The role of carotid atherosclerosis in the distinction between ischaemic and non-ischaemic cardiomyopathy.

AIM: Sometimes ischaemic cardiomyopathy is a result of severe coronary artery disease of an occult course, without typical symptoms or evidence of myocardial infarction. This form of presentation is usually indistinguishable from non-ischaemic dilated cardiomyopathy. Carotid bifurcation atherosclerosis and coronary artery disease have been shown to be strongly associated. We prospectively examined the value of extracranial carotid atherosclerosis in the distinction between ischaemic and non-ischaemic aetiology in patients with clinically unexplained cardiomyopathy. METHODS AND RESULTS: Seventy-eight patients with undetermined dilatation and diffuse impairment of the left ventricular contraction were studied within 28 months. They underwent carotid scan and coronary arteriography. Carotid atherosclerosis was found to be very common in ischaemic and rare in non-ischaemic cardiomyopathy. The presence of at least one abnormal carotid finding (intima-media thickness >1 mm, plaques, severe carotid stenosis) was 96% sensitive and 89% specific for ischaemic cardiomyopathy. CONCLUSION: Carotid scanning may be a useful screening and decision making tool in patients with cardiomyopathy of indecisive cause. Patients with carotid atherosclerosis are likely to suffer from severe coronary artery disease. Coronary angiography and subsequent myocardial viability studies, when indicated, could be considered early during their evaluation. In contrast, a negative carotid scan predicts non-ischaemic cardiomyopathy.

Effects of ischemia on P wave dispersion and maximum P wave duration during spontaneous anginal episodes.

P wave dispersion (P dispersion), defined as the difference between the maximum and the minimum P wave duration, and maximum P wave duration (P maximum) are electrocardiographic (ECG) markers that have been used to evaluate the discontinuous propagation of sinus impulses and the prolongation of atrial conduction time, respectively. To study the effects of myocardial ischemia on P dispersion and P maximum, 95 patients with coronary artery disease (CAD) and typical angina pectoris and 15 controls with angina like symptoms underwent 12-lead surface ECG during and after the relief of pain. During pain and during the asymptomatic period, P maximum and P dispersion were calculated from the averaged complexes of all 12 leads. P dispersion increased significantly during spontaneous angina (45+/-17 ms) compared to the asymptomatic period (40+/-15 ms), P < 0.001 only in the patient group. Both P maximum and P dispersion showed higher values during angina in those patients who developed diffuse ischemia, as estimated with ST segment changes in multiple ECG leads. P dispersion showed higher values during the anginal episode in patients with left ventricular dysfunction, independently of the presence of a previous myocardial infarction. Atrial conduction abnormalities, as estimated with P maximum and particularly P dispersion, are significantly influenced by myocardial ischemia in patients with CAD and spontaneous angina.

Effects of ischemia on QT dispersion during spontaneous anginal episodes.

Myocardial ischemia induced by pacing, angioplasty, or stress results in a significant increase in QT dispersion (QTd = QT maximum - QT minimum). This study investigated the effects of ischemia on QTd and the rate-corrected QTd (QT(c)d) during spontaneous anginal episodes in patients with coronary artery disease (CAD). Ninety-five patients with CAD and typical angina pectoris and 15 control subjects complaining of anginalike symptoms were studied. QTd and QT(c)d were calculated from 12-lead surface electrocardiograms recorded during and after the relief of pain. QTd and QT(c)d were significantly higher during the anginal episode (84+/-31 ms and 98+/-51 ms) compared to the painless conditions (69+/-24 ms and 71+/-24 ms) (P = .003 and P = .001 for QTd and QT(c)d, respectively) only in the 57 CAD patients who had a history of an old previous myocardial infarction. QTd and QT(c)d are significantly increased during spontaneous angina in patients with documented CAD and history of previous myocardial infarction.

Reliability of M-mode, two-dimensional and Doppler echocardiography in diagnosing a flail mitral valve leaflet.

The purpose of this study was to evaluate the M-mode, two-dimensional, and Doppler echocardiographic signs for a flail mitral valve leaflet. This was a retrospective evaluation of 54 patients who had (1) significant mitral regurgitation, (2) a technically adequate echocardiographic study, and (3) description of valve anatomy done at surgery or necropsy. The following M-mode signs were examined for their ability to detect a flail valve: (1) systolic flutter of the mitral valve closure line, sensitivity 29%, specificity 76%; (2) abnormal diastolic posterior leaflet motion, sensitivity 73%, specificity 71%; (3) abnormal diastolic anterior leaflet motion, sensitivity 67%, specificity 86%; (4) systolic atrial echoes, sensitivity 28%, specificity 68%; (5) multiple independent systolic closure lines, sensitivity 71%, specificity 52%. The two-dimensional echocardiographic signs evaluated were (1) diastolic inversion of the anterior leaflet toward the left atrium, sensitivity 29%, specificity 96%; (2) diastolic inversion of the posterior leaflet toward the left atrium, sensitivity 54%, specificity 93%, (3) systolic inversion of the anterior leaflet into the left atrium, sensitivity 57%, specificity 93%; (4) systolic inversion of the posterior leaflet into the left atrium, sensitivity 79%, specificity 86%; (5) systolic whipping of the mitral leaflets, sensitivity 73%, specificity 74%; (6) presence of floating apical chordae, sensitivity 30%, specificity 91%. Doppler echocardiographic signs evaluated were (1) presence of left atrial systolic antegrade flow, sensitivity 30%, specificity 91%; (2) vertical striations superimposed on the typical regurgitant flow pattern, sensitivity 75%, specificity 69%. When all the two-dimensional signs except systolic whipping and the M-mode signs for abnormal diastolic leaflet motion were combined, the sensitivity for detecting a flail mitral valve was maximized at 97%, but specificity was reduced to 64%. In conclusion, two-dimensional echocardiographic signs are more sensitive and specific than either M-mode or Doppler signs for detecting a flail mitral valve. The various M-mode, two-dimensional, and Doppler echocardiographic signs, however, are complementary to each other, and sensitivity is maximized when they are combined.