Evaluation – ABC CARDIOL

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Original Article

Three-Dimensional Volumetric Assessment of Diastolic Function by Cardiac Magnetic Resonance Imaging: The Multi-Ethnic Study of Atherosclerosis (MESA)

Marcelo S Nacif et al. Andre L. C. Almeida Alistair A Young Brett R Cowan … Anderson C Armstrong Eunice Yang Christopher T Sibley W. Gregory Hundley Songtao Liu Joao AC Lima David A Bluemke

Abstract

Background:

Cardiac Magnetic Resonance is in need of a simple and robust method for diastolic function assessment that can be done with routine protocol sequences.

Objective:

To develop and validate a three-dimensional (3D) model-based volumetric assessment of diastolic function using cardiac magnetic resonance (CMR) imaging and compare the results obtained with the model with those obtained by echocardiography.

Methods:

The study participants provided written informed consent and were included if having undergone both echocardiography and cine steady-state free precession (SSFP) CMR on the same day. Guide points at the septal and lateral mitral annulus were used to define the early longitudinal relaxation rate (E’), while a time-volume curve from the 3D model was used to assess diastolic filling parameters. We determined the correlation between 3D CMR and echocardiography and the accuracy of CMR in classifying the diastolic function grade.

Results:

The study included 102 subjects. The E/A ratio by CMR was positively associated with the E/A ratio by echocardiography (r = 0.71, p < 0.0001). The early diastolic relaxation velocity by tissue Doppler and longitudinal relaxation rate for the lateral mitral annulus displacement were positively associated (p = 0.007), as were the ratio between Doppler E/e' and CMR E/E' (p = 0.01). CMR-determined normalized peak E (NE) and deceleration time (DT) were able to predict diastolic dysfunction (areas under the curve [AUCs] = 0.70 and 0.72, respectively). In addition, the lateral E/E' ratio showed good utility in identifying diastolic dysfunction (AUC = 0.80). Overall, echocardiography and CMR interobserver and intraobserver agreements were excellent (intraclass correlation coefficient range 0.72 – 0.97).

Conclusion:

3D modeling of standard cine CMR images was able to identify study subjects with reduced diastolic function and showed good reproducibility, suggesting a potential for a routine diastolic function assessment by CMR.

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Review Article

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation

Artur Haddad Herdy et al. Luiz Eduardo Fonteles Ritt Ricardo Stein Claudio Gil Soares de Araújo … Mauricio Milani Romeu Sérgio Meneghelo Almir Sérgio Ferraz Carlos Hossri Antonio Eduardo Monteiro de Almeida Miguel Morita Fernandes-Silva Salvador Manoel Serra

Abstract

Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO₂); carbon dioxide production (VCO₂); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.^–

The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases.

Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals.

Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

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Original Article

Impact of Different Obesity Assessment Methods after Acute Coronary Syndromes

Caroline N. M. Nunes et al. Marcos F. Minicucci Elaine Farah Daniéliso Fusco … Paula S. Azevedo Sergio A. R. Paiva Leonardo A. M. Zornoff

Background:

Abdominal obesity is an important cardiovascular risk factor. Therefore, identifying the best method for measuring waist circumference (WC) is a priority.

Objective:

To evaluate the eight methods of measuring WC in patients with acute coronary syndrome (ACS) as a predictor of cardiovascular complications during hospitalization.

Methods:

Prospective study of patients with ACS. The measurement of WC was performed by eight known methods: midpoint between the last rib and the iliac crest (1), point of minimum circumference (2); immediately above the iliac crest (3), umbilicus (4), one inch above the umbilicus (5), one centimeter above the umbilicus (6), smallest rib and (7) the point of greatest circumference around the waist (8). Complications included: angina, arrhythmia, heart failure, cardiogenic shock, hypotension, pericarditis and death. Logistic regression tests were used for predictive factors.

Results:

A total of 55 patients were evaluated. During the hospitalization period, which corresponded on average to seven days, 37 (67%) patients had complications, with the exception of death, which was not observed in any of the cases. Of these complications, the only one that was associated with WC was angina, and with every cm of WC increase, the risk for angina increased from 7.5 to 9.9%, depending on the measurement site. It is noteworthy the fact that there was no difference between the different methods of measuring WC as a predictor of angina.

Conclusion:

The eight methods of measuring WC are also predictors of recurrent angina after acute coronary syndromes.

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Artigo Original

Assessment of cardiac allograft vasculopathy in cardiac transplantation: experience of a Brazilian center

Elide Sbardellotto Mariano da Costa et al. Ricardo Wang Michelle F. Susin Sergio Lopes Veiga … Francisco Costa Diniz Paulo Roberto Slud Brofman Lidia Ana Zytynski Moura

BACKGROUND: Cardiac transplantation continues to be the treatment of choice for heart failure refractory to optimized treatment. Two methods have high sensitivity for diagnosing allograft rejection episodes and cardiac allograft vasculopathy (CAV), important causes of mortality after transplantation. OBJECTIVE: To assess the relationship between intravascular ultrasound (IVUS) results and endomyocardial biopsy (BX) reports in the follow-up of patients undergoing cardiac transplantation in a Brazilian reference service. METHODS: A retrospective epidemiological observational study was carried out with patients undergoing orthotopic cardiac transplantation from 2000 to 2009. The study assessed the medical records of those patients and the results of the IVUS and BX routinely performed in the clinical post-transplant follow-up, as well as the therapy used. RESULTS: Of the 77 patients assessed, 63.63% were males, their ages ranging from 22 to 69 years. Regarding the IVUS results, 33.96% of the patients were classified as Stanford class I, and 32.08%, as Stanford class IV. Of the 143 BX reports, 51.08% were 1R, and 0.69%, 3R. The Quilty effect was described in 14.48% of the BX reports. All patients used antiproliferative agents, 80.51% used calcineurin inhibitors, and 19.48% used proliferation signal inhibitors. CONCLUSION: The assessment of cardiac transplant patients by use of IVUS provides detailed information for the early and sensitive diagnosis of CAV, which is complemented by histological data derived from BX, establishing a possible causal relationship between CAV and humoral rejection episodes.

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Point of view

Why publish in national journals?

Max Grinberg et al. Maria Cecília Solimene Maria do Carmo Cavarette Barreto

The reluctance of Brazilian authors to publish in Brazilian journals is historical and no longer justified. Currently, several Brazilian journals are indexed in international databases, of which English versions allow disclosure of our studies to foreign countries. The authors express their views on the importance of publishing in national journals and cite the example of the impact of publications from Instituto do Coração – InCor-HCFMUSP in the past two years.

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Case Report

Dynamic myocardial perfusion imaging by dual-source computed tomography

José Rodrigues Parga Filho et al. Cintia Souza Lima Moraes Lima Felipe Gallego Lima Tiago da Silveira Jaques … Luiz Francisco Rodrigues de Ávila Roberto Kalil Filho

We report a dual-source computed tomography study of dynamic and quantitative myocardial perfusion in a 44-year-old patient with previous documented coronary artery disease. Quantitatively, the tomography showed myocardial perfusion deficit in the territories with significant coronary stenosis, confirmed by computed tomography angiography and conventional angiography. Dual-source computed tomography allowed dynamic perfusion and anatomic evaluation in a single study during the follow-up of this patient.

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Artigo Original

Comparison of assessment methods of cardiac vagal modulation

Vagner Clayton de Paiva et al. Kelen Rabelo Santana Bruno Moreira Silva Plínio Santos Ramos … Júlio César Moraes Lovisi Claudio Gil Soares de Araújo Djalma Rabelo Ricardo

BACKGROUND: Several methods have been used to assess cardiac vagal modulation, but there are gaps regarding the association and accuracy of these methods. OBJECTIVE: To investigate the association between three valid, reproducible and commonly methods used to assess cardiac vagal modulation and compare their accuracies. METHODS: Thirty healthy men (23 ± 4 years) and 15 men with coronary artery disease (61 ± 10 years) were evaluated in counterbalanced design by Heart Rate Variability (HRV; variables: the time domain = pNN50, SDNN and RMSSD, the frequency domain HF = ms² and HF n.u.), Respiratory Sinus Arrhythmia (RSA) and 4-second Exercise Test (T4s). Thirty healthy men (23 ± 4 years) and 15 men with coronary artery disease (61 ± 10 years) were evaluated in counterbalanced order by Heart Rate Variability (HRV; variables: the time domain = pNN50, SDNN and RMSSD, the frequency domain HF = ms² and HF n.u.), Respiratory Sinus Arrhythmia (RSA) and 4-second Exercise Test (T4s). RESULTS: Healthy subjects had higher vagal modulation by the three methods (p <0.05). There was a correlation in the healthy group (p <0.05) between the results of HRV (SDNN and pNN50 and RSA, but there was no correlation between the T4s and the other two methods. In the group with coronary artery disease, there was a correlation between the results of HRV (pNN50, SDNN, RMSSD, HF ms² and HF n.u.) and RSA. In addition, there was a correlation between the RSA and T4s. Finally, the T4s and RSA methods presented more accurate effect size and better accuracy (p <0.05), when compared to the HRV. CONCLUSION: HRV and RSA generated partially redundant results in healthy subjects and in patients with coronary artery disease, while the T4s generated results that were complementary to HRV and RSA in healthy subjects. In addition, RSA and T4s methods were more accurate when discriminating cardiac vagal modulation between healthy subjects and patients with coronary artery disease, when compared to HRV.

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