Diagnostic Methods – ABC CARDIOL

ABCHF

Editorial

The Importance of the DEIC/GEMIC/SBC 2021 Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis to Clinical Practice

Marcus Vinicius Simões et al. Fabio Fernandes

Cardiac amyloidosis is a frequent cause of heart failure with preserved ejection fraction

The main cardiological phenotype of CA is that of an infiltrative restrictive cardiomyopathy, whose more general aspects of symptoms, increased thickness of the ventricular walls, and concentric remodeling of the left ventricle, overlap with those of heart failure with preserved ejection fraction (HFpEF), produced by risk factors such as high blood pressure, obesity, diabetes, and aging. Thus, CA should be considered as a differential diagnosis in patients who exhibit HFpEF.

It is worth remembering that, among the different amyloidogenic proteins that can be deposited in the myocardium and cause CA, the wild type transthyretin form (ATTR-CAwt), which is closely linked to aging, is the most frequently reported in several series of specialized medical literature. This has been repeated both in large reference centers and in real world registers. Accordingly, a recent article has shown a very significant increase in CA as a cause of hospitalizations due to heart failure in several regions of the United States, between 2000 and 2012, exceeding the rate of 65 cases per 100,000 people/year, indicating that CA is not a rare disease according to the current criteria of the World Health Organization ( ).

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Viewpoint

Cardiac Scintigraphy with Bone Markers in Clinical Practice: When to Solicit the Exam? How to Interpret the Results?

Marcus Vinicius Simões

When to solicit cardiac scintigraphy with bone markers?

In view of the aspects mentioned above, it is important for investigation of the specific form of ATTR-CA, using bone marker scintigraphy, to begin after 2 key preliminary steps: 1. establishing high clinical suspicion of the presence of CA and 2. ruling out the presence of immunoglobulin light chains, which would lead us to diagnosis of AL-CA.

It is fundamental to establish high clinical suspicion, given that negative scintigraphy does not rule out the presence of CA in its various forms, particularly the AL form. In other words, in a significant percentage of cases with high clinical suspicion and negative scintigraphy, investigation should continue with tissue biopsy, including endomyocardial biopsy, in order to conclude diagnosis. It is clear that endomyocardial biopsy should only be performed in cases of high clinical suspicion, as it is an invasive method with risks that, although low, are inherent to the procedure.

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ABC

Artigo Original

Increased rate-pressure product as predictor for the absence of significant obstructive coronary artery disease in patients with positive exercise test

Luis Domingos Fornitano et al. Moacir Fernandes de Godoy

OBJECTIVE: To correlate values of rate-pressure product (RPP) above 30,000 mmHg.bpm with or without significant obstructive coronary artery disease (CAD) in patients with positive exercise test. METHODS: A retrospective analysus of 246 patients that had been submitted to Exercise Treadmill Test (ETT) up to 30 days before coronary angiography on suspicion of obstructive disease. The 165 patients in which the ETT was positive were analyzed considering as positive the presence of horizontal or descending depression of the ST segment for at least 1 mm, 0.08 seconds after J point. RESULTS: Among the 165 appraised patients, 50 (30.3%) reached RPP > 30,000 mmHg.bpm, of which 38 (76%) had normal coronary vessel angiography or low degree obstructive coronary artery disease and 12 (24%) had significant. Among the remaining 115 appraised patients with positive ETT and RPP < 30,000 mmHg.bpm, 59 (51.3%) were normal or with low significance obstructive coronary artery disease, and 56 (48.7%) had significant disease. (Odds Ratio = 0.3327 CI 95% = 0.1579 to 0.7009; P=0.0034). CONCLUSION: Based on data collected in the present investigation, it has been demonstrated that RPP above 30,000 mmHg.bpm stands as a relevant variable to predict the absence of significant obstructive coronariopathy in individuals with positive ET and as a useful tool in making clinical decisions.

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ABC

Original Article

Noninvasive diagnosis of allograft vascular disease after heart transplantation

Fernando Bacal et al. Noedir Antonio Groppo Stolf Viviane Cordeiro Veiga William A. Chalela … Cesar Grupi Ana Clara Rodrigues Eulógio E. Martinez Alfredo Inácio Fiorelli Luiz Felipe Pinho Moreira Edimar Alcides Bocchi Giovanni Bellotti José Antonio Franchini Ramires

OBJECTIVE: To determine the predictive values of noninvasive tests for the detection of allograft vascular disease. METHODS: We studied 39 patients with mean ages of 48±13 years and a follow-up period of 86±13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or = 50% obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results. RESULTS: Allograft vascular disease was found in 15 (38%) patients. The Holter test showed 15.4% sensitivity, 95.5% specificity. For the treadmill stress test, sensitivity was 10%, specificity was 100%. When thallium scintigraphy was used, sensitivity was 40%, specificity 95.8%. On echocardiography with dobutamine, we found a 63.6% sensitivity, 91.3% specificity. When the dobutamine echocardiogram was associated with scintigraphy, sensitivity was 71.4%, specificity was 87%. CONCLUSION: In this group of patients, the combination of two noninvasive methods (dobutamine echocardiography and thallium scintigraphy) may be a good alternative for the detection of allograft vascular disease in asymptomatic patients with normal ventricular function.

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The Importance of the DEIC/GEMIC/SBC 2021 Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis to Clinical Practice

Cardiac amyloidosis is a frequent cause of heart failure with preserved ejection fraction

Cardiac Scintigraphy with Bone Markers in Clinical Practice: When to Solicit the Exam? How to Interpret the Results?

When to solicit cardiac scintigraphy with bone markers?

Increased rate-pressure product as predictor for the absence of significant obstructive coronary artery disease in patients with positive exercise test

Noninvasive diagnosis of allograft vascular disease after heart transplantation

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