José Rodrigues Parga Filho

Evaluation of subclinical atherosclerosis by computed tomography coronary angiography and its association with risk factors in familial hypercholesterolemia

BACKGROUND Increasing age and cholesterol levels, male gender, and family history of early coronary heart disease (CHD) are associated with early onset of CHD in familial hypercholesterolemia (FH). OBJECTIVE Assess subclinical atherosclerosis by computed tomography coronary angiography (CTCA) and its association with clinical and laboratorial parameters in asymptomatic FH subjects. METHODS 102 FH subjects (36% male, 45 ± 13 years, LDL-c 280 ± 54 mg/dL) and 35 controls (40% male, 46 ± 12 years, LDL-c 103 ± 18 mg/dL) were submitted to CTCA. Plaques were divided into calcified, mixed and non-calcified; luminal stenosis was characterized as >50% obstruction. RESULTS FH had a greater atherosclerotic burden represented by higher number of patients with: plaques (48% vs. 14%, p=0.0005), stenosis (19% vs. 3%, p=0.015), segments with plaques (2.05 ± 2.85 vs.0.43 ± 1.33, p=0.0016) and calcium scores (55 ± 129 vs. 38 ± 140, p=0.0028). After multivariate analysis, determinants of plaque presence were increasing age (OR=2.06, for age change of 10 years, CI95%: 1.38-3.07, p<0.001) and total cholesterol (OR=1.86, for cholesterol change by 1 standard deviation, CI95%: 1.09-3.15, p=0.027). Coronary calcium score was associated with the presence of stenosis (OR=1.54; CI95%: 1.27-1.86, p<0.001, for doubling the calcium score). Male gender was directly associated with the presence of non-calcified plaques (OR: 15.45, CI95% 1.72-138.23, p=0.014) and inversely with calcified plaques (OR=0.21, CI95%: 0.05-0.84, p=0.027). Family history of early CHD was associated with the presence of mixed plaques (OR=4.90, CI95%: 1.32-18.21, p=0.018). CONCLUSIONS Patients with FH had an increased burden of coronary atherosclerosis by CTCA. The burden of atherosclerosis and individual plaque subtypes differed with the presence of other associated risk factors, with age and cholesterol being most important. A coronary calcium score of zero ruled out obstructive disease in this higher risk population.

Symptoms, left ventricular function, and timing of valve replacement surgery in patients with aortic regurgitation

BACKGROUND Because cardiac decompensation is subtle, the best time to perform aortic valve replacement surgery may be difficult to determine. We investigated the relation of symptoms to left ventricular (LV) function and the timing of valve replacement in patients with aortic regurgitation (AR) of largely rheumatic origin. METHODS Sixty-eight initially asymptomatic patients (mean age 29 years) with severe chronic AR were monitored for 36 months. Assessments included baseline and yearly echocardiograms and radioisotope ventriculography (resting and exercise) and clinical examinations every 6 months. RESULTS Forty-seven patients (69%) remained asymptomatic and 21 (31%) had symptoms develop after 24 to 36 months. Compared with symptomatic patients, asymptomatic patients had significantly (P <.05) lower baseline LV end-diastolic diameter, end-systolic diameter, end-systolic stress, and volume/mass ratio but greater shortening fraction and ejection fraction (EF) at rest. These variables remained stable without statistically significant change until surgical correction in symptomatic patients. Percent variation of EF from rest to exercise increased in patients who remained asymptomatic (EF 2.8% +/- 10.6%) but decreased in those who became symptomatic (EF -4.2% +/- 13%; P <.05). Twenty symptomatic patients (New York Heart Association class III/IV, angina and/or syncope) had valve replacement surgery, after which all were in New York Heart Association class I/II and had significant decreases of LV end-diastolic and end-systolic diameters and an increase on percent variation of EF from rest to exercise (P <.0001). CONCLUSIONS Development of symptoms did not correlate with change in any ventricular function indexes. Surgery on appearance of symptoms restored LV function to near normal.

Myocardial fibrosis in patients with hypertrophic cardiomyopathy and high risk for sudden death

FUNDAMENTO: A estratificacao de risco para morte subita na cardiomiopatia hipertrofica (CMH), continua a ser um verdadeiro desafio devido a grande heterogeneidade da sua apresentacao, em que a maioria dos individuos permanecem assintomaticos por toda sua vida e outros apresentam a morte subita como primeiro sintoma. Recentes trabalhos vem sugerindo que a fibrose miocardica pode constituir-se em um importante substrato para as arritmias ventriculares malignas, responsaveis pela morte subita nesta doenca. OBJETIVO: Avaliacao da prevalencia e quantificacao da fibrose miocardica (FM), em pacientes com CMH com alto risco ou recuperados de morte subita, portadores de cardiodesfibrilador implantavel (CDI). METODOS: Vinte e oito pacientes com CMH portadores de CDI foram submetidos a tomografia computadorizada com multiplos detectores, para realizacao da tecnica de realce tardio, e avaliacao da fibrose miocardica. RESULTADOS: 96% dos pacientes apresentavam fibrose miocardica (20,38 ± 15,55 gramas) correspondendo a 15,96 ± 10,20% da massa miocardica total. A FM foi significativamente mais prevalente que os demais fatores de risco classicos para morte subita. CONCLUSAO: Concluimos que existe uma alta prevalencia de fibrose miocardica em pacientes com cardiomiopatia hipertrofica de alto risco ou recuperados de morte subita, como neste grupo - portadores de cardiodesfibrilador implantavel. A maior prevalencia da fibrose miocardica comparada aos fatores de risco de pior prognostico levantam a hipotese de que a fibrose miocardica possa ser um importante substrato potencialmente necessario na genese das arritmias desencadeadoras da morte subita.BACKGROUND The stratification of risk for sudden death in hypertrophic cardiomyopathy (HCM) continues to be a true challenge due to the great heterogeneity of this diseases presentation, as most individuals remain asymptomatic during their entire lives and others present sudden death as first symptom. Recent studies have suggested that myocardial fibrosis may represent an important substrate for the malignant ventricular arrhythmias, that are responsible for the cases of sudden death related to this disease. OBJECTIVE To assess the prevalence and quantification of myocardial fibrosis (MF) in hypertrophic cardiomyopathy (HCM) patients with implantablecardioverter - defibrillator (ICD) indicated due to their high risk or recovered from cardiac sudden death. METHODS Twenty-eight HCM patients with ICD were submitted to multidetector computed tomography to assess myocardial fibrosis by delayed enhancement technique. RESULTS Myocardial fibrosis was present in 96% of these HCM patients with (20.38 +/- 15.55 g) comprising 15.96 +/- 10.20% of the total myocardial mass. MF was observed in a significantly higher prevalence as compared to other classical risk factors for sudden death. CONCLUSION It is possible to conclude that there is a high prevalence of myocardial fibrosis in hypertrophic cardiomyopathy patients with high-risk or recovered from cardiac sudden death, like those with clinical indication to implantable cardioverter -defibrillator. The higher prevalence of myocardial fibrosis in comparison to classical risk factors of worse prognosis raise the hypothesis that the myocardial fibrosis may be an important substrate in the genesis of lifethreatening arrhythmias in these high risk HCM population.

Epipericardial fat necrosis: an underdiagnosed condition

OBJECTIVE Epipericardial fat necrosis (EFN) is an uncommon benign and self-limited condition that leads patients to the emergency department (ED) owing to the onset of acute pleuritic chest pain. The aim of this study was to describe the cases of this disease in our institution and to illustrate the associated clinical and radiological findings. METHODS We reviewed 3604 chest scans referred by the ED from November 2011 to July 2013. Patients diagnosed with epipericardial necrosis had their medical records and original tomography reports analysed. RESULTS Chest pain was the primary complaint in 426 patients; 11 of them had definitive EFN findings characterized by a round soft-tissue attenuation lesion with a varying degree of strands. All patients presented with pleuritic chest pain on the same side as the lesion. Pericardial thickening, pleural effusion and mild atelectasis were the associated tomography findings. Cardiac enzyme and D-dimer tests performed during the episode were normal in all cases. 27% of the cases only were correctly diagnosed with EFN at the time of presentation. CONCLUSION EFN is a benign inflammatory condition frequently overlooked in the ED by physicians and radiologists but is an important factor in the differential diagnosis of patients with acute chest pain. ADVANCES IN KNOWLEDGE The article adds clinically and radiologically useful information about the condition and displays the importance of making the correct diagnosis to avoid unnecessary examinations.

Fibrose miocárdica em pacientes com cardiomiopatia hipertrófica com alto risco para morte súbita cardíaca

FUNDAMENTO: A estratificacao de risco para morte subita na cardiomiopatia hipertrofica (CMH), continua a ser um verdadeiro desafio devido a grande heterogeneidade da sua apresentacao, em que a maioria dos individuos permanecem assintomaticos por toda sua vida e outros apresentam a morte subita como primeiro sintoma. Recentes trabalhos vem sugerindo que a fibrose miocardica pode constituir-se em um importante substrato para as arritmias ventriculares malignas, responsaveis pela morte subita nesta doenca. OBJETIVO: Avaliacao da prevalencia e quantificacao da fibrose miocardica (FM), em pacientes com CMH com alto risco ou recuperados de morte subita, portadores de cardiodesfibrilador implantavel (CDI). METODOS: Vinte e oito pacientes com CMH portadores de CDI foram submetidos a tomografia computadorizada com multiplos detectores, para realizacao da tecnica de realce tardio, e avaliacao da fibrose miocardica. RESULTADOS: 96% dos pacientes apresentavam fibrose miocardica (20,38 ± 15,55 gramas) correspondendo a 15,96 ± 10,20% da massa miocardica total. A FM foi significativamente mais prevalente que os demais fatores de risco classicos para morte subita. CONCLUSAO: Concluimos que existe uma alta prevalencia de fibrose miocardica em pacientes com cardiomiopatia hipertrofica de alto risco ou recuperados de morte subita, como neste grupo - portadores de cardiodesfibrilador implantavel. A maior prevalencia da fibrose miocardica comparada aos fatores de risco de pior prognostico levantam a hipotese de que a fibrose miocardica possa ser um importante substrato potencialmente necessario na genese das arritmias desencadeadoras da morte subita.BACKGROUND The stratification of risk for sudden death in hypertrophic cardiomyopathy (HCM) continues to be a true challenge due to the great heterogeneity of this diseases presentation, as most individuals remain asymptomatic during their entire lives and others present sudden death as first symptom. Recent studies have suggested that myocardial fibrosis may represent an important substrate for the malignant ventricular arrhythmias, that are responsible for the cases of sudden death related to this disease. OBJECTIVE To assess the prevalence and quantification of myocardial fibrosis (MF) in hypertrophic cardiomyopathy (HCM) patients with implantablecardioverter - defibrillator (ICD) indicated due to their high risk or recovered from cardiac sudden death. METHODS Twenty-eight HCM patients with ICD were submitted to multidetector computed tomography to assess myocardial fibrosis by delayed enhancement technique. RESULTS Myocardial fibrosis was present in 96% of these HCM patients with (20.38 +/- 15.55 g) comprising 15.96 +/- 10.20% of the total myocardial mass. MF was observed in a significantly higher prevalence as compared to other classical risk factors for sudden death. CONCLUSION It is possible to conclude that there is a high prevalence of myocardial fibrosis in hypertrophic cardiomyopathy patients with high-risk or recovered from cardiac sudden death, like those with clinical indication to implantable cardioverter -defibrillator. The higher prevalence of myocardial fibrosis in comparison to classical risk factors of worse prognosis raise the hypothesis that the myocardial fibrosis may be an important substrate in the genesis of lifethreatening arrhythmias in these high risk HCM population.

I Diretriz de Ressonância e Tomografia Cardiovascular da Sociedade Brasileira de Cardiologia Sumário Executivo

Cesar Augusto Mastrofrancisco Cattani, Dany Jasinowodolinsk, Fabiano Lucchesi, Fabio Berezowsky Rocha, Fatima Cristina Pedroti, Gilberto Szarf, Guilherme Urpia Monte, Iugiro Roberto Kuroki , Joalbo Andrade, Jose Rodrigues Parga Filho, Luis Claudio Correia, Luiz Francisco Avila, Marcelo Hadlich, Marcelo Zapparoli, Marcia Barbosa, Marcia Lima Mugnaini, Maria Helena Albernaz Siqueira, Marly Maria Uellendhal, Miguel Abraao Rosario Neto, Paulo R. Schwarzman, Raul Dias dos Santos Filho, Ricardo Loureiro, Roberto Kalil Filho, Robson de Macedo Vieira

Ressonância magnética vs cintilografia com pirofosfato marcado com tecnécio-99m para a detecção de necrose miocárdica perioperatória

BACKGROUND: Perioperative myocardial infarction (POMI) is a complication of coronary artery bypass grafting (CABG) with a potential prognostic impact. Technetium-99m pyrophosphate myocardial scintigraphy (MS) is used in the diagnosis of POMI; however it shows a limited sensitivity for subendocardial lesions. Cardiovascular magnetic resonance imaging (CMRI), in turn, has a high accuracy in the detection of myocardial necrosis. OBJECTIVE: To compare CMRI and MS for the detection of POMI after CABG. METHODS: A total of 24 patients with chronic coronary artery disease were studied using the delayed contrast enhanced CMRI and MS before and after CABG by analyzing the development of areas of perioperative myocardial necrosis (POMI). Biochemical markers of myocardial injury (CKMB and troponin I) were also determined before and after surgery. RESULTS: Nineteen patients completed the study. Of these, 6 (32%) presented POMI on CMRI and 4 (21%) on MS (p = NS). Of the 323 left ventricular segments assessed, 17 (5.3%) showed perioperative necrosis on CMRI and 7 (2.2%) on MS (p = 0.013). Moderate agreement was observed between the methods (kappa = 0.46). There was disagreement regarding the diagnosis of POMI in 4 (21%) cases, most of them with small areas of perioperative necrosis on CMRI which were not visualized on MS. In all cases with POMI on CMRI, significant CKMB and troponin I elevations were observed. CONCLUSION: Moderate diagnostic agreement was observed between the methods for the detection of POMI, but CMRI enabled visualization of small areas of perioperative myocardial necrosis which were not identified on MS and were associated with elevation of biochemical markers of myocardial injury.

Late enhancement and myocardial perfusion in hypertrophic cardiomyopathy (comparison betw een groups)

BACKGROUND The magnetic resonance imaging (MRI) is an effective method to study hypertrophic cardiomyopathy (HCM). OBJECTIVE To evaluate, using MRI, the parameters of systolic function, perfusion and myocardial viability in patients with HCM, comparing the groups with and without obstruction of the left ventricular outflow tract. METHODS Twenty-one patients with a diagnosis of HCM underwent the assessment of myocardial function, viability and perfusion under stress and at rest through MRI. RESULTS The ventricular segments most severely impaired by hypertrophy were those of the septal region. The obstructive group presented segmental myocardial thickening distribution similar to the non-obstructive group, but with higher means than the first group. The mean ejection fraction of the patients in the obstructive group was higher than in the non-obstructive group, whereas the means of the end systolic and diastolic volumes were lower in the obstructive group. There was a positive correlation between the ventricular segmental thickening and the late enhancement segmental mass. The stress induction resulted in an increase in the number of segments with perfusion alterations and this alteration was more evident in the obstructive group. CONCLUSION The thickest ventricular segments are the septal ones. The hypertrophic regions are associated to a greater extension of late enhancement. There was a positive correlation between the areas of ventricular hypertrophy and altered myocardial perfusion and these findings were more evident in the obstructive group.FUNDAMENTO: La resonancia magnetica es un metodo eficaz para estudio de la cardiomiopatia hipertrofica. OBJETIVO: Evaluar, por la resonancia magnetica, los parametros de funcion sistolica, perfusion y viabilidad miocardica en pacientes portadores de cardiomiopatia hipertrofica, comparando los grupos con y sin obstruccion en la via de salida del ventriculo izquierdo. METODO: Veinte y un pacientes con diagnostico de cardiomiopatia hipertrofica realizaron estudios de funcion, viabilidad y perfusion miocardica en las fases de estres y de reposo por la resonancia magnetica. RESULTADOS: Los segmentos ventriculares mas comprometidos por la hipertrofia fueron los de la region septal. El grupo obstructivo presento distribucion segmental de espesor miocardico semejante al no obstructivo, pero con mayores promedios que el primer grupo. El promedio de la fraccion de eyeccion de los pacientes del grupo obstructivo fue mayor que el grupo no obstructivo, mientras que los promedios de los volumenes sistolico y diastolico finales se hallaron menores en el grupo obstructivo. Hubo correlacion positiva entre el espesor de los segmentos del ventriculo y la masa segmental del realce tardio. La induccion de estres determino aumento del numero de segmentos con alteracion de perfusion, y esa alteracion fue mas evidente en el grupo obstructivo. CONCLUSION: Los segmentos ventriculares con mayor espesor son los septales. Las regiones hipertroficas estan asociadas a la mayor extension de realce tardio. Hubo correlacion positiva entre las areas de hipertrofia ventricular y perfusion miocardica alterada, y estos hallazgos fueron mas evidentes en el grupo obstructivo.

Realce tardio e perfusão miocárdica em cardiomiopatia hipertrófica (comparação entre grupos)

BACKGROUND The magnetic resonance imaging (MRI) is an effective method to study hypertrophic cardiomyopathy (HCM). OBJECTIVE To evaluate, using MRI, the parameters of systolic function, perfusion and myocardial viability in patients with HCM, comparing the groups with and without obstruction of the left ventricular outflow tract. METHODS Twenty-one patients with a diagnosis of HCM underwent the assessment of myocardial function, viability and perfusion under stress and at rest through MRI. RESULTS The ventricular segments most severely impaired by hypertrophy were those of the septal region. The obstructive group presented segmental myocardial thickening distribution similar to the non-obstructive group, but with higher means than the first group. The mean ejection fraction of the patients in the obstructive group was higher than in the non-obstructive group, whereas the means of the end systolic and diastolic volumes were lower in the obstructive group. There was a positive correlation between the ventricular segmental thickening and the late enhancement segmental mass. The stress induction resulted in an increase in the number of segments with perfusion alterations and this alteration was more evident in the obstructive group. CONCLUSION The thickest ventricular segments are the septal ones. The hypertrophic regions are associated to a greater extension of late enhancement. There was a positive correlation between the areas of ventricular hypertrophy and altered myocardial perfusion and these findings were more evident in the obstructive group.FUNDAMENTO: La resonancia magnetica es un metodo eficaz para estudio de la cardiomiopatia hipertrofica. OBJETIVO: Evaluar, por la resonancia magnetica, los parametros de funcion sistolica, perfusion y viabilidad miocardica en pacientes portadores de cardiomiopatia hipertrofica, comparando los grupos con y sin obstruccion en la via de salida del ventriculo izquierdo. METODO: Veinte y un pacientes con diagnostico de cardiomiopatia hipertrofica realizaron estudios de funcion, viabilidad y perfusion miocardica en las fases de estres y de reposo por la resonancia magnetica. RESULTADOS: Los segmentos ventriculares mas comprometidos por la hipertrofia fueron los de la region septal. El grupo obstructivo presento distribucion segmental de espesor miocardico semejante al no obstructivo, pero con mayores promedios que el primer grupo. El promedio de la fraccion de eyeccion de los pacientes del grupo obstructivo fue mayor que el grupo no obstructivo, mientras que los promedios de los volumenes sistolico y diastolico finales se hallaron menores en el grupo obstructivo. Hubo correlacion positiva entre el espesor de los segmentos del ventriculo y la masa segmental del realce tardio. La induccion de estres determino aumento del numero de segmentos con alteracion de perfusion, y esa alteracion fue mas evidente en el grupo obstructivo. CONCLUSION: Los segmentos ventriculares con mayor espesor son los septales. Las regiones hipertroficas estan asociadas a la mayor extension de realce tardio. Hubo correlacion positiva entre las areas de hipertrofia ventricular y perfusion miocardica alterada, y estos hallazgos fueron mas evidentes en el grupo obstructivo.

Epipericardial Fat Necrosis: Who Should Be a Candidate?

OBJECTIVE The objectives of the present study were to estimate the frequency of epipericardial fat necrosis among patients undergoing chest CT for chest pain and to compare the clinical and laboratory data between patients with epipericardial fat necrosis and control subjects. MATERIALS AND METHODS A retrospective review of 7463 chest CT studies performed in the emergency department from July 2011 to December 2014 was conducted to collect data regarding patient demographic characteristics and CT findings. Twenty patients who had epipericardial fat necrosis diagnosed were defined as the main patient group. An age- and sex-matched control group was selected from patients with chest pain who underwent chest CT during the same period. Linear regression models were used to assess data, and statistical significance was expressed as p values and 95% CIs. RESULTS We found that the frequency of epipericardial fat necrosis was 2.15% among patients who underwent chest CT for chest pain. Epipericardial fat necrosis was statistically significantly associated with a lack of medication use (p = 0.01; 95% CI, -3.33 to -0.40) and the absence of other symptoms (p = 0.005; 95% CI, -5.83 to -1.27). Epipericardial fat necrosis was most often observed as an ovoid lesion with mixed fat attenuation with little stranding in the left paracardiac region accompanied by pleural effusion. CONCLUSION Epipericardial fat necrosis is a significant clinical condition. For patients seen in the emergency department with isolated acute chest pain but no additional clinical history, no medication history, and normal laboratory results, chest CT is recommended to support a diagnosis of epipericardial fat necrosis.