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Recebido para publicao: Outubro de 2008 Aceite para publicao: Junho de 2009 Received for publication: October 2008 Accepted for publication: June 2009

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Sndroma X cardaca,gradientes intraventriculares

e bloqueadores beta adrenrgicos [15]CARLOS COTRIM*,***; A NA G ALMEIDA**,***; M ANUEL CARRAGETA*,***.

*Servio de Cardiologia, do Hospital Garcia de Orta, Almada, Portugal**Servio de Cardiologia do Hospital de Santa Maria, Lisboa, Portugal

*** Faculdade de Medicina de Lisboa, Lisboa, Portugal

Rev Port Cardiol 2010; 29 (02): 193-203

RESUMO

Introduo : O desenvolvimento de gradi-entes intraventriculares (GIV) durante o

esforo ocorre raramente numa populaono seleccionada. Num jovem de 23 anos,atleta, com prova de esforo positiva, com

ecocardiograma transtorcico (ETT) normale coronrias angiograficamente normais

(sndroma X) efectumos ecocardiograma deesforo (EE) e detectmos GIV de 102

mmHg e movimento sistlico anterior davlvula mitral (SAM). Posteriormente

estudmos 91 doentes (dts), 44 mulheres,com 51,4 12,1 anos (20 a 75), com provasde esforo positivas para isqumia que pos-teriormente efectuaram cateterismo que re-

velou coronrias angiograficamente normais.Em 33 (36%) dts detectmos gradienteintraventricular com pico telesistlico -

86 34 mmHg (30 a 165) acompanhadopor SAM em 23 dts. Os 20 doentes aos

quais foi possvel repetir EE sob teraputicacom bloqueadores beta adenrgicos

constituem a populao do presente estudo.Destes 7 (33%), so mulheres com

50,7 13,4 anos (23 a 72).Objectivo: O objectivo do presente estudo

foi avaliar o efeito dos bloqueadoresbeta adrenrgicos na ocorrncia de GIV e

SAM da vlvula mitral em doentes comsndroma X cardaca.

ABSTRACT

Cardiac syndrome X, intraventriculargradients and blockers

Introduction: Development of intraventricu-lar gradients (IVG) on exertion seldomoccurs in an unselected population. Weperformed exercise stress echocardiography(SE) in a 23-year-old athlete with a positive

treadmill ECG and normal resting echocar-diogram, but without angiographicallydemonstrable coronary disease (cardiacsyndrome X), during which he developed anIVG of 102 mmHg and systolic anterior motion (SAM) of the mitral valve.Subsequently, we performed SE in 91patients, 44 of whom were women, meanage 51.412.1 years (20-72), under similar circumstances positive treadmill testingand no angiographically demonstrable

coronary disease. In 33 (36%) of these,SE disclosed IVG with a mean end-systolicpeak of 8634 mmHg (30-165), together with mitral valve SAM in 23. The 20patients who repeated SE under -blocker therapy constitute the study population.Seven (35%) of them were women, meanage 50.713.4 years (23 to 72).Objective: To assess the effect of -blockerson the occurrence of IVG and mitral valveSAM in patients with cardiac syndrome X.

Methods: We repeated SE in 20 of the 33

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Recebido para publicao: ????????????? Aceite para publicao: ????????? Received for publication: ????????????? Accepted for publication: ?????????

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Populao e mtodos : Repetimos EE em 20dos 33 doentes doentes que desenvolveram

GIV sob teraputica com bloqueador betaadrenrgico. O EE foi efectuado com avali-ao ecogrfica bidimensional e Doppler

pulsado, contnuo e codificado em cor antes, durante e depois do esforo.

Resultados: O GIV nos 20 dts estudados foi97 31 mmHg no 1 EE. No EE efectuado

sob teraputica com bloqueador betaadrenrgico verificou-se que no surgiu

GIV em 11 dts e que nos restantes 9 estediminuiu significativamente: 46 13

mmHg. A frequncia cardaca atingida no1 EE foi 161 17 e no EE com blo-

queador beta adrenrgico foi 143 12(p


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ficamente normais detectmos, de modo ines-perado, um gradiente intraventricular de 102mmHg e movimento sistlico anterior davlvula mitral que no estava presente emrepouso (4). Um caso semelhante tinha sidopublicado previamente por Lau et al. (5) numdoente com angina, prova de esforo positivae coronrias angiograficamente normais. Estesautores demonstraram tambm a eficcia tera-putica dos bloqueadores no tratamentodeste doente.

OBJECTIVO

O objectivo do presente estudo foi avaliar o efeito dos bloqueadores na ocorrnciade GIV e SAM da vlvula mitral em doentescom angina, prova de esforo positiva paraisqumia e coronrias angiograficamentenormais.

POPULAO E MTODOS

PopulaoEstudmos previamente 91 doentes (dts),

44 mulheres, com 51,4 12,1 anos (20 a75), com provas de esforo positivas paraisqumia que posteriormente efectuaramcateterismo que revelou coronrias angio-graficamente normais. Em 33 (36%) dtsdetectmos gradiente intraventricular compico telesistlico - 86 34 mmHg (30 a 165) acompanhado por SAM em 23 dts (6). Os 20doentes aos quais foi possvel repetir EE sobteraputica com bloqueadores b constituema populao do presente estudo. Foramcritrios de excluso a presena de diabetesmellitus , hipertrofia ventricular esquerda,prolapso da vlvula mitral ou outra patologiavalvular e hipertenso arterial no contro-lada h pelo menos um ano. No momento darealizao do EE2 todos os doentes estavammedicados com bloqueadores beta adrenr-gicos mantendo-se inalterada a restanteteraputica. Os bloqueadores beta adrenr-

IVG of 102 mmHg and systolic anterior move-ment (SAM) of the mitral valve that was notpresent at rest (4). A similar case was reportedby Lau et al. (5) in a patient with angina, posi-tive exercise treadmill test and angiographi-cally normal coronary arteries. These authorsalso demonstrated the therapeutic efficacy of -blocker therapy in this patient.

OBJECTIVE

The aim of the present study was toassess the effect of -blockers on the occur-rence of IVG and mitral valve SAM inpatients with angina, positive exercise testfor ischemia and angiographically normalcoronary arteries.

METHODS

PopulationWe studied 91 patients, of whom 44 were

women, mean age 51.4 12.1 years (20-75),with positive treadmill testing for ischemiaand no angiographically demonstrable coro-nary disease. IVG were detected in 33(36%) of these patients, with a mean end-systolic peak of 86 34 mmHg (30-165),together with mitral valve SAM in 23 (6). The20 patients who repeated SE under -block-er therapy constitute the present study pop-ulation. Exclusion criteria were the pres-ence of diabetes, left ventricular (LV) hyper-trophy, mitral valve prolapse or other valvu-lar disease, and uncontrolled hypertensionfor at least a year. At the time of the secondSE assessment all patients were medicatedwith -blockers, other therapy remainingunchanged. In all cases, -blockers were takenat breakfast on the morning of the exam, andhad been prescribed by the patients gener-al practitioners: bisoprolol in nine, atenololin eight, metoprolol in two, and propranololin one. All patients gave their informed con-sent to participation in the study. 195

Carlos Cotrim, et alRev Port Cardiol 2010; 29: 193-203FEV 2010

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gicos foram sempre tomados ao pequeno al-moo da manh da realizao do EE, sendoprescritos pelos respectivos mdicos assis-tentes e eram: bisoprolol em 9 doentes, ate-nolol em 8 doentes, metoprolol em 2 doentese pro-pranolol em outro doente. Todos osdoentes deram consentimento informadopara a participao no estudo.

Ecocardiografia de esforoFoi efectuada uma avaliao ecocardio-

grfica completa que incluiu a medio dotrato de sada do ventrculo esquerdo e cl-culo do respectivo ndice (ITSVE), ndice demassa ventricular esquerda (IMVE), espes-sura relativa de parede (ERP), ndice devolume telediastlico do ventrculo esquerdo(IVOLTDVE). Foi tambm avaliada, comDoppler contnuo alinhado no tracto desada do ventrculo esquerdo no plano api-cal cinco cmaras, a velocidade mxima dofluxo para clculo do gradiente intraven-tricular. Os doentes efectuaram um primeiroecocardiograma de esforo sem bloqueado-res (EE1). Posteriormente os doentes fo-ram medicados com bloqueadores eefectuaram novamente ecocardiograma deesforo sob teraputica boqueadora (EE2)no decorrer do ano que se seguiu ao EE1. Aecocardiografia de esforo de acordo com ametodologia utilizada pelos autores (7) inclui aavaliao da contractilidade durante oesforo em tapete rolante, mas tambm aavaliao dos fluxos com Doppler pulsado econtnuo para deteco de GIV e Doppler codificado em cor. A motilidade da vlvulamitral tambm avaliada tendo em atenoparticularmente a ocorrncia de movimentosistlico anterior da vlvula mitral (SAM).Os estudos foram totalmente gravados emvdeo e parcialmente em disco ptico.Considerou-se gradiente intraventricular significativo o aumento de velocidade paramais de 2,5 m/s no final da sstole (picotelesistlico) tal como utilizado por outrosautores (8,9,10) . Os parmetros ecocardiogrfi-cos apresentados so a mdia de trs me-

Exercise stress echocardiographyA complete echocardiographic assess-

ment was performed, including measure-ment of the LV outflow tract and calcula-tion of the index, LV mass index, relativewall thickness, and LV end-diastolic vol-ume. Maximum flow velocity was alsoassessed by continuous wave Doppler inthe LV outflow tract in five-chamber apicalview to calculate the intraventricular gra-dient. The patients had previously under-gone exercise stress echocardiographywithout -blockers, and subsequentlyrepeated the exam under -blocker thera-py during the following year. The method-ology used (7) includes assessment of wallmotion during treadmill exercise, as wellas of flows by pulsed and continuous waveDoppler for detection of IVG and color Doppler. Mitral valve motion is alsoassessed, particularly for SAM. The examswere recorded on video in their entirety,with parts recorded on optical disk. A sig-nificant IVG was defined as an increase inflow velocity to more than 2.5 m/s at theend of systole (end-systolic peak), as usedby other authors (8-10). The echocardiograph-ic parameters presented are the mean of three measurements obtained on consecu-tive good-quality recordings.

Ergometric parametersThe following parameters were assessed

during SE: test duration (in seconds), sys-tolic blood pressure at rest and at peak exer-cise, heart rate at rest and at peak exercise,peak double product, and occurrence of ST-segment alterations ST depression of 1mm 80 ms after the J point. Occurrence of symptoms such as angina during the testsimilar to those that prompted the patientsoriginal assessment was also recorded.

Statistical analysisThe results are presented as means

standard deviation for continuous variables,and frequencies and percentages for cate-196

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dies de registos consecutivos de boa qua-lidade.

Parmetros ergomtricosRelativamente s provas de esforo foram

avaliados os seguintes parmetros: Duraoda prova em segundos (DurPE), tensoarterial sistlica em repouso (TASr) e nopico (TASp) de esforo, frequncia cardacaem repouso (FCr) e frequncia cardaca nopico (FCp), o duplo produto no Pico(DPPico) e a ocorrncia de alteraes de ST-infradesnivelamento de ST maior ou igual a1mm 80 ms depois do ponto J altST. Foiainda avaliada a ocorrncia de sintomasdurante a prova semelhantes (angor) aos queoriginaram a avaliao clnica dos doentes(reproduo dos sintomas REPsint)

Anlise estatisticaOs resultados so apresentados como

media DP para as variveis contnuas, epercentagem de frequncia para as variveiscategricas. As variveis foram comparadasentre os dois momentos de avaliao sendoutilizado o test T de student para as variveiscontnuas e o teste McNemar paracomparao de amostras emparelhadas paradados qualitativos nominais.

RESULTADOS

Foram includos no estudo vinte doentes.Destes, 7 (33%) so mulheres com 50,7 13,4 anos (23 a 72). Seis doentes (30%) sofumadores, 8 doentes (40%) tinham hiperco-lesterolmia, 8 doentes (40%) estavam medi-cados com nitratos, 3 doentes (15%) estavammedicados com antagonistas de clcio, 5 doen-tes estavam medicados com bloqueadores (que foram suspensos dois dias antes darealizao do 1 ecocardiograma de esforo),3 doentes (15%) com antagonistas dos recepto-res da angiotensina II ou dos inibidores doIECA e dois doentes (10%) com diurticos.

Relativamente aos parmetros avaliados

gorical variables, comparison between thetwo assessments being performed using theStudents t test for continuous variables andthe McNemar test for paired samples for nominal qualitative data.

RESULTS

Of the 20 patients enrolled in the study,seven (33%) were women, mean age50.7 13.4 years (23-72). Six (30%) weresmokers, eight (40%) had hypercholes-terolemia, eight (40%) were taking nitrates,three (15%) calcium channel blockers, five(25%) -blockers (which were suspendedtwo days before the first SE), three (15%)angiotensin receptor blockers or angiotensin-converting enzyme inhibitors, and two(10%) diuretics.

On the resting echocardiogram at thefirst assessment, LV outflow tract indexwas 10.30.8 mm/m 2, LV mass index was7512.5 g/m 2, relative wall thickness was0.370.07, and LV end-diastolic volumewas 429.5 ml/m 2. No wall motion abnor-malities were detected in any of the exams,with or without -blockers. IVG at peakexercise on the first assessment was 97 31mmHg. Fifteen patients (75%) showedimprovement in symptoms, with fewer episodes of angina and an increased levelof exercise required to trigger symptoms.The main results of the variables studiedare shown in Table I and Figure 1.

STUDY LIMITATIONS

The main limitations of the study are: 1)the small sample size; 2) the fact that bothpatients and investigators were aware of thetherapy in progress and that all tests under therapy were performed at the secondassessment, which may have influenced theresults, particularly treadmill test durationand how the patients rated their symptoms. 197


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no ecocardiograma em repouso na data doprimeiro exame, o ITSVE foi 10,3 0,8mm/m2, o IMVE foi 75 12,5 g/m 2 , a ERPfoi 0,37 0,07, o IVOLTDVE foi 42 9,5ml/m2. No detectmos alteraes dacontractilidade segmentar em nenhum dosEE efectuados com e sem bloqueadores. OGIV no pico de esforo do EE1 foi 97 31mmHg. Quinze doentes (75%) tiverammelhoria dos seus sintomas anginosos comdiminuio do nmero de episdios deangor e aumento do nvel de esforo neces-srio para a sua ocorrncia. Os resultadosrelevantes das variveis estudadas soapresentados no Quadro I e na Figura 1.

However, this would not influence objectiveparameters such as the presence andseverity of IVG, or heart rate and bloodpressure; 3) -blocker therapy variedaccording to how it was prescribed by the

patients general practitioners; 4) it wouldalso have been interesting to compare theclinical (angina and exercise tolerance)and echocardiographic response of cardiacsyndrome X patients with IVG who are notunder -blocker therapy with that of thepresent study population, but this was notpossible due to the small number of patients who met the criteria.

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Quadro I. Variveis avaliadas nos dois ecocardiogramas de esforo

Dur PE durao da prova de esforo; FCr frequncia cardaca em repouso; FCp frequncia cardaca no pico de esforo; TASr tenso arterial sistlica em repouso; TASp tenso arterial sistlica no pico de esforo; DPPico duplo produto no pico de esforo; REPsint reproduo dos sintomas durante o EE; GIV Pico gradiente intraventricular nopico de esforo; SAM movimento sistlico anterior da vlvula mitral; altST alteraes do segmento ST

EE1 EE2 p

Dur PE seg. 636 172 669 179 0,039

FCr 73 11 62 5 < 0,000

FCp 161 17 143 12 < 0,000

TASr mmHg 136 14 121 12 0,0001

TASp mmHg 175 22 154 17 < 0,000

DPPico 28424 5071 22101 3744 < 0,000

REPsint 14/20 (70%) 4/20(20%) 0,006

GIV Pico 20/20 (100%) 9/20 (45%) 0,001

SAM 16/20 (80%) 5/20 (25%) 0,001

altST 20/20 (100%) 6/20(30%) 0,000

Table I. Variables assessed in the two stress echocardiograms

DP: double product; HR: heart rate; IVG: intraventricular gradient; SAM: mitral valve systolic anterior motion; SBP: systolic blood pressure; SE: stress echocardiography

EE1 EE2 p

Test duration (sec) 636172 669179 0.039

Resting HR (bpm) 7311 625 < 0.000

Peak exercise HR (bpm) 16117 14312 < 0.000

Resting SBP (mmHg) 13614 12112 0.0001

Peak exercise SBP (mmHg) 17522 15417 < 0.000

Peak exercise DP 284245071 221013744 < 0.000

Symptoms during SE (n) 14/20 (70%) 4/20 (20%) 0.006

Peak IVG (n) 20/20 (100%) 9/20 (45%) 0.001

SAM (n) 16/20 (80%) 5/20 (25%) 0.001

ST-segment alterations (n) 20/20 (100%) 6/20 (30%) 0.000


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Limitaes do estudoComo principais limitaes do estudo

salientamos: 1 - A pequena dimenso daamostra estudada. 2 - O facto de os doentese investigadores terem conhecimento dateraputica em curso e de todas as provassob teraputica terem sido efectuadas emsegundo lugar. Este facto pode ter influen-ciado os resultados nomeadamente a du-rao das provas de esforo e a valorizao

DISCUSSION AND CONCLUSIONS

Patients with angina, positive exercisetest and normal coronary arteries have longconstituted an important clinical problem (11-13),the clinical entity characterized by theseinitial studies now being known as cardiacsyndrome X (14).

Intraventricular gradients in a patientwith this syndrome were first described by 199


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Figura 1. GIV detectado no pico de esforo sem e com teraputica com bloqueadores beta adrenrgicos.

Figure 1. IVG at peak exercise without and with -blockers. BBs: -blockers

IVG without BBs IVG with BBs

Figura 2. Caso ilustrativo de uma doente estudada antes (esquerda) e aps (direita) a teraputica com bloqueador beta adrenrgico.

Figure 2. Female patient assessed before (left) and after (right) -blocker therapy


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que o doente faz dos seus sintomas. Salien-tamos, no entanto, que parmetros objecti-vos como presena e o valor do GIV ou afrequncia cardaca e a presso arterial noso influenciados por este facto. 3 - Ateraputica com bloqueadores era hetero-gnea o que se deve ao facto de ser pres-crita livremente pelos mdicos assistentesrespectivos. 4 - Seria interessante tambmsaber a resposta clnica (angina e tolernciaao esforo) e ecocardiogrfica, de doentescom sndroma X com GIV que no fizerambloquedores beta adrenrgicos e comparar estes resultados com os doentes do presenteestudo no entanto tal no foi possvelatendendo ao diminuto nmero de doentesque satisfizeram estas condies.

Discusso e conclusesOs doentes com angina, prova de esforo

positiva e coronrias normais constituem umproblema com grande relevncia clnicadesde h longa data (11,12,13) . Estes primeirosestudos caracterizaram a entidade clnica aque hoje denominamos sndroma X cardaco (14).

A ocorrncia de gradiente intraventri-cular num doente com a sndroma Xcardaca foi descrita pela primeira vez por Lau (5) que no s detectou o fenmeno numdoente com angina de esforo como utilizoubisoprolol no seu tratamento conseguindomelhoria clnica e demonstrando uma signi-ficativa diminuio do gradiente intraventri-cular. Posteriormente tambm ns demons-trmos a presena de GIV em doentes comangina e coronrias angiograficamentenormais (4,15) o que conduziu ao estudo de 91doentes com a sndroma X (6) dos quaisviramos a seleccionar os 20 do presenteestudo. Recentemente Bueno (16) demonstrou,num pequeno nmero de doentes, apresena de gradientes intraventricularesem doentes com Sndroma X embora algunsdoentes tivessem hipertenso arterial ehipertrofia ventricular esquerda que, por definio de Sndroma X, foram excludosno presente estudo.

Lau et al. (5), who detected the phenomenonin a patient with effort angina and treated itwith bisoprolol, resulting in clinicalimprovement and a significant reduction inthe IVG. Subsequently, we also demonstrat-ed the presence of IVG in patients withangina and angiographically normal coro-nary arteries (4, 15), which led to a study of 91syndrome X patients (6), from among whomwe selected the 20 patients of the presentstudy. Bueno et al. (16), in a small number of patients, demonstrated the presence of IVGin syndrome X patients, although some hadhypertension and left ventricular hypertro-phy, conditions which would have excludedthem from the present study, based on thedefinition of the syndrome.

-blockers are used to treat patients withangina and angiographically normal coro-nary arteries not only because of their anti-ischemic and antianginal properties, butalso because of their effect on heart rate.They are particularly efficacious in control-ling chest pain in patients with increasedsympathetic activity, as well as in those withno alterations in cardiac autonomic control.One study (17) has shown that acebutulolimproves exercise tolerance in syndrome Xpatients who show signs of increased sympa-thetic activity during exercise, and other investigators have reported similar results inpatients with inverted T waves on the ECGand signs of adrenergic hyperreactivity (18).Chronic -blocker therapy has been shownto improve exercise tolerance and left ven-tricular filling dynamics (19), while another study found a good correlation between con-trol of anginal symptoms and normalizationof sympathetic hyperactivity in patients withangina (20). In general, -blockers should befirst-line pharmacological treatment (21, 22) inthese patients, particularly when there isevidence of increased sympathetic tone,such as high heart rate or diminished HRvariability on 24-hour Holter monitoring, or a rapid increase in heart rate or blood pres-sure during exercise testing (23).200


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Os bloqueadores tm sido utilizados nateraputica de doentes com angina e coro-nrias angiograficamente normais no sdevido ao seu efeito anti isqumico eantianginoso, mas tambm devido ao seuefeito sobre a frequncia cardaca. Osbloqueadores so particularmente eficazesno controlo da dor torcica em doentes comaumento da actividade simptica, noentanto tambm so eficazes em doentessem alteraes do controlo autonmicocardaco. Num estudo foi demonstrado que oacebutulol (17) melhora a tolerncia ao esforoem doentes com a sndroma X que tmsinais de aumento da actividade simpticadurante o esforo, tendo outros investiga-dores encontrado resultados semelhantesem doentes com ondas T invertidas noelectrocardiograma (18) e sinais de hiperacti-vidade adrenrgica. Foi demonstrado que ateraputica crnica com bloqueadores melhora a tolerncia ao esforo e o padrode enchimento do ventrculo esquerdo (19),tendo outro estudo verificado existir umaboa correlao entre o controlo da angina ea normalizao da hiperactividade simp-tica em doentes com angina (20). De um modogeral, os bloqueadores devem fazer parteda primeira linha na teraputica farmacol-gica (21,22) destes doentes sobretudo quandoexiste evidncia de um aumento do tnussimptico, como frequncia cardaca alta oudiminuio da variabilidade no Holter de 24horas ou um aumento muito rpido dafrequncia cardaca e da presso arterialdurante a prova de esforo (23).

A abordagem teraputica da sndroma X ainda actualmente um desafio para omdico e para o doente, o que compreens-vel se tivermos em conta a diversidade demecanismos que parecem estar envolvidosna sua fisiopatologia. A abordagem maisfrequente de informar o doente de que notem doena cardaca significativa tem sidoquestionada (24), sobretudo se tivermos emateno o facto de alguns subgrupos dedoentes com sndromes coronrias agudas

Management of syndrome X remains achallenge for the physician and the patient,which is understandable given the variety of mechanisms that appear to be involved in itspathophysiology. The usual approach of telling patients that they have no significantheart disease has been called into question (24),particularly in view of the fact that certainsubgroups of patients with cardiac syndromeX have significant event rates, and patientswith complete left bundle branch block alsohave worse prognosis. While the prognosisis good in most other patients (25), quality of life is significantly affected in many.

In our study we found that -blockersreduced heart rate, ST-segment depression,systolic blood pressure and hence peak dou-ble product, during exercise. The occur-rence of IVG and SAM on exertion alsodecreased significantly. These changes wereaccompanied by improvement in anginalsymptoms during follow-up and exercisetesting, as well as in functional capacity.

Improvement in symptoms with -block-er therapy in patients with documented IVGhas been demonstrated (26, 27, 5) ; these studiesalso clearly showed an association betweenreduced IVG and improvement of symptomsand functional capacity. Since -blockersare recommended in the treatment of syn-drome X patients, the results of this studysuggest that exercise stress echocardiogra-phy would help in selecting patients whodevelop IVG on exertion and who wouldrespond particularly well to these drugs.

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poderem ter uma taxa de eventos signi-ficativa. Os doentes com bloqueio completode ramo esquerdo tm tambm um pior prognstico e embora o prognstico dosrestantes doentes seja bom (25), a qualidadede vida est seriamente alterada numgrande nmero de doentes.

No nosso estudo verificmos que autilizao dos bloqueadores diminui afrequncia cardaca, o infradesnivelamentode ST, a tenso arterial sistlica e por consequncia o duplo produto mximoatingido durante o esforo. Tambm os GIVe a ocorrncia de SAM durante o esforodiminuem de modo significativo. Estasalteraes so acompanhadas de melhoriado angor durante o seguimento e durante aprova de esforo e tambm de um aumentoda capacidade funcional.

A melhoria dos sintomas conseguida,com o tratamento com bloqueadores , emdoentes em que foi demonstrada a presenade GIV, tinha j sido demonstrada (26,27,5) . Nas

mesmas publicaes foi tambm evidente aassociao entre a diminuio do GIV e amelhoria dos sintomas e da capacidadefuncional. Sendo os bloqueadores , umadas armas teraputicas preconizadas, emdoentes com sndroma X cardaca, osresultados deste estudo sugerem-nos que autilizao da ecocardiografia de esforo,pode permitir seleccionar um subgrupo dedoentes que desenvolvem GIV durante oesforo e que respondem particularmentebem teraputica com estes frmacos.

Pedido de separatas:Address for reprints:

Carlos CotrimHospital Garcia de OrtaAvenida Torrado da Silva2805-267 Almada - [email protected] 00351 916 885 153

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