ARTIGOS ORIGINAIS CONCISOS

Avaliao da Funo Sistlica e Sisto-diastlica - ndice de Tei no Enfarte Agudo do Miocrdio Submetido a Reperfuso Aguda - Avaliao Precoce e Tardia [42]
LUS ROCHA LOPES, ISABEL JOO, HUGO VINHAS, OTLIA SIMES, CARLOS COTRIM, CARLOS CATARINO, MANUEL CARRAGETA
Servio de Cardiologia, Hospital Garcia de Orta, E.P.E., Almada, Portugal Rev Port Cardiol 2007; 26 (6): 649-656

RESUMO Introduo: A determinao da funo sistlica e diastlica por mtodos no invasivos, na fase aguda do enfarte do miocrdio (EAM), tem importncia na estratificao de risco e no prognstico. A fraco de ejeco, pelo mtodo de Simpson, determinante na avaliao da funo sistlica ventricular esquerda (VE). O ndice de Tei (IT) um parmetro de Doppler que traduz a funo sisto-diastlica no EAM, com excelente correlao com o prognstico. Objectivo: O objectivo foi avaliar a funo sistlica e sisto-diastlica na fase aguda e tardia do EAM com supradesnivelamento ST, submetido a teraputica de reperfuso urgente. Material e Mtodos: Foram estudados doentes (dts) internados por EAM com supradesnivelamento ST, submetidos a teraputica de reperfuso urgente, avaliados por ecocardiografia nas primeiras 48 horas e ao fim de uma semana. Parmetros estudados: fraco de ejeco por mtodo de Simpson (FE), ndice de contractilidade segmentar (WMSI) e IT. Compararam-se os valores obtidos na primeira e segunda avaliao; correlacionaram-se com: tempo dor - reperfuso (<3 horas vs >3 horas); existncia de doena univaso ou multivaso; fraco de ejeco; CPK total (<1500 ou >1500 UI/L) e localizao do EAM (anterior versus outros). Resultados: Estudaram-se 40 dts, incluindo-se 19 dts, 15 (80%) do sexo masculino, idademdia de 57+14 anos. Os factores de risco presentes eram: hipertenso arterial (11 dts-

ABSTRACT Evaluation of Systolic and Systo-diastolic Function: the Tei Index in Acute Myocardial Infarction Treated with Acute Reperfusion Therapy - Early and Late Evaluation Introduction: Evaluation of systolic and diastolic function by non-invasive methods in the acute phase of myocardial infarction (MI) is of great importance for risk stratification and prognosis. Ejection fraction (EF), as determined by echocardiography using the Simpson method, is the main parameter for assessing left ventricular (LV) function. The Tei index (TI), a Doppler-derived index that reflects systolic and diastolic function in MI, has an excellent correlation with prognosis. Objective: The purpose of this study was to evaluate systolic and systo-diastolic function in the acute and late phase of ST-elevation MI treated with acute reperfusion therapy. Methods: Patients with ST-elevation MI who underwent acute reperfusion therapy were evaluated by echocardiography in the first 48 hours and after one week. The parameters studied were: EF, wall motion score index (WMSI), and TI. The values obtained at the first and second evaluation were compared and correlated with pain to reperfusion time (PRT) (<3 vs. >3 hours), presence of single or multivessel disease, ejection fraction, total CK (<1500 or >1500 UI/l), and MI location (anterior vs. other). Results: 40 patients were studied and 19 were
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58%), tabagismo (14 dts-74%), diabetes mellitus (6 dts-30%), dislipidemia (12 dts63%). Localizao do EAM: anterior (6 dts32%), inferior (13 dts-68%). Foram submetidos a fibrinlise 5 dts (26%) e interveno coronria percutnea (ICP) directa 14 dts (74%). Tempo dor-reperfuso (TDR) mdio 3,7+2,8 horas. Apresentavam doena de 1 vaso 4 dts (21%), doena multivaso 14 doentes (74%). A FE e o WMSI variaram significativamente entre as duas avaliaes. Encontrou-se significado estatstico s 48 h, para a relao entre: TDR e FE (p=0,001) e TDR e WMSI (p=0,020). Aps uma semana encontrou-se significado estatstico para as relaes entre: TDR e FE (p=0,01), TDR e IT (p=0,033), localizao do EAM e FE (p=0,005). Discusso e Concluses: A fraco de ejeco e o ndice de contractilidade segmentar traduzem a funo sistlica precoce e o remodelling do VE na primeira semana. O tratamento de reperfuso precoce influencia positivamente a funo sistlica e sisto-diastlica, precoces e tardias.

included, of whom 15 (80%) were male, mean age 5714 years. Risk factors included hypertension (11 patients, 58%), smoking (14, 74%), diabetes (6, 30%), and dyslipidemia (12, 63%). MI location was anterior in 6 patients (32%) and inferior in 13 (68%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct percutaneous coronary intervention. Mean pain to reperfusion time was 3.72.8 hours. Four patients (21%) had single vessel disease and 14 (74%) multivessel disease. Significant differences were found: a) in mean EF and WMSI between the two evaluations (p<0.0001 and p=0.002 respectively); b) between PRT and EF (p=0.001) and WMSI (p=0.020) at 48 hours; c) between PRT and EF (p=0.01) and TI (p=0.033), and MI location and EF (p=0.005) after one week. Discussion and conclusions: Early systolic function and LV remodeling one week after MI were accurately evaluated by EF and WMSI. Early reperfusion therapy positively influences early and late systolic and systo-diastolic function.

Palavras-Chave Enfarte agudo do miocrdio com supradesnivelamento ST; Ecocardiografia; Doppler; ndice de Tei; Funo ventricular sisto-diastlica; Tempo dor-reperfuso.

Key words Acute myocardial infarction with ST-elevation; Echocardiography; Doppler; Tei index; Systo-diastolic ventricular function; Pain to reperfusion time.

INTRODUO

INTRODUCTION

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determinao da funo sistlica e diastlica por mtodos no invasivos, na fase aguda do enfarte do miocrdio (EAM), tem importncia na estratificao de risco e no prognstico (1). A fraco de ejeco, calculada pelo mtodo de Simpson, um mtodo estabelecido na avaliao da funo sistlica ventricular esquerda (VE). O ndice de Tei (IT), inicialmente descrito em 1995 (2), um parmetro de ecocardiografiaDoppler que traduz a funo global (sistlica e diastlica) do ventrculo esquerdo, apresentando excelente correlaco com as avaliaes invasivas da funo diastlica e sistlica (3). A disfuno sistlica e diastlica ventriculares frequentemente coexistem no EAM e ambas so fundamentais e de valor independente na

valuation of systolic and diastolic function by non-invasive methods in the acute phase of myocardial infarction (MI) is of great importance for risk stratification and prognosis (1). Ejection fraction (EF), as determined by echocardiography using the Simpson method, is the main parameter for assessing left ventricular (LV) systolic function. The Tei index, first proposed in 1995 (2), is a Doppler-derived index that reflects global (systolic and diastolic) LV function and has an excellent correlation with invasive assessment (3). Systolic and diastolic dysfunction are frequently found together in MI and are both important and of independent value in assessing prognosis. Thus, an index that is able to assess these two types of LV dysfunction simultaneously may be

LUIS ROCHA LOPES, et al Rev Port Cardiol 2007; 26: 649-56

avaliao do prognstico. Nesse sentido, um ndice que avalie simultaneamente os dois tipos de disfuno VE pode ser mais til do que aqueles que avaliam apenas um deles. Tem sido descrita a utilidade do ndice de Tei no contexto do EAM, apresentado excelente correlao com a adequao da reperfuso (4) e com o prognstico (5,1) (nomeadamente com as complicaes precoces e tardias e mortalidade ps-EAM). Este parmetro tambm considerado, actualmente, um importante e independente predictor do desenvolvimento de insuficincia cardaca (6) e de mortalidade cardiovascular (7) em homens idosos saudveis. considerado de avaliao simples, reprodutvel, no afectado pela geometria ventricular, independente de factores como a frequncia cardaca, presso arterial ou pr-carga (8). O valor mdio em indviduos normais, na primeira srie descrita, era de 0,390,05 (2). Os estudos realizados demonstram claramente que o prognstico tanto mais favorvel quanto menores os valores deste ndice.

more useful than those that assess only one. The Tei index in the context of MI has been described as having an excellent correlation with adequate reperfusion (4) and with prognosis (1, 5), particularly in terms of early and late complications and postinfarction mortality. It is also now considered a strong and independent predictor of development of heart failure(6) and of cardiovascular mortality (7) in healthy elderly men. It is simple to calculate, reproducible, unaffected by ventricular morphology, and independent of factors such as heart rate, blood pressure and preload (8). Its mean value in normal individuals was 0.390.05 in the first published series (2). Studies have clearly demonstrated that the lower the index, the more favorable the prognosis.

OBJECTIVE The purpose of this study was to evaluate systolic and systo-diastolic function in the acute phase of ST-elevation MI and after one week, following acute reperfusion therapy (thrombolysis or angioplasty).

OBJECTIVO O objectivo deste estudo foi avaliar a funo sistlica e sisto-diastlica na fase aguda e aps uma semana de EAM com supradesnivelamento ST, submetido a teraputica de reperfuso urgente (tromblise ou angioplastia). METHODS Population We studied prospectively consecutive patients admitted for ST-elevation MI undergoing acute reperfusion therapy- per cutaneous coronary intervention (PCI) or thrombolysis- between October and December 2005. Of a total of 40 patients fulfilling these inclusion criteria, 21 were excluded as they had previous PCI or revascularization surgery, previous MI, significant valve disease, atrial fibrillation, permanent pacemaker or hemodynamic instability. Of the remaining 19 patients, 15 (79%) were male and 4 (21%) female, mean age 5714 years (39-88). The diagnosis of ST-elevation MI was made according to the following criteria, which all had to be met: a) typical angina lasting at least 30 minutes; b) ST elevation of >1 mm on the electrocardiogram in at least two adjacent leads; c) elevation of myocardial necrosis markers. Echocardiographic study The patients were assessed by transthoracic

MATERIAL E MTODOS A) Populao Foram estudados prospectivamente doentes consecutivos, internados por EAM com supradesnivelamento ST, submetidos a teraputica de reperfuso urgente - interveno coronria percutnea (ICP) ou tromblise, no perodo compreendido entre Outubro e Dezembro de 2005. De um nmero total de 40 doentes com estes critrios de incluso, foram excludos 21, por apresentarem: ICP ou cirurgia de revascularizao prvias, EAM prvio, valvulopatia significativa, fibrilhao auricular, pacemaker permanente ou instabilidade hemodinmica. Incluram-se 19 doentes, 15 (79%) eram do sexo masculino e 4 (21%) do sexo feminino. A idade-mdia era de 57 14 anos (mnima de 39 e mxima de 88). O

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diagnstico de EAM com supradesnivelamento ST foi feito de acordo com os seguintes critrios (todos teriam que se verificar): a) dor anginosa tpica com o mnimo de 30 minutos de durao; b) supradesnivelamento ST >1mm no electrocardiograma, em pelo menos duas derivaes contguas; c) elevao dos marcadores de necrose miocrdica. B) Estudo ecocardiogrfico Os doentes foram avaliados por ecocardiografia transtorcica bidimensional (2D), modo M e Doppler nas primeiras 48 horas aps a teraputica de reperfuso e admisso na unidade coronria e ao fim de uma semana. Utilizou-se um ecocardigrafo Philips Sonos 7500 e uma sonda S3 (1-3 MHz). Todos os dados foram gravados em suporte digital (disco ptico) para reviso posterior. Para alm das medies standard em Modo M, calcularam-se em cada momento de avaliao os seguintes parmetros em 2D: a) volume ventricular esquerdo tele-sistlico e telediastlico e fraco de ejeco por mtodo de Simpson (FE), na incidncia de apical 4-cmaras; b) ndice de contractilidade segmentar (WMSI): com base na diviso em 16 segmentos do VE da American Society of Echocardiography, a cada segmento atribudo uma pontuao de acordo com a sua contractilidade avaliada visualmente: 1 - normal, 2 - hipocintico, 3 acintico; 4 - discintico; 5 - aneurismtico. O WMSI obtido dividindo a soma das pontuaes pelo nmero total de segmentos analisados. Avaliou-se ainda, por Doppler pulsado, com uma velocidade de varrimento de 100 mm/seg, em incidncia apical, o fluxo transmitral, colocando a amostra ao nvel da extremidade dos folhetos valvulares e o fluxo da cmara de sada do VE, com a amostra abaixo do plano valvular artico. Mediu-se: velocidade mxima da onda E, velocidade mxima da onda A, razo E/A, tempo de desacelerao da onda E (do pico da onda E ao ponto em que a descendente da onda intercepta a linha de base), tempo de relaxamento isovolumtrico (TRIV). Calculou-se o ndice de Tei de acordo com a seguinte frmula: (intervalo entre o final e o incio do fluxo mitral (a) - tempo de ejeco (b)) / tempo de ejeco (b). O intervalo (a) corresponde soma do tempo de contraco isovolumtrico, tempo de ejeco e TRIV. (Figura 1). Foi tambm feito estudo de Doppler

two-dimensional (2D), M-mode and Doppler echocardiography within 48 hours of reperfusion therapy and admission to the coronary care unit and again after one week. The equipment used was a Philips Sonos 7500 with an S3 (1-3 MHz) probe. All data were saved onto optical disk for later review. Besides the standard M-mode measurements, the following parameters were calculated in 2D mode throughout the assessments: a) end-systolic and end-diastolic LV volume and EF using the Simpson method, in 4-chamber apical view; and b) wall motion score index (WMSI), which is based on the American Society of Echocardiography's division of the LV into 16 segments, a score being attributed to each segment according to visual assessment of its motion: 1 - normal, 2 - hypokinetic, 3 - akinetic, 4 - dyskinetic and 5 - aneurysmal. The WMSI is obtained by dividing the sum of the scores by the number of segments analyzed. Transmitral flow was also assessed by pulsed Doppler, at a scanning speed of 100 mm/s in apical view, with the sample positioned at the tip of the valve leaflets and the LV outflow tract and below the aortic valve plane. The following were measured: peak E-wave velocity, peak A-wave velocity, E/A ratio, E-wave deceleration time (E-wave peak to the point where the descending wave intercepts the zero line), and isovolumic relaxation time (IRT). The Tei index was calculated using the following formula: (interval between the end and the beginning of mitral flow (a) - ejection time (b)) / ejection time (b). Interval a corresponds to the sum of isovolumic contraction time, ejection time and IRT (Figure 1). The valves were studied by color Doppler to exclude significant regurgitation. EF and all Doppler parameters were calculated using the mean of three cardiac cycles. Statistical analysis The values obtained for the various parameters on the first and second evaluations were compared using the Student's t test. These parameters were correlated with pain to reperfusion time (PRT) (<3 vs. >3 hours), single or multivessel disease, EF, total CK (<1500 or >1500 UI/l), and MI location (anterior vs. other), at each point of the echocardiographic assessment. The statistical software used was SPSS version 11.5. The level of statistical significance was

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a b

defined as p<0.05.

RESULTS Patient characterization Forty patients were studied and 19 were included, of whom 15 (79%) were male and 4 (21%) female. Mean age was 57.713.6 years (39-88). Risk factors included hypertension (11 patients, 58%), smoking (14, 74%), diabetes (6, 32%), dyslipidemia (12, 63%), and family history (5, 26%). MI location was anterior in 6 patients (32%) and inferior in 13 (68%). Five patients (26%) underwent fibrinolysis and 14 (74%) direct PCI. Mean PRT was 3.72.8 hours (0.6-12h). All patients were treated with aspirin, clopidogrel, angiotensin-converting enzyme inhibitors and statins. Sixteen (84%) were treated with betablockers, 26% with diuretics, and 68% with nitrates. Mean peak troponin was 7.36.2 g/l and mean peak CK 21781769 UI/l. Four patients (21%) had single-vessel disease and 14 (74%) multivessel disease. Echocardiographic results EF and WMSI varied significantly between the two evaluations (5412% to 6016%, p<0.0001, and 1.750.16 to 1.710.19, p=0.002, respectively). The mean value of the Tei index was within normal limits in both assessments, with no significant differences. Results and comparisons of the two echocardiographic evaluations are shown in Table I. At 48 hours, there were statistically significant correlations between PRT and EF (43.6%9.3% for PRT >3h vs. 60.7%7.9% for PRT <3h, p=0.001) and WMSI (1.60.16 for PRT e3h vs. 1.80.16 for PRT <3h, p=0.020). After one week, there were statistically significance correlations between PRT and EF (47.3%9% for PRT >3h vs. 66.4%15% for PRT <3h, p=0.01), PRT and the Tei index (0.410.12 for PRT <3h vs. 0.300.09 for PRT <3h, p=0.033), and between MI location and EF (46.5%12.6% for anterior vs. 66.8%12.6% for other locations, p=0.005).

Figura 1. Intervalos ecocardiogrficos/Doppler, necessrios ao clculo do ndice de Tei. a: intervalo entre o final e incio do fluxo transmitral; b: tempo de ejeco; c: tempo de contraco isovolumtrico; d: tempo de relaxamento isovolumtrico. ndice de Tei = (a-b) / b. Figure 1. Doppler echo times required to calculate the Tei index. a: interval between the end and beginning of transmitral flow; b: ejection time; c: isovolumic contraction time; d: isovolumic relaxation time. Tei index = (a-b)/b.

cor das vlvulas, para se excluirem regurgitaes significativas. A FE e todos os parmetros Doppler foram calculados atravs da mdia de 3 ciclos cardacos. C) Anlise estatstica Atravs do teste t de Student, utilizando o programa informtico SPSS verso 11.5, compararam-se os valores obtidos na primeira e segunda avaliao, em relao aos vrios parmetros referidos. Correlacionaram-se esses parmetros com: tempo dor - reperfuso (<3 horas versus >3 horas); existncia de doena univaso ou multivaso; fraco de ejeco; CPK total (<1500 ou >1500 UI/L) e localizao do EAM (anterior versus outras localizaes), para cada um dos momentos de avaliao ecocardiogrfica. O nvel de significncia estatstica foi definido como um p inferior a 0,05.

RESULTADOS A) Caracterizao clnica da amostra Estudaram-se 40 doentes e foram includos 19 doentes. 15 (79%) eram do sexo masculino e 4 (21%) do sexo feminino. A idade-mdia era de 57,7 13,6 anos (mnima de 39 e mxima de 88). Os factores de risco presentes eram: hipertenso arterial (11 doentes - 58%), tabagismo (14 doentes - 74%), diabetes mellitus (6 doentes 32%), dislipidemia (12 doentes - 63%),

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Tabela I Resultados ecocardiogrficos. Comparao entre os dois momentos de avaliao. Parmetros FE (%) WMSI ndice Tei <48 horas 54 12 1,75 0,16 0,35 0,08 1 semana 60 16 1,71 0,19 0,34 0,11 p < 0,0001 0,002 NS

Table I Echocardiographic results - Comparison between the two assessments Parameters EF (%) WMSI Tei index <48 hours 5412 1.750.16 0.350.08 At one week 6016 1.710.19 0.340.11 p <0.0001 0.002 NS

antecedentes familiares (5 doentes - 26%). A localizao do EAM foi anterior em 6 doentes (32%) e inferior em 13 doentes (68%). Foram submetidos a fibrinlise 5 doentes (26%) e interveno coronria percutnea (ICP) directa 14 doentes (74%). O tempo dor-reperfuso mdio foi de 3,72,8 horas (mnimo de 0,6 h e mximo de 12 h). Todos os doentes foram tratados com cido acetilsaliclico, clopidogrel, inibidores da enzima conversora da angiotensina e estatinas. 16 doentes (84%) foram tratados com betabloqueantes, 26% com diurticos, 68% com nitratos. A mdia do pico de troponina foi de 7,36,2 ug/L e o de CPK de 21781769 UI/L. Apresentavam doena de 1 vaso 4 doentes (21%) e doena multivaso 14 doentes (74%). B) Resultados ecocardiogrficos A FE e o WMSI variaram significativamente (5412% para 6016%, p<0,0001 e 1,750,16 para 1,710,19, p=0,002, respectivamente). O valor mdio do ndice de Tei encontrava-se dentro da normalidade nas duas avaliaes, sem variao significativa. Os resultados da avaliao ecocardiogrfica e a comparao entre os dois momentos de avaliao encontram-se na Tabela 1. s 48 horas, encontrou-se significado estatstico para a correlaco entre o tempo dorreperfuso (TDR) e: FE (43,6%9,3% para TDR >3h versus 60,7%7,9% para TDR <3h, p=0,001) e WMSI (1,60,16 para TDR >3h versus 1,8+0,16 para TDR <3h, p=0,020). Aps uma semana, encontrou-se significado estatstico para a correlaco entre: tempo dorreperfuso e FE (47,3%9% para TDR >3h versus 66,4%15% para TDR <3h, p=0,01), tempo dor-reperfuso e ndice de Tei (0,410,12 para TDR <3h versus 0,300,09 para TDR <3h, p=0,033) e localizao anterior do EAM e FE (46,5%12,6% para os EAM anteriores versus 66,8%12,6% para as outras localizaes, p=0,005).

DISCUSSION MI is characterized by loss of contractile tissue and changes in ventricular morphology, prognosis being dependent on protecting the remaining tissue. In the acute phase, the ischemic cascade leads to increased isovolumic contraction and relaxation times and possibly to reduced ejection time. Ejection fraction is the standard parameter used to assess prognosis and stratify risk in these patients. While this is an important aid to therapeutic decision-making and in predicting future events, it only assesses systolic function, but diastolic function is also known to be impaired in MI. Thus, an index that simultaneously assesses both, such as the Tei index, may be more useful than those that only assess one, in terms of the ability to predict postinfarction morbidity and mortality. In our study, ejection fraction and the wall motion score index enabled accurate assessment of early systolic function, as well as of positive LV remodeling in the first week after MI treated by acute reperfusion therapy, showing improved systolic, global and segmental function after one week. Early reperfusion therapy (shorter pain to reperfusion time) positively influenced LV systolic function, both global (as shown by higher ejection fraction in patients with PRT <3 hours) and segmental (lower WMSI in patients reperfused earlier). This correlation was clearly apparent in both the initial and the second assessment after one week, which highlights the importance of early acute reperfusion therapy in maintaining LV function, with significant implications for prognosis. Furthermore, on the second evaluation, the Tei index was lower in patients reperfused earlier, which demonstrates the beneficial effect of early treatment of ST-elevation MI on diastolic and systolic function assessed together. This finding confirms the importance attributed to this

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DISCUSSO O EAM caracterizado por perda de tecido contrctil e modificaes da geometria ventricular, sendo o prognstico dependente da proteco dos elementos contrcteis restantes. Na fase aguda, a cascata isqumica leva ao aumento dos perodos de contraco e relaxamento isovolumtricos e eventualmente diminuio do tempo de ejeco. A fraco de ejeco o mtodo clssico de avaliao prognstica e estratificao de risco nestes doentes. Apesar de ser um instrumento importante para escolha de teraputica e predico de eventos futuros, avalia apenas a funo sistlica, sabendo-se que tambm a diastlica se encontra comprometida no EAM. Assim, um ndice que avalie simultaneamente os dois tipos de disfuno, como o ndice de Tei, pode ser mais til do que aqueles que avaliam apenas um deles, no que respeita capacidade preditiva de morbimortalidade aps EAM. No nosso estudo, a fraco de ejeco e o ndice de contractilidade segmentar permitiram aferir precocemente a funo sistlica, bem como o remodelling positivo do VE na primeira semana ps-EAM, submetido a reperfuso aguda, reflectindo uma melhoria da funo sistlica, global e segmentar, ao fim da primeira semana. O tratamento de reperfuso precoce (menor tempo de dor-reperfuso) influenciou positivamente a funo sistlica do VE, tanto global (o que se reflecte pelas maiores fraces de ejeco em doentes com tempo dor-reperfuso < 3 horas), como segmentar (WMSI mais baixos em doentes reperfundidos mais precocemente). Esta relao foi bem patente tanto no momento de avaliao inicial como ao fim de uma semana, o que reala a extrema importncia de uma teraputica de reperfuso urgente mais precoce na manuteno da funo ventricular esquerda, com importantes implicaes em termos prognsticos. Por outro lado, o ndice de Tei revelou-se mais baixo, na avaliao realizada ao fim de uma semana, nos doentes reperfundidos mais precocemente, reflectindo o benefcio do tratamento precoce no EAM com supradesnivelamento ST no que respeita funo diastlica e sistlica avaliadas em conjunto. Este achado concordante com a importncia atribuda a este parmetro de funo ventricular global, no que respeita capacidade de predico de

parameter of global ventricular function, in terms of its ability to predict acute and late complications of MI, long-term preservation of function, and as an indicator of adequate reperfusion. The fact that the Tei index showed statistically significant differences between the two groups as determined by pain to reperfusion time only after one week probably reflects ventricular remodeling processes during that period, with progressive changes in systodiastolic function, which were greater in individuals reperfused later.

STUDY LIMITATIONS The limitations of the study relate to the small size of the sample and the short follow-up to date, which does not enable a correlation to be established at this point between the results and future adverse events.

CONCLUSIONS Early reperfusion therapy positively influences systolic and systo-diastolic function. The Tei index is a marker of ventricular dysfunction that shows little variation in the first week after MI, but whose initial value may have important prognostic implications. A longer follow-up will enable the prognostic value of this index to be assessed, particularly with regard to development of heart failure and late mortality. One of the most promising aspects of the Tei index is its prognostic value for the early identification of patients at greater risk of ventricular remodeling, enabling early implementation of preventive strategies.

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complicaes agudas e tardias no EAM, preservao da funo a longo prazo, ou mesmo como indicador da adequao da reperfuso. O facto do ndice de Tei apenas apresentar diferena estatisticamente significativa entre os dois grupos relativos ao tempo de reperfuso ao fim de uma semana, reflecte provavelmente os mecanismos de remodelling ventricular ocorridos durante a mesma, com alterao progressiva da funo sisto-diastlica, maior nos indivduos em que a reperfuso se d mais tarde.

LIMITAES DO ESTUDO As limitaes deste estudo prendem-se com o reduzido nmero de doentes da amostra e com um curto perodo de follow-up, at ao momento, que no permite ainda estabelecer correlaco da avaliao realizada com possveis eventos adversos futuros.

O ndice de Tei um marcador de disfuno ventricular que no apresenta grande variabilidade na primeira semana aps EAM, mas cujo valor inicial pode ter importantes implicaes prognsticas. Um seguimento mais prolongado permitir avaliar o valor prognstico do IT, nomeadamente em relao ao desenvolvimento de insuficincia cardaca ou mortalidade tardia. Uma das principais promessas do ndice de Tei ser o seu valor prognstico na identificao mais precoce de doentes com maior risco de remodelling ventricular, permitindo definir mais cedo estratgias teraputicas que o previnam.

Pedidos de separatas para: Address for reprints: LUS ROCHA LOPES Servio de Cardiologia. Hospital Garcia de Orta, Av. Torrado da Silva, Pragal. 2801-951 Almada, PORTUGAL e-mail: luisrlopes@hotmail.com

CONCLUSES O tratamento de reperfuso precoce influencia positivamente a funo sistlica e sistodiastlica.

BIBLIOGRAFIA / REFERENCES
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