Prognostic value of left and right coronary flow reserve assessment in nonischemic dilated cardiomyopathy by transthoracic Doppler echocardiography.

BACKGROUND: Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can be reduced in nonischemic dilated cardiomyopathy (DCM). The aim of this study was to assess the prognostic value of CFR in LAD and in the posterior descending artery (PD) in DCM patients. METHODS: Seventy-two DCM patients (44 men, mean age 64 ± 13 years) underwent dipyridamole (0.84 mg/kg in 6 minutes) stress echo. CFR was defined as the ratio between maximal vasodilation and rest peak diastolic flow velocity in LAD and PD. RESULTS: CFR was abnormal in LAD in 42 out of 72 patients and in PD in 31 out of 55. All patients completed the clinical follow-up, and 56 patients completed the echocardiographic follow-up. During median follow-up of 42 months, 33 events (7 deaths, 26 major cardiac events) occurred. Event rate was markedly higher for patients with reduced CFR compared with DCM patients with normal CRF in LAD (0 vs 19 events; P < .001) and in PD (1 vs 13 events; P < .001). CFR in LAD and in PD were significantly related to the change in end-systolic volume during follow-up (r = -0.481, P < .001; and r = -0.407, P = .028; respectively). Preserved CFR in both LAD and PD was associated with better (P < .0001) event-free survival compared with abnormal CFR (log rank: 28.1; P < .0001). CONCLUSIONS: In DCM patients, impairment of CFR in LAD and PD is related to a worse outcome; CFR impairment is more relevant when it occurs in LAD. PD evaluation may be redundant and time-consuming, because the additive value is small and the feasibility suboptimal.

Diffuse, marked, reversible impairment in coronary microcirculation in stress cardiomyopathy: a Doppler transthoracic echo study.

UNLABELLED: The aim of the study was to assess coronary flow reserve (CFR) in tako-tsubo cardiomyopathy (TC). METHODS AND RESULTS: Thirty consecutive patients (5 males; age 68+/-12 years) meeting diagnostic criteria for TC were evaluated with transthoracic dipyridamole (0.84 mg/kg over 6 min) stress echo and pulsed Doppler CFR assessment on mid-distal left anterior descending (LAD) and posterior descending of right coronary artery (PD). Wall motion score index (WMSI) was evaluated at base-line and during stress. All patients were followed up clinically and-on day 1, day 7 (+/-2 days), and at 6 months-by repeat stress echo. Thirty gender- matched controls were also studied. CFR was obtained in all patients on LAD and in 25 on PD. All showed a transient apical ballooning in the acute phase (day 1 of admission), with progressive recovery of function at follow-up (WMSI, day 1 = 1.7+/-0.2; day 7 = 1.4+/-0.14; 6 months = 1.0+/-0.1; P<0.001 versus day 1 and versus day 7). When compared to controls (3.1+/-0.5), CFR on LAD was reduced on day 1 (1.8+/-0.24, P<0.001) (upon admission), and it showed early recovery in the subacute (pre-discharge) assessment on day 7. CFR values remained stable at 6-month follow-up (2.6+/-0.3). CONCLUSION: TC is characterized by a profound, diffuse coronary microcirculatory disturbance in the acute phase, with early reversal to near-normal values within a few days, paralleling the functional recovery in regional wall motion.

Transthoracic echocardiographic imaging of coronary arteries: tips, traps, and pitfalls.

The aim of this paper is to highlight coronary investigation by transthoracic Doppler evaluation. This application has recently been introduced into clinical practice and has received enthusiastic feedback in terms of coronary flow reserve evaluation on left anterior coronary artery disease diagnosis. Such diagnosis represents the most important clinical application but has in itself some limitations regarding anatomical and technological knowledge. The purpose of this paper is to offer a didactic approach on how to investigate the different segments of left anterior and posterior descending coronary arteries by transthoracic ultrasound using different anatomical key structures as markers. We will conclude by underlining that, nowadays, innovative technology allows complete evaluation of both major coronary arteries in many patients in a resting condition as well as during pharmacology stress-tests, but we often do not know it.

Non-cardiovascular mortality, low-density lipoprotein cholesterol and statins: a meta-regression analysis.

BACKGROUND: As of today, the effect of statins on non-cardiovascular mortality is still being debated. Single studies have not been able to provide definite answers. We performed a meta-regression analysis on randomized statin trials in order to provide evidence that non-cardiovascular mortality is related to statin treatment and low-density lipoprotein (LDL) cholesterol plasma level. METHODS: We selected 29 randomized controlled trials of statins versus placebo, a total of 90,480 patients, with a follow-up of >12 months. Baseline and follow-up LDL levels and all-cause, cardiovascular and non-cardiovascular mortality were recorded. Weighted linear regression analysis was carried out separately for placebo and treatment groups. RESULTS: LDL level was inversely related to overall mortality (p = 0.0105) and non-cardiovascular mortality (p = 0.0171) in the treatment group. By contrast, in the placebo group only non-cardiovascular mortality was inversely correlated to LDL (p = 0.0032). The regression lines have similar slopes and run almost parallel to each other, with the treatment line lying below the placebo line. To identify the threshold of risk for starting statin therapy, we analysed the relationship between baseline cardiovascular risk and overall mortality in the two groups. Both correlations are highly significant and regression lines intersect at a risk of 0.29% per year. This implies that the effects of statins are favourable when the baseline cardiovascular risk exceeds approximately 3% in 10 years. CONCLUSIONS: A trend of increased non-cardiovascular mortality with decreased LDL exists both in placebo and treatment groups. However, at each given LDL cholesterol level, non-cardiovascular mortality is lower in treated patients. Therefore, statin therapy may improve the biological impact of LDL on non-cardiovascular mortality.