fracción de eyección conservada / Right ventricular septal stimulation would produce similar bi-ventricular dyssynchrony as does apical stimulation in patients with normal ejection fraction

Objetivo: Determinar si la estimulación medioseptal genera menor disincronía interventricular e intraventricular que la apical evaluada mediante ecocardiografía en pacientes con fracción de eyección conservada sometidos al implante de marcapasos VVI. Método: Estudio prospectivo que incluyó a 19 pacientes > 70 años, con indicación de implante de marcapasos VVI por bloqueo auriculoventricular completo degenerativo, frecuencia ventricular ≤ 50 lpm y fracción de eyección ≥ 45%. Se excluyeron portadores de fibrilación auricular, insuficiencia cardiaca, aquellos que en ritmo sinusal presentaron QRS > 120 mseg o bloqueo de rama izquierda. Se aleatorizaron 19 pacientes a 2 grupos: grupo A (47%) a implante apical y grupo B (53%) a implante septal. Resultados: La edad media fue de 75 años (± 8). Ninguno tuvo diagnóstico de insuficiencia cardiaca o cardiopatía isquémica. La disincronía intraventricular fue de A: 14.44 ± 19.76 mseg vs. B: 9 ± 36.45 mseg; A: 6.11 ± 62.11 mseg vs. B: 13 ± 38.31 mseg; A: 77 ± 53.51 mseg vs. B: 24.29 ± 80.90 mseg, p = NS. La disincronía interventricular fue de A: 46.44 ± 19.76 mseg vs. B: 42.20 ± 29.56 mseg; A: 45.33 ± 45.67 mseg vs. B: 29.80 ± 44.66 mseg; A: 46.38 ± 20 .mseg vs. B: 21 ± 27.20 mseg, p = NS) a las 48 h, 5 y 48 meses, respectivamente. Conclusión: El sitio de estimulación no generó diferencias en la disincronía biventricular. La estimulación septal presentó una tendencia no significativa a menor disincronía interventricular.

Objective: To determine in patients with normal ejection fraction, undergoing permanent VVI pacing, if medial septal stimulation has lower dyssynchrony than apical stimulation assessed by echocardiography. Method: A prospective trial, 19 patients > 70 years old, scheduled for VVI pacemaker implantation for complete degenerative atrioventricular block, ventricular frequency < 50 beat per minute and ejection fraction ≥ 45%. Patients with atrial fibrillation, heart failure, left bundle branch block and QRS durations longer than 120 milliseconds in surface electrocardiogram with sinus rhythm were excluded. Patients were randomized to apical implantation group A: 47% and septal implantation group B: 53%. Echocardiographic parameters were measured previous to the implant, 48 h, 5 and 48 months after implantation. Results: No patients had diagnosis of ischemic cardiomyopathy or heart failure. Echocardiographic parameters for interventricular dyssynchrony between groups were A: 14.44 ± 19.76 msec vs. B: 9 ± 36.45 msec; A: 6.11 ± 62.11 msec vs. B: 13 ± 38.31 msec; A: 77 ± 53.51 msec vs. B: 24.29 ± 80.90 msec, P = NS). For interventricular dyssynchrony were A: 46.44 ± 19.76 msec vs. B: 42.20 ± 29.56 msec; A: 45.33 ± 45.67 msec vs. B: 29.80 ± 44.66 msec; A: 46,38 ± 20 msec vs. B: 21 ± 27.20 msec, P = NS) at 48 h, 5 and 48 months, respectively. Conclusion: Apical site of stimulation does not increase ventricular dyssynchrony rate in patients with preserved ejection fraction. Septal stimulation showed decreased trend in interventricular dyssynchrony.

[Right ventricular septal stimulation would produce similar bi-ventricular dyssynchrony as does apical stimulation in patients with normal ejection fraction]. / La estimulación septal del ventrículo derecho generaría igual disincronía biventricular que la estimulación apical en pacientes con fracción de eyección conservada.

OBJECTIVE: To determine in patients with normal ejection fraction, undergoing permanent VVI pacing, if medial septal stimulation has lower dyssynchrony than apical stimulation assessed by echocardiography. METHOD: A prospective trial, 19 patients>70 years old, scheduled for VVI pacemaker implantation for complete degenerative atrioventricular block, ventricular frequency<50beat per minute and ejection fraction≥45%. Patients with atrial fibrillation, heart failure, left bundle branch block and QRS durations longer than 120milliseconds in surface electrocardiogram with sinus rhythm were excluded. Patients were randomized to apical implantation group A: 47% and septal implantation group B: 53%. Echocardiographic parameters were measured previous to the implant, 48h, 5 and 48 months after implantation. RESULTS: No patients had diagnosis of ischemic cardiomyopathy or heart failure. Echocardiographic parameters for interventricular dyssynchrony between groups were A: 14.44±19.76msec vs. B: 9±36.45msec; A: 6.11±62.11msec vs. B: 13±38.31msec; A: 77±53.51msec vs. B: 24.29±80.90msec, P=NS). For interventricular dyssynchrony were A: 46.44±19.76msec vs. B: 42.20±29.56msec; A: 45.33±45.67msec vs. B: 29.80±44.66msec; A: 46,38±20 msec vs. B: 21±27.20msec, P=NS) at 48h, 5 and 48 months, respectively. CONCLUSION: Apical site of stimulation does not increase ventricular dyssynchrony rate in patients with preserved ejection fraction. Septal stimulation showed decreased trend in interventricular dyssynchrony.

Minor myocardial damage is a prevalent condition in patients with acute heart failure syndromes and preserved systolic function with long-term prognostic implications: a report from the CIAST-HF (Collaborative Italo-Argentinean Study on cardiac Troponin T in Heart Failure) study.

BACKGROUND: Half of patients with acute heart failure syndromes (AHFS) have preserved left ventricular ejection fraction (PLVEF). In this setting, the role of minor myocardial damage (MMD), as identified by cardiac troponin T (cTnT), remains to be established. AIM: To evaluate the prevalence and long-term prognostic significance of cTnT elevations in patients with AHFS and PLVEF. PATIENTS AND METHODS: This retrospective, multicenter, collaborative study included 500 patients hospitalized for AHFS with PLVEF (ejection fraction ≥40%) between October 2000 and December 2006. Blood samples were collected within 12 hours after admission and were assayed for cTnT. MMD was defined as a cTnT value of ≥0.020 ng/mL. RESULTS: Mean age was 73 ± 12 years, 47% were female, 38% had an ischemic etiology, and New York Heart Association (NYHA) class was 2.2 ± 0.7. Mean cTnT value was 0.149 ± 0.484 ng/mL, and cTnT was directly correlated with serum creatinine (Spearman's Rho = 0.35, P < .001) and NYHA class (0.25, P < .001). MMD was diagnosed in 220 patients (44%). Patients with MMD showed lower left ventricular ejection fraction (P < .05), higher serum creatinine (P < .001), higher prevalence of ischemic etiology and diabetes mellitus, a worse NYHA class (P < .001), and higher natriuretic peptide levels (P < .001) as compared with patients without MMD. At 6-month follow-up, overall event-free survival was 55% and 75% in patients with and without MMD (P < .001), respectively. On multivariate Cox regression analysis, only NYHA class (HR = 1.50; P = .002) and MMD (HR = 1.81; P = .001) were identified as predictors of events. CONCLUSIONS: Increased cTnT levels were detected in approximately 50% of patients with AHFS with preserved systolic function, and were found to correlate with clinical measures of disease severity. The presence of MMD was associated with a worse long-term outcome, lending support to cTnT-based risk stratification in the setting of AHFS.

Reduced systolic performance by tissue Doppler in patients with preserved and abnormal ejection fraction: new insights in chronic heart failure.

BACKGROUND: Tissue Doppler imaging (TDI) is useful in the evaluation of systolic and diastolic function. It allows assessment of ventricular dynamics in its longitudinal axis. We sought to investigate the difference in systolic and diastolic longitudinal function in patients with chronic heart failure (CHF) with normal and reduced ejection fraction. METHODS AND RESULTS: One hundred ten outpatients with CHF and 68 controls were included. Ejection fraction (EF) was obtained and longitudinal systolic (S) and diastolic (E' and A') wall velocities were recorded from basal septum. Group A (controls) were normal and CHF patients were classified by EF in Group B1: > 45% and B2: < or = 45%. In A, B1 and B2 the mean S peak was 7.74; 5.45 and 4.89 cm/s (p<0.001); the mean E' peak was 8.56; 5.72 and 6.1 cm/s (p<0.001); and the mean A' peak was 10.2; 7.3 and 5.3 cm/s (p<0.001). Also, isovolumic contraction and relaxation time were different among control and CHF groups, (both p<0.001). The most useful parameters for identifying diastolic CHF were IVRT and S peak, with area under ROC curves of 0.93 and 0.89. The cut-off of 115 ms for IVRT and 5.8 cm/s for S peak showed a sensitivity of 94 and 97%, with a specificity of 82 and 73%, respectively. CONCLUSION: These findings suggest that impairment of left ventricular systolic function is present even in those with diastolic heart failure, and that abnormalities may have an important role to identifying the condition.

Nefropatía por contraste, un problema común en cardiología intervencionista / Radiocontrast nephropathy

La incidencia de deterioro de la función renal inducida por agentes de contraste (nefropatía por contraste) ha aumentado significativamente en los últimos años a consecuencia del creciente número de procedimientos intervencionistas diagnósticos y terapéuticos realizados en pacientes con patologías cardíacas ó extracardíacas. La nefropatía por contraste, si bien suele ser reversible, dista de ser una complicación benigna, ya que supone una prolongación de la estadía hospitalaria y en algunos casos, en particular en pacientes de alto riesgo, conlleva el riesgo de deterioro irreversible de la función renal. A partir de un conocimiento más acabado de su fisiopatología se han ensayado diversas estrategias para reducir la incidencia de la nefropatía por contraste. De ellas, las más eficaces resultaron ser la hidratación correcta y la utilización de medios de contraste de baja osmolaridad. Resulta entonces sumamente importante alertar, no sólo a cardiólogos intervencionistas, sino también a todos los médicos que deciden derivar a sus pacientes a este tipo de procedimientos con agentes de radiocontraste acerca de la fisiopatología, la presentación clínica y la identificación de grupos de riesgo, a fin de implementar simples medidas preventivas o terapéuticas.

Nefropatía por contraste, un problema común en cardiología intervencionista / Radiocontrast nephropathy

La incidencia de deterioro de la función renal inducida por agentes de contraste (nefropatía por contraste) ha aumentado significativamente en los últimos años a consecuencia del creciente número de procedimientos intervencionistas diagnósticos y terapéuticos realizados en pacientes con patologías cardíacas ó extracardíacas. La nefropatía por contraste, si bien suele ser reversible, dista de ser una complicación benigna, ya que supone una prolongación de la estadía hospitalaria y en algunos casos, en particular en pacientes de alto riesgo, conlleva el riesgo de deterioro irreversible de la función renal. A partir de un conocimiento más acabado de su fisiopatología se han ensayado diversas estrategias para reducir la incidencia de la nefropatía por contraste. De ellas, las más eficaces resultaron ser la hidratación correcta y la utilización de medios de contraste de baja osmolaridad. Resulta entonces sumamente importante alertar, no sólo a cardiólogos intervencionistas, sino también a todos los médicos que deciden derivar a sus pacientes a este tipo de procedimientos con agentes de radiocontraste acerca de la fisiopatología, la presentación clínica y la identificación de grupos de riesgo, a fin de implementar simples medidas preventivas o terapéuticas. (AU)

Cardiac troponin T levels are associated with poor short- and long-term prognosis in patients with acute cardiogenic pulmonary edema.

BACKGROUND: The clinical determinants of increased cardiac troponin T (cTnT) in patients with acute cardiogenic pulmonary edema are not well defined, and the ability of this marker to predict long-term mortality has not yet been documented. METHODS: Eighty-four patients with acute cardiogenic pulmonary edema without acute myocardial infarction were prospectively enrolled. cTnT was measured in samples obtained 6 and 12 hours after admission. RESULTS: cTnT levels of 0.1 ng/mL or greater were found in 46 patients (55%). Thirty-two patients (38%) died during follow-up. The area under the receiver operating characteristic curve for cTnT was 0.70 and 0.69 at 6 and 12 hours (P =.47), and the cTnT cutoff value of 0.1 ng/mL was 66% and 69% sensitive and 63% and 71% specific, respectively, in predicting subsequent mortality. Patients were assigned to group 1 if they had cTnT lower than 0.1 ng/mL and to group 2 if they had cTnT levels of 0.1 ng/mL or greater. A history of coronary artery disease was present in 72% of group 2 versus 50% of group 1 patients (P =.04). Patients in group 2 were also older than those in group 1 (mean age, 68 years vs 61 years; P =.021). The 3-year survival in group 1 was 76% compared with 29% in group 2 (log-rank test, P <.001). In a Cox proportional hazards model, elevated cTnT emerged as the only prognostic marker of long-term mortality (risk ratio [RR] = 2.31; 95% CI, 1.011-5.280; P =.047). CONCLUSIONS: A cTnT level of 0.1 ng/mL or greater was associated with poor long-term survival and emerged as a powerful independent predictor of mortality in patients with acute cardiogenic pulmonary edema.