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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic cardiomyopathy &#40;HCM&#41; is the most common genetic heart disease inherited as an autosomal dominant trait&#46; Its main characteristic is left ventricular hypertrophy that occurs in the absence of other conditions that trigger this change&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Disease penetrance and the age of phenotypic development range over generations&#59; initial presentations may vary from asymptomatic forms found in routine echocardiography to manifestations of heart failure or sudden cardiac death&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Despite having a low long-term mortality&#44; the burden of morbidity in Portugal remains considerable&#46; Age at diagnosis is relatively advanced&#44; emphasizing both the need for better diagnostic strategies and better treatments targeting symptomatic control and the natural history of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical scores have been developed to provide prognostic and functional assessments and to enable risk stratification&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Additionally&#44; high-resolution imaging methods&#44; such as cardiac magnetic resonance &#40;CMR&#41;&#44; represent an important complement to echocardiography in different clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> CMR is becoming increasingly used in HCM&#44; especially for the identification of other important hallmarks of the disease&#58; myocardial fibrosis &#40;which is usually more prominent in the most hypertrophic segments&#41; and coronary microvascular disfunction &#40;CMD&#41;&#46; Both these features have been proven to be directly linked to&#44; but also to be independently associated with poor outcomes in HCM patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this issue of the Journal&#44; Rosa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> present part of their research into CMD in patients with HCM&#44; using both regadenoson stress-rest CMR and the invasive assessment of the index of microcirculatory resistance &#40;IMR&#41; during coronary catheterization&#46; For the first time&#44; IMR has been used for the assessment of CMD in HCM patients without epicardial coronary artery disease&#44; adding an important contribution to the scientific knowledge in his field&#46; Despite the inherent limitations associated with the number sample size&#44; this pilot study has the advantage of the simultaneous use of two very different techniques &#40;CMR and IMR&#41; for the assessment of CMD&#46; This approach enables a direct comparison of the findings and opens up an interesting discussion on how to correlate and interpret the results&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As the authors correctly state&#44; CMD is one of the less understood pathophysiological features of HCM&#46; Several methods can be used for the assessment of CMD but there is no universal gold-standard and the different methods are probably measuring different markers of the same reality&#46; Therefore&#44; it is interesting to note that patients with abnormal IMR seemed to have more significant tissue abnormalities as defined by CMR&#44; namely fibrosis and increased extracellular volume &#40;as assessed by late gadolinium enhancement and T1-mapping&#41;&#46; And&#44; in my view&#44; it is particularly exciting to interpret the somehow discordant results obtained with the two techniques&#46; The concordance between IMR and CFR was found in only six patients &#40;43&#37;&#41; and the prevalence of CMD by IMR was significantly lower than the detection of ischemia using stress CMR&#46; The authors raise the hypothesis that lower IMR values may be found in HCM patients compared with other diseases&#44; and postulate that HCM may run its course with a reduction in coronary flow reserve secondary to near maximal baseline vasodilation of the microcirculation&#44; instead of an increase in coronary microvascular resistance due to a narrowing of small vessels or external compression&#46; This type of CMD would be detected using CMR&#44; which is sensible for myocardial perfusion flow reserve&#44; but not for IMR&#44; since microvascular resistance would not be significantly&#46; Another interesting point is that CMR is able to simultaneously assess the cumulative global impact of CMD in the whole myocardium&#44; while IMR and the other invasive techniques such as coronary flow reserve measurement have the advantage of being vessel-specific but may lose some sensitivity in a global microvascular tree assessment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As good research often does&#44; this study raises more questions than it gives answers&#46; Nevertheless&#44; it is another piece of a puzzle that is far from being complete and invites us to conduct further research into the potential of IMR and the value of CMD assessment in patients with HCM&#46; We will be sitting on the front row to see what this approach may bring to the management of these patients&#44; especially for the diagnosis&#44; symptom control and prognosis-modifying treatment&#46;</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&#46;</p></span></span>"
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Invasive versus non-invasive coronary microvascular assessment in hypertrophic myocardiopathy – Are we measuring the same thing?
Avaliação invasiva e não-invasiva da doença microvascular na miocardiopatia hipertrófica – Estaremos a medir a mesma coisa?
Nuno Bettencourt
Unidade de Investigação Cardiovascular – Faculdade de Medicina do Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic cardiomyopathy &#40;HCM&#41; is the most common genetic heart disease inherited as an autosomal dominant trait&#46; Its main characteristic is left ventricular hypertrophy that occurs in the absence of other conditions that trigger this change&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Disease penetrance and the age of phenotypic development range over generations&#59; initial presentations may vary from asymptomatic forms found in routine echocardiography to manifestations of heart failure or sudden cardiac death&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Despite having a low long-term mortality&#44; the burden of morbidity in Portugal remains considerable&#46; Age at diagnosis is relatively advanced&#44; emphasizing both the need for better diagnostic strategies and better treatments targeting symptomatic control and the natural history of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical scores have been developed to provide prognostic and functional assessments and to enable risk stratification&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Additionally&#44; high-resolution imaging methods&#44; such as cardiac magnetic resonance &#40;CMR&#41;&#44; represent an important complement to echocardiography in different clinical scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> CMR is becoming increasingly used in HCM&#44; especially for the identification of other important hallmarks of the disease&#58; myocardial fibrosis &#40;which is usually more prominent in the most hypertrophic segments&#41; and coronary microvascular disfunction &#40;CMD&#41;&#46; Both these features have been proven to be directly linked to&#44; but also to be independently associated with poor outcomes in HCM patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this issue of the Journal&#44; Rosa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> present part of their research into CMD in patients with HCM&#44; using both regadenoson stress-rest CMR and the invasive assessment of the index of microcirculatory resistance &#40;IMR&#41; during coronary catheterization&#46; For the first time&#44; IMR has been used for the assessment of CMD in HCM patients without epicardial coronary artery disease&#44; adding an important contribution to the scientific knowledge in his field&#46; Despite the inherent limitations associated with the number sample size&#44; this pilot study has the advantage of the simultaneous use of two very different techniques &#40;CMR and IMR&#41; for the assessment of CMD&#46; This approach enables a direct comparison of the findings and opens up an interesting discussion on how to correlate and interpret the results&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As the authors correctly state&#44; CMD is one of the less understood pathophysiological features of HCM&#46; Several methods can be used for the assessment of CMD but there is no universal gold-standard and the different methods are probably measuring different markers of the same reality&#46; Therefore&#44; it is interesting to note that patients with abnormal IMR seemed to have more significant tissue abnormalities as defined by CMR&#44; namely fibrosis and increased extracellular volume &#40;as assessed by late gadolinium enhancement and T1-mapping&#41;&#46; And&#44; in my view&#44; it is particularly exciting to interpret the somehow discordant results obtained with the two techniques&#46; The concordance between IMR and CFR was found in only six patients &#40;43&#37;&#41; and the prevalence of CMD by IMR was significantly lower than the detection of ischemia using stress CMR&#46; The authors raise the hypothesis that lower IMR values may be found in HCM patients compared with other diseases&#44; and postulate that HCM may run its course with a reduction in coronary flow reserve secondary to near maximal baseline vasodilation of the microcirculation&#44; instead of an increase in coronary microvascular resistance due to a narrowing of small vessels or external compression&#46; This type of CMD would be detected using CMR&#44; which is sensible for myocardial perfusion flow reserve&#44; but not for IMR&#44; since microvascular resistance would not be significantly&#46; Another interesting point is that CMR is able to simultaneously assess the cumulative global impact of CMD in the whole myocardium&#44; while IMR and the other invasive techniques such as coronary flow reserve measurement have the advantage of being vessel-specific but may lose some sensitivity in a global microvascular tree assessment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">As good research often does&#44; this study raises more questions than it gives answers&#46; Nevertheless&#44; it is another piece of a puzzle that is far from being complete and invites us to conduct further research into the potential of IMR and the value of CMD assessment in patients with HCM&#46; We will be sitting on the front row to see what this approach may bring to the management of these patients&#44; especially for the diagnosis&#44; symptom control and prognosis-modifying treatment&#46;</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&#46;</p></span></span>"
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