ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 Table 7 – Geometric patterns of the left ventricle 99 Left ventricle geometry Left ventricle mass / body surface (g/m 2 ) Left ventricle mass /body surface (g/m 2 ) Normal ≤ 115 (men) or ≤ 95 (women) ≤ 0.42 Concentric hypertrophy > 115 (men) or > 95 (women) > 0.42 Eccentric hypertrophy > 115 (men) or > 95 (women) ≤ 0.42 Concentric remodeling ≤ 115 (men) or ≤ 95 (women) > 0.42 *Measures taken by the linear method. to cardiovascular risk. Four patterns of LV geometry 99 are described in (Table 7). The altered geometric patterns (concentric LVH, eccentric LVH and concentric remodeling) are predictors of cardiovascular complications in hypertensive patients, with concentric LVH being associated with higher risk of events. 103 Another frequent finding in SAH is the presence of LV diastolic dysfunction. 101 Hypertensive individuals with heart failure commonly present with LVH, abnormalities in diastolic function and preserved ejection fraction. In these cases, diastolic dysfunction alone may be responsible for the signs and symptoms of heart failure. 105 In addition, E/e’ ratio > 13 is associated with high cardiac risk in hypertensive patients, regardless of LVM. 106 The use of GLS, obtained by 2D speckle tracking, allows for the early identification of subclinical systolic dysfunction in several scenarios, including hypertensive patients without LVH. 107 GLS decline was related to hospitalization by heart failure, infarction, stroke, and death in patients with asymptomatic hypertensive heart disease. 108 The regression of LVH in hypertensive patients, evaluated by serial echocardiographies after therapeutic interventions, is associated with decreased risk of fatal and non-fatal cardiovascular events, even in those cases where LVH has not been detected by the electrocardiogram. 109 This benefit is directly related to the degree of reduction of LVM indexed to body surface, regardless of ambulatory blood pressure. LVH regression is also associated with an improvement in LV systolic 110 and diastolic function 111 in hypertensive patients. The thoracic aorta is more frequently affected by dilatation in hypertensive patients without adequate blood pressure control than in normotensive and controlled hypertensive ones. 112 Long-term follow-up has shown that blood pressure levels are one of the main modifiable factors of adult aortic root dilatation. 113 The recommendations for performing the echocardiography in SAH are listed in table 8. 2.5. Athletes The clinical entity called “athlete’s heart” has been recognized for more than two decades 114 and is characterized by cardiac morphological alterations, mainly of increased ventricular mass, secondary to physical training stimulus. These alterations are not accompanied by changes in myocardial function, not only by conventional echocardiographic methods but also by techniques such as tissue Doppler and strain. 115,116 Still, as a result of intact ventricular function, there is no significant increase in atrial cavities 117 and reversibility of morphological alterations after discontinuation of training may be a decisive diagnostic factor in doubtful cases. The use of TTE, therefore, can elucidate cases of doubtful diagnosis between this situation and hypertrophies or pathological ventricular remodeling, such as HCM or even hypertrophy secondary to SAH. 115 However, the use of echocardiography as a routine method in the follow-up of athletes lacks robust scientific evidence. Events of sudden death in athletes constitute an important clinical scenario and the potential prevention of some situations through clinical cardiological evaluation raises the discussion about the need to use complementary methods in this evaluation. Although not all deaths in athletes are cardiovascular, pathologies such as hypertrophic cardiomyopathy and coronary anomalies are among the Table 8 – Recommendations of the echocardiography in the evaluation of hypertensive patients Recommendation Class of recommendation Level of evidence LVH detection I A Assessment of systolic and diastolic function in hypertensive patients with clinical suspicion of heart failure I A Hypertensive patients with left bundle branch block I C Assessment of the aortic diameter in hypertension without adequate blood pressure control I B Hypertensive patients with LVH on ECG for quantification of LVH and definition of LV geometric pattern IIa B Global longitudinal strain evaluation in patients with hypertensive cardiopathy IIa C Reassessment of patients with hypertensive heart disease without alteration of their clinical status IIb B Assessment of first-degree relatives of hypertensive patients III C Selection of antihypertensive therapy III C Monitoring of antihypertensive therapy in controlled and asymptomatic individuals III C LVH: left ventricular hypertrophy; ECG: electrocardiogram; LV: left ventricle. 149