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versión impresa ISSN 0066-782X
Arq. Bras. Cardiol. vol.98 no.1 São Paulo enero 2012
Carlos E. Rochitte
Instituto do Coração - InCor/HCFMUSP; Hospital do Coração - HCOR, São Paulo, SP, Brazil
Keywords: Periodicals, image processing, computer-assisted/trends, image interpretation, computer-assisted/methods.
We witness the "Renaissance" of cardiovascular imaging. Non-invasive cardiovascular imaging has concomitantly shown the solidification and maturation of more traditional imaging techniques and the exponential growth of the modalities most recently introduced in the armamentarium. The integration of imaging techniques has also allowed a more rational and effective use of specific imaging methods, favoring a more accurate diagnosis at a lower cost and with less overlap of exams. Smart algorithms for both the combined and non-combined selection of non-invasive exams in cardiology have allowed a much better cost-effectiveness ratio for establishing the final diagnosis, currently a crucial factor for all health care systems in both Brazil and the rest of the world. In Brazil, as in many other countries and following an international trend, the Department of Cardiovascular Imaging of the Brazilian Society of Cardiology has been created. It harmonically integrates professionals of the areas of echocardiography, nuclear medicine, magnetic resonance imaging, and cardiovascular computed tomography. This multimodality approach has helped the rapid progression of knowledge and the continuous development of the area. Integration has been proposed for a while with seminal publications describing models of integration that enable better efficiency1. Another development of this truly new subspecialty, cardiovascular imaging, is the launch in both Europe and the United States of scientific journals dedicated to cardiovascular imaging derived from the highest-impact scientific journals in the world, such as the Circulation Cardiovascular Imaging, JACC Cardiovascular Imaging, and European Heart Journal Cardiovascular Imaging (to be launched at the beginning of 2012). Of the Brazilian journals indexed in Pubmed, the Arquivos Brasileiros de Cardiologia has published a significant number of valuable national and international contributions in the area of cardiovascular imaging.
Of the most traditional modalities, echocardiography has undergone a significant development, with the appearance of new techniques, such as 3D echocardiography, tissue Doppler imaging, and, more recently, speckle tracking echocardiography. Experienced researchers in those areas have refined the use of such techniques allowing new and more accurate diagnoses, with significant impact on the patient's prognosis. Brazilian researchers, with their usual creativity, have surpassed expectations, conducting important research on relevant topics in the area. In an original way, epicardial fat accumulation has been assessed by use of echocardiography2. The prognostic value of dipyridamole stress echocardiography in women has also been demonstrated in publications of the Arquivos Brasileiros de Cardiologia3. Diastolic dysfunction, an area in which echocardiography indisputably predominates, has been carefully assessed in patients with chronic renal disease by Barberato et al4. For rejection after heart transplantation, tissue Doppler echocardiography has shown its value5. In reverse remodeling after resynchronization therapy, two-dimensional and three-dimensional echocardiography has proved useful6. That small sample of state-of-the-art articles published in the Arquivos Brasileiros de Cardiologia is also aligned with important journals of the world echocardiography7,8.
Nuclear medicine has also been present in Arquivos Brasileiros de Cardiologia. Its diagnostic value in patients with multivessel coronary artery disease (CAD) has been confirmed in Brazil9. In an article using an innovative technique, mental-stress-induced myocardial ischemia has been assessed10.
Cardiovascular magnetic resonance imaging has also been approached in the "how do I do it?" format11. Such educational approach, especially regarding its most recent modalities, is of paramount importance to clinical cardiologists, who need to understand the details of the new and sophisticated exams to better instruct imaging specialist physicians on the focus of the exam in a specific patient, and to better interpret the results of such tests. Continuing education leads to a more rational and accurate use of imaging methods and better cost-effectiveness of the diagnostic activity. In addition, sophisticated state-of-the-art techniques have been considered in the Arquivos Brasileiros de Cardiologia. An example is assessing the metabolism of high-energy phosphates in patients with Chagas' disease by use of phosphorus-31 nuclear magnetic resonance spectroscopy12. Another example is the unprecedented assessment of myocardial fibrosis in hypertrophic cardiomyopathy in Brazil by use of delayed enhancement magnetic resonance and its correlation with the risk of sudden death13. Articles providing an equivalent treatment of the application of that technique, published in the same year in JACC, have been considered landmark papers14,15.
The modality of cardiovascular computed tomography, particularly the computed tomography of the coronary arteries, has shown vertiginous progress. Computed tomography calcium score and coronary angiography have taken over the risk stratification of asymptomatic patients at intermediate risk for CAD and the non-invasive assessment of the anatomy of coronary arteries, respectively. Coronary angiotomography has proved to be a useful instrument for both detecting coronary stenosis, and quantifying the calcification of the atherosclerotic plaque. Calcium score has been used for patients with pre-transplantation chronic renal failure and has proved its value in both risk stratification and prediction of obstructive CAD, which would be detected by subsequent catheterization16. A very original and creative study has shown that the drop in the number of publications about electron beam computed tomography (EBCT) and the increase in multiple-detector computed tomography (MDCT) have revealed the replacement of one technology by the other17. In addition, new cases have been described by use of those new technologies, such as MDCT18. In a pioneer way and pointing to the possible future of coronary tomography, cases of coronary artery bypass graft surgery performed based only on coronary angiotomography have been reported19. Such reports are aligned with a landmark publication in the NEJM, a multicenter study in which Brazil had an important participation. In addition to validating coronary angiotomography against invasive catheterization, that study has reported that the prediction of revascularization was similar by use of both non-invasive coronary angiotomography and invasive catheterization20.
Hybrid techniques have been increasingly used in clinical practice and research. State-of-the-art technological innovation applied in Brazil has earned space in the Arquivos Brasileiros de Cardiologia, represented by the imaging fusion technique of F18-fluorodeoxyglucose positron emission tomography (FDG PET) and magnetic resonance imaging to characterize atherosclerotic plaques21. This preceded in two years the acquisition of the RM-PET equipment by the NIH of the United States for performing that type of hybrid image, which is currently simultaneously acquired. In that same year of 2009, the pioneer characterization of the atherosclerotic plaque was published by Motoyama et al22 in the JACC. Invasive imaging has also contributed with important data in the characterization of the atherosclerotic plaque. A study reviewing optical coherence tomography, with impressive images, has been published in the Arquivos Brasileiros de Cardiologia23.
Another relevant topic approached in the Arquivos Brasileiros de Cardiologia has been subclinical atherosclerosis, in which diastolic function24 has been assessed in depth. Current topics, such as metabolic syndrome and visceral fat, have been approached in the Arquivos Brasileiros de Cardiologia25,26.
Again, the Arquivos Brasileiros de Cardiologia have proved to be aligned with the major scientific journals worldwide regarding cardiovascular imaging developments.
The integration of images has allowed the comparison and validation of ventricular ejection fraction by use of three-dimensional echocardiography, having MDCT as reference27.
The integration of image modalities has followed the quality in cardiovascular imaging criteria proposed by Pamela Douglas28,29 and supported by the American College of Cardiology. Those documents have also established the strategy for better cost-effectiveness of imaging diagnostic methods.
In addition to the cardiovascular imaging subespecialty, other diagnostic areas of fundamental importance in Cardiology have been present in the Arquivos Brasileiros de Cardiologia, represented by high-quality and impact articles. An example is conventional ECG, which has been rediscovered for specific applications, such as Duchenne's muscular dystrophy30, or used in new methodologies with T-wave alternans31. Ergometry has some representative examples as follows: detailed assessment of left bundle branch block32; autonomic dysfunction in type 1 diabetes33; new electrocardiographic score in ischemic preconditioning34 and stable CAD35; exaggerated pressure response to exercise36; and heart rate predictive value for mortality37.
Another method that has gained significant space in recent publications of the Arquivos Brasileiros de Cardiologia was ambulatory blood pressure monitoring (ABPM). Some examples of contribution were as follows: comparison of ABPM with self-measurement of blood pressure38; assessment of resistant arterial hypertension39 in general and in women40; and subclinical hypothyroidism40.
Briefly, scientific publications in the area of non-invasive cardiovascular imaging and cardiovascular diagnosis are abundant and of high quality in Brazil. The Arquivos Brasileiros de Cardiologia has a fundamental role in disclosing such information to the final player in health care, the assisting physician. It has also served its purposes regarding stimulus to publication with instructions and training to improve the scientific quality of its papers.
In addition to efforts in other areas of cardiological knowledge published in the Arquivos Brasileiros de Cardiologia, cardiovascular imaging has helped to increase the impact factor of that scientific journal, which represents the Brazilian cardiology in the international literature scenario.
In conclusion, we can certainly state that the Arquivos Brasileiros de Cardiologia are contributing to current topics of great clinical relevance in the area of cardiovascular imaging, in addition to being aligned with the major medical journals of high impact in the subspecialty.
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2. Mustelier JV, Rego JO, Gonzalez AG, Sarmiento JC, Riveron BV. Echocardiographic parameters of epicardial fat deposition and its relation to coronary artery disease. Arq Bras Cardiol. 2011;97(2):122-9. [ Links ]
3. Almeida MC, Markman Filho B. Prognostic value of dipyridamole stress echocardiography in women. Arq Bras Cardiol. 2011;96(1):31-7. [ Links ]
4. Barberato SH, Bucharles SG, Sousa AM, Costantini CO, Costantini CR, Pecoits-Filho R. [Prevalence and prognostic impact of diastolic dysfunction in patients with chronic kidney disease on hemodialysis]. Arq Bras Cardiol. 2010;94(4):457-62. [ Links ]
5. Resende MV, Vieira ML, Bacal F, Andrade JL, Stolf NA, Bocchi EA. Tissue doppler echocardiography in the diagnosis of heart transplantation rejection. Arq Bras Cardiol. 2011;97(1):8-16. [ Links ]
6. Hotta VT, Martinelli Filho M, Mady C, Mathias W Jr, Vieira ML. Comparison between 2D and 3D echocardiography in the evaluation of reverse remodeling after CRT. Arq Bras Cardiol. 2011;97(2):111-21. [ Links ]
7. Tsang W, Weinert L, Sugeng L, Chandra S, Ahmad H, Spencer K, et al. The value of three-dimensional echocardiography derived mitral valve parametric maps and the role of experience in the diagnosis of pathology. J Am Soc Echocardiogr. 2011;24(8):860-7. [ Links ]
8. Sengul C, Cevik C, Ozveren O, Oduncu V, Sunbul A, Akgun T, et al. Echocardiographic epicardial fat thickness is associated with carotid intima-media thickness in patients with metabolic syndrome. Echocardiography. 2011;28(8):853-8. [ Links ]
9. de Siqueira ME, Neto EM, Kelendjian JF, Smanio PE. Diagnostic value of myocardial radionuclide imaging in patients with multivessel coronary disease. Arq Bras Cardiol. 2011;97(3):194-8. [ Links ]
10. Barbirato GB, Felix R, de Azevedo JC, Corrêa PL, de Nóbrega AC, Coimbra A, et al. Prevalence of induced ischemia by mental distress. Arq Bras Cardiol. 2010;94(3):301-7. [ Links ]
11. Nacif MS, Oliveira Junior AC, Carvalho AC, Rochitte CE. Cardiac magnetic resonance and its anatomical planes: how do i do it? Arq Bras Cardiol. 2010;95(6):756-63. [ Links ]
12. Leme AM, Salemi VM, Parga JR, Ianni BM, Mady C, Weiss RG, et al. Evaluation of the metabolism of high energy phosphates in patients with chagas' disease. Arq Bras Cardiol. 2010;95(2):264-70. [ Links ]
13. Shiozaki AA, Senra T, Arteaga E, Pita CG, Martinelli Filho M, Avila LF, et al. Myocardial fibrosis in patients with hypertrophic cardiomyopathy and high risk for sudden death. Arq Bras Cardiol. 2010;94(4):535-40. [ Links ]
14. Bruder O, Wagner A, Jensen CJ, Schneider S, Ong P, Kispert EM, et al. Myocardial scar visualized by cardiovascular magnetic resonance imaging predicts major adverse events in patients with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2010;56(11):875-87. [ Links ]
15. O'Hanlon R, Grasso A, Roughton M, Moon JC, Clark S, Wage R, et al. Prognostic significance of myocardial fibrosis in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2010;56(11):867-74. [ Links ]
16. Rosario MA, Lima JJ, Parga JR, Avila LF, Gowdak LH, Lemos PA, et al. [Coronary calcium score as predictor of stenosis and events in pretransplant renal chronic failure]. Arq Bras Cardiol. 2010;94(2):252-60. [ Links ]
17. Duarte PS. Technologies for the investigation of CAD: association between scientific publications and clinical use. Arq Bras Cardiol. 2010;94(3):379-382. [ Links ]
18. Nacif MS, Luz JH, Moreira DM, Rochitte CE, Oliveira Junior AC. [Anomalous origin of coronary artery (ALCAPA) in 64-channel TC scanner]. Arq Bras Cardiol. 2010;94(6):143-6. [ Links ]
19. Gaia DF, Palma JH, Branco JN, Teles CA, Catani R, Buffolo E. Coronary artery bypass using only computed tomography as pre-operative angiogram. Arq Bras Cardiol. 2009;93(3):e45-7. [ Links ]
20. Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359(22):2324-36. [ Links ]
21. Benedetto R, Carneiro MP, Junqueira FA, Coutinho A Jr, von Ristow A, Fonseca LM. (18)F-FDG in distinction of atherosclerotic plaque: Innovation in PET/MRI technology. Arq Bras Cardiol. 2009;93(6):e84-7. [ Links ]
22. Motoyama S, Sarai M, Harigaya H, Anno H, Inoue K, Hara T, et al. Computed tomographic angiography characteristics of atherosclerotic plaques subsequently resulting in acute coronary syndrome. J Am Coll Cardiol. 2009;54(1):49-57. [ Links ]
23. Coletta J, Suzuki N, Nascimento BR, Bezerra HG, Rosenthal N, Guagliumi G, et al. Use of optical coherence tomography for accurate characterization of atherosclerosis. Arq Bras Cardiol. 2010;94(2):250-4. [ Links ]
24. Garcia MM, Rodrigues MG, Reis Neto JA, Correia LC. Influence of subclinical atherosclerosis on diastolic function in individuals free of cardiovascular disease. Arq Bras Cardiol.2010;95(4):473-8. [ Links ]
25. Roriz AK, Mello AL, Guimaraes JF, dos Santos FC, Medeiros JM, Sampaio LR. Imaging assessment of visceral adipose tissue area and its correlations with metabolic alterations. Arq Bras Cardiol. 2010;95(6):698-704. [ Links ]
26. Ivanovic BA, Tadic MV, Simic DV. Predictors of global left ventricular function in metabolic syndrome. Arq Bras Cardiol. 2011;96(5):377-84. [ Links ]
27. Vieira ML, Nomura CH, Tranchesi Junior B, Oliveira WA, Naccarato G, Serpa BS, et al. Left ventricular ejection fraction and volumes as measured by 3d echocardiography and ultrafast computed tomography. Arq Bras Cardiol. 2009;92(4):294-301. [ Links ]
28. Douglas P, Iskandrian AE, Krumholz HM, Gillam L, Hendel R, Jollis J, et al. Achieving quality in cardiovascular imaging: proceedings from the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging. J Am Coll Cardiol. 2006;48(10):2141-51. [ Links ]
29. Douglas PS. Improving imaging: our professional imperative. J Am Coll Cardiol. 2006;48(10):2152-5. [ Links ]
30. Santos MA, Costa Fde A, Travessa AF, Bombig MT, Fonseca FH, Luna Filho B, et al. [Duchenne muscular dystrophy: electrocardiographic analysis of 131 patients]. Arq Bras Cardiol. 2010;94(5):620-4. [ Links ]
31. Garcia EV, Pastore CA, Samesima N, Pereira Filho HG. T-wave alternans: Clinical performance, limitations and analysis methodologies. Arq Bras Cardiol. 2011;96(3):e53-61. [ Links ]
32. Stein R, Ho M, Oliveira CM, Ribeiro JP, Lata K, Abella J, et al. Exercise-induced left bundle branch block: prevalence and prognosis. Arq Bras Cardiol. 2011;97(1):26-32. [ Links ]
33. Almeida FK, Gross JL, Rodrigues TC. Microvascular complications and cardiac autonomic dysfunction in patients with diabetes mellitus type 1. Arq Bras Cardiol. 2011;96(6):484-9. [ Links ]
34. Uchida A, Moffa P, Hueb W, Cesar LA, Ferreira BM, Ramires JA. Electrocardiographic score: application in exercise test for the assessment of ischemic preconditioning. Arq Bras Cardiol. 2010;95(4):486-92. [ Links ]
35. Coutinho Storti F, Moffa PJ, Uchida AH, Hueb WA, Machado Cesar LA, Ferreira BM, et al. New prognostic score for stable coronary disease evaluation. Arq Bras Cardiol. 2011;96(5):411-8. [ Links ]
36. Ramos PS, Araujo CG. Normotensive individuals with exaggerated exercise blood pressure response have increased cardiac vagal tone. Arq Bras Cardiol. 2010;95(1):85-90. [ Links ]
37. Fagundes JE, Castro I. Predictive value of resting heart rate for cardiovascular and all-cause mortality. Arq Bras Cardiol. 2010;95(6):713-9. [ Links ]
38. Souza WK, Jardim PC, Porto LB, Araujo FA, Sousa AL, Salgado CM. Comparison and correlation between self-measured blood pressure, casual blood pressure measurement and ambulatory blood pressure monitoring. Arq Bras Cardiol. 2011;97(2):148-55. [ Links ]
39. Marui FR, Bombig MT, Francisco YA, Thalenberg JM, Fonseca FA, Souza D, et al. Assessment of resistant hypertension with home blood pressure monitoring. Arq Bras Cardiol. 2010;95(4):536-40. [ Links ]
40. Magnanini MM, Nogueira Ada R, Carvalho MS, Bloch KV. Ambulatory blood pressure monitoring and cardiovascular risk in resistant hypertensive women. Arq Bras Cardiol. 2009;92(6):448-53. [ Links ]
Mailing Address: Manuscript received December 08, 2011; revised manuscript receibed December 08, 2011; accepted December 08, 2011.
Carlos E. Rochitte
Av. Dr. Enéas de Carvalho Aguiar 44 - Andar AB - Ressonância & Tomografia - Cerqueira César
05403-000 - São Paulo, SP, Brasil
E-mail: email@example.com, firstname.lastname@example.org
Manuscript received December 08, 2011; revised manuscript receibed December 08, 2011; accepted December 08, 2011.