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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary embolism &#40;PE&#41; is a relatively common entity in the emergency department&#44; with high rates of mortality and morbidity when not treated promptly&#46; It is also a diagnostic challenge in clinical practice&#44; with a clinical presentation that is often unclear&#44; especially in an acute context&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Mortality in undiagnosed PE is 4&#8211;6 times higher than in patients who are diagnosed and treated appropriately &#40;in-hospital mortality of 6&#8211;8&#37;&#44; as opposed to overall mortality of 25&#8211;30&#37; in untreated PE&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The main difficulty for effective treatment of PE is timely diagnosis&#46; Among the reasons for this diagnostic challenge are its sometimes subtle and non-specific clinical presentation&#44; the need for a variety of diagnostic techniques&#44; and the lack of a gold standard exam that is both readily available and easy to interpret&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Presented at the last Congress of the European Society of Cardiology &#40;ESC&#41;&#44; the latest ESC guidelines on the diagnosis and management of acute pulmonary embolism&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which replace the previous guidelines published in 2000 and 2008&#44; focus on optimizing the diagnosis and treatment of PE&#44; among other areas&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In more severe cases&#44; occlusion of the pulmonary arterial bed by thromboemboli can cause acute right ventricular &#40;RV&#41; failure&#44; which although potentially reversible&#44; can be fatal&#46; As the therapeutic approach depends on clinical presentation&#44; immediate restoration of blood flow in obstructed pulmonary arteries is vital in hemodynamically unstable patients&#46; Routine diagnostic exams such as chest X-ray&#44; electrocardiogram and blood gas analysis are often altered in PE and their positive and negative predictive value for a diagnosis of PE are low&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Patients with echocardiographic evidence of right heart failure and increased filling pressures have double the risk of death if they have PE&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> In the literature&#44; the prevalence of RV dysfunction on echocardiography ranges between 30&#37; and 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Despite the complex geometry of the right ventricle and resulting difficulty in assessing systolic and diastolic function&#44; it is essential to understand the mechanisms behind right heart failure&#44; since this is one of the main causes of premature death in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Selcuk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> present an elegant study entitled &#8220;The value of isovolumic acceleration for the assessment of RV function in acute pulmonary embolism&#8221;&#46; In it&#44; echocardiographic indices of RV function were assessed in 15 patients with acute PE &#40;mean age 60&#46;6&#177;11&#46;3 years&#41; and a control group &#40;mean age 60&#46;3&#177;11&#46;5 years&#41; at two time points&#46; Although the population was relatively small&#44; the study is a good example of the deliberate early use of echocardiography in acute PE&#46; Although information on the risk factors of the patients in the study is not provided&#44; the benefits and accessibility of the technique are of great value in the early management of these patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There are several echocardiographic indices that are important in PE&#44; particularly the so-called &#8216;60&#8211;60 sign&#8217; &#40;reduced RV ejection fraction&#41; and depressed contractility of the RV free wall compared with the RV apex &#40;&#8216;McConnell sign&#8217;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The main point of Selcuk et al&#46;&#8217;s study&#44; and its main merit&#44; is to highlight the role of isovolumic acceleration time &#40;IVA&#41; in the early diagnosis of RV dysfunction&#46; They found a statistically significant improvement in IVA at one-month follow-up &#40;2&#46;0&#177;0&#46;1 m&#47;s<span class="elsevierStyleSup">2</span> at the time of diagnosis and 2&#46;9&#177;0&#46;1 m&#47;s<span class="elsevierStyleSup">2</span> at one month&#44; p&#60;0&#46;0001&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">As more sophisticated and specialized imaging techniques have become available at the bedside in acute situations&#44; tissue Doppler echocardiography is increasingly used to assess RV function&#44; particularly through IVA&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> which&#44; being unaffected by pre- or afterload&#44; provides valuable information for the diagnosis and management of acute PE&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It should be used serially&#44; particularly in more severe cases with hemodynamic compromise&#44; as one of the routine diagnostic exams for such situations&#46; Analysis of receiver operating characteristic &#40;ROC&#41; curves is a promising method for ascertaining the best cutoff of IVA for early identification of RV dysfunction&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Assessment of RV function can also be complemented by measurement of brain-type natriuretic peptide &#40;BNP&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> which is elevated when intracardiac pressures are increased&#46; The N-terminal portion of BNP &#40;NT-proBNP&#41; has also been identified as an important marker of RV dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Analysis of the relationship between RV systolic dysfunction by tissue Doppler and the functional repercussions of RV overload as estimated by BNP levels could also be of clinical value&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Zimbarra Cabrita I&#46; Imagiologia card&#237;aca no tromboembolismo pulmonar&#58; avalia&#231;&#227;o da disfun&#231;&#227;o ventricular direita por Doppler tecidular&#46; Rev Port Cardiol&#46; 2014&#59;33&#58;597&#8211;598&#46;</p>"
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