Role of echocardiography in diagnosis and risk stratification in heart failure with left ventricular systolic dysfunction

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Echocardiography represents the "gold standard" in the assessment of LV systolic dysfunction and in the recognition of systolic heart failure, since dilatation of the LV results in alteration of intracardiac geometry and hemodynamics leading to increased morbidity and mortality

Identification of responders to cardiac resynchronization therapy by contractile reserve during stress echocardiography

Aims The identification of responders to cardiac resynchronization therapy (CRT) remains a challenge. We assessed the role of dyssynchrony (DYS) and contractile reserve (CR) in identifying CRT responders. Methods and results Sixty-nine patients (55% with ischaemic aetiology) referred for CRT (ejection fraction 35%, New York Heart Association III, and QRS duration 120 ms) underwent baseline evaluation of DYS and dobutamine stress-echo [up to 40 mg/kg/min: CR was defined as a wall motion score index (WMSI) variation 0.20]. CRT responders were identified by clinical and/or echocardiographic [end-systolic volume (ESV) decrease 15%] follow-up criteria. During a median follow-up of 11 months, 46 patients (66%) were classified as clinical responders. Reverse remodelling was found in 34 of the 59 patients (58%) with echocardiographic follow-up. CR was present in 78% of clinical responders (P ? 0.001) and in 69% with reverse remodelling (P ? 0.005). DYS was equally present in the two groups. Reverse remodelling was correlated with rest-stress changes in ESV (r ? 0.439, P ? 0.003) and in WMSI (r ? 0.450, P ? 0.001), but not with DYS. CR (OR ? 6.2, 95% CI ? 1.4-27.6, P ? 0.015) was the best predictor of response to CRT. Conclusion Patients with CR show a favourable clinical and reverse LV remodelling response to CRT. This finding shifts the focus from electrical (dyssynchrony) to the myocardial substrate of functional response

Force-frequency relationship during dobutamine stress echocardiography predicts exercise tolerance and BNP levels in patients with chronic congestive heart failure

Purpose: D obutamine stress echocardiography (DSE) is widely used to evaluate myocardial contractile reserve; it provides prognostic information in patients with chronic congestive heart failure (CHF). The force?frequency relationship (FFR) is a method for evaluate LV contractility during DSE . The aim of our study is to assess the relationship among FFR, BNP levels, and aerobic exercise capacity in CHF patients. Methods and materials: 37 CHF patients (age 67?8 years, 54% with an ischemic etiology), underwent high dose DSE (up to 40 m g/kg/min). FFR was determined as a ratio between systolic cuff pressure and end-systolic volume (biplane using a Simposon rule) assessed at baseline and peak DSE . BNP levels were determined on blood samples withdrawn at baseline. After a few hours, CHF patients underwent cardiopulmonary exercise test with expired gas measurement. Results: Mean ejection fraction was 32?7% and NHYA class 2.5?0.6. FFR was directly related to peak oxygen consumption (Figure Left), LV ejection fraction (r=0.398, p=0.015) and mitral annulus peak systolic velocity (r=0.428, p=0.013). FFR was inversely related to NYHA class (r=-0.43, p=0.013), LV end-diastolic diameter (r=-0.377, p=0.022), LV intraventricular dyssynchrony (r=-0.394, p=0.016), and BNP levels (Figure Right). At multiple regression analysis, FFR (B=0.502, p= 0.004) and E/Ea ratio (B=-0.336, p=0.044) were the best predictors of exercise tolerance. Conclusions: In patients with stable CHF, impaired myocardial contractility during DSE is related to higher BNP levels and poorer exercise tolerance

Low back pain and headache as important aspects of chronic pain in primary health care in a community of the brazilian amazon region

A dor tem sido descrita como sendo uma experiência sensorial e emocional desagradável que é associada ou descrita em termos de lesão tecidual. Na atenção primária à saúde, a dor crônica atinge altos níveis de prevalência, especialmente devido aos quadros de lombalgia e de cefaléias. O objetivo do presente estudo foi investigar a prevalência de dor crônica na atenção primária à saúde na cidade de Buriticupu, localizada no estado do Maranhão, Brasil. Dentre todos os quadros clínicos, a dor crônica foi o diagnóstico mais prevalente entre os pacientes investigados, sendo encontrada em 539 pacientes (23,02%). Dor músculo-esquelética foi o quadro de dor crônica mais comum, atingindo 250 pacientes (10,62%), sendo que lombalgia foi o diagnóstico mais prevalente entre os quadros de dor músculo-esquelética, sendo encontrada em 120 pacientes (5,12%). Por outro lado, as cefaléias foram o segundo quadro de dor crônica mais comum, depois da dor músculo-esquelética, tendo sido diagnosticada em 212 pacientes (9,05%). Assim, 61,6% dos pacientes com dor crônica apresentavam lombalgia ou cefaléia. Análise estatística univariada encontrou associação entre gênero feminino e cefaléia, entre idade avançada e os principais tipos de dor crônica que foram avaliados neste estudo (músculo-esquelética, lombalgia e cefaléia), e entre índice de massa corpórea e dor músculo-esquelética e lombalgia. Quando a análise multivariada foi conduzida, as associações observadas com gênero feminino e idade avançada não mostraram alterações, mantendo os mesmos padrões de associação. No entanto, o índice de massa corpórea não apresentou mais associação com qualquer tipo de dor crônica.Pain has been described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. In primary care health system, chronic pain reaches high levels of prevalence, mainly due to low back pain and headaches. The aim of the present study was to evaluate the prevalence of chronic pain in the primary healthcare system in the town of Buriticupu, located in the state of Maranhao, northeastern Brazil. Chronic pain disorders were the most prevalent medical diagnosis in the investigated sample, being found in 539 patients (23.02%). Musculoskeletal pain disorders were the most important etiology of the chronic pain, affecting 250 patients (10.62%), and among the musculoskeletal pain disorders, low back pain was the most prevalent one, observed in 120 (5.12%) patients. Headaches were the second most common cause of chronic pain, diagnosed in 212 (9.05%) patients. Thus, 61.6% of the chronic pain disorders were due to low back pain and headaches. The univariate statistical analysis demonstrated an association between female gender and headaches, between advanced age and all groups of chronic pain (musculoskeletal, low back pain and headaches), and between body mass index and musculoskeletal and low back pain. When the multivariate regression analysis was performed, the correlations between gender and age remained unaltered, maintaining the same patterns of association. However, body mass index no longer showed an association with any chronic pain disorder

Stress echo 2020: the international stress echo study in ischemic and non-ischemic heart disease

BACKGROUND: Stress echocardiography (SE) has an established role in evidence-based guidelines, but recently its breadth and variety of applications have extended well beyond coronary artery disease (CAD). We lack a prospective research study of SE applications, in and beyond CAD, also considering a variety of signs in addition to regional wall motion abnormalities. METHODS: In a prospective, multicenter, international, observational study design, > 100 certified high-volume SE labs (initially from Italy, Brazil, Hungary, and Serbia) will be networked with an organized system of clinical, laboratory and imaging data collection at the time of physical or pharmacological SE, with structured follow-up information. The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on: contractile reserve for prediction of cardiac resynchronization or medical therapy response; stress B-lines in heart failure; hypertrophic cardiomyopathy; heart failure with preserved ejection fraction; mitral regurgitation after either transcatheter or surgical aortic valve replacement; outdoor SE in extreme physiology; right ventricular contractile reserve in repaired Tetralogy of Fallot; suspected or initial pulmonary arterial hypertension; coronary flow velocity, left ventricular elastance reserve and B-lines in known or suspected CAD; identification of subclinical familial disease in genotype-positive, phenotype- negative healthy relatives of inherited disease (such as hypertrophic cardiomyopathy). RESULTS: We expect to recruit about 10,000 patients over a 5-year period (2016-2020), with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot. This data-base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios. CONCLUSIONS: The study will create the cultural, informatic and scientific infrastructure connecting high-volume, accredited SE labs, sharing common criteria of indication, execution, reporting and image storage of SE to obtain original safety, feasibility, and outcome data in evidence-poor diagnostic fields, also outside the established core application of SE in CAD based on regional wall motion abnormalities. The study will standardize procedures, validate emerging signs, and integrate the new information with established knowledge, helping to build a next-generation SE lab without inner walls