Romeu Sérgio Meneghelo

Evaluation of prescription of exercise, for rehabilitation of coronary artery disease patients by myocardial scintigraphy.

BACKGROUNDnIt is advisable that the intensity of the exercises for rehabilitation of patients with coronary artery disease does not cause myocardial ischemia.nnnOBJECTIVEnCompare the capacity of myocardial tomographic scintigraphy with the electrocardiogram capacity in ischemia detection during rehabilitation session.nnnMETHODSnTwenty six patients with coronary artery disease, undergoing the rehabilitation program and with previous scintigraphy, with transient hypo-uptake have been administered a new injection of MIBI-Tc-99m during a training session when they were also monitored with dynamic electrocardiography. The rest scintigraphies, after ergometric treadmill test and rehabilitation session, were assessed in a semi-quantitative way using scores from 0 to 4 to classify each one of the chosen segments (0 = normal; 1 = discrete hypo-uptake; 2 = moderate; 3 = intense; 4 = lack of uptake).nnnRESULTSnThe means of the total scores found were: at rest = 12.9; after treadmill test = 19.3; after rehabilitation session = 15.1. There were statistically significant differences among them. An individual assessment showed that in 14 cases (53.8 %) hypo-uptake to some degree was identified during rehabilitation and in 12 cases (46.6%) it was not. Monitoring with the Holter system didnt show in any of the cases a ST segment depression equal or greater than 1mm.nnnCONCLUSIONnThe exercises prescribed for patients with coronary artery disease, according to recommendations found in the literature, may trigger myocardial ischemia, assessed by scintigraphy during a rehabilitation session.

Distribuição dos escores de cálcio coronariano determinados pela tomografia ultra-rápida em 2.253 homens brancos assintomáticos

OBJETIVE: To describe the distribution of coronary artery calcium scores in a population of asymptomatic white Brazilian men undergoing assessment with ultrafast computed tomography. METHODS: The study assessed 2.253 men aged 22 to 88 years undergoing computed tomography in an ImatronR C150 device for detecting coronary calcium. Data were divided based on the patients age into 7 groups: 65 years. RESULTS: The mean and standard deviation of age were 50.0 ± 9.7 years. In 48.8% of the cases, the coronary artery calcium score was > zero, with a non-Gaussian distribution and a large variation for the same age group. A direct correlation between age and the coronary artery calcium score was observed (r=0.4, P<0.01). Except for the comparison of individuals in the age groups 60-64 years, below 55-60 years, and above 65 years, the older the age group, the greater the medians of the coronary artery calcium scores (P<0.0001). Coronary artery calcium scores were reported according to the 25th, 50th, 75th, and 90th percentiles for the age groups. CONCLUSION: This study, the first to report the distribution of the coronary artery calcium scores in a sample of white Brazilian men, may be useful for stratifying the risk of coronary events.

Incidência de distúrbios da condução atrioventricular e intraventricular após implante percutâneo da bioprótese valvar aórtica CoreValve

INTRODUCAO: O sistema de conducao localizado no septo interventricular encontra-se anatomicamente contiguo ao anel valvar aortico. Por isso, disturbios na conducao atrioventricular e intraventricular podem decorrer de inflamacao, edema e estresse mecânico causados pelas hastes metalicas da bioprotese CoreValve. O objetivo deste estudo foi avaliar a incidencia de disturbios da conducao atrioventricular e intraventricular apos implante percutâneo da CoreValve METODO: Entre janeiro de 2008 e abril de 2010, 23 pacientes portadores de estenose aortica foram submetidos a implante da CoreValve. A media de idade foi de 81 ± 8,3 anos, e 12 (52,1%) pacientes eram do sexo masculino RESULTADOS: Apos o implante valvar, constataram-se as seguintes alteracoes na conducao atrioventricular: 3 (13%) bloqueios atrioventriculares totais, 2 (8,7%) bloqueios atrioventriculares de 2o grau e 8 (34,8%) bloqueios atrioventriculares de 1o grau, sendo 4 (17,4%) novos e 4 preexistentes. Assim, disturbios de conducao mais avancados, como bloqueio atrioventricular de 2o grau e/ou bloqueio atrioventricular total ocorreram em 5 (21,7%) pacientes. Em relacao aos disturbios da conducao intraventricular pos-implante, foram detectados 14 (60,9%) bloqueios completos de ramo esquerdo, sendo 2 (8,7%) com bloqueio completo de ramo direito e bloqueio completo de ramo esquerdo alternante. Nesta serie, 7 (30,4%) pacientes foram submetidos a implante de marca-passo permanente, 6 (26,1%) deles por indicacao absoluta. Todos os pacientes que apresentavam bloqueio completo de ramo direito antes do procedimento necessitaram do marca-passo permanente CONCLUSAO: Disturbios da conducao atrioventricular e, principalmente, bloqueio de ramo esquerdo sao comuns apos implante percutâneo da bioprotese CoreValve. O implante de marcapasso permanente e necessario em aproximadamente um quarto dos casos. A presenca de bloqueio completo de ramo direito pre-implante valvar esta relacionada a maior risco de desenvolvimento de disturbios da conducao de grau avancado.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation

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.1-6 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.

Reduction in Post-Marathon Peak Oxygen Consumption: Sign of Cardiac Fatigue in Amateur Runners?

Background Prolonged aerobic exercise, such as running a marathon, produces supraphysiological stress that can affect the athletes homeostasis. Some degree of transient myocardial dysfunction (cardiac fatigue) can be observed for several days after the race. Objective To verify if there are changes in the cardiopulmonary capacity, and cardiac inotropy and lusitropy in amateur marathoners after running a marathon. Methods The sample comprised 6 male amateur runners. All of them underwent cardiopulmonary exercise testing (CPET) one week before the São Paulo Marathon, and 3 to 4 days after that race. They underwent echocardiography 24 hours prior to and immediately after the marathon. All subjects were instructed not to exercise, to maintain their regular diet, ingest the same usual amount of liquids, and rest at least 8 hours a day in the period preceding the CPET. Results The athletes completed the marathon in 221.5 (207; 250) minutes. In the post-marathon CPET, there was a significant reduction in peak oxygen consumption and peak oxygen pulse compared to the results obtained before the race (50.75 and 46.35 mL.kg-1 .min-1; 19.4 and 18.1 mL.btm, respectively). The echocardiography showed a significant reduction in the s wave (inotropic marker), but no significant change in the E/e ratio (lusitropic marker). Conclusions In amateur runners, the marathon seems to promote changes in the cardiopulmonary capacity identified within 4 days after the race, with a reduction in the cardiac contractility. Such changes suggest that some degree of cardiac fatigue can occur.

Avaliação não Invasiva de Pacientes Submetidos à Intervenção Percutânea no Infarto do Miocárdio Noninvasive Assessment of Patients Undergoing Percutaneous Intervention in Myocardial Infarction

BACKGROUNDnRestenosis after primary percutaneous coronary intervention (PPCI) remains an important clinical problem, even with stent implantation. The ability of noninvasive testing to diagnose restenosis has had only inconsistent demonstration.nnnOBJECTIVEnOur objective was to evaluate the ability of exercise treadmill testing (ETT) and myocardial perfusion imaging (MPI) to diagnose restenosis in patients treated by PPCI within 12 hours of ST-elevation myocardial infarction (STEMI).nnnMETHODSnFrom August 2003 to January 2006, 64 patients (mean age of 56.2±10.2 years, 53 males) were enrolled after PPCI. Only patients with left ventricular ejection fraction (LVEF) > 40%, as assessed by resting transthoracic echocardiography (TTE), were included. ETT with 12-lead ECG monitoring and right precordial leads, as also MPI were performed at 6 weeks, 6 months, and one year after intervention. Coronary angiography was performed at six months.nnnRESULTSnSingle-vessel disease was observed in 46.9% of the patients. The left anterior descending coronary artery was treated in 48.4% of the patients. Angiographic restenosis occurred in 28.8%. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of ETT in detecting restenosis were not significant. Right precordial leads did not add information. MPI sensitivity, specificity, PPV, NPV, and accuracy correlated with restenosis only in the 6-month follow-up, both when considering summed difference score >2 (p=0.006) and >4 (p=0.014).nnnCONCLUSIONnETT did not discriminate restenosis in this population. MPI performed at 6 months correlated with restenosis and proved useful during follow-up.

Cintilografia do miocárdio com tecnécio 99m-MIBI e administração de adenosina em portadores de doença arterial coronária: correlação dos resultados com a angiografia coronária e o ultra-som intracoronário

OBJECTIVEnTo correlate myocardial perfusion scintigraphy (MPS) with Tc-99m-MIBI and adenosine infusion using quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS).nnnMETHODSnSeventy patients with coronary artery disease (CAD) referred for myocardial perfusion scintigraphy (MPS) with MIBI and adenosine were studied. Clinical, electrocardiographic (ECG), and scintigraphic findings were correlated with variables of visual and quantitative angiographic analysis, as well as to those of IVUS.nnnRESULTSnThe mean age of patients was 60.6 years, and 39 were male. Coronary angiography showed percentage of diameter stenosis (% DS) of 49.94% in 105 arteries, 83 of which were re-evaluated by QCA (79%), mean of 44.20%, p<0.05. ST-segment depression during adenosine infusion was associated with higher degrees of % DS (55.0% vs. 47.8%), p<0.05). Scintigraphic ischemia was correlated with greater cross-sectional area of lumen obstruction by IVUS (% CSA). Clinical, ECG, and IVUS findings were considered together and expressed as global ischemic versus non-ischemic responses. Ischemia was associated with lower values of minimal lumen diameter (MLD) and minimal lumen area (MLA) determined by QCA and IVUS.nnnCONCLUSIONnTc-99m-MIBI and adenosine myocardial SPECT is correlated with % CSA on IVUS, perfusion images considered. Global results assessment showed association between lumen diameter and area at obstructed sites as determined by QCA and IVUS.

Time of exercise as indicator of quality control in ergometry services.

Background The search for quality requires assessment tools in the various subdivisions of a health complex. In diagnostic medicine, they are scarce and in ergometry suggestions of indicators were not found. Objective To establish indicator for quality control on ergometry based on III Guidelines of the Brazilian Cardiology Society About Ergometric Test; to verify the percentage of tests that have presented the indicator within the compliance in two services of the same institution before and after the publication of the document. Methods A critical analysis of the guidelines in the search for indicator that would present: accuracy, reliability, simplicity, validity, sensitivity and ability to quantitatively measure the variations in the behavior of quality criteria and that would be applicable to all tests. The indicator was applied in tests of 2010 and 2011 prior to the publication, and after it was adopted by two services of the same institution. Results The indicator that has met the criteria was the percentage of ergometric tests with exercise duration between 8 and 12 minutes. In the years 2010 and 2011, respectively, the percentage of ergometric tests within compliance were 85.5% and 86.1% (p = 0.068) at the General Hospital, and 81.5% and 85.7% (p <0.001) the Service of Periodic Health Assessment. Conclusion The exercise time between 8 and 12 minutes can be used as a quality criterion in ergometric and services where it was applied, at least 80% of the ergometric tests were compliant.

Mechanical Dyssynchrony is Similar in Different Patterns of Left Bundle-Branch Block

Background Left bundle-branch block (LBBB) and the presence of systolic dysfunction are the major indications for cardiac resynchronization therapy (CRT). Mechanical ventricular dyssynchrony on echocardiography can help identify patients responsive to CRT. Left bundle-branch block can have different morphologic patterns. Objective To compare the prevalence of mechanical dyssynchrony in different patterns of LBBB in patients with left systolic dysfunction. Methods This study assessed 48 patients with ejection fraction (EF) < 40% and LBBB consecutively referred for dyssynchrony analysis. Conventional echocardiography and mechanical dyssynchrony analysis were performed, interventricular and intraventricular, with ten known methods, using M mode, Doppler and tissue Doppler imaging, isolated or combined. The LBBB morphology was categorized according to left electrical axis deviation in the frontal plane and QRS duration > 150 ms. Results The patients mean age was 60 ± 11 years, 24 were males, and mean EF was 29% ± 7%. Thirty-two had QRS > 150 ms, and 22, an electrical axis between −30° and +90°. Interventricular dyssynchrony was identified in 73% of the patients, while intraventricular dyssynchrony, in 37%-98%. Patients with QRS > 150 ms had larger left atrium and ventricle, and lower EF (p < 0.05). Left electrical axis deviation associated with worse diastolic function and greater atrial diameter. Interventricular and intraventricular mechanical dyssynchrony (ten methods) was similar in the different LBBB patterns (p = ns). Conclusion In the two different electrocardiographic patterns of LBBB analyzed, no difference regarding the presence of mechanical dyssynchrony was observed.