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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">A insufici&#234;ncia card&#237;aca &#40;IC&#41; &#233; um problema de sa&#250;de p&#250;blica em todo o mundo e uma em cada cinco pessoas com mais de 40 anos ir&#227;o desenvolver IC durante a sua vida&#46; IC &#233; no Brasil a principal causa de interna&#231;&#227;o entre os idosos com mais de 60 anos<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Mais da metade dos doentes com IC s&#227;o classificados como IC com fra&#231;&#227;o de eje&#231;&#227;o preservada &#40;ICFEP&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> e a propor&#231;&#227;o de doentes com ICFEP tem crescido tanto em pa&#237;ses desenvolvidos como naqueles em desenvolvimento devido ao envelhecimento da popula&#231;&#227;o e ao aumento do reconhecimento m&#233;dico da s&#237;ndrome que compromete principalmente mulheres e doentes com m&#250;ltiplas comorbidades<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a>&#46; Gastos associados com IC s&#227;o elevados tanto em doentes no ambiente hospitalar como no cen&#225;rio ambulatorial&#44; independentemente da fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo &#40;FEVE&#41;&#46; Portanto&#44; a utiliza&#231;&#227;o de um exame de f&#225;cil execu&#231;&#227;o pode ser &#250;til na triagem desses doentes para realiza&#231;&#227;o de uma investiga&#231;&#227;o mais complexa<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">O pept&#237;deo natriur&#233;tico tipo B &#40;BNP&#41; &#233; liberado em resposta ao aumento da press&#227;o de enchimento do ventr&#237;culo esquerdo &#40;VE&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> e ao estresse parietal diast&#243;lico final do VE<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> e n&#237;veis s&#233;ricos de BNP s&#227;o &#250;teis tanto para o diagn&#243;stico &#40;confirmando ou n&#227;o a presen&#231;a de IC&#41; como para avalia&#231;&#227;o do progn&#243;stico da IC<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Artigo escrito por Paulus et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> prop&#244;s crit&#233;rios para diagn&#243;stico e exclus&#227;o de ICFEP que incluem par&#226;metros ecodopplercardiogr&#225;ficos e doseamento do BNP<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; O ponto de corte do BNP utilizado por Paulus et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> foi baseado em dados do estudo de Maisel et al&#46;&#44; que utilizou doentes agudos na sala de emerg&#234;ncia com IC aguda<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Por outro lado&#44; estudos usando valores de BNP em doentes ambulat&#243;rios mostraram valores menores do que os utilizados por Paulus para diagn&#243;stico de ICFEP&#44; por&#233;m com crit&#233;rios ecodopplercardiogr&#225;ficos diferentes para confirma&#231;&#227;o diagn&#243;stica<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Portanto&#44; o melhor valor do ponto de corte do BNP para confirmar ou excluir ICFEP em doentes ambulat&#243;rios pelos crit&#233;rios propostos por Paulus n&#227;o foram validados na pr&#225;tica cl&#237;nica e a realiza&#231;&#227;o de um exame de baixo custo&#44; como o BNP&#44; pode ajudar a excluir ICFEP e direcionar a investiga&#231;&#227;o das queixas do paciente para outras &#225;reas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">O objetivo desse estudo &#233; tentar identificar a acuidade diagn&#243;stica e o melhor valor de corte do BNP em doentes ambulat&#243;rios para confirmar ou excluir ICFEP de acordo com os crit&#233;rios de Paulus et al&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Metodologia</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Popula&#231;&#227;o</span><p id="par0040" class="elsevierStylePara elsevierViewall">Estudo prospectivo&#44; observacional e transversal envolvendo consecutivamente 161 doentes ambulat&#243;rios &#40;m&#233;dia de idade 68&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;5 anos&#59; 72&#37; mulheres&#41; com suspeita cl&#237;nica de IC&#46; Todos os doentes estavam em classe funcional <span class="elsevierStyleSmallCaps">II</span> ou <span class="elsevierStyleSmallCaps">III</span> da <span class="elsevierStyleItalic">New York Heart Association</span>&#46; ICFEP foi definida de acordo com os crit&#233;rios da SEC que inclu&#237;am presen&#231;a de sinais ou sintomas de IC&#44; FEVE &#8805;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; volume diast&#243;lico final indexado do VE &#40;VDF-<span class="elsevierStyleSmallCaps">I</span>&#41; &#8804;<span class="elsevierStyleHsp" style=""></span>97<span class="elsevierStyleHsp" style=""></span>mL&#47;m<span class="elsevierStyleSup">2</span> e presen&#231;a de disfun&#231;&#227;o diast&#243;lica<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Evid&#234;ncias diagn&#243;sticas de disfun&#231;&#227;o diast&#243;lica foram obtidas pelo ecocardiograma com Doppler tecidual &#40;EDT&#41; pela presen&#231;a da rela&#231;&#227;o E&#47;E&#8217; &#62;<span class="elsevierStyleHsp" style=""></span>15&#46; Se E&#47;E&#8217; fosse sugestiva de disfun&#231;&#227;o diast&#243;lica &#40;entre 8-15&#41;&#44; outras medidas ecocardiogr&#225;ficas deveriam ser utilizadas para confirmar o diagn&#243;stico como massa do VE indexada &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>122 e &#8805;<span class="elsevierStyleHsp" style=""></span>149<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span> para mulheres e homens respectivamente&#41;&#44; volume da aur&#237;cula esquerda indexado &#40;VAE-<span class="elsevierStyleSmallCaps">I</span> &#8805;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mL&#47;m<span class="elsevierStyleSup">2</span>&#41;&#44; rela&#231;&#227;o E&#47;A &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;5 com tempo de desacelera&#231;&#227;o de E &#62;<span class="elsevierStyleHsp" style=""></span>280<span class="elsevierStyleHsp" style=""></span>ms&#46; Um eletrocardiograma com fibrila&#231;&#227;o atrial na presen&#231;a de rela&#231;&#227;o E&#47;E&#8217; entre -15 tamb&#233;m confirmaria o diagn&#243;stico de ICFEP<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Doentes com doen&#231;a valvular card&#237;aca severa&#44; portadores de marca-passo definitivo&#44; doentes submetidos a cirurgia card&#237;aca nos &#250;ltimos seis meses e portadores de doen&#231;a pulmonar obstrutiva cr&#244;nica severa foram exclu&#237;dos do estudo&#46; O estudo encontra-se de acordo com os princ&#237;pios estabelecidos na declara&#231;&#227;o de Helsinki e o protocolo foi aprovado pelo comit&#234; de &#233;tica da institui&#231;&#227;o &#40;n&#250;mero 00410&#46;258&#46;000-08&#41; e todos os doentes assinaram o termo de consentimento livre e esclarecido antes da inclus&#227;o no estudo&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ecocardiograma convencional e Doppler tecidual</span><p id="par0055" class="elsevierStylePara elsevierViewall">O ecodopplercardiograma foi realizado por um ecocardiografista com utiliza&#231;&#227;o do aparelho VIVID 7 &#40;GE<span class="elsevierStyleSup">&#174;</span> EUA&#41;&#44; e analisado com <span class="elsevierStyleItalic">software</span> ECHOPAC por um investigador experiente sem o conhecimento pr&#233;vio dos resultados dos outros exames&#46; O exame foi realizado segundo as recomenda&#231;&#245;es para quantifica&#231;&#227;o de c&#226;maras da ASE&#47;EAE<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">A fun&#231;&#227;o sist&#243;lica foi avaliada pela medida da FEVE e pelo estiramento do eixo longitudinal &#40;S&#8217;&#41; obtido pelo Doppler tecidual&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A medida do VAE foi obtida atrav&#233;s do m&#233;todo biplanar de discos &#40;regra de Simpson modificada&#41; com a utiliza&#231;&#227;o do corte apical quatro e duas c&#226;maras em s&#237;stole ventricular esquerda final&#44; indexado a superf&#237;cie corporal&#46; Os par&#226;metros da fun&#231;&#227;o diast&#243;lica foram estimados pela m&#233;dia de cinco batimentos consecutivos&#46; O fluxo transmitral inicial &#40;E&#41; e tardio &#40;A&#41; e o tempo de desacelera&#231;&#227;o da onda E foram medidos&#46; A velocidade do relaxamento mioc&#225;rdico no in&#237;cio da di&#225;stole &#40;E&#8216;&#41; foi medida pelo EDT nos segmentos septal e lateral do anel mitral e a m&#233;dia dessas medidas obtidas&#46; Todos os exames foram gravados em m&#237;dia digital para futuras an&#225;lises e revis&#245;es&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Eletrocardiograma</span><p id="par0070" class="elsevierStylePara elsevierViewall">Todos os doentes foram submetidos ao exame de ECG em 12 deriva&#231;&#245;es em repouso para identificar a presen&#231;a de fibrila&#231;&#227;o atrial&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Pept&#237;deo natriur&#233;tico do tipo B O BNP foi dosado no sangue atrav&#233;s do <span class="elsevierStyleItalic">Triage</span> BNP <span class="elsevierStyleItalic">Test</span> &#40;BIOSITE &#8211; EUA&#41;&#44; que &#233; um teste r&#225;pido por fluoroimunoan&#225;lise para medida quantitativa de BNP com leitura pelo <span class="elsevierStyleItalic">Triage Meter</span>&#46; Os valores de BNP foram expressos em pg&#47;mL&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">An&#225;lise estat&#237;stica</span><p id="par0080" class="elsevierStylePara elsevierViewall">A an&#225;lise estat&#237;stica foi processada pelo <span class="elsevierStyleItalic">software</span> SPSS<span class="elsevierStyleSup">&#174;</span> vers&#227;o 15&#46;0&#46; As vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o normal foram expressas em m&#233;dia<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>desvio padr&#227;o e as demais em mediana&#46; Foram usados os testes ANOVA e qui-quadrado para testar diferen&#231;a de m&#233;dias entre vari&#225;veis cont&#237;nuas com distribui&#231;&#227;o normal&#44; entre as cont&#237;nuas sem distribui&#231;&#227;o normal e entre as vari&#225;veis categ&#243;ricas&#44; respectivamente&#46; A correla&#231;&#227;o de Spearman &#40;rho&#41; foi utilizada para medir a associa&#231;&#227;o entre o BNP e as vari&#225;veis cl&#237;nicas e ecocardiogr&#225;ficas&#46; Uma curva <span class="elsevierStyleItalic">receiver operator characteristic</span> &#40;ROC&#41; foi constru&#237;da para expressar a sensibilidade e especificidade do BNP em diagnosticar ICFEP&#46; Foi adotado um n&#237;vel de signific&#226;ncia estat&#237;stica de 0&#44;05&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0085" class="elsevierStylePara elsevierViewall">As caracter&#237;sticas cl&#237;nicas&#44; laboratoriais e ecocardiogr&#225;ficas dos doentes s&#227;o mostradas na <a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Doentes com ICFEP eram mais idosos&#44; com maior preval&#234;ncia de hipertens&#227;o arterial&#44; diabetes&#44; fibrila&#231;&#227;o atrial e menores valores na taxa de filtra&#231;&#227;o glomerular &#40;TFG&#41; em rela&#231;&#227;o aos doentes sem ICFEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Os par&#226;metros de fun&#231;&#227;o sist&#243;lica e diast&#243;lica avaliados pelo ecodopplercardiograma demonstraram disfun&#231;&#227;o sist&#243;lica e diast&#243;lica mais acentuada no grupo com ICFEP em rela&#231;&#227;o ao grupo sem ICFEP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Tabela 1</a>&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">BNP foi significativamente diferente entre doentes com e sem ICFEP &#40;144&#44;4 mediana de 113<span class="elsevierStyleHsp" style=""></span>pg&#47;<span class="elsevierStyleItalic">versus</span> 27&#44;6 mediana de 16&#44;7<span class="elsevierStyleHsp" style=""></span>pg&#47;mL p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">A <a class="elsevierStyleCrossRef" href="#tbl0010">Tabela 2</a> mostra a correla&#231;&#227;o do BNP com as vari&#225;veis cl&#237;nicas e ecocardiogr&#225;ficas&#46; Observa-se uma correla&#231;&#227;o direta entre valores do VAE-<span class="elsevierStyleSmallCaps">I</span>&#44; idade e da rela&#231;&#227;o E&#47;E&#8217; e indireta da taxa de filtra&#231;&#227;o glomerular estimada com os n&#237;veis de BNP&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">A &#225;rea sob a curva ROC para o BNP detectar ICFEP foi de 0&#44;92 &#40;95&#37; IC&#44; 0&#44;87-0&#44;96&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figura 1</a>&#41; e o valor de corte do BNP de 51<span class="elsevierStyleHsp" style=""></span>pg&#47;mL foi o que melhor se correlacionou com o diagn&#243;stico de ICFEP em doentes ambulat&#243;rios com uma sensibilidade de 86&#37;&#44; especificidade de 86&#37;&#44; valor preditivo positivo de 93&#37; e valor preditivo negativo de 72&#37;&#44; com uma acuidade diagn&#243;stica de 86&#37;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discuss&#227;o</span><p id="par0115" class="elsevierStylePara elsevierViewall">Esse trabalho foi o primeiro a utilizar os crit&#233;rios da SEC<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> para diagn&#243;stico e exclus&#227;o de ICFEP&#44; de modo prospectivo&#44; em doentes ambulat&#243;rios e demonstrar que doentes com ICFEP apresentam valores elevados de BNP&#44; por&#233;m com valores menores daqueles encontrados em doentes na sala de emerg&#234;ncia&#46; Nossos dados sugerem que valores de corte de BNP para ICFEP em doentes ambulat&#243;rios poderiam ser menores do que os valores apresentados no consenso da SEC&#44; que foi baseado em estudos com doentes apresentando IC aguda<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Na sala de emerg&#234;ncia&#44; sinais e sintomas de IC congestiva est&#227;o usualmente presentes e como muitos doentes s&#227;o hospitalizados por edema agudo de pulm&#227;o valores de BNP s&#227;o mais elevados quando comparados a doentes ambulat&#243;rios como j&#225; foi demonstrado pelo estudo BNP envolvendo 1&#46;586 doentes em que um valor de corte do BNP de 100<span class="elsevierStyleHsp" style=""></span>pg&#47;mL teve uma sensibilidade de 90&#37; e especificidade de 76&#37; para diferenciar IC aguda independente do valor da FEVE&#44; de outras causas de dispneia<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Em doentes ambulat&#243;rios com ICFEP a &#250;nica queixa apresentada pelo paciente pode ser a dispneia aos esfor&#231;os sem sinais de congest&#227;o e esses doentes s&#227;o geralmente mulheres&#44; idosos&#44; obesos e com m&#250;ltiplas comorbidades<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; O diagn&#243;stico de ICFEP nesses casos &#233; um desafio para o m&#233;dico e o uso de um biomarcador como o BNP seria &#250;til na identifica&#231;&#227;o desses doentes&#44; por&#233;m esses doentes ir&#227;o ter valores menores de BNP quando comparados com doentes na sala de emerg&#234;ncia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Nossos dados demonstram que doentes com ICFEP apresentam importante disfun&#231;&#227;o diast&#243;lica caracterizada por altera&#231;&#245;es do relaxamento ventricular &#40;E&#8217;&#41; e aumento nas press&#245;es de enchimento do VE &#40;VAE-<span class="elsevierStyleSmallCaps">I</span> e rela&#231;&#227;o E&#47;E&#8217;&#41; na presen&#231;a de FEVE normal&#46; A correla&#231;&#227;o dos valores de BNP com par&#226;metros ecocardiogr&#225;ficos observados nesse estudo refletem a associa&#231;&#227;o do BNP com a fun&#231;&#227;o diast&#243;lica do VE&#46; Portanto BNP &#233; uma importante ferramenta de f&#225;cil execu&#231;&#227;o na avalia&#231;&#227;o de dispneia em doentes ambulat&#243;rios com suspeita de IC&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Arques et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> estudaram 26 doentes ambulat&#243;rios que apresentavam dispneia cr&#244;nica como &#250;nica manifesta&#231;&#227;o de IC&#44; estes doentes foram submetidos a cateteriza&#231;&#227;o card&#237;aca&#44; considerado o padr&#227;o ouro para confirmar o diagn&#243;stico de ICFEP<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; O estudo demonstrou que valores de BNP de 31<span class="elsevierStyleHsp" style=""></span>pg&#47;mL eram preditivos de ICFEP &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; com 67&#37; de sensibilidade e 73&#37; de especificidade &#40;&#225;rea sob a curva ROC de 0&#44;76&#44; IC 0&#44;55-0&#44;90&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Penicka et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> avaliaram 30 doentes ambulat&#243;rios &#40;73&#37; mulheres&#41; com dispneia cr&#244;nica n&#227;o explicada em classe funcional <span class="elsevierStyleSmallCaps">II</span> e <span class="elsevierStyleSmallCaps">III</span> e FEVE &#62;<span class="elsevierStyleHsp" style=""></span>50&#37; que foram submetidos a cateteriza&#231;&#227;o card&#237;aca&#46; Nesses doentes ICFEP foi definida pela presen&#231;a de uma press&#227;o diast&#243;lica final do VE &#62;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>mmHg em repouso durante a interven&#231;&#227;o hemodin&#226;mica e 20 doentes &#40;66&#37;&#41; tiveram o diagn&#243;stico de ICFEP confirmado&#46; BNP foi mais elevado no grupo ICFEP comparado com o grupo controle &#40;68 <span class="elsevierStyleItalic">versus</span> 21<span class="elsevierStyleHsp" style=""></span>pg&#47;ml p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;09&#41;&#46; Neste estudo somente tr&#234;s doentes mostraram valores de BNP acima do ponto de corte recomendado propostos por Paulus et al<span class="elsevierStyleItalic">&#46;</span> &#40;200<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41; para diagn&#243;stico de ICFEP<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Kitzman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> avaliando 147 doentes ambulat&#243;rios em que 59 eram portadores de ICFEP&#44; observaram um valor m&#233;dio de BNP no grupo ICFEP de 56<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Os dados desses estudos em rela&#231;&#227;o a valores de corte do BNP<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;17&#44;19</span></a>&#44; em doentes com ICFEP&#44; s&#227;o consistentes com o que foi observado em nosso trabalho&#44; confirmando que doentes ambulat&#243;rios com ICFEP podem ter valores de corte do BNP bem menores do que os valores estabelecidos pela SEC<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Estabelecer um valor de corte do BNP mais adequado para doentes ambulat&#243;rios com suspeita de ICFEP em vez dos valores hoje utilizados poderia ajudar na triagem desses doentes na aten&#231;&#227;o prim&#225;ria&#46; Zuber et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> estudaram 384 doentes para avaliar a acuidade dos pept&#237;deos natriur&#233;ticos no diagn&#243;stico de IC na aten&#231;&#227;o prim&#225;ria&#46; Doentes foram divididos de acordo com dados cl&#237;nicos e ecocardiogr&#225;ficos em ICFEP &#40;31-8&#37;&#41; e ICFER &#40;193 &#8211; 50&#37;&#41; e foi utilizado o valor de corte recomendado para BNP de 100<span class="elsevierStyleHsp" style=""></span>pg&#47;mL para diagnosticar e excluir IC&#44; sendo que esse valor apresentou resultado falso negativo em 25&#37; dos doentes com IC&#46; O estudo concluiu que o valor de corte de 100<span class="elsevierStyleHsp" style=""></span>pg&#47;mL falhou na exclus&#227;o de doentes com IC na aten&#231;&#227;o prim&#225;ria&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">A recente diretriz europeia para o diagn&#243;stico e tratamento da IC aguda e cr&#244;nica<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> prop&#245;e um novo ponto de corte do BNP &#40;35<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#41; para excluir IC &#40;fra&#231;&#227;o de eje&#231;&#227;o reduzida ou preservada&#41; em doentes no ambulat&#243;rio capaz de minimizar a ocorr&#234;ncia de falsos negativos e a&#160;realiza&#231;&#227;o de ecocardiogramas desnecess&#225;rios&#46; Este valor foi baseado em dados de oito artigos<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;29</span></a> que utilizaram doentes com suspeita de IC ou em risco de desenvolver IC devido a presen&#231;a de disfun&#231;&#227;o ventricular&#46; O ponto de corte de 51<span class="elsevierStyleHsp" style=""></span>pg&#47;mL encontrado em nosso artigo &#233; espec&#237;fico para ICFEP e apresenta um valor preditivo positivo de 93&#37; e negativo de 72&#37;&#44; sendo &#250;til para confirmar ou excluir ICFEP em doentes no ambulat&#243;rio&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Com o acentuado envelhecimento observado na popula&#231;&#227;o&#44; que ter&#225; como causa um aumento do n&#250;mero de casos de ICFEP&#44; o doseamento do BNP pode se tornar uma ferramenta de baixo custo e de mais f&#225;cil execu&#231;&#227;o que o ecocardiograma para triagem desses doentes no ambulat&#243;rio&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Nosso estudo precisa ser interpretado &#224; luz de suas limita&#231;&#245;es&#46; Como o n&#250;mero absoluto de doentes em que ICFEP foi confirmada era pequeno e considerando o car&#225;ter heterog&#234;neo da s&#237;ndrome e os efeitos resultantes da presen&#231;a de comorbidades que podem interferir nos valores do BNP&#44; futuros estudos envolvendo amostras com um grande n&#250;mero de doentes ambulat&#243;rios se tornam necess&#225;rios para validar esses achados&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclus&#227;o</span><p id="par0175" class="elsevierStylePara elsevierViewall">Valores de BNP em doentes ambulat&#243;rios com ICFEP&#44; diagnosticados pelos crit&#233;rios da Sociedade Europeia de Cardiologia&#44; s&#227;o mais elevados em rela&#231;&#227;o aos doentes em que ICFEP foi exclu&#237;da&#46; O valor de corte de 51<span class="elsevierStyleHsp" style=""></span>pg&#47;mL nesta popula&#231;&#227;o estudada foi o que apresentou melhor acuidade diagn&#243;stica para ICFEP em doentes ambulat&#243;rios&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Responsabilidades &#233;ticas</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Prote&#231;&#227;o dos seres humanos e animais</span><p id="par0180" class="elsevierStylePara elsevierViewall">Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos respons&#225;veis da Comiss&#227;o de Investiga&#231;&#227;o Cl&#237;nica e &#201;tica e de acordo com os da Associa&#231;&#227;o M&#233;dica Mundial e da Declara&#231;&#227;o de Helsinki&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidencialidade dos dados</span><p id="par0185" class="elsevierStylePara elsevierViewall">Os autores declaram ter seguido os protocolos de seu centro de trabalho acerca da publica&#231;&#227;o dos dados de pacientes e que todos os pacientes inclu&#237;dos no estudo receberam informa&#231;&#245;es suficientes e deram o seu consentimento informado por escrito para participar nesse estudo&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Direito &#224; privacidade e consentimento escrito</span><p id="par0190" class="elsevierStylePara elsevierViewall">Os autores declaram ter recebido consentimento escrito dos pacientes e&#47;ou sujeitos mencionados no artigo&#46; O autor para correspond&#234;ncia deve estar na posse deste documento&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflito de interesses</span><p id="par0195" class="elsevierStylePara elsevierViewall">Os autores declaram n&#227;o haver conflito de interesses&#46;</p></span></span>"
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    "fechaRecibido" => "2012-06-14"
    "fechaAceptado" => "2012-10-11"
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          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec258648"
          "palabras" => array:4 [
            0 => "Pept&#237;deo natriur&#233;tico tipo B"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Insufici&#234;ncia card&#237;aca com fra&#231;&#227;o de eje&#231;&#227;o preservada &#40;ICFEP&#41; &#233; uma s&#237;ndrome de alta preval&#234;ncia e dif&#237;cil diagn&#243;stico no ambulat&#243;rio&#46; O doseamento de pept&#237;deo natriur&#233;tico tipo B &#40;BNP&#41; pode ser &#250;til no diagn&#243;stico de ICFEP&#44; por&#233;m com valor de corte diferente daquele utilizado na sala de emerg&#234;ncia&#46; O objetivo desse estudo foi identificar o ponto de corte do BNP em doentes ambulat&#243;rios para diagn&#243;stico de ICFEP&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0010">M&#233;todos&#47;resultados</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudo prospectivo observacional envolvendo 161 doentes ambulat&#243;rios &#40;68&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;5 anos&#44; 72&#37; mulheres&#41; com suspeita de ICFEP&#46; Doentes foram submetidos a exame cl&#237;nico&#44; eletrocardiograma&#44; ecocardiograma com Doppler tecidual e doseamento de BNP e classificados de acordo com crit&#233;rios propostos por Paulus et al&#46; para diagn&#243;stico de ICFEP&#46; ICFEP foi confirmada em 49 doentes que apresentavam valores mais elevados de BNP &#40;144&#44;4<span class="elsevierStyleHsp" style=""></span>pg&#47;mL mediana 113<span class="elsevierStyleHsp" style=""></span>pg&#47;mL <span class="elsevierStyleItalic">versus</span> 27&#44;6<span class="elsevierStyleHsp" style=""></span>pg&#47;mL mediana 16&#44;7<span class="elsevierStyleHsp" style=""></span>pg&#47;mL p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; Uma correla&#231;&#227;o significativa foi mostrada entre BNP e volume da aur&#237;cula esquerda indexada &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;554&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#44; idade &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;452&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; e rela&#231;&#227;o E&#47;E&#8217; &#40;rho<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;345&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41;&#46; A &#225;rea sob a curva ROC para BNP detectar ICFEP foi 0&#44;92 &#40;95&#37; IC&#44; 0&#44;87-0&#44;96&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; e o valor de corte de 51<span class="elsevierStyleHsp" style=""></span>pg&#47;mL foi o que melhor se correlacionou com o diagn&#243;stico de ICFEP &#40;sensibilidade 86&#37;&#44; especificidade 86&#37;&#44; acuidade de 86&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Conclus&#227;o</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Valores de BNP em doentes ambulat&#243;rios com ICFEP s&#227;o significativamente mais elevados que os valores dos doentes sem ICFEP&#46; O valor de corte do BNP de 51<span class="elsevierStyleHsp" style=""></span>pg&#47;mL apresentou melhor acuidade diagn&#243;stica para ICFEP em doentes ambulat&#243;rios&#46;</p>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Heart failure with preserved ejection fraction &#40;HFPEF&#41; is a highly prevalent syndrome that is difficult to diagnose in outpatients&#46; The measurement of B-type natriuretic peptide &#40;BNP&#41; may be useful in the diagnosis of HFPEF&#44; but with a different cutoff from that used in the emergency room&#46; The aim of this study was to identify the BNP cutoff for a diagnosis of HFPEF in outpatients&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Methods and Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">This prospective&#44; observational study enrolled 161 outpatients &#40;aged 68&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;5 years&#44; 72&#37; female&#41; with suspected HFPEF&#46; Patients underwent ECG&#44; tissue Doppler imaging&#44; and plasma BNP measurement&#44; and were classified in accordance with algorithms for the diagnosis of HFPEF&#46; HFPEF was confirmed in 49 patients&#44; who presented higher BNP values &#40;mean 144&#46;4<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; median 113<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; vs&#46; mean 27&#46;6<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; median 16&#46;7<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The results showed a significant correlation between BNP levels and left atrial volume index &#40;r&#61;0&#46;554&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; age &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;452&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and E&#47;E&#8242; ratio &#40;r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;345&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; The area under the ROC curve for BNP to detect HFPEF was 0&#46;92 &#40;95&#37; confidence interval&#58; 0&#46;87-0&#46;96&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and 51<span class="elsevierStyleHsp" style=""></span>pg&#47;ml was identified as the best cutoff to detect HFPEF&#44; with sensitivity of 86&#37;&#44; specificity of 86&#37; and accuracy of 86&#37;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BNP levels in outpatients with HFPEF are significantly higher than in those without&#46; A cutoff value of 51<span class="elsevierStyleHsp" style=""></span>pg&#47;ml had the best diagnostic accuracy in outpatients&#46;</p>"
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          "pt" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Curva <span class="elsevierStyleItalic">Receiver operating characteristic</span> &#40;ROC&#41; para estabelecer o melhor ponto de corte do BNP para diagnosticar ICFEP em doentes ambulat&#243;rios&#46;</p>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">BNP&#58; pept&#237;deo natriur&#233;tico tipo B&#59; FC&#58; frequ&#234;ncia card&#237;aca&#59; FEVE&#58; fra&#231;&#227;o de eje&#231;&#227;o do ventr&#237;culo esquerdo&#59; HAS hipertens&#227;o arterial&#59; IMC&#58; &#237;ndice de massa corporal&#59; PAS&#58; press&#227;o arterial sist&#243;lica&#59; PCR US prote&#237;na C reativa ultra-sens&#237;vel&#59;&#59;TFG taxa de filtra&#231;&#227;o glomerular estimada&#59; VAE-<span class="elsevierStyleSmallCaps">I</span>&#58; volume da aur&#237;cula esquerda indexada&#59; massa VE-<span class="elsevierStyleSmallCaps">I</span>&#58; massa do ventr&#237;culo esquerdo indexado&#59; Vari&#225;veis categ&#243;ricas&#58; Pearson <span class="elsevierStyleItalic">chi-square</span>&#59; Vari&#225;veis num&#233;ricas &#8211; ANOVA&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Total &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>161&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Com ICFEP &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Sem ICFEP &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>112&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BNP pg&#47;mL</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">63&#44;1 &#40;28&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">144&#44;4 &#40;113&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">27&#44;6 &#40;16&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Idade &#40;anos&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">68&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">74&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">65&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sexo feminino &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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