IJCS | Volume 32, Nº5, September/October 2019

510 Table 1 - Clinical criteria for the diagnosis of heart failure - modified Framingham Major criteria Minor criteria Paroxysmal nocturnal dyspnea Edema Orthopnea Nocturnal cough Abnormal jugular venous distension Dyspnea on exertion Lung crackles Hepatomegaly Cardiomegaly Pleural effusion Pulmonary edema Tachycardia (> 120 bpm) Hepatojugular reflux Weight loss ≥ 4.5 kg in 5 days Heart failure is considered to be present if two major criteria or one major and two minor criteria are present. Inclusion criteria were: age equal to or over 45 years and signed Informed Consent Form. Individuals with clinical heart failure (using the major and minor clinical criteria – Table 1), those impeded to carry out the necessary procedures for the evaluation and patients with clinical conditions that would enable them to attend the health unit to undergo the exams were excluded. Two deviceswere used to perform the echocardiogram and tissueDoppler imaging: Cypress 20Acuson (Siemens, Mountain View, EUA) and AU-3 Partner (Esaote, Florence, Italy). The examinations were performed by two experienced echocardiographists without previous knowledge of the results of other clinical and laboratory tests. Three repeated measurements were obtained from each parameter and the resulting mean was used in the study. The tests were performed according to the recommendations for the quantification of chambers of the American Society of Echocardiography (ASE) and European Association of Echocardiography (EAE). 12 Systolic function was assessed by measurement of left ventricular ejection fraction (LVEF) using Simpson’s method and the longitudinal axis stretching (S’). Diastolic function parameters were obtained using tissue Doppler (TDE). Diastolic diameter, cm, 3.9-5.3 (women) and 4.2-5.9 (men), indexed to 2.4-3.2 cm/cm 2 and 2.2-3.1 cm/cm 2 , and systolic diameter of 2.1-4.0 cm, indexed to 1.4-2.1 cm/cm 2 . 13 Left atrial volume (LAV) was obtained using Simpson’s method of disks, in which the left atrial endocardial border is traced in the apical 4- and apical 2-chamber views, as shown by Figure 2. The areas are obtained in the apical positions, excluding the left atrial appendage and the confluence of the pulmonary veins; the perpendicular length is measured between the MV annulus plane and the upper portion of the LA, and reference value is 28 mL/m 2 for both sexes. 14 In the study, increase in LAV-I from 28 mL/m 2 was considered. Echodopplercardiography and tissue Doppler (TDE) were performed by an experienced echocardiographer, using pre-established patterns and without prior knowledge of the results of other tests. All exams were reviewed by another echocardiographer, whowould emit the reports independently of the first examiner. Diastolic dysfunction has been defined as the presence of abnormalities in ventricular relaxation, assessed by the measurement of the septal E’ wave less than 8 cm/s and/or the presence of increased filling pressures of the left ventricle, using E/E’ greater than or equal to 15 and the increase in indexed left atrial volume greater than or equal to 28 mL/m 2 . 13 TDE measurements for the mitral annulus velocity in early diastole in the septal wall (E’ wave) reflects LV relaxation and, in combination with the measurement of transmitral flow in early diastole (E wave), E/E’ ratio, can be used to predict LV filling pressures. 15 Diastolic function parameters obtained with TDE, in the long-axis and four-chamber view, were performed in the septal and lateral regions of the mitral annulus, and early (E') and late (A') diastolic mitral annular velocities were obtained from a long-axis view. Transmitral early diastolic flow velocity (E), deceleration time (DT) and transmitral end diastolic flow velocity (A) were assessed by conventional echo- Doppler cardiography. Measurements of left ventricular (LV) and LA dimensionsweremade byM-mode fromparasternal view. Diastolic dysfunction (DD) grades were established according to the following criteria: Grade I DD (mild) - presence of E’ < 8 and/or LAV-I ≥ 28 mL/m 2 with E/E’ ratio < 8. Grade II DD (moderate) - presence of E’ < 8 and/or LAV-I ≥ 28 mL/m 2 with E/E’ ratio ≥ 8 and < 15. Grade III DD (severe) - presence of E/E’ ratio ≥ 15. The determination of Vitamin D levels was performed using the LIAISON ® 25 OHVitamin DAssay and a direct Macedo et al. Increased left atrial volume Int J Cardiovasc Sci. 2019;32(5):508-516 Original Article