Frederico José Neves Mancuso

Focused Cardiac Ultrasound Using a Pocket-Size Device in the Emergency Room

Background Cardiovascular urgencies are frequent reasons for seeking medical care. Prompt and accurate medical diagnosis is critical to reduce the morbidity and mortality of these conditions. Objective To evaluate the use of a pocket-size echocardiography in addition to clinical history and physical exam in a tertiary medical emergency care. Methods One hundred adult patients without known cardiac or lung diseases who sought emergency care with cardiac complaints were included. Patients with ischemic changes in the electrocardiography or fever were excluded. A focused echocardiography with GE Vscan equipment was performed after the initial evaluation in the emergency room. Cardiac chambers dimensions, left and right ventricular systolic function, intracardiac flows with color, pericardium, and aorta were evaluated. Results The mean age was 61 ± 17 years old. The patient complaint was chest pain in 51 patients, dyspnea in 32 patients, arrhythmia to evaluate the left ventricular function in ten patients, hypotension/dizziness in five patients and edema in one patient. In 28 patients, the focused echocardiography allowed to confirm the initial diagnosis: 19 patients with heart failure, five with acute coronary syndrome, two with pulmonary embolism and two patients with cardiac tamponade. In 17 patients, the echocardiography changed the diagnosis: ten with suspicious of heart failure, two with pulmonary embolism suspicious, two with hypotension without cause, one suspicious of acute coronary syndrome, one of cardiac tamponade and one of aortic dissection. Conclusion The focused echocardiography with pocket-size equipment in the emergency care may allow a prompt diagnosis and, consequently, an earlier initiation of the therapy.

Exercise Ventilation in COPD: Influence of Systolic Heart Failure

ABSTRACT Systolic heart failure is a common and disabling co-morbidity of chronic obstructive pulmonary disease (COPD) which may increase exercise ventilation due to heightened neural drive and/or impaired pulmonary gas exchange efficiency. The influence of heart failure on exercise ventilation, however, remains poorly characterized in COPD. In a prospective study, 98 patients with moderate to very severe COPD [41 with coexisting heart failure; ‘overlap’ (left ventricular ejection fraction < 50%)] underwent an incremental cardiopulmonary exercise test (CPET). Compared to COPD, overlap had lower peak exercise capacity despite higher FEV1. Overlap showed lower operating lung volumes, greater ventilatory inefficiency and larger decrements in end-tidal CO2 (PETCO2) (P < 0.05). These results were consistent with those found in FEV1-matched patients. Larger areas under receiver operating characteristic curves to discriminate overlap from COPD were found for ventilation (E)-CO2 output CO2) intercept, E-CO2 slope, peak E/CO2 ratio and peak PETCO2. Multiple logistic regression analysis revealed that CO2 intercept ≤ 3.5 L/minute [odds ratios (95% CI) = 7.69 (2.61–22.65), P < 0.001] plus E-CO2 slope ≥ 34 [2.18 (0.73–6.50), P = 0.14] or peak E/CO2 ratio ≥ 37 [5.35 (1.96–14.59), P = 0.001] plus peak PETCO2 ≤ 31 mmHg [5.73 (1.42–23.15), P = 0.01] were indicative of overlapping. Heart failure increases the ventilatory response to metabolic demand in COPD. Variables reflecting excessive ventilation might prove useful to assist clinical interpretation of CPET responses in COPD patients presenting heart failure as co-morbidity.

Heart Failure Impairs Muscle Blood Flow and Endurance Exercise Tolerance in COPD

Abstract Heart failure, a prevalent and disabling co-morbidity of COPD, may impair cardiac output and muscle blood flow thereby contributing to exercise intolerance. To investigate the role of impaired central and peripheral hemodynamics in limiting exercise tolerance in COPD-heart failure overlap, cycle ergometer exercise tests at 20% and 80% peak work rate were performed by overlap (FEV1 = 56.9 ± 15.9% predicted, ejection fraction = 32.5 ± 6.9%; N = 16), FEV1-matched COPD (N = 16), ejection fraction-matched heart failure patients (N = 15) and controls (N = 12). Differences (Δ) in cardiac output (impedance cardiography) and vastus lateralis blood flow (indocyanine green) and deoxygenation (near-infrared spectroscopy) between work rates were expressed relative to concurrent changes in muscle metabolic demands (ΔO2 uptake). Overlap patients had approximately 30% lower endurance exercise tolerance than COPD and heart failure (p < 0.05). ΔBlood flow was closely proportional to Δcardiac output in all groups (r = 0.89–0.98; p < 0.01). Overlap showed the largest impairments in Δcardiac output/ΔO2 uptake and Δblood flow/ΔO2 uptake (p < 0.05). Systemic arterial oxygenation, however, was preserved in overlap compared to COPD. Blunted limb perfusion was related to greater muscle deoxygenation and lactate concentration in overlap (r = 0.78 and r = 0.73, respectively; p < 0.05). ΔBlood flow/ΔO2 uptake was related to time to exercise intolerance only in overlap and heart failure (p < 0.01). In conclusion, COPD and heart failure add to decrease exercising cardiac output and skeletal muscle perfusion to a greater extent than that expected by heart failure alone. Treatment strategies that increase muscle O2 delivery and/or decrease O2 demand may be particularly helpful to improve exercise tolerance in COPD patients presenting heart failure as co-morbidity.

Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device

Training requirements for general cardiologists without echocardiographic expertise to perform focused cardiac ultrasound (FCU) with portable devices have not yet been defined. The objective of this study was to evaluate a training program to instruct cardiology residents to perform FCU with a hand‐carried device (HCD) in different clinical settings.

Excess Ventilation in Chronic Obstructive Pulmonary Disease–Heart Failure Overlap. Implications for Dyspnea and Exercise Intolerance

Rationale: An increased ventilatory response to exertional metabolic demand (high &OV0312;e/&OV0312;co2 relationship) is a common finding in patients with coexistent chronic obstructive pulmonary disease and heart failure. Objectives: We aimed to determine the mechanisms underlying high &OV0312;e/&OV0312;co2 and its impact on operating lung volumes, dyspnea, and exercise tolerance in these patients. Methods: Twenty‐two ex‐smokers with combined chronic obstructive pulmonary disease and heart failure with reduced left ventricular ejection fraction undertook, after careful treatment optimization, a progressive cycle exercise test with capillary (c) blood gas collection. Measurements and Main Results: Regardless of the chosen metric (increased &OV0312;e‐&OV0312;co2 slope, &OV0312;e/&OV0312;co2 nadir, or end‐exercise &OV0312;e/&OV0312;co2), ventilatory inefficiency was closely related to PcCO2 (r values from −0.80 to −0.84; P < 0.001) but not dead space/tidal volume ratio. Ten patients consistently maintained exercise PcCO2 less than or equal to 35 mm Hg (hypocapnia). These patients had particularly poor ventilatory efficiency compared with patients without hypocapnia (P < 0.05). Despite the lack of between‐group differences in spirometry, lung volumes, and left ventricular ejection fraction, patients with hypocapnia had lower resting PaCO2 and lung diffusing capacity (P < 0.01). Excessive ventilatory response in this group was associated with higher exertional PcO2. The group with hypocapnia, however, had worse mechanical inspiratory constraints and higher dyspnea scores for a given work rate leading to poorer exercise tolerance compared with their counterparts (P < 0.05). Conclusions: Heightened neural drive promoting a ventilatory response beyond that required to overcome an increased “wasted” ventilation led to hypocapnia and poor exercise ventilatory efficiency in chronic obstructive pulmonary disease‐heart failure overlap. Excessive ventilation led to better arterial oxygenation but at the expense of earlier critical mechanical constraints and intolerable dyspnea.

Simplified Single Plane Echocardiography Is Comparable to Conventional Biplane Two‐Dimensional Echocardiography in the Evaluation of Left Atrial Volume: A Study Validated by Three‐Dimensional Echocardiography in 143 Individuals

The left atrial volume index (LAVI) is a biomarker of diastolic dysfunction and a predictor of cardiovascular events. Three‐dimensional echocardiography (3DE) is highly accurate for LAVI measurements but is not widely available. Furthermore, biplane two‐dimensional echocardiography (B2DE) may occasionally not be feasible due to a suboptimal two‐chamber apical view. Simplified single plane two‐dimensional echocardiography (S2DE) could overcome these limitations. We aimed to compare the reliability of S2DE with other validated echocardiographic methods in the measurement of the LAVI. We examined 143 individuals (54 ± 13 years old; 112 with heart disease and 31 healthy volunteers; all with sinus rhythm, with a wide range of LAVI). The results for all the individuals were compared with B2DE‐derived LAVIs and validated using 3DE. The LAVIs, as determined using S2DE (32.7 ± 13.1 mL/m2), B2DE (31.9 ± 12.7 mL/m2), and 3DE (33.1 ± 13.4 mL/m2), were not significantly different from each other (P = 0.85). The S2DE‐derived LAVIs correlated significantly with those obtained using both B2DE (r = 0.98; P < 0.001) and 3DE (r = 0.93; P < 0.001). The mean difference between the S2DE and B2DE measurements was <1.0 mL/m2. Using the American Society of Echocardiography criteria for grading LAVI enlargement (normal, mild, moderate, severe), we observed an excellent agreement between the S2DE‐ and B2DE‐derived classifications (κ = 0.89; P < 0.001). S2DE is a simple, rapid, and reliable method for LAVI measurement that may expand the use of this important biomarker in routine echocardiographic practice.

Does Exercise Ventilatory Inefficiency Predict Poor Outcome in Heart Failure Patients With COPD

PURPOSE: To investigate whether the opposite effects of heart failure (HF) and chronic obstructive pulmonary disease (COPD) on exercise ventilatory inefficiency (minute ventilation [ E]-carbon dioxide output [ CO2] relationship) would negatively impact its prognostic relevance. METHODS: After treatment optimization and an incremental cardiopulmonary exercise test, 30 male patients with HF-COPD (forced expiratory volume in 1 second [FEV1] = 57% ± 17% predicted, ejection fraction = 35% ± 6%) were prospectively followed up during 412 ± 261 days for major cardiac events. RESULTS: Fourteen patients (46%) had a negative outcome. Patients who had an event had lower echocardiographically determined right ventricular fractional area change (RVFAC), greater ventilatory inefficiency (higher E/ CO2 nadir), and lower end-tidal CO2 (PETCO2) (all P < .05). Multivariate Cox models revealed that E/ CO2 nadir >36, &Dgr;PETCO2(PEAK-REST)≥2 mm Hg, and PETCO2PEAK⩽33 mm Hg added prognostic value to RVFAC⩽45%. Kaplan-Meyer analyses showed that although 18% of patients with RVFAC>45% had a major cardiac event after 1 year, no patient with RVFAC>45% and E/ CO2 nadir ⩽36 (or PETCO2PEAK>33 mm Hg) had a negative event. Conversely, although 69% of patients with RVFAC⩽45% had a major cardiac event after 1 year, all patients with RVFAC⩽45% and &Dgr;PETCO2(PEAK-REST)≥2 mm Hg had a negative event. CONCLUSION: Ventilatory inefficiency remains a powerful prognostic marker in HF despite the presence of mechanical ventilatory constraints induced by COPD. If these preliminary findings are confirmed in larger studies, optimal thresholds for outcome prediction are likely greater than those traditionally recommended for HF patients without COPD.

Left Atrial Volume Determinants in Patients with Non-Ischemic Dilated Cardiomyopathy

Background Left atrial volume (LAV) is a predictor of prognosis in patients with heart failure. Objective We aimed to evaluate the determinants of LAV in patients with dilated cardiomyopathy (DCM). Methods Ninety patients with DCM and left ventricular (LV) ejection fraction ≤ 0.50 were included. LAV was measured with real-time three-dimensional echocardiography (eco3D). The variables evaluated were heart rate, systolic blood pressure, LV end-diastolic volume and end-systolic volume and ejection fraction (eco3D), mitral inflow E wave, tissue Doppler e´ wave, E/e´ ratio, intraventricular dyssynchrony, 3D dyssynchrony index and mitral regurgitation vena contracta. Pearson´s coefficient was used to identify the correlation of the LAV with the assessed variables. A multiple linear regression model was developed that included LAV as the dependent variable and the variables correlated with it as the predictive variables. Results Mean age was 52 ± 11 years-old, LV ejection fraction: 31.5 ± 8.0% (16-50%) and LAV: 39.2±15.7 ml/m2. The variables that correlated with the LAV were LV end-diastolic volume (r = 0.38; p < 0.01), LV end-systolic volume (r = 0.43; p < 0.001), LV ejection fraction (r = -0.36; p < 0.01), E wave (r = 0.50; p < 0.01), E/e´ ratio (r = 0.51; p < 0.01) and mitral regurgitation (r = 0.53; p < 0.01). A multivariate analysis identified the E/e´ ratio (p = 0.02) and mitral regurgitation (p = 0.02) as the only independent variables associated with LAV increase. Conclusion The LAV is independently determined by LV filling pressures (E/e´ ratio) and mitral regurgitation in DCM.

Validation of a novel sleep-quality questionnaire to assess sleep in the coronary care unit: a polysomnography study

INTRODUCTION The sleep of patients admitted to coronary care unit (CCU) may be compromised. A feasible and cost-effective tool to evaluate sleep in this scenario could provide important data. The aim of this study was to evaluate sleep with a questionnaire developed specifically for the CCU and to validate it with polysomnography (PSG). METHODS Ninety-nine patients (68% male; 56 ± 10 years old) with acute coronary syndrome were included. PSG was performed within 36 h of admission. A specific 18-question questionnaire (CCU questionnaire) was developed and applied after the PSG. Cronbachs alpha test was used to validate the questionnaire. The Spearman test was used to analyze the correlation between the PSG variables and the questionnaire, and the Kruskal-Wallis test was used to compare the PSG variables among patients with good, regular, or poor sleep. RESULTS The total sleep time was 265 ± 81 min, sleep efficiency 62 ± 18%, REM sleep 10 ± 7%, apnea/hypopnea index 15 ± 23, and the arousal index 24 ± 15. Cronbachs alpha test was 0.69. The CCU questionnaire showed correlation with the sleep efficiency evaluated by PSG (r: 0.52; p < 0.001). Sleep quality was divided into three categories according to the CCU questionnaire: patients with good sleep had a sleep efficiency of 72 ± 9%, better than those with a regular or poor sleep (60 ± 16% and 53 ± 20%, respectively; p < 0.01). CONCLUSION The CCU questionnaire is a feasible and reliable tool to evaluate sleep in the CCU, showing correlation with the PSG sleep efficiency.

Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy

Background Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. Objective We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. Methods Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. Results MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa = 0.11; p < 0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p < 0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) Conclusion The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients.