Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication.

AIM: The aim of this study was to provide cost-description and cost-effectiveness of a short-course intensive in-hospital rehabilitation program in patients with intermittent claudication. METHODS: Costs per case treated were calculated according to a local standard protocol including diagnostic evaluation of peripheral arterial disease and other related cardiovascular conditions, physical training, and secondary prevention. Three additional less structured scenarios were also evaluated. RESULTS: All 107 enrolled patients (males 91%, mean age 65+/-8 years) completed the program (4-week duration; twice a day walking exercise) and showed significant increases in walking performance, as evaluated by constant treadmill-test. At admission, the mean values of initial claudication distance (ICD) and absolute claudication distance (ACD) were 150+/-111 and 432+/-327 m, respectively. At the end of the program, 12 (11%) patients completed the treadmill test without pain, while 31 (29%) completed the test without stopping due to maximal pain. Among the remaining 64 (60%) patients, the ICD and ACD increased by 137% and 112%, respectively. The cost per case treated ranged from Euro 1733.2 (standard protocol) to Euro 918.9 (physical training only). By adding the cost of hospitalization and indirect costs, the same costs ranged from Euro 4626.2 to Euro 3811.9. The average cost to walk one additional meter without pain as a result of the rehabilitation program was Euro 57.5, while the cost to walk one additional meter before stopping was Euro 27. As showed by sensitivity analysis, the maintenance of the expected level of treatment success was crucial for program's cost-effectiveness. CONCLUSION: From the societal viewpoint, short-course intensive rehabilitation may be cost-effective in patients with stable intermittent claudication and could be considered in decision models evaluating different therapeutic options.

Clinical validation of an anxiety and depression screening test for intensive in-hospital rehabilitation.

Routine hospital psychological care must necessarily make use of a clinically reliable screening instrument for the identification of the patients to be referred for a clinical interview with a psychologist. This study compared two tests for the evaluation of anxiety and depression that are widely used in the hospital setting: the Hospital Anxiety and Depression Scale (HADS) and Form A-D, consisting of the State-Trait Anxiety Inventory (STAI-X1) for the evaluation of anxiety, and the Depression Questionnaire (DQ) for measuring depression. The aim of the study was to identify which of these instruments is the most suitable for screening a population admitted at in-hospital intensive rehabilitation using the clinical interview-based psychological evaluation as the gold standard. Both of the tests showed a concordance with the clinical opinion expressed by the psychologist, whose judgement was guided by the use of the validation study evaluation form. The analyses confirmed the good correlation of the two instruments in measuring anxiety and depression. The sensitivity of the STAI-X1 (52%) was less than that of HADS section A (72%), but its specificity (99%) was greater than that observed with the application of the HADS Anxiety subscale (84%). Analysis of the ROC curves showed that the STAI-X1 percentages of sensitivity and specificity tended to balance at higher level with a cut-off point equal to the 80th percentile. The results of the analysis of the DQ demonstrated equivalence with the results obtained using HADS section D, with a cut-off point of the 90th percentile. On the basis of these results, and given that both the STAI-X1 and the DQ have a broadly based Italian normative population, we feel that they can be recommended for psychological screening of patients in an in-hospital intensive rehabilitation.

Functional and psychological recovery during intensive hospital rehabilitation following cardiac surgery in the elderly.

UNLABELLED: The recovery process in the elderly after cardiac surgery is influenced not only by clinical cardiac conditions, but also by comorbidity, cognitive decline and disability. We evaluated the relationship between clinical objective and self-perceived factors and their influence on functional recovery in 204 consecutive, over-70s pts who were admitted into an intensive hospital rehabilitation program following cardiac surgery. The variables taken into consideration were: comorbidity (Charlson index), length of hospital stay and complications in cardiac surgery and rehabilitation, disability (nursing needs score index), functional status (6-min walking test), left ventricular EF, number of training sessions, self-perceived health status (EuroQol questionnaire), emotional impairment (anxiety/depression, CBA-2.0/interview). RESULTS: Functional capacity: the distance walked was 198 +/- 103 m at admission and 287 +/- 121 m at discharge (p < 0.0001). Only the nursing needs score index resulted as a weak, independent predictor of the distance walked at admission (r2 = 0.14, p < 0.001, beta = 0-.21), which (beta = 0.49), together with complications during rehabilitation (beta = -0.15), self-perceived health status at discharge (beta = 0.15) and number of training sessions (beta = 0.20), was independently correlated with the distance walked at time of discharge (r2 = 050, p < 0.0001). Patients mood: anxiety correlated with depression. Emotional scores did not correlate with functional measures. Patients self-perceived health status: only the nursing needs score index was a weak, independent predictor of well-being at entry (r2 = 0.15, p < 0.0001, beta = -0.29), which, in turn, was the only predictor of perception at discharge (r2 = 0.33, p < 0.0001, beta = 0-.42). CONCLUSIONS: In an intensive hospital rehabilitation program following cardiac surgery in patients over 70 a) there was no correlation between clinical and psychological variables; b) anxiety and depression were associated, but neither influenced the recovery process nor correlated to health status perception; c) functional impairment was strongly influenced by nursing needs which also affected the self-perceived health status; d) both functional and perception recovery were influenced by disability at time of admission and reacted positively after rehabilitation.

Despite good compliance, very low fat diet alone does not achieve recommended cholesterol goals in outpatients with coronary heart disease.

AIM: A low-saturated, low-cholesterol diet is important in the treatment of hypercholesterolaemia in patients with coronary heart disease. The aim of this study was to investigate the efficacy of a very low fat diet to achieve a targeted serum low density lipoprotein (LDL) cholesterol level (3.37mmol x l-1 were investigated 12-14 weeks after an acute coronary event. After overnight fasting each patient had (a) his resting energy expenditure measured (indirect calorimetry using standard protocol) and (b) venous blood sampled from a forearm vein to determine lipid profile. All the patients were randomly allocated to four groups of treatment: Group A on a very low fat diet (resting energy expenditure-fat diet, where fat intake was

Aortic valve regurgitation as the presenting sign of Takayasu arteritis.

UNLABELLED: Takayasu arteritis is a rare chronic vasculitis primarily involving the aorta and its main branches. We report an adolescent girl with Takayasu arteritis who presented with an isolated aortic valve regurgitation as part of a systemic inflammatory process. This patient was initially misdiagnosed as having rheumatic heart disease and the correct diagnosis was made only 1 year later. CONCLUSION: Takayasu arteritis should be considered among the diagnostic possibilities in patients who present with an unexplained systemic inflammatory syndrome and a cardiac murmur.

Prognosis in myocardial infarction survivors with left ventricular dysfunction is predicted by electrocardiographic RR interval but not QT dispersion.

OBJECTIVES: The aim of the study was to assess if QT dispersion and RR interval on the standard 12-lead electrocardiogram (ECG) predict cardiac death and late arrhythmic events in postinfarction patients with low left ventricular ejection fraction (LVEF). QT dispersion on a standard electrocardiogram (ECG) is a measure of repolarization inhomogeneity, but its prognostic meaning in myocardial infarction (MI) survivors is unclear, especially in patients with left ventricular dysfunction. RR interval has been shown to predict mortality in post-MI patients, but its prognostic power has not been compared with other noninvasive risk factors. METHODS: Retrospective cohort study. Ninety patients were identified, from a series of 547 consecutive postinfarction patients admitted to our institution for phase II cardiac rehabilitation, as having a LVEF of <0.40 at two-dimensional echocardiography (mean LVEF 0.35+/-0.04; range 0.20-0.39). QT dispersion and RR interval were analyzed on the admission 12-lead electrocardiogram, 20+/-10 (range 8-45) days after MI, using specially designed software. Additional risk markers were collected from clinical variables, signal-averaged ECG and Holter recording. RESULTS: During 24+/-18 (range 1-63) months of follow-up, 10 of 90 patients (11%) died, all from cardiac causes, and there were 18 late arrhythmic events, defined as sudden death or the occurrence of a sustained ventricular arrhythmia > or =5 days after the index MI. QT interval and dispersion were not significantly prolonged in patients who died compared to survivors and not significantly different between patients with and without arrhythmic events. Mean RR interval from standard ECG was significantly shorter in patients with both cardiac death (682+/-99 vs. 811+/-134 ms; P=0.004) and arrhythmic events (720+/-100 vs. 818+/-139 ms; P=0.006). A Cox proportional hazards model identified RR interval from standard ECG (P<0.001) and a history of more than one MI (P=0.002) as significant predictors of cardiac death independent of thrombolytic therapy, LVEF, filtered QRS complex duration at signal-averaged ECG, mean RR and its standard deviation at 24-h Holter monitoring. CONCLUSIONS: Measurement of QT interval and dispersion 3 weeks after MI has no prognostic power in patients with LV dysfunction after a recent MI. RR interval on standard 12-lead ECG is as good a prognostic indicator as other, more expensive, noninvasive markers. These findings may be relevant in this era of limited health care resources.

Evaluation of regional left ventricular wall motion with color kinesis: comparison with two-dimensional echocardiography in patients after acute myocardial infarction.

BACKGROUND: Color kinesis (CK) is a new echocardiographic technique for the assessment of left ventricular (LV) wall motion based on acoustic quantification. Using integrated backscatter data, this technique identifies the pixel value transitions from blood to myocardial tissue throughout systole and tracks endocardial motion in real time. The color-encoded images, built on a frame-by-frame basis by adding one color at a time, provide an integrated display of the timing and amplitude of endocardial motion in a single end-systolic frame. Recent studies have shown that CK is a promising clinical tool for quantitative assessment of regional LV function. OBJECTIVES: The aim of this study was to evaluate the feasibility and accuracy of CK in identifying the regional wall-motion abnormalities diagnosed by conventional two-dimensional (2-D) echocardiography in patients after acute myocardial infarction (AMI). METHODS: The end-systolic color overlays were analyzed using a method to quantify the regional timing and amplitude of endocardial systolic excursion (ESE) based on the count of the numbers of colors. At this point, the total duration (ESE timing) and distance (ESE amplitude) of endocardial excursion from end-diastolic to end-systolic color-frame was calculated in each segment. In 54 patients after AMI, we compared the feasibility and ability of CK superimposed on 2-D superimposed on 2-D superimposed on 2-D echocardiographic images and visual 2-D echo analysis to evaluate the endocardial border excursion in parasternal short-axis (SAX) and apical four-(AP4CH) and two-(AP2CH) chamber views. In 20 normal subjects, the end-systolic color overlays were used to evaluate the variability of the measurements of ESE timing (msec) and amplitude (cm) and to define the reference values. Image quality was considered adequate if at least 12 of 16 segments could be evaluated for systolic function by conventional visual 2-D echo. Among 54 patients, 35 with adequate studies were selected to determine the accuracy of quantitative analysis of CK images in identifying regional wall-motion abnormalities. RESULTS: The SAX view was obtained in 36 of 54 patients; of the possible 216 segments, 210 (97%) were adequately visualized by 2-D echocardiography and 207 (96%) by CK. Apical views were obtained in 50 patients (93%); of the possible 300 segments, 93% were visualized by 2-D echocardiography and 90% by CK in the AP4CH view and 94% and 92%, respectively, were visualized by the two methods in the AP2CH view. In normal subjects, measurements of ESE timing and amplitude were found to be consistent and the mean values were 346 msec (range 280-360) and 0.99 cm (range 0.72-1.26) respectively. In the 35 selected patients, 2-D echocardiography identified 355 normokinetic segments in which ESE timing and amplitude were similar to the reference values. In 83 hypokinetic segments and 108 akinetic segments, ESE timing and amplitude were significantly inferior to values of normokinetic segments (p < 0.001). An ESE timing below the reference values of 280 msec identified all of the 191 asynergic segments (sensitivity and specificity = 100%) and an ESE amplitude of less than 0.70 cm identified 188 asynergic segments (sensitivity = 98% and specificity = 99%). CONCLUSIONS: CK showed good feasibility and diagnostic accuracy in identifying regional wall motion abnormalities in patients with acute myocardial infarction. The model used in our study for the quantitative analysis of color kinesis images, which provided easy and feasible indices of timing and amplitude of endocardial excursion, enabled fast and objective evaluation of LV regional wall motion.

Cost-effectiveness analysis of invasive and noninvasive tests in high risk patients treated with amiodarone after acute myocardial infarction.

OBJECTIVES: We sought to evaluate 1) the cost-effectiveness of amiodarone therapy in postinfarction patients; and 2) the influence of alternative diagnostic strategies (noninvasive only vs. noninvasive and electrophysiologic testing) on survival benefit and cost-effectiveness ratio of amiodarone therapy. BACKGROUND: The cost-effectiveness of amiodarone therapy in postinfarction patients is still unknown, and no study has determined which diagnostic strategy should be used to maximize amiodarone survival benefit while improving its cost-effectiveness ratio. METHODS: We designed a postinfarction scenario wherein heart rate variability analysis on 24-h Holter monitoring was used as a screening test for 2-year amiodarone therapy in a cohort of survivors (mean age 57 years) of a recent myocardial infarction. Three different therapeutic strategies were compared: 1) no amiodarone; 2) amiodarone in patients with depressed heart rate variability; 3) amiodarone in patients with depressed heart rate variability and a positive programmed ventricular stimulation. Total variable costs and quality-adjusted life expectancy during a 20-year period were predicted with use of a Markov simulation model. Costs and charges were calculated with reference to an Italian and American hospital. RESULTS: Amiodarone therapy in patients with depressed heart rate variability and a positive programmed ventricular stimulation was dominated by a blend of the two alternatives. Compared with the no-treatment strategy, the incremental cost-effectiveness ratio of amiodarone therapy in patients with depressed heart rate variability was $10,633 and $39,422 per gained quality-adjusted life-year using Italian costs and American charges, respectively. CONCLUSIONS: Compared with a noninterventional option, amiodarone prescription in all patients with depressed heart rate variability seems to be a more appropriate approach than the alternative based on the combined use of heart rate variability and electrophysiologic study.

Cardiac and vascular sources of peripheral thromboembolism in patients with atrial fibrillation. A combined transesophageal and vascular ultrasonographic study.

Atrial fibrillation is associated with an increased risk of peripheral thromboembolism. Although emboli arising from the left atrium are the most probable causes of peripheral ischemic events, coexistent vascular mechanisms may play a role in the genesis of thromboembolism. To assess the prevalence and the relative role of cardiac and vascular sources of thromboembolism in patients with atrial fibrillation 101 consecutive patients with (group 1: 47 patients) and without (group 2: 54 patients) recent thromboembolism were studied by transesophageal echocardiography and ultrasound duplex scanning of carotid arteries. Left atrial thrombosis was found in 19 (40%) group 1 patients and in 3 (5%) group 2 patients. Left atrial thrombosis and/or spontaneous echocardiographic contrast were significantly more frequent in group 1 patients than in group 2 (70% vs 20%, p < 0.001). Stepwise regression analysis revealed that they were the only independent predictors of thromboembolism (p = 0.018, p = 0.0003 respectively). Among clinical and transthoracic echocardiographic variables, left atrial diameter (p = 0.022), rheumatic mitral stenosis (p = 0.0058) and absence of significant mitral regurgitation (p = 0.027) emerged as independent predictors of left atrial thrombosis and/or spontaneous echocardiographic contrast. When transesophageal parameters were also entered into the analysis, the only independent predictor was low blood flow velocity within the left atrial appendage (p = 0.0001). Vascular sources (obstructive carotid arteries plaques, non-obstructive ulcerated carotid plaques and thoracic aortic atherosclerotic debris) were found in 30.6% of patients. Their prevalence was not significantly different in the two groups (34% in group 1, 27% in group 2). Vascular and cardiac sources coexisted in 23% of patients with thromboembolism. Seven of the 10 patients with more severe vascular lesions (i.e., obstructive carotid artery lesions or pedunculated mobile aortic debris) were from group 1 and 5 of them had negative cardiac results. In conclusion, these results indicate that a cardioembolic mechanism due to blood stasis within the left atrium is involved in most of the atrial fibrillation-related thromboembolic events. In patients with atrial fibrillation vascular sources are not infrequent and may be involved in the genesis of ischemic events in some patients. Transesophageal echocardiography may be useful in identifying subgroups of patients with atrial fibrillation who are at high thromboembolic risk.

Embolizing fibroelastoma of the aortic valve.

Papillary fibroelastomas are very rare cardiac tumours that can present with embolization of coronary and peripheral arteries and sudden death. The diagnosis can be made by two-dimensional or transoesophageal echocardiography. A 53-year-old man with an aortic valve papillary fibroelastoma who presented with several transient ischaemic attacks is reported.

[Effectiveness and tolerability of simvastatin in subjects with primary hypercholesterolemia. Multicenter study]. / Efficacia e tollerabilità della simvastatina in soggetti con ipercolesterolemia primitiva. Studio policentrico.

The efficacy and safety of simvastatin were evaluated in an open multicenter study over a 24-week period. One hundred seventy-two patients (91 men, 81 women) with primary hypercholesterolemia (mostly polygenic) were enrolled in 14 Centers in Northern Italy. The mean age was 55.8 +/- 9.7 years and the mean baseline total cholesterol level was 305 +/- 59 mg/dL. After 4 weeks on an AHA step 1 diet, patients who met the inclusion criterion (total cholesterol > or = 250 mg/dL) were given simvastatin 10 or 20 mg in the evening. The dose could be titrated up to a maximum of 40 mg o.d. at week 6 and 12. No dose titration was allowed after week 12. One hundred forty-nine patients (86.6%) completed the study according to the protocol, 2 (1.2%) were withdrawn from the study because of adverse events not related to the drug, 21 (12.2%) were unavailable for follow-up. Simvastatin treatment was associated with a sustained dose-related reduction in total and LDL cholesterol (-28% and -39% respectively at the end of the study). Triglycerides showed a significant descending trend (-16% at week 24) and HDL-C increased by 9%. Apolipoproteins were measured in only 25 patients: apo B was reduced by 30% and apo A1 increased by 9%. Clinical side effects were not relevant. Mean levels of GOT, GPT and CPK significantly increased after 6 weeks on simvastatin, but remained stable and at any rate ioitlin the normal range thereafter. Eight patients (5.4%) experienced small transaminase level elevations (< 3ULN) and six (4%) small CPK elevations.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of echo/Doppler in the diagnosis of pulmonary embolism.

Echocardiography supplemented with pulsed and continuous wave Doppler facilities is a potent diagnostic tool in many cardiovascular disorders. Its potential role in the management of patients with suspected pulmonary embolism, though less extensively studied, deserves attention. Benefits of echo/Doppler in these patients are as follows: (1) Echo/Doppler is a noninvasive, relatively inexpensive technique, readily available and repeatable in critically ill patients at the bedside. (2) Echo/Doppler provides a number of independent parameters related to the pulmonary hemodynamics. These parameters include: (a) characteristics of blood flow velocity curves across the right heart valves as well as systolic and diastolic time intervals of the right ventricle (b) motion pattern of the interventricular septum (c) dimensions of the heart chambers and inferior vena cava (d) thickness of the right ventricular free wall (3) Echocardiography allows detection of thrombi within right heart chambers or in major branches of the pulmonary artery in some patients. (4) Echo/Doppler may disclose alternative abnormalities explaining symptoms found in a patient with suspected pulmonary embolism such as pericardial disease, myocardial infarction, aortic dissection, hypovolemic shock, etc.

[Non-invasive methods for determining the pulmonary blood pressure using ultrasonics in patients with chronic respiratory diseases]. / Méthodes non invasives pour la détermination de la pression artérielle pulmonaire par ultrasons chez les malades atteints de maladies respiratoires chroniques.

Ultrasound techniques and especially Doppler echocardiography offer several approaches to non-invasive assessment of pulmonary arterial pressure. The method based on the measurement of the velocity of the jets of tricuspid or pulmonary regurgitation is the most straightforward one, in most cases allowing for reliable quantitative assessment of pulmonary hypertension and thus should be applied as a method of choice whenever possible. Unfortunately, its application in patients with lung hyperinflation is limited by topographic factors. Short acceleration time of flow velocity in the right ventricular outflow tract (AcT less than 70-75 msec), especially accompanied by midsystolic deceleration occurring at end-expiration, is a strong evidence of severe pulmonary hypertension. Long AcT (above 115-120 msec) is virtually diagnostic of normal pulmonary arterial pressure. If high speed Doppler tracings of both pulmonary and tricuspid valve flow are available right ventricular isovolumic relaxation time may be used for estimation of pulmonary systolic pressure. However, the elaboration of the laboratory's own regression formula rather than application of Burstin nomogram seems more advisable in such cases. The future of non-invasive assessment of pulmonary hemodynamics will depend on the reliability to monitor acute and chronic changes not only in pulmonary arterial pressure, but also in flow and resistance. At present, echocardiography should be considered as a good screening test allowing also to stratify moderate and severe pulmonary hypertension. The exact assessment of pulmonary hemodynamics, especially in patients with chronic respiratory disease, when needed for important therapeutic decisions, should in most cases rely on right heart catheterization.

Left atrial appendage dysfunction: a cause of thrombosis? Evidence by transesophageal echocardiography-Doppler studies.

The blood flow velocity patterns within the left atrial appendage were studied by transesophageal color flow imaging and pulsed Doppler in 84 patients. At the time of the study, 57 of the patients were in sinus rhythm, 25 were in atrial fibrillation, and two were in atrial flutter. The relationships between atrial rhythm, blood flow pattern and the presence/absence of spontaneous echocardiographic contrast or thrombus within the appendage were investigated. Transesophageal echocardiography allowed recording of blood flow velocities in 81 of the 84 patients studied. In 51 of the 55 patients in sinus rhythm the pulsed Doppler study showed a biphasic blood flow pattern, whereas a multiphasic pattern was found in the two patients with atrial flutter and in 14 patients with atrial fibrillation. In four patients with sinus rhythm and 10 patients with atrial fibrillation, no significant blood flow velocity could be detected. Thrombus or spontaneous echocardiographic contrast were found within the left atrial appendage in 20 patients, and in all these patients blood flow was either absent or significantly reduced. Our findings indicate that an absent or low blood flow velocity within the left atrial appendage represents a predisposing factor for thrombosis. Isolated left atrial appendage dysfunction has been documented in four patients during sinus rhythm, which may lead to thrombosis. This observation may offer an explanation for cardioembolic events that occur occasionally in patients without apparent heart disease and sinus rhythm.

[Echocardiographic assessment of segmental kinetic changes of the left ventricle during ischemic attacks induced by slow hyperventilation]. / Valutazione ecocardiografica delle modificazioni della cinetica segmentale del ventricolo sinistro durante attacchi ischemici indotti dalla iperventilazione lenta.

UNLABELLED: The detection of stress-induced wall motion abnormalities by means of 2D Echo represents a reliable marker of ischemia. Few reports about two-dimensional echocardiography and provocative tests in patients suffering from primary angina are available in the literature. Twenty patients with electrocardiographically documented ischemic transitory attacks at rest underwent hyperventilation test 2-15 days after a spontaneous episode. A new wall motion abnormality and/or a worsening of an asynergy already present at rest occurred in ten patients; eight of them also showed diagnostic ECG changes. Wall motion abnormalities arose significantly earlier (from the end of hyperventilation: 1.7 +/- .84 vs 2.16 +/- 1.15 min, p less than .05). Three patients had angina, which, in all patients started after echocardiographic and ECG changes. All patients experienced paresthesia, and two patients tinnitus due to blood alkalosis. No clinical adverse reaction resulted from the test. Only one patient had ventricular arrhythmias in the recovery phase of the ischemia. IN CONCLUSION: As concerns hyperventilation test, echocardiography has proven useful in identifying myocardial ischemia, comparable to electrocardiography. Moreover, in this study some patients had echocardiographic but not electrocardiographic changes as ischemic manifestations. Events after induction of ischemia with hyperventilation seem to follow the same sequence already observed in spontaneous attacks.

Doppler echocardiographic evaluation of pulmonary artery pressure in chronic obstructive pulmonary disease. A European multicentre study. Working Group on Noninvasive Evaluation of Pulmonary Artery Pressure. European Office of the World Health Organization, Copenhagen.

The feasibility, reproducibility and reliability of Doppler echocardiography in evaluation of pulmonary artery pressure in patients with chronic obstructive pulmonary disease (COPD) were determined in a multicentre study. In 100 COPD patients with mean pulmonary artery pressure ranging from 10 to 62 mmHg at cardiac catheterization, pulmonary pressure estimation was attempted by four Doppler echocardiographic methods. These methods comprised the calculation of transtricuspid and transpulmonary pressure gradients from Doppler-detected tricuspid or pulmonary regurgitation, the evaluation of right ventricular outflow tract velocity profiles with the measurement of right ventricular systolic time intervals and the measurement of the right ventricular isovolumic relaxation time. In 98 (98%) patients at least one of the methods could be employed. A tricuspid regurgitation jet was detected in 47 (47%) patients but its quality was adequate for measurement in 30 (30%). Pulmonary regurgitation jet velocity was measured only in five cases. The standard error of estimate in testing intra- and interobserver reproducibility of Doppler systolic time intervals was less than 5%. The predictive value of right ventricular outflow tract acceleration time less than 90 ms in the identification of patients with mean pulmonary artery pressure greater than 20 mmHg was 80%. Of Doppler echocardiographic data, best correlations with mean pulmonary artery pressure were found for the transtricupid gradient (r = 0.73, SEE = 7.4 mmHg), for the right ventricular acceleration time (r = 0.65, SEE = 8 mmHg) and right ventricular isovolumic relaxation time (r = 0.61, SEE = 8.5 mmHg).(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal echocardiography in the definition of intracardiac sources of emboli in patients with recent ischemic stroke.

Using both transthoracic and transesophageal echocardiography we studied 13 consecutive patients with recent CT-proven ischemic stroke in which a carotid arteries high-resolution ultrasound study failed to detect thrombosis or other relevant atherosclerotic lesions in the pertinent arteries. The mean age was 53 years (range: 36-65). Two patients exhibited clinical signs of cardiac disease at physical examination i.e. absolute arrhythmia, mitral stenosis. Conventional transthoracic echocardiography allowed the detection of potential cardiac sources of emboli in 2/13 patients (15.4%): mitral stenosis in one patient and dilated cardiomyopathy in another. Transesophageal echocardiography was successfully performed without general sedation in all patients. Potential cardiac sources of emboli could be identified in 12/13 patients (92%). Left atrial thrombi were found in 3 patients: in two of them they were associated with rheumatic alterations of mitral valve leaflets; in the third patient a small thrombus was located inside a normal-sized, poorly contracting left atrial appendage. Left atrial appendage could be clearly visualized in all patients. A myxoid degeneration of a prolapsing mitral leaflet was found in 3 patients and an interatrial septum aneurysm in 2. Furthermore, at color-flow Doppler and contrast transesophageal echocardiography, 7 patients (54%) showed patency of the foramen ovale. In 5 of these patients paradoxical right to left shunting after cough or Valsalva manoeuvre could be evidenced. With reference to 11/13 patients with no clinical signs of cardiac disease at physical examination, subclinical potential cardiac sources of emboli could be detected at conventional transthoracic echocardiography in 1 and at transesophageal echocardiography in 10 patients (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsed Doppler evaluation of left ventricular filling in subjects with pathologic and physiologic third heart sound.

Haemodynamic studies suggest that the rapid deceleration of left ventricular inflow at the end of early diastole may play an important role in the genesis of the third heart sound (S3). To confirm this hypothesis noninvasively, pulsed Doppler of transmitral flow was used. Mitral flow velocity wave was recorded in 20 post-infarction patients with audible S3 (Group 1), in 20 young healthy individuals with physiologic S3 (Group II), in 20 postinfarction patients without S3 (Group III) and in 20 normal adults (Group IV). Peak flow velocity in early diastole (Ev), peak flow velocity during atrial systole (Av), the Ev/Av ratio, the deceleration of early diastolic flow (EF slope), the ratio of the time velocity integral of early diastole to the total time velocity integral (TVle/TVlt) and the isovolumic relaxation time (IVRT) were measured from Doppler recordings. The time relation between S3, the mitral valve motion on M-mode tracing, and the mitral flow velocity wave were analysed comparing the intervals from the second sound to Ev (A2-Ev), to the E point of mitral valve motion (A2-Em) and to the S3 (A2-S3). In groups I and II Ev/Av ratio was higher (respectively 4.4 +/- 2.2 and 2.8 +/- 1.1) than in group III (0.8 +/- 0.4) and IV (1.3 +/- 0.3). Similar results were found for the TVle/TVlt ratio. In both groups with S3, EF slope was significantly steeper (respectively 9 +/- 1.8 and 7.5 +/- 1.1 m s) than in normal adults (4.4 +/- 1.1 m s) and patients without S3 (3.6 +/- 1.1 m s).(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous Doppler and thermodilution assessment of pulmonary artery flow during acute interventions in patients with chronic obstructive pulmonary disease.

Subcostal pulsed wave Doppler echocardiography of the right ventricular outflow tract was used to assess pulmonary arterial flow at basal conditions and during interventions in 20 patients with chronic obstructive pulmonary disease. The changes in the pulmonary flow induced by interventions ranged from -1.5 l/min to +4.18 l/min (73% to 183% of the basal value). When considered alone, heart rate changes induced by the interventions could explain 53% of the changes in pulmonary flow measured with thermodilution. When Doppler-assessed right ventricular stroke volume changes were also considered the coefficient of determination (R) increased to 77% (r = 0.88, p less than 0.001, SEE = 12%). Doppler echocardiography was less precise in predicting absolute basal values of pulmonary artery flow (r = 0.70, p less than 0.001, SEE = 1.00 l/min), probably indicating inaccurate assessment of the diameter of the right ventricular outflow tract.

Resting and exertional haemodynamic effects of buccal nitroglycerin: acute and chronic discontinuous treatment in post-myocardial infarction patients with heart failure.

The resting and exertional haemodynamic effects of acute and chronic discontinuous (one tablet every 6 h) treatment with 5 mg of buccal nitroglycerin (BN) have been assessed in nine postinfarction heart failure patients. At rest, pulmonary artery (PAP), pulmonary wedge (PWP), and right atrial pressures (RAP) were reduced by 42%, 55% and 77%, respectively, after the first dose and by 26%, 32% and 45%, respectively, after the chronic (three weeks) treatment with BN. During exercise, at the same workload, PAP, PWP and RAP were significantly reduced by 44%, 54% and 62%, respectively, after acute treatment and by 28%, 34% and 44%, respectively, after chronic treatment. The maximal workload (Kgm) increased by 179% and 166% and the exercise time increased by 78% and 71% after acute and chronic therapy, respectively. At the maximal workload, after acute BN, overall haemodynamics were better than in the basal state. PAP, PWP and RAP were still reduced by 19%, 31% and 31%, respectively, after acute treatment, while after chronic phase the results did not differ from control. The severity of cardiac failure, according to the Weber classification, was reduced by acute and chronic therapy. We can conclude that the buccal nitroglycerin showed clear efficacy in improving overall haemodynamic parameters both at rest and during exercise in post-myocardial infarction patients with heart failure. The discontinuous treatment maintained the effect of nitroglycerin without clear evidence of tolerance during chronic therapy.