Ingrid Kowatsch

University of São Paulo, San Paulo, São Paulo, Brazil

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Publications (21)98.43 Total impact

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    ABSTRACT: BACKGROUND: Quantification of myocardial blood flow reserve in patients with coronary artery disease using real-time myocardial perfusion echocardiography (RTMPE) has been demonstrated to further improve accuracy over the analysis of wall motion and qualitative analysis of myocardial perfusion. The aim of this study was to determine the prognostic value of qualitative and quantitative analyses obtained by RTMPE in patients with known or suspected coronary artery disease. METHODS: From March 2003 to December 2008, 227 consecutive patients with normal left ventricular function who underwent RTMPE were prospectively studied. Replenishment velocity reserve (β) and myocardial blood flow reserve were derived from RTMPE. Primary outcomes were cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization, and secondary outcomes were coronary bypass graft surgery or angioplasty. RESULTS: During a median follow-up period of 32 months (range, 5 days to 6.9 years), 19 major events (two deaths, six myocardial infarctions, and 11 episodes of unstable angina) and 46 total events occurred. Wall motion (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.4-5.6; P = .003) and qualitative myocardial perfusion analysis (HR, 4.3; 95% CI, 2.1-8.5; P < .001) were predictors of total events but not primary events. Abnormal myocardial blood flow reserve and abnormal β reserve were predictors of total events (HR, 8.1; 95% CI, 3-21; P < .001; and HR, 16.5; 95% CI, 5.5-49; P < .001) and primary events (HR, 3.8; 95% CI, 1-15; P = .048; and HR, 8.7; 95% CI, 1.8-40; P = .005). On multivariate analysis, only abnormal β reserve was an independent predictor of total (HR, 10.6; 95% CI, 2.5-43; P = .001) and primary (HR, 10.5; 95% CI, 1.5-6; P = .015) events. Abnormal β reserve added incremental value in predicting primary events (χ(2) = 2.0-13.2; P = .014). CONCLUSIONS: Quantitative adenosine stress RTMPE added independent and additional prognostic information over wall motion and qualitative myocardial perfusion analysis in patients with known or suspected coronary artery disease and normal left ventricular function.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 02/2013; · 2.98 Impact Factor
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    ABSTRACT: Background: Hypercholesterolemia induces early microcirculatory functional and structural alterations that are reversible by cholesterol reduction. Real time myocardial contrast echocardiography (RTMCE) and vascular ultrasound evaluate the effects of hyperlipidemia on peripheral and central blood flow reserve. This study investigated the effects of lipid-lowering therapy on coronary and peripheral artery circulation in patients with familial hypercholesterolemia (FH). Methods: RTMCE and vascular ultrasound were performed in 10 healthy volunteers (validation group) at baseline and after 12-week clinical observation, and in 16 age- and sex-matched FH patients without obstructive coronary artery disease (CAD) by computed tomography angiography at baseline and after 12-week atorvastatin treatment. Indexes of relative myocardial blood flow (MBF) were obtained at rest and during adenosine infusion. Results: In validation group, there was no significant difference between flow-mediated dilation (FMD) at baseline and after 12 weeks (0.15 ± 0.02 vs. 0.14 ± 0.03; P = 0.39). Similarly, no differences were observed in MBF reserve at baseline and after 12 weeks (3.31 ± 0.63 vs. 3.48 ± 0.89; P = 0.89). FMD was blunted in FH patients, at baseline, as compared with validation group (0.08 ± 0.04 vs. 0.15 ± 0.02; P < 0.001) and became similar to that group (0.13 ± 0.05 vs. 0.14 ± 0.03; P = 0.07) after treatment. MBF reserve was blunted at baseline in FH patients in comparison with the validation group (2.78 ± 0.71 vs. 3.31 ± 0.63; P = 0.003). After treatment, MBF reserve values were no longer different (3.43 ± 0.66 and 3.48 ± 0.89; P = 0.84, respectively, for FH and validation groups). Conclusion: Patients with FH and no obstructive CAD have blunted MBF reserve and lower FMD values as compared with healthy volunteers. Both FMD and MBF reserve were normalized after atorvastatin treatment.
    Echocardiography 09/2012; · 1.26 Impact Factor
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    ABSTRACT: A ecocardiografia com perfusão miocárdica (EPM) permite avaliação quantitativa da velocidade de fluxo miocárdico (VFM) e reserva de fluxo coronário (RFC) de forma nãoinvasiva. Objetivo: Determinar o comportamento da reserva de VFM e RFC durante as diferentes fases da EPM sob estresse pela dobutamina utilizando protocolo recentemente introduzido de injeção precoce de atropina e administração de betabloqueador no final do estresse. Método: Foram avaliados pacientes submetidos à ecocardiografia com perfusão miocárdica (EPM) sob estresse pela dobutamina-atropina e angiografia coronária. A reserva de VFM e RFC foram obtidos pela análise quantitativa da dinâmica de repreenchimento de contraste ecocardiográfico após destruição das microbolhas no miocárdico com flash manual. Resultados: A reserva de VFM e RFC foram obtidos na fase de repouso, baixa dose de dobutamina, pico do estresse e após metoprotol em 45 pacientes (59±9 anos). Doença arterial coronária (DAC) foi detectada em 42% dos pacientes e 23% dos territórios arteriais. A reserva de VFM e RFC nos pacientes com e sem DAC estão descritos nas figuras 1 e 2. Reserva de VFM foi menor em pacientes DAC nos estágios intermediário e no pico do estresse, mas não houve diferença entre os grupos após injeção de metoprolol. Os valores de corte de reserva VFM obtidos por curva ROC nos estágios intermediário, pico e pós-metoprolol foram 1,78, 2,09 e 1,70, respectivamente. Em pacientes sem DAC, a RFC aumentou do estágio intermediário para o pico e diminuiu com metoprolol. Tal comportamento não foi observado em pacientes com DAC. Os valores de corte de RFC nos estágios intermediário e pico foram 2,43 e 2,41, respectivamente. Conclusão: Este é o primeiro estudo em humanos demonstrando que a EPM permite a quantificação de alterações dinâmicas de VFM e RFC durante cada estágio do estresse pela dobutamina-atropina. A reserva de VFM foi o melhor parâmetro para diferenciar pacientes e territórios com e sem DAC.
    Arquivos brasileiros de cardiologia 09/2011; 97(3(1)):52-52. · 1.32 Impact Factor
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    ABSTRACT: Although dobutamine-atropine stress echocardiography (DASE) has been widely used for evaluating patients with coronary artery disease (CAD), dynamic changes that occur at microcirculatory level during each stage of stress have not been demonstrated in humans. We sought to determine variations in myocardial blood flow (MBF) during DASE using quantitative real time myocardial contrast echocardiography (RTMCE). We studied 45 patients who underwent coronary angiography and RTMCE. Replenishment velocity of microbubbles in the myocardium (β) and MBF reserves were obtained at baseline, intermediate stage (70% of maximal predicted heart rate), peak stress, and recovery phase. β and MBF reserves were lower in patients with than without CAD at intermediate (1.65 vs. 2.10; P=0.001 and 2.44 vs. 3.23; P=0.004) and peak (1.63 vs. 3.00; P<0.001 and 2.14 vs. 3.98; P<0.001, respectively). In patients without CAD, β, and MBF reserves increased from intermediate to peak and decreased at recovery, while in those without CAD reserves did not change significantly. Optimal cutoff values of β reserve at intermediate, peak, and recovery were 1.78, 2.09, and 1.70, with areas under the curves of 0.80 (95%CI=0.67-0.94), 0.89 (95%CI=0.79-0.99), and 0.69 (95%CI=0.53-0.85). Sensitivity, specificity and accuracy for detecting CAD at intermediate stage were 68% (95%CI=48-89), 85% (95%CI=71-98), and 78% (95%CI=66-90), at peak stress were 79% (95%CI=61-97), 96% (95%CI=89-100), and 89% (95%CI=80-98), and at recovery were 74% (95%CI=54-93), 65% (95%CI=47-84), and 69% (95%CI=55-82), respectively. RTMCE allows for quantification of dynamic changes in microcirculatory blood flow at each stage of DASE. The best parameter for detecting CAD in all stages was β reserve.
    Echocardiography 08/2011; 28(9):993-1001. · 1.26 Impact Factor
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    ABSTRACT: Exercise training has been shown to be effective in improving exercise capacity and quality of life in patients with heart failure and left ventricular (LV) systolic dysfunction. Real-time myocardial contrast echocardiography (RTMCE) is a new technique that allows quantitative analysis of myocardial blood flow (MBF). The aim of this study was to determine the effects of exercise training on MBF in patients with LV dysfunction. We studied 23 patients with LV dysfunction who underwent RTMCE and cardiopulmonary exercise testing at baseline and 4 months after medical treatment (control group, n = 10) or medical treatment plus exercise training (trained group, n = 13). Replenishment velocity (beta) and MBF reserves were derived from quantitative RTMCE. The 4-month exercise training consisted of 3 60-minute exercise sessions/week at an intensity corresponding to anaerobic threshold, 10% below the respiratory compensation point. Aerobic exercise training did not change LV diameters, volumes, or ejection fraction. At baseline, no difference was observed in MBF reserve between the control and trained groups (1.89, 1.67 to 1.98, vs 1.81, 1.28 to 2.38, p = 0.38). Four-month exercise training resulted in a significant increase in beta reserve from 1.72 (1.45 to 1.48) to 2.20 (1.69 to 2.77, p <0.001) and an MBF reserve from 1.81 (1.28 to 2.38) to 3.05 (2.07 to 3.93, p <0.001). In the control group, beta reserve decreased from 1.51 (1.10 to 1.85) to 1.46 (1.14 to 2.33, p = 0.03) and MBF reserve from 1.89 (1.67 to 1.98) to 1.55 (1.11 to 2.27, p <0.001). Peak oxygen consumption increased by 13.8% after 4 months of exercise training and decreased by 1.9% in the control group. In conclusion, exercise training resulted in significant improvement of MBF reserve in patients with heart failure and LV dysfunction.
    The American journal of cardiology 01/2010; 105(2):243-8. · 3.58 Impact Factor
  • The American Journal of Cardiology 01/2010; · 3.43 Impact Factor
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    ABSTRACT: Background: The extent of myocardial salvage after acute myocardial infarction (AMI) treated with thrombolysis or percutaneous transluminal coronary angioplasty is variable and cannot be predicted based on either vessel patency or early regional wall motion assessment.Aim: To evaluate the predictor value of myocardial contrast echocardiography (MCE) using intermittent second harmonic imaging, in left ventricular remodeling and regional contractile function at rest and under stress during the first 48 hour after first anterior wall AMI treated with successful thrombolysis or angioplasty.Methods: We studied 31 patients with mean age 64 ± 12 years, 20 men. MCE was performed 34 hour, 5.5 days and 36 days after AMI, and evaluation of the change in left ventricular volumes and regional function was done in 6 months, using MCE at rest and dobutamine-atropine stress. In order to analyze the contraction and myocardial perfusion, left ventricular wall motion score index (WMSI) and myocardial perfusion score index (MPSI) were calculated using a 16-segment model. Patients were divided into two groups: ventricular remodeling group (RG)—20% increase in left ventricular end-diastolic and end-systolic volumes (19 patients) - and no ventricular remodeling group (NRG) (12 patients). patients were also classified according to the number of no-contrast opacification myocardial segments observed in the first MCE: reflow up to 2 segments and no reflow over 2 segments.Results: In the first echocardiography, no statistical difference was observed between groups regarding left ventricular volumes and ejection fraction, but WMSI (p = 0.049), MPSI (p = 0.006) and the number of no-contrast opacification myocardial segments (p = 0.018) were higher in RG. Left ventricular end-diastolic and end-systolic volumes and WMSI increased significantly (p < 0.001) in the GR from the first echo to that at 6 months follow-up, and decreased (p < 0.001) in the NRG. Left ventricular ejection fraction decreased in the RG (p < 0.001) and increased in the NRG (p < 0.001). There was a significant increase in the MPSI in the RG between the first echo and that at 36 days follow-up (p = 0.011). Logistic regression analysis showed that only the MPSI was an independent predictor of left ventricular remodeling (odds ratio of 1.8, p = 0.010). Twenty-eight patients performed dobutamine stress echocardiography, of whom 15 were no reflow and 13 patients were Reflow. Only 27.8 ± 19.9% of the anterior wall myocardial segments had functional recovery or contractile reserve at 6 months follow-up in no reflow patients, whereas, in reflow patients, 69.9 ± 31,2% of the anterior wall myocardial segments had functional recovery or contractile reserve (p < 0.001).Conclusion: Left ventricular MPSI analyzed at first 48 h after the anterior wall AMI treated with successful thrombolysis or angioplasty is an independent predictor of left ventricular remodeling. Moreover, patients with a maximum of 2 no-contrast opacification myocardial segments by MCE revealed a higher percentage of myocardial segments with functional recovery or contractile reserve.
    Echocardiography 09/2009; 21(2):209 - 210. · 1.26 Impact Factor
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    ABSTRACT: We conducted a meta-analysis to evaluate the accuracy of quantitative stress myocardial contrast echocardiography (MCE) in coronary artery disease (CAD). Database search was performed through January 2008. We included studies evaluating accuracy of quantitative stress MCE for detection of CAD compared with coronary angiography or single-photon emission computed tomography (SPECT) and measuring reserve parameters of A, beta, and Abeta. Data from studies were verified and supplemented by the authors of each study. Using random effects meta-analysis, we estimated weighted mean difference (WMD), likelihood ratios (LRs), diagnostic odds ratios (DORs), and summary area under curve (AUC), all with 95% confidence interval (CI). Of 1443 studies, 13 including 627 patients (age range, 38-75 years) and comparing MCE with angiography (n = 10), SPECT (n = 1), or both (n = 2) were eligible. WMD (95% CI) were significantly less in CAD group than no-CAD group: 0.12 (0.06-0.18) (P < 0.001), 1.38 (1.28-1.52) (P < 0.001), and 1.47 (1.18-1.76) (P < 0.001) for A, beta, and Abeta reserves, respectively. Pooled LRs for positive test were 1.33 (1.13-1.57), 3.76 (2.43-5.80), and 3.64 (2.87-4.78) and LRs for negative test were 0.68 (0.55-0.83), 0.30 (0.24-0.38), and 0.27 (0.22-0.34) for A, beta, and Abeta reserves, respectively. Pooled DORs were 2.09 (1.42-3.07), 15.11 (7.90-28.91), and 14.73 (9.61-22.57) and AUCs were 0.637 (0.594-0.677), 0.851 (0.828-0.872), and 0.859 (0.842-0.750) for A, beta, and Abeta reserves, respectively. Evidence supports the use of quantitative MCE as a non-invasive test for detection of CAD. Standardizing MCE quantification analysis and adherence to reporting standards for diagnostic tests could enhance the quality of evidence in this field.
    European Heart Journal – Cardiovascular Imaging 06/2009; 10(7):813-25. · 2.65 Impact Factor
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    ABSTRACT: This is the report of a 74-year-old female patient with a history of systemic hypertension and peripheral vascular disease who presented acute coronary syndrome symptoms. Coronary angiography showed coronary arteries with no significant obstructions. Ventriculography and echocardiography showed akinesia in mid and apical segments; and hyperkinesia of left ventricle basal segments. Two weeks after the onset of symptoms, a new echocardiogram demonstrated normal global and regional systolic function. The uncommon, reversible pattern for systolic dysfunction and segmental compromising that gives left ventricle a Takotsubo-like shape is known today as stress cardiomyopathy.
    Arquivos brasileiros de cardiologia 04/2008; 90(3):e16-9. · 1.32 Impact Factor
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    ABSTRACT: We sought to determine the value of dobutamine versus adenosine real-time myocardial perfusion (MP) echocardiography for detecting coronary artery disease and the value of quantitative analysis of MP over electrocardiography, wall motion, and qualitative MP. We studied 54 patients by real-time MP echocardiography and coronary angiography. Replenishment velocity (beta) and an index of myocardial blood flow (A(n)xbeta) were derived from quantitative MP. During dobutamine stress, beta (1.7 +/- 0.7 vs 2.7 +/- 1.2; P < .001) and A(n)xbeta (2.2 +/- 1.0 vs 3.5 +/- 1.6; P < .001) reserves were lower in patients with coronary artery disease. The same was observed with adenosine for beta (1.7 +/- 0.8 vs 2.5 +/- 1.1; P < .001) and A(n)xbeta (1.9 +/- 0.7 vs 3.2 +/- 1.4; P < .001) reserves. Accuracy of electrocardiography, wall motion, qualitative MP, and quantitative MP were 61%, 76%, 76%, and 80% for dobutamine and 70%, 70%, 76%, and 80% for adenosine, respectively. Quantitative MP had incremental diagnostic value over other variables during dobutamine (chi(2) 23.7-38.4; P < .001) and adenosine (chi(2) 26.7-59.4; P < .001). In conclusion, dobutamine and adenosine real-time MP echocardiography hold similar accuracy for detecting coronary artery disease. Quantitative MP provides incremental diagnostic information over other variables.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 09/2007; 20(9):1109-17. · 2.98 Impact Factor
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    ABSTRACT: We sought to compare the feasibility and accuracy of myocardial blood flow reserve (MBFR) measured by quantitative real-time myocardial contrast echocardiography with those of coronary flow velocity reserve (CFVR) obtained by transthoracic Doppler echocardiography for detecting left anterior descending coronary artery (LAD) stenosis. We studied 71 patients who underwent adenosine stress contrast echocardiography, transthoracic Doppler echocardiography, and quantitative coronary angiography within 1 month. An index of myocardial blood flow (A x beta) was determined by quantification of peak plateau acoustic intensity (A) and microbubble replenishment velocity (beta) by contrast echocardiography. Feasibilities of qualitative analysis of myocardial perfusion, and CFVR and MBFR measurements were 98%, 83%, and 94%, respectively. Patients with LAD stenosis had lower CFVR (1.1 +/- 0.4 vs 2.7 +/- 0.8, P < .001), MBFR (1.2 +/- 0.5 vs 2.5 +/- 0.8, P < .001), and beta reserve (1.1 +/- 0.5 vs 2.4 +/- 0.6, P < .001) than those without lesion. Sensitivities, specificities, and accuracies for detecting LAD stenosis were 64%, 93%, and 80% for qualitative analysis of myocardial perfusion; 92%, 94%, and 93% for CFVR; 84%, 87%, and 86% for MBFR; and 80%, 97%, and 89% for beta reserve. In this selected study population, CFVR was the best index for detecting LAD stenosis (odds ratio = 1.78, 95% confidence interval = 1.28-2.47).
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 07/2007; 20(6):709-16. · 2.98 Impact Factor
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    ABSTRACT: Devido aos efeitos cronotrópicos e inotrópicos negativos dos beta-bloqueadores (BB), recomenda-se que estas medicações sejam suspensas antes da realização de testes sob estresse. Entretanto, na prática clínica, tal conduta nem sempre é seguida. Objetivo: Determinar o efeito do uso BB no valor prognóstico da ecocardiografia sob estresse pela dobutamina com injeção precoce de atropina (EED- AP). Métodos: Estudados retrospectivamente 693 pacientes (60±12 anos, 393 homens) submetidos a EED- AP (início na dose de 20 µg/Kg/min). Dentre eles, 262 (38%) estavam em uso de BB. Os pacientes foram acompanhados por um período médio de 20 meses (máximo 65 meses) Eventos foram definidos como morte, infarto não fatal (IAM) e revascularização. Resultados: EED foi - em 448 (65%), + em 172 (25%) e inconclusiva em 73 (10%) pts. Eventos ocorreram em 80 (12%) pts (27 mortes, 12 IAMs, 10 revascularização cirúrgicas, 31 intervenções percutâneas). Pela análise univariada os preditores de eventos foram diabetes (p=0,008), revascularização prévia (p<0,001), sexo masculino (p=0,011), uso BB (p=0,04), IAM prévio (p=0,009), fração de ejeção <50% (p<0,001), e EED + (p<0,001). Pela análise multivariada o único preditor independente de eventos foi EED + (OR 4,99, IC 95% 2,98-8,35; p<0,001). A taxa de eventos em 2 anos em pts sem BB e EED- foi 4%, com BB e EED- foi 7%, sem BB e EED+ foi 34% e com BB e EED + foi 24% (p<0,001, Figura).Conclusão: A detecção de isquemia durante a EED com injeção precoce de atropina foi um preditor independente de eventos. Pts com EED- em uso crônico de BB tiveram uma taxa discretamente maior de eventos que aqueles sem BB. Pts com EED + sob efeito de BB tiveram melhor prognóstico que aqueles sem BB, provavelmente devido aos efeitos terapêuticos do BB em pacientes com doença arterial coronária.
    Revista da Sociedade de Cardiologia do Estado de São Paulo. 01/2007; 17:54.
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    ABSTRACT: This is the report on a 45-year-old female, with a history of systemic arterial hypertension and cigarette smoking, submitted to dobutamine-atropine stress echocardiography for the investigation of coronary artery disease. At stress peak, the patient reported sudden, highly intense precordial pain. The 12-lead electrocardiogram showed ST segment elevation in DII, DIII, aVF, V5 and V6, and depression in DI, aVL, V2 and V3. Echocardiographic imaging monitoring showed dyskinesia of inferior septum and akinesia of inferior wall. The test was interrupted immediately. The patient was medicated and improved her precordial pain condition as well as wall motion abnormalities. Coronary angiography showed irregular coronary lesions with <50% luminal diameter obstruction. It is a case of coronary spasm induced by alpha-adrenergic stimulation during dobutamine-atropine stress echocardiography.
    Arquivos brasileiros de cardiologia 12/2006; 87(6):e250-3. · 1.32 Impact Factor
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    ABSTRACT: Objective: To determine the effect of BB on the prognostic value of EA-DSE. Methods: We studied 693 patients (pts) who underwent EA-DSE (started at 20 µg/Kg/min of dobutamine) for known or suspected coronary artery disease (CAD). Among them, 262 (38%) were using BB, not discontinued before test. Pts were followed for a median of 20 months (up to 65 months). Results: EA-DSE was negative in 448 (65%), positive in 172 (25%) and inconclusive in 73 (10%) pts due to chronotropic incompetence. 80 events occurred(27 deaths, 12 myocardial infarction (MI), 41 revasculariza-tions). By univariate analysis the predictors of events were diabetes (p=0.008), previous coronary bypass graft (p<0.001), male sex (p=0.011), BB (p=0.04), previous MI (p=0.009), ejection fraction<50% (p<0.001), and positive EA-DSE (p<0.001). By multivariate analysis the only independent predictor was positive EA-DSE (OR 4.99, 95% CI 2.98 – 8.35;p<0.001). Two-year event rate in pts without BB and negative EA-DSE was 4%, with BB and negative EA-DSE was 7%, without BB and positive EA-DSE was 34% and with BB and positive EA-DSE was 24% (p<0.001, Figure). Conclusion: Detection of ischemia during EA-DSE was an independent predictor of events. Patients with negative EA-DSE under BB had a slightly higher event rate than those without BB. Patients with a positive EA-DSE under BB had better prognosis than those without therapy, probably due to the therapeutical effects of BB in pts with CAD.
    Circulation 11/2006; 114:II 480. · 14.95 Impact Factor
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    ABSTRACT: Influência do uso crônico de betabloqueadores no valor prognóstico da ecocardiografia sob estresse pela dobutamina com injeção precoce de atropina Devido aos efeitos cronotrópicos e inotrópicos negativos dos beta-bloqueadores (BB), recomenda-se que estas medicações sejam suspensas antes da realização da ecocardiografia sob estresse pela dobutamina (EED). Entretanto, na prática clínica, tal conduta nem sempre é possível. A influência do uso crônico de BB no valor prognóstico da EED com injeção precoce de atropina permanece desconhecida. objetivo: Determinar o valor prognóstico da EED com injeção precoce de atropina em pacientes com e sem uso crônico de BB. métodos: Estudados retrospectivamente 693 pts (60±12 anos, 393 homens) submetidos a EED com injeção precoce de atropina (início na dose de 20 µg/Kg/min). 262 (38%) pts usavam BB. Pts foram acompanhados por 20 meses (até 65 meses). Eventos foram definidos como morte, infarto(IAM) não fatal e revascularização. resultados: Eventos ocorreram em 80 (11.5%) pacientes (27 mortes, 12 IAM, 10 cirurgias de revascularização, 31 intervenções percutâneas). Pela análise univariada, os preditores de eventos foram diabetes melito (p=0,008), revascularização prévia (p<0,001), sexo masculino (p=0,011), uso de BB (p=0,04), IAM prévio (p=0,009), fração de ejeção <50% (p<0,001), e EED positiva (p<0,001). Pela análise multivariada, o único preditor independente de eventos foi EED positiva (RR 4,99, 95% CI 2,98-8,35; p<0,001). A taxa de eventos em dois anos em pts sem BB e EED negativa foi 4%, em pts com BB e EED negativa foi 7%, pts com BB e EED positiva foi 34% e BB com EED positiva foi 24% (p<0,001 entre grupos). Conclusão: A detecção de isquemia pela EED com injeção precoce de atropina é um preditor independente de eventos. Pacientes com EED negativa sob uso de BB tem uma taxa de eventos discretamente maior que sem BB. Pts com EED positiva com BB tem melhor prognóstico provavelmente devido aos efeitos terapêuticos do BB em pacientes com doença arterial coronariana.
    revista brasileira de ecocardiografia. 01/2006; 19:26-26.
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    Arquivos Brasileiros de Cardiologia 01/2006; 87(6). · 1.12 Impact Factor
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    ABSTRACT: To determine the safety and cardiac chronotropic responsiveness to early atropine dobutamine stress echocardiography (DSE) in the elderly. Retrospective study of 258 patients >or= 70 years who underwent early atropine DSE and 290 patients >or= 70 years who underwent conventional DSE. In the early atropine protocol, atropine was started at 20 microg/kg/min of dobutamine if heart rate was < 100 beats/min, up to 2 mg. The cardiac chronotropic responsiveness in the elderly was compared with a control group of patients < 70 years matched for sex, myocardial infarction, diabetes, and treatment with beta blockers and calcium channel blockers. The dose of dobutamine given to elderly patients was lower during early atropine than during conventional DSE (mean (SD) 29 (7) v 38 (4) microg/kg/min, p = 0.001). Early atropine DSE resulted in diminished incidence of ventricular extrasystoles, non-sustained ventricular tachycardia, bradycardia, and hypotension compared with conventional DSE. In comparison with patients < 70 years, elderly patients required lower doses of dobutamine and atropine and achieved a higher percentage of predicted maximum heart rate (92 (9)% v 88 (10)%, p = 0.0001). Except for more common hypotension (16% v 10%, p = 0.004), no other difference in adverse effects was observed between patients >or= 70 and < 70 years. Early atropine DSE is a safe strategy in the elderly resulting in lower incidence of minor adverse effects than with the conventional protocol. Elderly patients presented adequate cardiac chronotropic responsiveness to early injections of atropine, requiring lower doses of drugs to reach test end points.
    Heart (British Cardiac Society) 12/2005; 91(12):1563-7. · 6.02 Impact Factor
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    ABSTRACT: We sought to study the value of microvascular perfusion assessed by myocardial contrast echocardiography in predicting left ventricular remodeling after anterior wall acute myocardial infarction. In 31 patients myocardial contrast echocardiography was performed up to 48 hours after acute myocardial infarction with determination of end-diastolic and end-systolic volumes, wall-motion score index, and myocardial perfusion score index (MPSI) at rest and under dobutamine stress at 6 months. Patients were classified into remodeling group (RG) (n = 19) and non-RG (n = 12), and, according to number of segments without opacification, reflow (< or =2 segments, n = 15) and no-reflow (>2 segments, n = 16) groups. Wall-motion score index (1.84 +/- 0.22 vs 1.64 +/- 0.3; P =.049), MPSI (1.53 +/- 0.25 vs 1.26 +/- 0.17; P =.006), and number of segments without contrast (3.11 +/- 2.23 vs 1.08 +/- 1.38; P =.018) were higher in RG than in non-RG. End-diastolic and end-systolic volumes, and wall-motion score index, increased significantly in RG at 6 months and decreased in non-RG. MPSI increased in RG (1.53 +/- 0.25-1.66 +/- 0.21; P =.011) and was the only independent predictor of left ventricular remodeling (odds ratio = 1.8; 95% confidence interval = 1.15-2.82; P =.010). No-reflow group presented 27.8 +/- 19.9% of segments with resting functional recovery or contractile reserve, and reflow group presented 69.9 +/- 31.2% (P <.001). MPSI obtained 48 hours after acute myocardial infarction is an independent predictor of left ventricular remodeling. Patients with two or fewer segments without opacification revealed a better prognosis of resting ventricular function and contractile reserve.
    Journal of the American Society of Echocardiography 10/2004; 17(9):923-32. · 3.99 Impact Factor
  • Journal of the American College of Cardiology 03/2004; 43(5). · 15.34 Impact Factor
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    ABSTRACT: We studied the value of a rapid beta-blocker injection at peak dobutamine-atropine stress echocardiography (DASE) for the detection of coronary artery disease (CAD). The presence of tachycardia and hyperdynamic wall motion may make it difficult to recognize a new wall motion abnormality (NWMA) at peak stress. We studied 101 patients (mean age 58.2 +/- 9.8 years) who underwent effective DASE and coronary angiography. All patients received a rapid intravenous injection of metoprolol immediately after peak DASE image acquisition. Positivity in combined peak plus post-metoprolol images was defined when there was only peak NWMA, maintenance of peak NWMA, or NWMA detected only after metoprolol injection. Significant CAD was defined as >or=50% stenosis by quantitative angiography. There were 37 patients without and 64 with CAD. The sensitivity, specificity, accuracy, and positive and negative predictive values for the detection of CAD at peak stress were 84%, 92%, 87%, 95%, and 77%, respectively. Five patients with CAD had negative peak images that became positive only after metoprolol. Extension of peak NWMA during metoprolol was observed in 14 patients, and multivessel CAD was detected in 10 of them. The sensitivity, specificity, accuracy, and positive and negative predictive values for peak plus metoprolol images were 92%, 89%, 91%, 94%, and 87%, respectively. The use of metoprolol injected at peak of dobutamine infusion improved the detection of CAD by DASE.
    Journal of the American College of Cardiology 05/2003; 41(9):1583-9. · 15.34 Impact Factor