The incremental prognostic value of pharmacological stress echo over exercise electrocardiography in women with chest pain of unknown origin.

AIMS: The value of exercise electrocardiography in evaluating women with suspected coronary artery disease is limited. Conversely, stress echocardiography is effective for both diagnostic and prognostic purposes in females. The purpose of the study was to determine the relative prognostic value of exercise electrocardiography and pharmacological stress echocardiography in a cohort of women with chest pain of unknown origin, in order to verify whether criteria could be established for the daily non-invasive evaluation of such a low-risk profile population. METHODS AND RESULTS: Exercise electrocardiography and pharmacological stress echocardiography (171 dipyridamole, 73 dobutamine) were performed in 244 women (age 60+/-10 years) with chest pain and known coronary artery disease. A positive result of exercise electrocardiography (ST-segment shift > or =1 mm at 80 ms after the J point) was detected in 95 patients; a positive result of stress echocardiography (new regional wall motion abnormalities) was observed in 33 patients. During follow-up (36+/-18 months), two deaths, five infarctions, seven unstable anginas, and 11 coronary revascularizations occurred. Using Cox analysis, the positive result of stress echocardiography (odds ratio=40.1) alone, was independently related to hard cardiac events (death, infarction). With spontaneous cardiac events (death, infarction, and unstable angina) as end-points, the multivariate prognostic predictors were a positive result of stress echocardiography (odds ratio=37.0), a family history of coronary artery disease (odds ratio=4.1), typical chest pain (odds ratio=3.7), and a positive exercise electrocardiography result with a rate-pressure product < or =20 000 (odds ratio=3.5). By adopting an interactive stepwise procedure, the prognostic value of stress echocardiography was incremental to that of clinical and exercise electrocardiography data. Nevertheless, the negative result of exercise electrocardiography and pharmacological stress predicted a very high and comparable (P=ns) 24-month survival rate when both hard and spontaneous cardiac events were taken as end-points. CONCLUSIONS: In women with chest pain, stress echocardiography is a strong and independent prognostic indicator, incremental to that shown by exercise electrocardiography. However, the two tests have a similar high negative predictive value in this population. Therefore, exercise electrocardiography has to be considered the initial approach and the only test when the result is negative, whereas stress echocardiography is warranted in selected conditions, including those in women with uninterpretable electrocardiograms, those unable to exercise maximally, and those with an ambiguous or ischaemic response to exercise electrocardiography.

[The evaluation of the appropriateness of instrumental exams in cardiology. The case of echocardiography]. / La valutazione dell'appropriatezza degli esami strumentali in cardiologia. Il caso dell'ecocardiografia.

BACKGROUND: The aim of this study was to evaluate the appropriateness and utility rates of echocardiograms performed in 309 patients in an outpatient clinical setting. METHODS: Data were collected by means of a questionnaire filled in by the cardiologists who performed the examinations. Appropriateness was evaluated according to international guidelines and scored as class I: appropriate, class II: doubtful appropriateness, class III: inappropriate; the exam was deemed useful if it was able to influence the clinical decision-making; normalcy rate was also checked. The relationship between both the referring physicians and motivation of the exam and its appropriateness, and the relationship between appropriateness and both the normalcy rate and utility of the exam were assessed. RESULTS: An echocardiogram was requested by the cardiologist in 46% of patients; the more common reasons for the exam were arterial hypertension (26%), cardiac murmur (18%), palpitations (15%), and known coronary artery disease (10%). The echocardiogram was appropriate (class I) in 25% of patients, doubtfully appropriate (class II) in 39% of patients and inappropriate (class III) in 36% of patients. The appropriateness rate between the cardiologists was similar to that of other prescribing clinicians (p = NS). The highest class III rate was found in patients with hypertension, while the highest class I rate was found in patients with a cardiac murmur (p < 0.01). Normalcy rate was lower in class I than in class II and III exams (p < 0.001). The utility rate was higher in class I (76%) than in class II (13%) and III (< 1%) exams (p < 0.01). CONCLUSIONS: International guidelines can be used effectively and safely to identify (not to prescribe) the useless echocardiograms.

Anomalous "VVI" pacing of a dual chamber pacemaker when programmed in DDI(R) mode.

We describe the case of a dual chamber rate responsive pacemaker (Relay, model 294-03, Intermedics, Angleton, TX, USA) implanted in a 68-year-old male for sick sinus syndrome, which was not working properly when programmed in the DDIR mode, thus determining occasionally a sort of "VVI" pacing. However, the pacemaker performed well when programmed in the DDDR mode. We discovered that this was not a malfunction of a single device but rather a general behavior of this family of Intermedics dual chamber pacemakers (also not rate responsive), caused by a software problem.

[Variation in the evoked ventricular potentials after the implantation of an endocardiac catheter; the correlation with stimulation thresholds]. / Variazione dei potenziali ventricolari evocati dopo l'impianto di un catetere endocardico; correlazione con le soglie di stimolazione.

BACKGROUND: The drop in T wave amplitude of the ventricular pace-evoked response (VER) is a well-recognized and reliable mean of detecting localized conditions of myocardial hypoxia. In patients who undergo pacemaker implantation, the post-implant change at the electrode-tissue interface consists of an early inflammatory reaction. The aim of this study was to establish whether the extent of the inflammatory reaction following an endocardial lead can be assessed by the changes in the T wave amplitude of VER. METHODS: Modifications in VER amplitude and the correlation between these changes and pacing threshold time-course were evaluated in 30 patients receiving an endocardial catheter. Telemetered endocardial recordings of T wave amplitude and pacing thresholds were measured at the time of implant and after 1, 2, 3, 7, 14 and 30 days. RESULTS: A biphasic time-course was observed for T wave, characterized by reduction in amplitude of 48% (p < 0.005) from baseline at day 3 and subsequent increment up to 84% (p = ns) of the baseline value at day 30. By using a linear regression analysis, a significant correlation between T wave changes and increment in pacing threshold was found (r = 0.81; p < 0.002). A higher pacing threshold increment was observed in patients having a decrease in VER amplitude > or = 1 mV at 3rd in comparison with patients with a decrease in VER amplitude < 1 mV (1.1 +/- 0.4 vs 0.2 +/- 0.2 V; p < 0.001). CONCLUSIONS: VER recordings during the first days after endocardial lead implantation may be a valuable means of assessing the extent of the inflammatory reaction developing at the electrode-tissue interface. This method may be useful for early identification of patients at risk of increases in pacing threshold and for evaluation of the biocompatibility of different leads.

[Echocardiographic evaluation of left ventricular diastolic function in patients with dilated cardiomyopathy: correlation among doppler, hemodynamic and clinical findings]. / Studio ecocardiografico della funzione diastolica ventricolare sinistra in pazienti con cardiomiopatia dilatativa: correlazione tra indici Doppler, emodinamici e clinici.

In order to evaluate the prognostic implications of either transmitral filling parameters and pulmonary artery capillary pressure, 35 patients (23 men, age 63 +/- 13 years, +/- SD) with idiopathic (n = 19) or ischemic (n = 16) dilated cardiomyopathy (NYHA class II-IV) underwent Doppler echocardiography and right cardiac catheterization. None of them had atrial fibrillation, severe mitralic valvular disease, a advanced atrial-ventricular heart block, or was pace-maker implanted. Two groups of patients were identified on the basis of status symptoms: Group 1 (n = 12; NYHA class IIa-IIb), Group 2 (n = 23; NYHA class III-IV). As to diastolic parameters, the 2 groups significantly differed in peak E velocity (p < 0.001), deceleration time (p < 0.001), E/A ratio (p = 0.0004), E wave duration (p < 0.05) and isovolumetric time relaxation (p < 0.05). A restrictive-type transmitralic filling (high mitral E wave velocity, low mitral A wave velocity, low deceleration time), was found in 4 (33%) patients of Group 1 and in 20 (86%) patients of Group 2. Group 2 patients had significantly higher pulmonary artery capillary pressure (p < 0.001) than Group 1 patients. During the follow-up (18 +/- 6 months; from 8 to 22 months), 6 patients experienced cardiac death (4 died of sudden death and 2 for congestive heart failure), 1 patient underwent cardiac transplantation, and 6 patients had deterioration of status symptoms. All of the 7 major cardiac events and 3 out of 6 deteriorations of status symptoms occurred in patients of Group 2. With a Cox analysis, deceleration time (beta-0.096, SE = 0.03, p < 0.005), pulmonary artery capillary pressure (beta-0.027, SE = 0.01, p < 0.001), and left ventricular ejection fraction (beta-0.098, SE = 0.32, p < 0.006) were predictive of major cardiac events. The univariate prognostic predictors were found to be: E/A ratio (r = 0.72, p < 0.05), deceleration time (r = -0.90, p < 0.05), and isovolumetric time relaxation (r = -0.74, p < 0.05). Assessment of transmitral filling by Doppler echocardiography is a simple, reproducible and noninvasive method, providing effective functional and prognostic information on patients with dilated cardiomyopathy. The correlation found between several transmitral filling parameters and pulmonary artery capillary pressure provides an accurate noninvasive estimation of hemodynamics in these patients.

Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease.

OBJECTIVES: In this study we sought to investigate the prognostic value of pharmacological stress echocardiography in women referred for chest pain, having unknown coronary artery disease. BACKGROUND: The noninvasive identification of a high-risk subgroup among women with chest pain and unknown coronary artery disease is an unresolved task to date. METHODS: A total of 456 women (mean [+/-SD] age 63+/-10 years) underwent pharmacological stress echocardiography with either dipyridamole (n = 305) or dobutamine (n = 151) for evaluation of chest pain and were followed-up for 32+/-19 months. None of them had a previous diagnosis of coronary artery disease. RESULTS: No major complication occurred during stress testing. Five tests (1.1%) were prematurely interrupted because of the appearance of side effects. Echocardiographic positivity was identified in 51 patients. During the follow-up, 23 cardiac events occurred: 3 deaths, 10 infarctions and 10 cases of unstable angina; an additional 21 patients underwent coronary revascularization. At Cox analysis, the echocardiographic evidence of ischemia was found as the only independent predictor of hard cardiac events (death, infarction) (odds ratio [OR] = 27.5; 95% confidence interval [CI] = (6.5 to 115.5; p = 0.0000). When spontaneous cardiac events (death, infarction and unstable angina) were considered as endpoints, the positive echocardiographic result (OR = 23.9; 95% CI = 8.6 to 66.8; p = 0.0000) and family history of coronary artery disease (OR = 3.7; 95% CI = 1.5 to 9.1; p = 0.0037) were independently correlated with prognosis. By using an interactive stepwise procedure, the prognostic value of stress echocardiography was found to be incremental to that provided by clinical variables, both considering hard and spontaneous cardiac events as endpoints. The 3-year survival rate for the negative and the positive population was respectively, 99.5% and 69.5% (p = 0.0000) considering hard cardiac events, 99.2% and 50.6% (p = 0.0000) considering spontaneous cardiac events. CONCLUSIONS: Pharmacological stress echocardiography is safe, highly feasible and effective in risk stratification of women with chest pain and unknown coronary artery disease, also when hard endpoints are considered. Its use can have relevant implications in daily clinical practice for selection of patients needing further investigations.

Risk stratification by pharmacological stress echocardiography in a primary care cardiology centre. Experience in 1082 patients.

AIM: In this study we sought to determine the safety, feasibility and prognostic value of pharmacological stress echocardiography performed in a primary care cardiology centre, populated by unselected patients evaluated with the aid of limited financial and technological resources. METHODS AND RESULTS: The study population was 1082 patients undergoing pharmacological stress echocardiography with either dipyridamole (n=714) or dobutamine (n=368) for the evaluation of known or suspected coronary artery disease. The echocardiogram was positive in 284 (26%) patients. Two sustained ventricular tachycardias, reversible by antidote, occurred during stress testing. Limiting ischaemia-independent side effects occurred in 1.5% dipyridamole and in 2.4% dobutamine stress echocardiograms. During follow-up (33+/-18 months), 17 cardiac deaths and 27 non-fatal myocardial infarctions occurred. One hundred and twenty-seven patients underwent coronary revascularization, of whom 105 (37%) had a positive and 22 (3%) a negative stress testing result (P<0.0001). At Cox analysis, allowing for 14 clinical and stress-echo variables. the independent predictors of cardiac death were, in decreasing order, a positive stress testing result (Odds ratio [OR]=6.0), resting wall motion score index (OR=5.7), age greater than 65 years (OR=4.9), previous Q-wave myocardial infarction (OR=3.5), and hypercolesterolaemia (OR=2.7). The 4-year survival rate was 99.2% for patients with a negative and 89.8% for patients with a positive stress testing result (P=0.0000). When cardiac hard events (cardiac death and non-fatal myocardial infarction) were considered as end-points, the following variables were independently associated with prognosis: positive result of stress testing (OR=3.1), hypercolesterolaemia (OR=2.4), and resting wall motion score index (OR=2.7). The 4-year infarction-free survival rate was 97.0% for patients with a negative and 81.4% for patients with a positive stress testing result (P=0.0000). CONCLUSIONS: Pharmacological stress echocardiography with either dipyridamole or dobutamine was safe and feasible, providing an excellent tool for prognostic assessment of coronary artery disease in a primary care cardiology centre.

Dipyridamole stress echocardiography for risk stratification in hypertensive patients with chest pain.

BACKGROUND: The noninvasive prognostic assessment of coronary artery disease (CAD) in hypertensive patients represents an unresolved task to date. In this study, we investigated the value of dipyridamole stress echocardiography in risk stratification of hypertensive patients with chest pain and unknown CAD. METHODS AND RESULTS: Dipyridamole stress echocardiography was performed in 257 hypertensives (110 men; age, 63+/-9 years) complaining of chest pain and without a history of CAD. No major complications occurred. Four tests were interrupted prematurely because of side effects, with 98. 4% feasibility of test. A positive echocardiographic response was found in 72 patients (27 during the low-dose [0.56 mg/kg]). During the follow-up (32+/-18 months), 27 cardiac events occurred: 3 deaths, 8 infarctions, and 16 cases of unstable angina. Moreover, 27 patients underwent coronary revascularization. At multivariate analysis, the positive echocardiographic result (OR, 5.5; 95% CI, 1.4 to 16.6) was the only predictor of hard cardiac events (death, infarction). Considering spontaneous cardiac events (death, infarction, and unstable angina) as end points, the positive echocardiographic result (OR, 4.2; 95% CI, 1.8 to 9.6) and family history of CAD (OR, 4.2; 95% CI, 1.5 to 6. 9) were independently associated with prognosis. The 3-year survival rates for the negative and the positive populations were, respectively, 97% and 87% (P=0.0019) considering hard cardiac events and 96% and 74% (P=0.0000) considering spontaneous cardiac events. CONCLUSIONS: Dipyridamole stress echocardiography is safe, highly feasible, and effective in risk stratification of hypertensives with chest pain and unknown CAD. At present, it represents an attractive option for prognostic assessment of this clinically defined population.

Significance of myocardial ischemic electrocardiographic changes during dipyridamole stress echocardiography.

The aim of this study was to assess the diagnostic and prognostic value of the presence and characteristics of ischemic electrocardiographic (ECG) changes during dipyridamole stress echocardiography. The ECG response in 178 patients with echocardiographic evidence of myocardial ischemia during dipyridamole stress testing was analyzed. ECG changes occurred in 105 patients (59%). Patients with ECG changes had a higher incidence of echocardiographic signs of ischemia at a low dose than patients with an unchanged electrocardiogram (50% vs 23%; p = 0.0002). Three-vessel and/or left main coronary artery disease (CAD) was found in 41% of patients with and in 21% of patients without ECG changes (p = 0.029). During follow-up (33 +/- 19 months), 30 cardiac events occurred: 10 deaths, 6 infarctions, and 14 unstable anginas. Coronary revascularization was performed in 48 patients with and in 17 patients without ECG changes (p = 0.0022). The univariate predictors of cardiac events were: presence of ischemia in > or =4 ECG leads (p = 0.0004), echocardiographic evidence of ischemia at a low dose (p = 0.0062), ST-segment shift on precordial leads (p = 0.0094), family history of CAD (p = 0.0115), coexistence of > or =3 cardiovascular risk factors (p = 0.0156), ST-segment depression (p = 0.0172), and ECG changes during testing (p = 0.0335). At Cox analysis, occurrence of ischemia at a low dose (odds ratio 3.0; 95% confidence interval 1.3 to 6.8) and the presence of ischemia in > or =4 ECG leads (odds ratio 3.5; 95% confidence interval 1.3 to 9.3) had an independent prognostic importance. In conclusion, the presence and characteristics of ischemic ECG changes are associated with more extensive CAD and worse prognostic outlook than are echocardiographic changes alone during dipyridamole stress echocardiography.

Value of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease: a report from the Echo-Persantine and Echo-Dobutamine International Cooperative Studies.

OBJECTIVES: This study sought to verify the effectiveness of pharmacologic stress echocardiography in risk stratification of patients with single-vessel disease. BACKGROUND: Noninvasive prognostic assessment of single-vessel disease is an unresolved issue to date. METHODS: The study evaluated prospectively collected data from 754 patients with angiographic single-vessel disease who underwent either dipyridamole (n = 576) or dobutamine (n = 178) stress echocardiography. Invasive treatment (coronary revascularization within 3 months of stress testing) was performed in 260 patients and medical treatment in 494. RESULTS: Echocardiographic positivity was observed in 421 patients (56%). Patients treated invasively had a higher incidence of stress test positivity (69% vs. 49%, p < 0.001) and left anterior descending coronary artery involvement (60% vs. 46%, p < 0.001) than patients maintained with medical therapy. During a mean follow-up of 37 months, 54 hard cardiac events occurred (14 deaths, 40 nonfatal infarctions): 37 in medically and 17 in invasively treated patients (7.5% vs. 6.5%, p = NS). On Cox analysis, a positive result on stress testing was the only independent prognostic predictor in medically treated patients (relative risk 2.92, 95% confidence interval 1.29 to 6.59). The 4-year infarction-free survival rate was higher for a negative than a positive stress test result in medically (93.9% vs. 87.3%, p = 0.009) but not invasively treated patients (92.7% vs. 97.1%, p = 0.545). Moreover, a significantly higher 4-year infarction-free survival rate was found in invasively versus medically treated patients with a positive (p = 0.012), but not in those with a negative, stress test result (p = 0.853). CONCLUSIONS: Pharmacologic stress echocardiography is effective in risk stratification of single-vessel disease and can accurately discriminate patients in whom coronary revascularization can have the maximal beneficial effect. These findings have a potential favorable impact on the cost-effectiveness of invasive procedures.

Acute hemodynamic effects of endogenous adenosine in patients with chronic heart failure.

OBJECTIVE: The objective of this study was to assess the acute hemodynamic effects of endogenous adenosine accumulation in patients with chronic heart failure. Exogenously administered adenosine has been shown to reduce pulmonary vascular resistance and to increase cardiac index in normal subjects and in patients with pulmonary hypertension or end-stage biventricular heart failure. Endogenous adenosine accumulation can be provoked by dipyridamole. METHODS AND RESULTS: Ultra-low-dose dipyridamole (0.07 mg/kg/min for 4 minutes) was administered in 20 patients with either symptomatic idiopathic (n = 12) or ischemic (n = 8) dilated cardiomyopathy and reduced left ventricular ejection fraction (mean 25%+/-5%). Hemodynamic variables were measured before and within 1 minute from the end of dipyridamole infusion. After dipyridamole administration, a mild but significant increase in heart rate (4.5%; p = 0.03) and reduction in mean blood pressure (6.8%; p < 0.001) without changes in right atrial pressure (p = NS) were detected. Dipyridamole increased cardiac output by 26.6% (p < 0.001), cardiac index by 24% (p < 0.001), and stroke volume by 19.8% (p < 0.001), with concomitant 24.6% reduction of systemic vascular resistance (p < 0.001). Moreover, dipyridamole reduced mean pulmonary artery pressure by 8.3% (p < 0.01) and pulmonary vascular resistance by 33.3% (p = 0.001), without changes in pulmonary wedge pressure (p = NS). A significant correlation between percent decrease from baseline in pulmonary and systemic vascular resistance (r = 0.66; p = 0.002) was found after administration of dipyridamole. CONCLUSIONS: Endogenous adenosine accumulation induced by ultra-low-dose dipyridamole infusion acutely improves the hemodynamic profile, decreasing pulmonary and, to a lower extent, systemic vascular resistance and increasing cardiac index in patients with severe chronic heart failure.

[Femoral compression neuropathy caused by spontaneous hematoma during heparin therapy: description of a case]. / Neuropatia femorale da compressione di ematoma spontaneo in corso di terapia eparinica: descrizione di un caso.

Heparin therapy has become widespread during the past few years. Consequently, the haemorrhagic complications of this therapy have become more common. In some cases, the clinical manifestations do not directly recall the haemorrhagic episode but rather, they simulate intercurrent pathologies. This is the case with femoral neuropathy from psoas haematoma which we refer to here.