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.Fundamento:A busca pela qualidade exige ferramentas de avaliação nas diversas subdivisões de um complexo de saúde. Na medicina diagnóstica eles são escassos e em ergometria não foram encontradas sugestões de indicadores.Objetivo:Estabelecer indicador para controle de qualidade em ergometria baseado nas III Diretrizes da Sociedade Brasileira de Cardiologia Sobre Teste Ergométrico; verificar o percentual dos testes que apresentaram o indicador dentro da conformidade em dois serviços de uma mesma instituição, antes e após a publicação do documento.Métodos:Foi realizada análise crítica das diretrizes em busca de indicador que apresentasse: exatidão, confiabilidade, simplicidade, validade, sensibilidade e capacidade de medir quantitativamente as variações no comportamento dos critérios de qualidade e que fosse aplicável a todos os testes. O indicador foi aplicado nos testes de 2010, anterior à publicação e 2011, depois que ele foi adotado, por dois serviços de uma mesma instituição.Resultados:O indicador que preencheu os critérios foi o de percentual de exames ergométricos com duração do exercício entre 8 e 12 minutos. Nos anos 2010 e 2011, respectivamente, os percentuais de testes ergométricos dentro da conformidade foram 85,5% e 86,1% (p = 0,068) no Hospital Geral, e 81,5% e 85,7% (p < 0,001) no Serviço de Avaliação Periódica de Saúde.Conclusão:O tempo do exercício entre 8 e 12 minutos pode ser utilizado como critério de qualidade em ergometria e nos serviços onde ele foi aplicado, pelo menos 80% dos testes ergométricos estiveram conformes.Universidade Federal de São Paulo (UNIFESP) Grupo Interdepartamental de Economia da SaudeHospital Israelita Albert Einstein São PauloUNIFESP, Grupo Interdepartamental de Economia da SaudeSciEL

Preoperative left ventricular ejection fraction and left atrium reverse remodeling after mitral regurgitation surgery

Background: Left atrium enlargement has been associated with cardiac events in patients with mitral regurgitation (MR). Left atrium reverse remodeling (LARR) occur after surgical correction of MR, but the preoperative predictors of this phenomenon are not well known. It is therefore important to identify preoperative predictors for postoperative LARR.Methods: We enrolled 62 patients with chronic severe MR (prolapse or flail leaflet) who underwent successful mitral valve surgery (repair or replacement); all with pre-and postoperative echocardiography. LARR was defined as a reduction in left atrium volume index (LAVI) of >= 25%. Stepwise multiple regression analysis was used to identify independent predictors of LARR.Results: LARR occurred in 46 patients (74.2%), with the mean LAVI decreasing from 85.5 mL/m(2) to 49.7 mL/m(2) (p = 25% with a sensitivity of 71.7% and a specificity of 56.3%.Conclusions: LARR occurs frequently after mitral valve surgery and is associated with preoperative LVEF higher than 63.5%.Inst Dante Pazzanese Cardiol, São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo, BrazilDisciplina Cardiol, BR-04024002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, São Paulo, BrazilWeb of Scienc

Coronary artery disease in asymptomatic type-2 diabetic women: a comparative study between exercise test, cardiopulmonary exercise test, and dipyridamole myocardial perfusion scintigraphy in the identification of ischemia

BACKGROUND: Cardiovascular disease is the leading cause of morbidity and mortality among diabetic individuals. Myocardial ischemia is frequently asymptomatic, thus leading to a late diagnosis and worse prognosis. Diabetic women are known to have a cardiovascular death risk higher than that in men. OBJECTIVE: To assess the prevalence of coronary artery disease (CAD) in asymptomatic diabetic women. To compare the results of exercise test (ET), cardiopulmonary exercise test (CPET), and dipyridamole myocardial perfusion scintigraphy (MPS) with the findings of coronary angiography, (ANGI) in order of identify the most accurate method in the detection of significant CAD. METHODS: A total of 104 diabetic women were assessed with ET, CPET and MPS in the period within two months from the ANGI. MIBI-99mTc scintigraphy was performed using the gated-SPECT technique. Pearson's chi-square, Student's t tests were used for the statistical analysis and also the logistic regression analysis. RESULTS: The prevalence of CAD in the group studied was 32.7%. For the ET, an effective test (p=0.045), the chronotropic incompetence (p=0.031), and the exercise time performed (p=0.022) showed a significant association with DAC. For CPET, peak VO2 and HR achieved were associated with CAD (p=0.004 and p=0.025, respectively). Most of the MPS variables showed a significant association with CAD (p=0.001, for all). CONCLUSION: The results obtained may suggest a high prevalence of CAD in diabetic women. Thus, this population should be investigated from the cardiovascular point of view even without cardiac symptom. Of the noninvasive diagnostic methods used, dipyridamole MPS was the one that showed the highest discrimination power in relation to diabetic women with CAD.FUNDAMENTO: A doença cardiovascular é a principal causa de morbi-mortalidade nos diabéticos. A isquemia do miocárdio é freqüentemente assintomática levando ao diagnóstico tardio e pior prognóstico. Sabe-se que a mulher diabética tem risco de morte cardiovascular maior em relação ao sexo masculino. OBJETIVO: Avaliar a prevalência de doença arterial coronariana (DAC) em diabéticas assintomáticas. Comparar os resultados do teste ergométrico (TE), do teste cardiopulmonar (TCP) e da cintilografia do miocárdio sob estímulo farmacológico com dipiridamol (CM) com os achados da cinecoronariografia (CINE) verificando o método de maior acurácia na identificação de DAC significativa. MÉTODOS: Foram avaliadas 104 diabéticas que realizaram TE, TCP e CM no período de dois meses da CINE. As cintilografias com MIBI-99mTc foram realizadas pela técnica de gated-SPECT. A análise estatística foi realizada pelos testes x² de Pearson e t de Student, sendo realizada, ainda, análise de regressão logística. RESULTADOS: A prevalência de DAC no grupo estudado foi de 32,7%. No TE, o teste eficaz (p=0,045), a incompetência cronotrópica (p=0,031) e o tempo de esforço realizado (p=0,022) apresentaram associação significativa com DAC. No TCP, o VO2pico e a FC atingida apresentaram associação com DAC (p=0,004 e p=0,025). A maioria das variáveis da CM mostrou importante associação com DAC (todas com p=0,001). CONCLUSÃO: Os resultados obtidos sugerem elevada prevalência de DAC em pacientes diabéticas assintomáticas, devendo ser essa uma população investigada do ponto de vista cardiovascular. Dos métodos diagnósticos não-invasivos que foram empregados, o que mostrou ter maior poder de discriminação em relação às portadoras de DAC foi a CM com dipiridamol.Universidade Federal de São Paulo (UNIFESP) Instituto Dante Pazzanese de CardiologiaUNIFESP, Instituto Dante Pazzanese de CardiologiaSciEL

Noninvasive assessment of patients undergoing percutaneous intervention in myocardial infarction

FUNDAMENTO: A reestenose pós-intervenção coronariana percutânea primária permanece um problema de relevância clínica, mesmo com o implante de stents. A capacidade das provas não invasivas para detecção de reestenose não foi totalmente demonstrada. OBJETIVO: Avaliar a habilidade do teste ergométrico (TE) e da cintilografia de perfusão miocárdica (CPM) no diagnóstico de reestenose em pacientes com infarto agudo do miocárdio, e supradenivelamento do segmento ST, submetidos à angioplastia coronariana percutânea primária (ACPP), com implante de stent nas primeiras 12 horas de evolução. MÉTODOS: De Ago/2003-Jan/2006, foram selecionados 64 pacientes (ps) (56,2 ± 10,2 anos, 53 homens) submetidos à ACPP. Apenas ps com fração de ejeção do ventrículo esquerdo > 40,0%, definida por ecocardiograma de repouso, foram incluídos. Teste ergométrico, com as 12 derivações do ECG associadas a precordiais direitas, e CPM foram realizados 6 semanas, 6 meses e um ano após o tratamento. Foi realizada cinecoronariografia no 6º mês. RESULTADOS: Doença uniarterial ocorreu em 46,9% dos ps, sendo a artéria descendente anterior tratada em 48,4%. Reestenose angiográfica ocorreu em 28,8%. Sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN) e acurácia do TE para detecção de reestenose não foram significativos. A adição de derivações precordiais direitas não proporcionou informações adicionais. Sensibilidade, especificidade, VPP, VPN e acurácia da CPM apresentaram correlação com reestenose apenas no 6º mês, considerando-se summed difference score > 2 (p = 0,006) e > 4 (p = 0,014). CONCLUSÃO: O TE não discriminou reestenose. A CPM realizada no 6º mês foi relacionada à reestenose e mostrou-se útil durante a evolução.BACKGROUND: Restenosis 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. OBJECTIVE: Our 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). METHODS: From 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. RESULTS: Single-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). CONCLUSION: ETT did not discriminate restenosis in this population. MPI performed at 6 months correlated with restenosis and proved useful during follow-up

TCT-44 Independent Mitral Valve Restenosis Predictors After Percutaneous Mitral Balloon Valvuloplasty In A Large, Consecutive Cohort Followed For More Than Two Decades

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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