Prevalência da doença arterial coronariana em mulheres diabéticas assintomáticas: estudo comparativo entre o teste ergométrico, o teste cardiopulmonar e a cintilografia do miocárdio com dipiridamol na identificação de isquemia e de lesão obstrutiva significativa pela cinecoronariografia
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Data
2005
Autores
Smanio, Paola Emanuela Poggio [UNIFESP]
Orientadores
Carvalho, Antonio Carlos [UNIFESP]
Tipo
Tese de doutorado
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A doença cardiovascular é a principal causa de morbi-mortalidade em pacientes diabéticos. A isquemia do miocárdio é freqüentemente assintomática, leva ao diagnóstico tardio e prejudica o prognóstico. Como o risco de eventos cardiovasculares pode ser modificado pela triagem apropriada, a identificação precoce da doença arterial coronariana é de grande benefício, em particular no sexo feminino. A decisão sobre qual o método diagnóstico não-invasivo deve ser empregado na triagem inicial é complexa e carece do conhecimento da prevalência da doença para justificar investigação de rotina. Objetivos: Avaliar a prevalência de doença arterial coronariana em pacientes diabéticos sem sintomas cardiovasculares. Comparar os resultados obtidos respectivamente pelos testes ergométrico e cardiopulmonar, bem como pela cintilografia do miocárdio, sob estímulo farmacológico com dipiridamol, com os achados da cinecoronariografia quantitativa, identificando o método de maior eficácia na investigação de DAC significativa (obstrução> 70 por cento). Verificar quais parâmetros encontrados nos três métodos estariam associados à presença de DAC. Pacientes e Métodos: Estudaram-se, prospectivamente, 104 mulheres diabéticas assintomáticas, com média de idade igual a 59 anos, selecionadas consecutivamente após a realização da cinecoronariografia. Após consentimento informado, todas se submeteram a TE, TCP e CPM com dipiridamol e dosagem de hemoglobina glicada, no período de dois meses da CINE e sem procedimentos cardiovasculares neste período. Nos teste de esforço (TE e TCP) utilizou-se o protoloco de esforço modificado de Bruce (1971), já padronizado. As cintilografias associadas ao estímulo farmacológico e em repouso foram realizadas pela técnica de gated-SPECT, pelo protocolo de dois dias, utilizando-se como indicador de perfusão 2-metoxi-isobutil-isonitrila-99mTc (MIBI-99mTc). Todos os exames foram avaliados por dois observadores, e a concordância de cada método entre eles foi avaliada pela estatística kappa (para as variáveis categóricas) e pelo coeficiente de correlação intraclasses (para as variáveis numéricas). Na análise estatística variáveis numéricas com o uso do teste t de Student para amostras não-relacionadas. De posse das informações da análise preliminar, utilizou-se a análise discriminante para diferenciar pacientes portadoras de doença arterial coronariana significativa. Resultados: A prevalência de doença arterial coronariana significativa no grupo estudado foi de 32,7 por cento. Ao comparar-se o resultado das variáveis do teste ergométrico com os obtidos na cinecoronariografia, observou-se que a precordialgia ao esforço (p = 0,053), o teste eficaz (p = 0,045), a incompetência cronotrópica (p = 0,031) e o tempo de esforço atingido (p = 0,022) apresentaram associação significativa com a doença objeto deste estudo. A variável infradesnível do segmento ST (p = 0,589) não mostrou associação com DAC. Em relação ao teste cardiopulmonar, apenas o VOz pico apresentou associação com a cinecoronariografia (p = 0,004). A maioria das variáveis da cintilografia do miocárdio com dipiridamol, mostrou importante associação com DAC: isquemia, fibrose, valores de fração de ejeção basal e após dipiridamol, alterações de espessamento sistólico, contratilidade regional e dilatação transitória ventricular esquerda (todas com p = 0,001). Mostraram associação, ainda, dilatação de ventrículo esquerdo e a captação pulmonar do radiofármaco (p = 0,017 e p = 0,003). Não se observaram paraefeitos graves durante a infusão de dipiridamol, como morte ou infarto do miocárdio. Conclusões: Os resultados obtidos indicam que a prevalência de doença arterial coronariana em pacientes diabéticas sem sintomas cardiovasculares é elevada (32,7 por cento); portanto esta população precisa ser investigada do ponto de vista cardiovascular. O método diagnóstico não--invasivo que mostrou maior associação com esta doença foi a cintilografia de perfusão do miocárdio com estímulo farmacológico com dipiridamol, método de escolha para este grupo específico de pacientes.
Background: Cardiovascular disease is the main cause of cardiac death among diabetic patients. The myocardial ischemia is frequently asymptomatic, leading to late diagnosis and making prognosis worse. This is particularly true for women, for whom this diagnostic possibility is often disregarded. As the risk of coronary artery disease (CAD) can be modified by appropriate screening, early diagnosis is highly beneficial, particularly when regarding females. The decision of which non-invasive diagnostic method should be used in the initial screening is difficult. The prevalence of the disease must be known in order to justify a broad survey, mainly in the female population. Objectives: Assessing the prevalence of CAD in female patients with type two diabetes without cardiovascular symptoms. Comparing the obtained results by the exercise treadmill test (ETT), cardiopulmonary test (CPT) and myocardial perfusion scintigraphy (MPS) with 99mTc-MIBI after intravenous dipyridamole with the results from quantitative cinecoronariography (CINE), with the aim of identifying the most efficient method in the investigation of significant CAD (more than 70% obstruction). Verifying which of the parameters found on the three methods would be linked to the presence of CAD. Patients and Methods: The prospective study included 104 type 2 diabetic female patients, mean age 59 years, with no cardiac symptoms, who had already been submitted to CINE. After formal authorization, all patients performed ETT, CPT, MPS, as well as HbA1c dosage, within two months from CINE and without cardiovascular procedures in between. Exercise treadmill test and the CPT were performed using the standard modified Bruce protocol. Pharmacological MPS was performed by gatedSPECT technique with MIBI-99mTc and two days protocol. For each method two experts blinded to all other results analyzed studies. The agreement between observers was assessed by Kappa statistics (for categorical variables) and by interclass correlation coefficient (for numerical variables). For the statistical analysis of the results patients groups were compared by Pearson’s Chi-squared (χ 2 ) test for categorical variables and by Student T test for numerical variables. Results: The observed prevalence of significant CAD was 32,7%. The parameters from ETT, which showed association with CAD were chest pain during exercise, (p = 0,053), chronotropic incompetence (p = 0,031), the time of exercise performed (p = 0,022) and the possibility to achieve at least 85% of predicted maximal heart rate during the ETT (p = 0,045). The presence of STsegment depression had no significant association with CAD (p = 0,589). From the CPT the only parameter that showed association with CAD was peak oxygen uptake (p = 0,004). Many parameters from MPS with dipyridamole infusion presented significant association with CAD: presence of suggestive ischemia or scar at perfusion imaging (p=0,001); the severity and the extension of ischemia (p = 0,001); basal left ventricular ejection fraction (LVEF) and also LVEF after dipyridamole (p = 0,001); transient ischemic dilation (p = 0,001); wall motion and wall thickening abnormalities (p = 0,001); LV enlargement (p = 0,017), higher diastolic and systolic volumes (p = 0,001) and pulmonary uptake (p = 0,017).There were no severe side-effects during dipyridamole infusion. Conclusions: The obtained results suggest a high prevalence of CAD in asymptomatic female patients with type 2 diabetes. The non-invasive method which has shown best association with the presence of significant CAD is pharmacological myocardial perfusion imaging with dipyridamole. Thus, this should be the screening test of choice in this specific patient group.
Background: Cardiovascular disease is the main cause of cardiac death among diabetic patients. The myocardial ischemia is frequently asymptomatic, leading to late diagnosis and making prognosis worse. This is particularly true for women, for whom this diagnostic possibility is often disregarded. As the risk of coronary artery disease (CAD) can be modified by appropriate screening, early diagnosis is highly beneficial, particularly when regarding females. The decision of which non-invasive diagnostic method should be used in the initial screening is difficult. The prevalence of the disease must be known in order to justify a broad survey, mainly in the female population. Objectives: Assessing the prevalence of CAD in female patients with type two diabetes without cardiovascular symptoms. Comparing the obtained results by the exercise treadmill test (ETT), cardiopulmonary test (CPT) and myocardial perfusion scintigraphy (MPS) with 99mTc-MIBI after intravenous dipyridamole with the results from quantitative cinecoronariography (CINE), with the aim of identifying the most efficient method in the investigation of significant CAD (more than 70% obstruction). Verifying which of the parameters found on the three methods would be linked to the presence of CAD. Patients and Methods: The prospective study included 104 type 2 diabetic female patients, mean age 59 years, with no cardiac symptoms, who had already been submitted to CINE. After formal authorization, all patients performed ETT, CPT, MPS, as well as HbA1c dosage, within two months from CINE and without cardiovascular procedures in between. Exercise treadmill test and the CPT were performed using the standard modified Bruce protocol. Pharmacological MPS was performed by gatedSPECT technique with MIBI-99mTc and two days protocol. For each method two experts blinded to all other results analyzed studies. The agreement between observers was assessed by Kappa statistics (for categorical variables) and by interclass correlation coefficient (for numerical variables). For the statistical analysis of the results patients groups were compared by Pearson’s Chi-squared (χ 2 ) test for categorical variables and by Student T test for numerical variables. Results: The observed prevalence of significant CAD was 32,7%. The parameters from ETT, which showed association with CAD were chest pain during exercise, (p = 0,053), chronotropic incompetence (p = 0,031), the time of exercise performed (p = 0,022) and the possibility to achieve at least 85% of predicted maximal heart rate during the ETT (p = 0,045). The presence of STsegment depression had no significant association with CAD (p = 0,589). From the CPT the only parameter that showed association with CAD was peak oxygen uptake (p = 0,004). Many parameters from MPS with dipyridamole infusion presented significant association with CAD: presence of suggestive ischemia or scar at perfusion imaging (p=0,001); the severity and the extension of ischemia (p = 0,001); basal left ventricular ejection fraction (LVEF) and also LVEF after dipyridamole (p = 0,001); transient ischemic dilation (p = 0,001); wall motion and wall thickening abnormalities (p = 0,001); LV enlargement (p = 0,017), higher diastolic and systolic volumes (p = 0,001) and pulmonary uptake (p = 0,017).There were no severe side-effects during dipyridamole infusion. Conclusions: The obtained results suggest a high prevalence of CAD in asymptomatic female patients with type 2 diabetes. The non-invasive method which has shown best association with the presence of significant CAD is pharmacological myocardial perfusion imaging with dipyridamole. Thus, this should be the screening test of choice in this specific patient group.
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SMANIO, Paola Emanuela Poggio. Prevalência da doença arterial coronariana em mulheres diabéticas assintomáticas: estudo comparativo entre o teste ergométrico, o teste cardiopulmonar e a cintilografia do miocárdio com dipiridamol na identificação de isquemia e de lesão obstrutiva significativa pela cinecoronariografia. 2005. 145 f. Tese (Doutorado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2005.