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ISSN (Print): 2359-4802 | ISSN (Online): 2359-5647

Cardiovascular Imaging - Special Guideline

Guideline for Rest and Stress Myocardial Perfusion Scintigraphy

Bárbara Juarez Amorim; Cláudio Tinoco Mesquita

This is an article about Guidelines for Rest and Stress Myocardial Scintigraphy. It was developed and written by the Brazilian Society of Nuclear Medicine to serve as a best-practices guidelines used in Nuclear Medicine. It is an educational tool to help Nuclear Medicine Services in Brazil to guarantee a quality care to the patients.

Information to the Scientific Community


It was with great satisfaction that we received the information that the Advisory Committee SciELO in its XLVI Meeting has given its assent to the inclusion of the International Journal of Cardiovascular Sciences (IJCS - On-line) to the SciELO Brazil database.
This fact leads to greater visibility of IJCS, because the Scientific Electronic Library Online - SciELO is an electronic library that encompasses a selected collection of scientific journals. The SCIELO database has more than 1,000 scientific journals in open access and has a rate of more than 500,000 downloads a day.
This is the result of the unrelenting work of several editors, reviewers and technical staff that came before us and understood that the path to be followed by the national cardiology entailed the presence of another qualified journal. Many editorial changes were made in IJCS for it to meet the criteria for evaluation, indexing and permanence of journals in the SciELO collection.
Because of the need for constant improvement and the opportunity for strengthening and developing the national scientific production, an agreement was reached between the Cardiology Society of Rio de Janeiro (Sociedade de Cardiologia do Rio de Janeiro - SOCERJ), which was responsible for IJCS, and the Brazilian Society of Cardiology (Sociedade Brasileira de Cardiologia - SBC), which is responsible for the Brazilian Archives of Cardiology, the main journal in the national cardiology area. The IJCS is now the responsibility of the SBC and so the two journals have now joined their strengths and are part of a single portal, sharing the same management, aligning their strategies so that they complement the needs of Brazilian and international researchers that seek modern and reliable journals with good visibility to aid their scientific production. With this achievement, the IJCS can benefit from the entire editorial structure that characterizes the Brazilian Archives of Cardiology and can increase its quality, while maintaining its modern characteristics, which led to the SciELO indexing.
The editors of the Brazilian Archives of Cardiology and the International Journal of Cardiovascular Sciences are committed to the pursuit of excellence and cooperation so that the criteria for evaluation, indexing and permanence of journals in the SciELO collection will always be met.

Original Article

Acute effects of functional electrical stimulation and inspiratory muscle training in patients with heart failure: a randomized crossover clinical trial

Graziela Valle Nicolodi; Graciele Sbruzzi; Fabrício Edler Macagnan; Thiago Dipp; Aline Chagastelles Pinto de Macedo; Karina Rabello Casali; Rodrigo Della Méa Plentz

Original Article

Mean platelet volume is associated with inadequate reperfusion detected by angiography in patients with successful fibrinolytic therapy

Abdurrahman Arslan; Mehmet Eyuboglu; Omer Senarslan; Mehmet Akif Ekinci; Mustafa Aytek Simsek; Onder Kirimli

Video

Editors of Journals Arquivos Brasileiros de Cardiologia (Brazilian Archives of Cardiology) and International Journal of Cardiovascular Sciences, Luiz Felipe P. Moreira and Claudio Tinoco Mesquita, announce the integration of IJCS into the scientific journals portfolio of the Brazilian Society of Cardiology.

Editorial

International Journal of Cardiovascular Sciences and the scientific production in cardiology in Latin America

International Journal of Cardiovascular Sciences e a produção científica em cardiologia na América Latina

Cláudio Tinoco Mesquita

Int J Cardiovasc Sci. 2016;29(3):156-157

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Keywords: Cardiovascular Diseases; Latin America; Periodicals; Databases Bibliographic / trends.

Original Article

Acute effects of functional electrical stimulation and inspiratory muscle training in patients with heart failure: a randomized crossover clinical trial

Efeitos agudos da estimulação elétrica funcional e do treinamento muscular inspiratório em pacientes com insuficiência cardíaca: ensaio clínico randomizado cruzado

Graziela Valle Nicolodi; Graciele Sbruzzi; Fabrício Edler Macagnan; Thiago Dipp; Aline Chagastelles Pinto de Macedo; Karina Rabello Casali; Rodrigo Della Méa Plentz

Int J Cardiovasc Sci. 2016;29(3):158-167

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BACKGROUND: Heart Failure is a multisystem disorder, which includes autonomic dysfunction.
OBJECTIVE: To evaluate the acute effects of Functional Electrical Stimulation (FES) and Inspiratory Muscle Training (IMT) on autonomic control, endothelial function and inflammatory cytokine levels in patients with HF.
METHODS: Randomized crossover trial including 12 patients undergoing three randomized interventions: FES, IMT, and FES+IMT, with a 1-week interval between sessions. IMT was performed for 15 minutes with 30% of the maximal inspiratory pressure. FES was performed in the vastus lateralis and vastus medialis muscles, at 20Hz for 30 minutes. The autonomic control was measured using beat-to-beat blood pressure monitoring (Finapres); the endothelial function, using the flow-mediated dilation technique (FMD); and inflammatory cytokine levels were assessed before and after the sessions.
RESULTS: Autonomic control after FES decreased regarding LF/HF (p=0.01) and LFn.u (p=0.03), and increased regarding mean RR (p=0.005). Increased mean RR was observed after IMT (p=0.005) and after FES+IMT (p=0.02). No differences were found in FMD and blood lactate concentration. As regards the cytokines, FES led to a decrease in TNF-α levels (pre vs. 24 hours post, p = 0.05). IMT resulted in increased IL-10 levels (pre vs. 24 hours post, p=0.05) and decreased TNF-α levels (1 hour post vs. 24 hours post, p = 0.03). No difference was observed when the two interventions were associated.
CONCLUSION: FES, IMT, and FES+IMT changed the autonomic control without changing the endothelial function. FES and IMT separately changed inflammatory cytokine levels. Clinical Trials: NCT01325597. (Int J Cardiovasc Sci. 2016;29(3):158-167)


Keywords: Breathing Exercises; Heart Failure; Electric Stimulation; Randomized Controlled Trial.

Mean platelet volume is associated with inadequate reperfusion detected by angiography in patients with successful fibrinolytic therapy

Volume plaquetário médio está associado com reperfusão inadequada detectada por angiografia em pacientes com terapia fibrinolítica bem sucedida

Abdurrahman Arslan; Mehmet Eyuboglu; Omer Senarslan; Mehmet Akif Ekinci; Mustafa Aytek Simsek; Onder Kirimli

Int J Cardiovasc Sci. 2016;29(3):168-174

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BACKGROUND: Higher Mean platelet volume (MPV) is associated with fibrinolysis failure and adverse outcomes in patients with ST elevation myocardial infarction (STEMI). However, there are no data about the effects of MPV on antegrade coronary blood flow and the degree of reperfusion in patients with successful fibrinolysis.
OBJECTIVE: The aim of our study was to investigate the role of MPV on coronary circulation via thrombolysis in myocardial infarction (TIMI) frame count (TFC) after successful fibrinolytic therapy.
METHODS: Among 145 patients treated with fibrinolytics, 123 (84.8%) consecutive patients with successful fibrinolysis determined by electrocardiography criteria were included. The patients were divided into two groups according to TFC. TFC > 40 was accepted as a marker for inadequate reperfusion and TFC < 40 was accepted as an indicator of complete reperfusion.
RESULTS: After coronary angiography, 57 patients had TFC < 40 and 66 patients had TFC > 40. MPV was significantly higher in the inadequate reperfusion group (8.93 ± 0.87 fl vs 7.92 ± 0.80 fl, p < 0.001). Higher MPV was found to be an indicator of inadequate reperfusion and coordinates of the ROC curve indicated a cutoff value of 8.3 fl for MPV.
CONCLUSION: Higher MPV on admission in STEMI patients treated with successful fibrinolytic therapy was found to be associated with inadequate reperfusion detected by TFC. (Int J Cardiovasc Sci. 2016;29(3):168-174)


Keywords: mean platelet volume; ST elevation myocardial infarction; fibrinolytic therapy; TIMI frame count.

Hypertriglyceridemic waist in hypertensive patients

Cintura hipertrigliceridêmica em pacientes hipertensos

Amanda Pereira Mota; Maria Ester Pereira da Conceição Machado; Maiara dos Reis Almeida; Marcela Ramos da Silva; Débora Bahia de Mattos; Thainá Leal Oliveira; Jairza Maria Barreto Medeiros

Int J Cardiovasc Sci. 2016;29(3):175-180

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BACKGROUND: The adoption of different criteria to determine the occurrence of the hypertriglyceridemic waist (HTW) can result in inaccurate interpretations, compromising the diagnosis of patients at risk of developing cardiovascular diseases.
OBJECTIVE: To evaluate the diagnostic agreement of HTW using different cut-off points for waist circumference in hypertensive patients.
METHODS: Cross-sectional study including 120 patients of both sexes, aged 30 to 74 years and receiving care on an outpatient basis. We assessed the participants' anthropometric data (weight, height, and waist circumference) and determined their serum triglycerides levels. The diagnosis of HTW was defined by concurrent increased waist circumference and hypertriglyceridemia. The agreement among the diagnoses of HTW was assessed with the kappa index.
RESULTS: In adults of both sexes, the HTW had a higher prevalence (28%) when determined by the criteria defined by the International Diabetes Federation (IDF) and the World Health Organization (WHO) than by those defined by the National Cholesterol Education Program - Adult Treatment Panel III (NCEP-ATP III, 22.7%). We identified an almost perfect agreement (0.864) between the diagnosis of HTW determined by the cut-off points of the IDF versus NCEP-ATP III and by the WHO versus NCEP-ATP III. The correlation was perfect between the diagnoses established by the IDF and WHO.
CONCLUSION: The cut-off points for waist circumference proposed by the IDF and WHO was better than those by the NCEP-ATP III to characterize individuals with HTW. (Int J Cardiovasc Sci. 2016;29(3)175-180)


Keywords: Hypertriglyceridemic Waist; Obesity, Abdominal; Hypertension; Waist Circumference; Hypertriglyceridemia.

Ventricular mass and atrial size in diabetic hypertensive patients using losartan or benazepril

Massa ventricular e tamanho atrial em diabéticos hipertensos em uso de losartana ou benazepril

Ricardo Bedirian; Mario Fritsch Neves; Wille Oigman; Ronaldo Altenburg Odebrecht Curi Gismondi; Cesar Romaro Pozzobon; Marcia Cristina Boaventura Ladeira; Márcia Bueno Castie

Int J Cardiovasc Sci. 2016;29(3):181-188

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BACKGROUND: Hypertensive diabetic patients are more likely to develop left ventricular hypertrophy and atrial fibrillation. Evidence suggests that renin-angiotensin-aldosterone system blockers should be used in this group of patients.
OBJECTIVE: To evaluate if there are differences between the effects of angiotensin-converting enzyme benazepril and the angiotensin-receptor blocker losartan on left atrial size and ventricular mass when associated to the treatment of diabetic hypertensive patients using amlodipine.
METHODS: 34 hypertensive type-2 diabetic outpatients from the Internal Medicine service of Universidade do Estado do Rio de Janeiro were randomized into two groups, after a period of 6 weeks receiving only amlodipine, to receive losartan or benazepril. At the beginning and end of the combined treatment, patients were submitted to echocardiography for cavity assessment, wall thickness and flow measurements.
RESULTS: There was reduction in left ventricular mass index in the losartan group (from 81.1 ± 23.5 to 76.9 ± 23.8 g/m2; p = 0.044), with no difference in the benazepril group (from 81.8 ± 10.8 to 79.7 ± 12.1 g/m2; p = 0.520). The left atrial diameter index was lower at 12 weeks (p = 0.034) in the losartan group, which ranged from 2.12 ± 0.23 to 2.03 ± 0.22 cm/m2 (p = 0.103) when compared to the benazepril group, which ranged from 2.12 ± 0.30 to 2.23 ± 0.29 cm/m2 (p = 0.064).
CONCLUSION: The losartan and amlodipine combination was better than the benazepril and amlodipine combination for left ventricular mass and left atrial size reduction in this sample of type 2 diabetic hypertensive patients. (Int J Cardiovasc Sci. 2016;29(3):181-188)


Keywords: Diabetes Mellitus; Hypertrophy, Left Ventricular; Hypertension; Atrial Fibrillation; Renin-Angiotensin System.

Validation of TIMI risk score for STEMI

Validação do escore TIMI de risco para infarto agudo com supradesnivelamento do segmento ST

Daniel Souto Silveira; Cristiano Pederneiras Jaeger; Luciano Hatschbach; Euler Roberto Fernandes Manenti

Int J Cardiovasc Sci. 2016;29(3):189-197

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BACKGROUND: TIMI risk score for ST elevation myocardial infarction (STEMI) is an important tool to assess mortality risk; however, it has not yet been validated in Brazil.
OBJECTIVES: To validate the TIMI risk score for STEMI patients as a predictor of in-hospital mortality and to identify new independent predictors of in-hospital mortality not described by this score. A new risk score called "Modified TIMI Risk Score" was created in an attempt to increase its discriminatory power.
METHODS: Retrospective cohort study evaluating 983 patients with STEMI, obtained from a database of two leading cardiology institutions in Rio Grande do Sul. Clinical variables described for the TIMI risk score were tested using univariate analysis and multivariate analysis by logistic regression. Area under curve (AUC) was used to define sensitivity, specificity and discriminatory power of the score. Non-significant variables on multivariate analysis were excluded, and the discriminatory power of the modified TIMI risk score was calculated.
RESULTS: In-hospital mortality was 8.6%. The TIMI risk score for STEMI showed a discriminatory power of 0.82, with no identification of new predictors of mortality. In the multivariate analysis, weight < 67 Kg, previous infarction, left bundle branch block and hypertension did not show statistical significance. A modified TIMI score that excluded these variables had discriminatory power of 0.84.
CONCLUSION: TIMI risk score for STEMI presented good discriminatory power as a predictor of in-hospital mortality. No new predictors of in-hospital mortality were found. The modified TIMI score did not present a discriminatory power that was superior to the TIMI score. (Int J Cardiovasc Sci. 2016;29(3):189-197)


Keywords: Cardiovascular Diseases/mortality; Myocardial Infarction/mortality; Hospital Mortality; Risk Assessment; Validation Studies.

Electrocardiogram in acute myocardial infarction: what to expect?

Eletrocardiograma no infarto agudo do miocárdio: o que esperar?

Ana Rita Pereira Alves Ferreira; Manuel Vaz da Silva; Julia Maciel

Int J Cardiovasc Sci. 2016;29(3):198-209

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BACKGROUND: Cardiovascular diseases are the leading cause of death. The electrocardiogram (ECG) is an accessible and useful tool in the initial evaluation of acute coronary syndromes (ACS).
OBJECTIVE: To identify and correlate electrocardiographic changes in different leads with the location of the intracoronary thrombus in the artery involved in the coronary event.
METHODS: Retrospective and observational study conducted with 179 patients with ACS. The data were analyzed considering three diagnostic groups: unstable angina (n = 31), non-ST-elevation myocardial infarction (n = 86), and ST-elevation myocardial infarction of the anterior (n = 34) and inferior (n = 28) walls. Data obtained from ECG, coronary angiography, and transthoracic echocardiogram tests were analyzed and compared among the three groups.
RESULTS: The sensitivity and specificity of the ECG in detecting the culprit coronary artery were 70.0% and 79.1%, respectively. The positive and negative predictive values for ECG location of the proximal segment of the left anterior descending (LAD) artery were 70.6% and 66.7%, respectively. Regarding the distal segment of the LAD, the positive and negative predictive values were 100.0% and 28.0%, respectively. With ECG analysis, we were able to identify the right coronary (RC) artery as the culprit artery in 88.9% of the cases, with positive and negative predictive values of 90.0% and 14.3%, respectively.
CONCLUSION: The ECG is an indispensable diagnostic method in ACS, even though it fails to locate the culprit artery accurately. (Int J Cardiovasc Sci. 2016;29(3):198-209)


Keywords: Myocardial Infarction / mortality; Electrocardiography / diagnosis; Acute Coronary Syndrome; Coronary Angiography.

Original Article

Antioxidant vitamin intake in dyslipidemic overweight individuals

Consumo de vitaminas antioxidantes em dislipidêmicos com excesso de peso

Mauara Scorsatto; Glorimar Rosa; Gláucia Maria Moraes de Oliveira

Int J Cardiovasc Sci. 2016;29(3):210-217

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BACKGROUND: Insufficient consumption of fruits, vegetables and pulses is associated with dyslipidemia and obesity and with antioxidant status imbalance.
OBJECTIVE: To assess the dietary intake of vitamins A, E and C and of macronutrients, correlating them with biomarkers in dyslipidemic overweight individuals.
METHODS: Dyslipidemic individuals of both sexes, aged > 20 years, with body mass index (BMI) >25 kg/m2 were selected. Individuals on anorectic drugs and/or hypocaloric diets were excluded. Anthropometric [body mass, height, waist circumference (WC), BMI] and biochemical variables [total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, and plasma F2-isoprostane) were assessed. Food intake was assessed using the Food Frequency Questionnaire. Statistical analyses were performed with SPSS 18.
RESULTS: Of the 284 participants, 264 (93.1%) were women. Mean BMI and WC values were 36.0 ± 5.8 kg/m2 and 106.2 ± 12.7 cm, respectively. The intakes of vitamins A and C, carbohydrates, proteins, sugar, saturated and trans fatty acids were above the recommended values; the intakes of vitamin E, polyunsaturated fatty acids, and monounsaturated fatty acids were below 50% of the recommended values. There was a negative correlation between the following variables: vitamin E, LDL-C and TC; sugar and HDL-C; and polyunsaturated fatty acids, TC and LDL-C. Positive correlations were observed between dietary cholesterol, WC and BMI; and between fat mass and triglycerides.
CONCLUSION: Inappropriate intakes of vitamin E, sugar, polyunsaturated and trans fatty acids were observed, but not of vitamins A and C. No correlation of biomarkers and dietary variables was observed with plasma F2-isoprostane. (Int J Cardiovasc Sci. 2016;29(3):210-217)


Keywords: Dyslipidemias; Obesity; Food Consumption; Vitamins; Antioxidants.

Review Article

Diagnostic accuracy measures in cardiovascular research

Medidas de acurácia diagnóstica na pesquisa cardiovascular

Leonardo Silva Roever Borges

Int J Cardiovasc Sci. 2016;29(3):218-222

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Diagnostic accuracy is the ability of a test to discriminate between the target condition and health; it can be quantitated using diagnostic accuracy measures such as sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, the area under the ROC curve, odds ratio of the diagnosis and Youden index. The diagnostic accuracy measures are related to the different aspects of the diagnostic procedure. Some measures are used to evaluate the discriminative property of the test, while others are used to assess its predictive ability. Diagnostic accuracy measures are not fixed indicators of a test performance; some are very sensitive to disease prevalence, while others are sensitive to disease spectrum and definition. This review described the definitions and characteristics of diagnostic accuracy measures used in cardiovascular research.


Keywords: Diagnosis; Data Accuracy; Evidence-Based Medicine; Clinical Study.

Clinical applications and methods of intravascular imaging of atherosclerosis

Aplicações clínicas e métodos de imagem intravascular da aterosclerose

Leonardo Silva Roever Borges; Cláudio Tinoco Mesquita

Int J Cardiovasc Sci. 2016;29(3):223-232

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Atherosclerosis is the leading cause of coronary artery disease, stroke and peripheral artery disease. The onset of atherosclerotic coronary lesions occurs through accumulation and oxidation of low-density lipoprotein (LDL). Oxidized LDL promotes the recruitment and activation of leukocytes, as well as cell death and generation of complex atherosclerotic plaques. These plaques have high necrotic core content, a thin fibrous inflamed layer, and intense accumulation of macrophages. In the initial stage of the formation of atheroma, remodeling of the vessel wall generally prevents the plate from invading the lumen, thereby masking the presence of atheroma in angiography. Advances have contributed to the study of atherosclerosis by intravascular imaging. Methods such as intravascular ultrasound, optical coherence tomography, intravascular magnetic resonance spectroscopy, infrared spectroscopy, Raman spectroscopy, fluorescence spectroscopy, intravascular magnetic resonance imaging and infrared fluorescence have been used in the intravascular evaluation of atherosclerosis. Intravascular ultrasound can assess the extent of the disease in the axial and longitudinal plane and contribute to the understanding of the pathophysiology of coronary artery disease. This manuscript describes the characteristics and clinical applications of the methods of coronary intravascular imaging.


Keywords: Atherosclerosis; Coronary artery disease; Diagnostic imaging.

Point of View

Narrative medicine: beyond the single story

Medicina narrativa: para além de uma história única

Ana Luisa Rocha Mallet; Luciana Andrade; Fátima Geovanini; Silvia Barbosa de Carvalho

Int J Cardiovasc Sci. 2016;29(3):233-235

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Chimamanda Adichie is a Nigerian author of great success. With a Master's degree in creative writing from the Johns Hopkins University and Yale School of Arts, she wrote Americanah, which sold over half a million books during her scholarship period at Harvard. She received several literary awards, including the National Book Critics, in 2013. She attended 2 years of medical school, and her sister is a doctor in the United States. She presented two of the most viewed TED talks (non-profit organization dedicated to the dissemination of ideas, usually in the form of short lectures, with free internet access, with more than 1 billion views). The danger of a single story is one of Chimamanda's TED talks, which has many possible interfaces with Medicine, some of which are presented in this article, emphasizing narrative medicine as a possible antidote to the danger of a single story.


Keywords: Humanities; Literature; Narratives Personal as Subject.

Case Report

Asystole during exercise stress test: analysis of cardioinhibitory response

Assistolia durante o teste ergométrico: análise da resposta cardioinibitória

Luis Sérgio Carvalho Luciano; Fabrício Bonotto Mallmann; Daniel Medeiros Moreira; Gabriela Nassar Frederico; Maíra Fracasso

Int J Cardiovasc Sci. 2016;29(3):236-238

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This is the case of asystole during stress test at the stage of physical stress in a 30-year-old man with previous history of syncope. The episode was related to a cardioinhibitory response with asystole during the exercise test stress stage, which is not frequent in the literature.


Keywords: Exercise test; Syncope; Bradycardia.

Abnormal myocardial perfusion scintigraphy in patient with zero calcium score: is it possible?

Cintilografia de perfusão miocárdica positiva em paciente com escore coronariano zero: é possível?

Felipe Villela Pedras; Bruno Villela Pedras; Marcos Villela Pedras Polonia; Dauro Villela Pedras; Flavia Paiva Proença Lobo Lopes

Int J Cardiovasc Sci. 2016;29(3):239-242

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Female patient, 68, hypertensive and dyslipidemic with atypical chest pain. Calcium score: zero. Due to the symptoms, investigation was conducted using myocardial perfusion scintigraphy (MPS). Moderate ischemia on the anterior, septal and apical left ventricular walls was found to be associated with other indirect markers of severity and abnormal exercise electrocardiography. Coronary computed tomography angiography (CCTA) revealed anterior descending artery with significant obstructive lesion confirmed by coronary angiography. Percutaneous revascularization provided improvement of symptoms, normalization of MPS and exercise electrocardiography. This report emphasizes the importance of assessing the pretest probability of coronary artery disease for the correct indication of the imaging methods.


Keywords: Radionuclide imaging; Coronary disease; Diagnostic imaging.

Cardiovascular Imaging - Special Guideline

Guideline for Rest and Stress Myocardial Perfusion Scintigraphy

Diretriz para Cintilografia de Perfusão Miocárdica de Repouso e Estresse

Bárbara Juarez Amorim; Cláudio Tinoco Mesquita

Int J Cardiovasc Sci. 2016;29(3):243-247

AbstractPDF PORTPDF ENGLISH

This is an article about Guidelines for Rest and Stress Myocardial Scintigraphy. It was developed and written by the Brazilian Society of Nuclear Medicine to serve as a best-practices guidelines used in Nuclear Medicine. It is an educational tool to help Nuclear Medicine Services in Brazil to guarantee a quality care to the patients.


Keywords: Myocardial Perfusion Imaging/radionuclide imaging; Practice Guideline; Diagnostic Imaging.

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