Editorial comment
Is there still a place for new echocardiographic parameters in risk stratification after acute myocardial infarction?
Ainda haverá lugar para novos parâmetros ecocardiográficos na estratificação de risco após enfarte agudo do miocárdio?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "809" "paginaFinal" => "810" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Ana Teresa Timóteo" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Ana Teresa" "apellidos" => "Timóteo" "email" => array:1 [ 0 => "ana_timoteo@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Centro Universitário de Cardiologia, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Nova Medical School, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ainda haverá lugar para novos parâmetros ecocardiográficos na estratificação de risco após enfarte agudo do miocárdio?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Left atrial (LA) function is essential for correct left ventricular filling and is directly related to diastolic function, and LA volume index (LAVI) is an important parameter in the guidelines for evaluation of diastolic function.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is also of acknowledged prognostic value in various heart diseases, including atrial fibrillation, aortic valve stenosis, congenital heart disease, heart failure and others,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–6</span></a> and has recently taken the place of previously used parameters such as LA anteroposterior diameter and area by planimetry.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the current issue of the <span class="elsevierStyleItalic">Journal</span>, Cordeiro et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> analyze the prognostic impact of LAVI, a simple echocardiographic measure, in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention and enrolled over a five-year period. LA volume was determined by the area-length method and indexed to body surface area, and was increased in 42% of patients. In a median follow-up of 28 months, 7.0% of the subjects died, 26.5% had the cardiac composite endpoint and 29% had the cardiovascular composite endpoint. These events were more frequent in patients with LA enlargement, which was an independent predictor of mortality and the composite endpoints.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study is not original, since this association has been suggested by previous studies with similar population sizes.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> Nevertheless, it has the merit of being carried out in Portugal and thus validating these findings for this country. However, there are some contentious points. The authors calculated LA volume using the area-length method, which although one of the techniques recommended for LA assessment, assumes that the atrium is ellipsoidal in shape, which is not always the case. Other authors have shown that the area-length method gives higher values than the other main recommended technique, the method of disks, and that if the latter is applied up to 18% of patients will be reclassified on the basis of the 2015 guidelines.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> At all events, increased LA volume is associated with worse prognosis irrespective of the thresholds considered or the techniques used.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In addition, in their multivariate analysis, the authors did not adjust for other clinical and laboratory variables with known prognostic impact in acute coronary syndrome, including renal function, Killip class, heart rate and blood pressure, or for the presence of hypertension, which affects LA dimensions. If these variables had been included, they might have reduced or nullified the independent effect observed. Another variable that was not accounted for was ischemia time. It is now known that longer ischemia time is associated with increased LA volume, and so this parameter should have been included in the statistical analysis.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, another important limitation – acknowledged by the authors – is the sample size, which, although reasonable, is insufficient for the proposed analysis, and the rather low number of certain events, obliging the authors to use composite endpoints. The consequences are particularly evident in the wide confidence intervals presented for some events, as well as in the absence of statistical significance in some comparisons between groups despite clear differences in values and percentages.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The use of LAVI, an easily obtained echocardiographic parameter, appears to be a promising tool for prognostic assessment. Echocardiographic assessment is in fact mandatory according to quality criteria in acute coronary syndromes, and therefore any information with prognostic value that echocardiography can provide should always be taken into account. However, certain questions need to be borne in mind. Should we increase the complexity of risk stratification by adding the new parameters that are continually being described? Is the prognostic value of LA volume superior to that of other well-established parameters, used in isolation or as part of risk scores such as GRACE? What are the real clinical implications of a dilated left atrium, and should its presence alter clinical practice? These issues require further investigation, for which larger studies, with sufficient statistical power, will be needed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Timóteo AT. Ainda haverá lugar para novos parâmetros ecocardiográficos na estratificação de risco após enfarte agudo do miocárdio?. Rev Port Cardiol. 2018;37:809–810.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.F. Nagueh" 1 => "A.O. Smiseth" 2 => "C.P. 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| 2022 January | 15 | 21 | 36 |
| 2021 December | 22 | 26 | 48 |
| 2021 November | 31 | 38 | 69 |
| 2021 October | 29 | 34 | 63 |
| 2021 September | 24 | 26 | 50 |
| 2021 August | 26 | 24 | 50 |
| 2021 July | 20 | 24 | 44 |
| 2021 June | 20 | 17 | 37 |
| 2021 May | 27 | 34 | 61 |
| 2021 April | 54 | 33 | 87 |
| 2021 March | 42 | 17 | 59 |
| 2021 February | 22 | 21 | 43 |
| 2021 January | 20 | 8 | 28 |
| 2020 December | 27 | 12 | 39 |
| 2020 November | 15 | 13 | 28 |
| 2020 October | 10 | 12 | 22 |
| 2020 September | 10 | 6 | 16 |
| 2020 August | 7 | 9 | 16 |
| 2020 July | 11 | 5 | 16 |
| 2020 June | 4 | 4 | 8 |
| 2020 May | 13 | 17 | 30 |
| 2020 April | 10 | 5 | 15 |
| 2020 March | 8 | 10 | 18 |
| 2020 February | 17 | 28 | 45 |
| 2020 January | 8 | 10 | 18 |
| 2019 December | 10 | 4 | 14 |
| 2019 November | 7 | 7 | 14 |
| 2019 October | 10 | 4 | 14 |
| 2019 September | 9 | 8 | 17 |
| 2019 August | 21 | 5 | 26 |
| 2019 July | 12 | 7 | 19 |
| 2019 June | 25 | 16 | 41 |
| 2019 May | 30 | 8 | 38 |
| 2019 April | 16 | 13 | 29 |
| 2019 March | 11 | 14 | 25 |
| 2019 February | 13 | 12 | 25 |
| 2019 January | 16 | 6 | 22 |
| 2018 December | 12 | 21 | 33 |
| 2018 November | 47 | 28 | 75 |
| 2018 October | 19 | 10 | 29 |
Show all
