Myocardial infarction in young adults with low-density lipoprotein cholesterol levels < or = 100 mg/dL: clinical profile and 1-year outcomes.

STUDY OBJECTIVES: To define the clinical profile of young adults with optimal low-density lipoprotein (LDL) cholesterol levels who present with acute myocardial infarctions (MIs); to compare and contrast differences in the clinical profiles of young adults admitted to the hospital with MIs who have LDL cholesterol levels < or = 100 mg/dL and those with LDL cholesterol values > or = 160 mg/dL; and to evaluate the clinical outcomes for the two groups at 1 year. DESIGN: A retrospective chart review was conducted on all young men (55 years) and women (65 years) admitted to the hospital for MIs within a 2-year period (n = 232). A history of cardiovascular risk factors and 1-year outcomes were obtained. SETTING: Rural community medical center serving a tri-state area in the midwestern United States. PATIENTS: Patients were included in this analysis if (1) a lipid profile was drawn within 24 h of hospital admission and (2) the patient was not receiving a statin medication on hospital admission. MEASUREMENTS AND RESULTS: Of the 183 patients who met the inclusion criteria, as many as 68% (124 patients) had LDL cholesterol levels of < or = 130 mg/dL, 29% (53 patients) had LDL cholesterol level of < or = 100 mg/dL, and only 14% (26 patients) had LDL cholesterol levels of > or = 160 mg/dL. Patients were categorized into group 1 if their LDL cholesterol level was < or = 100 mg/dL and were categorized into group 2 if their LDL cholesterol level was > or = 160 mg/dL. In group 2, 92% of patients were placed on a statin medication. By 1 year, the mean LDL cholesterol level had decreased from 188 to 106 mg/dL. The rate of coronary artery bypass graft and percutaneous coronary intervention procedures was similar between groups. Hospital readmission rates (43.4% vs 50%, respectively) and 1-year mortality rates (9% vs 8%, respectively) were not different between groups group 1 and 2. CONCLUSIONS: Young adults experiencing acute MIs typically have acceptable cholesterol levels (ie, < or = 130 mg/dL) or optimal values (ie, < or = 100 mg/dL). In those patients with abnormal cholesterol levels, a combined strategy of aggressive intervention and adherence to secondary prevention protocols including lipid control is successful in improving outcomes.

Chronic heart failure in the community: missed diagnosis and missed opportunities.

BACKGROUND: The aim of this study was to determine the incidence of congestive heart failure (CHF) in patients discharged from a hospital without a diagnosis of CHF who were admitted with shortness of breath and had a low left ventricular ejection fraction (LVEF). CHF is a devastating disease in terms of financial cost, prevalence, and effect on morbidity and mortality. The true incidence rate is not known because of reliance on discharge records and death certificates, and because diagnosis remains a clinical judgment. METHODS AND RESULTS: CHF was diagnosed by the Framingham criteria. We retrospectively reviewed the records of 225 randomly selected patients admitted with a complaint of shortness of breath and discharged without a diagnosis of CHF (group 1). We compared group 1 with patients admitted at the same time with a diagnosis of CHF and of similar age and LVEF (group 2). In group 1, 100 patients had a low LVEF (< or =40%) and 51% met criteria for CHF that had been missed. Readmission rate was high (42%). Mortality at 12 months was 18%. Rate of cardiomegaly on x-ray films was similar in groups 1 and 2 (64.6% v 64.4%, respectively). Third heart sound (39% v 10%; P <.001) and heart rate > 120 beats/min (41.7% v 12.5%; P <.001) were significantly more frequent in group 1. By contrast, signs and symptoms suggestive of fluid overload were more frequent in group 2. CONCLUSIONS: Many patients admitted with shortness of breath and low LVEF have CHF but are not diagnosed. Physicians are more likely to miss CHF in patients presenting without signs of fluid overload even when third heart sound is present with resting tachycardia. A missed diagnosis of CHF is associated with a high readmission rate, multiple admissions, and a mortality rate comparable to that of patients with newly diagnosed CHF.

Mild hypercholesterolemia and premature heart disease: do the national criteria underestimate disease risk?

OBJECTIVES: To determine the frequency of hospital admissions for acute coronary syndrome in young adults and to examine the risk factors that predispose to the development of premature heart disease. BACKGROUND: Significant coronary heart disease (CHD) is considered rare in the young adult. Current guidelines do not recommend treatment of mild cholesterol abnormalities for primary prevention of CHD in the young. METHODS: This is a large case series of 449 adults (< or =50 years) admitted to the hospital with acute coronary syndrome. A history of cardiovascular risk factors and lipid profile were recorded. The presence and extent of CHD were established. RESULTS: Mean patient age was 44 +/- 6 years. Documented CHD was present in 61% of hospital admissions. Multivariate analysis revealed that history of hypercholesterolemia, history of smoking and diabetes were independently associated with premature CHD. The fasting lipid profiles were only borderline to mildly abnormal. Serum total cholesterol, low-density lipoprotein (LDL) and triglyceride levels were not different in cases compared with control subjects. Nearly half (49%) of those with LDL levels of > or =160 mg/dl had only one additional risk factor or none. Despite this, a history of hypercholesterolemia had independent and incremental value on other risk factors for the likelihood of premature CHD. CONCLUSIONS: The magnitude of hospital admissions relating to premature CHD is high. In this population, the presence of borderline or mild hypercholesterolemia has significant effects on the development of premature CHD. These observations have significant implications in the development of guidelines for primary prevention of premature CHD.

Safety profile and hemodynamic responses to beta-adrenergic stimulation by dobutamine in heart transplant patients.

STUDY OBJECTIVE: Dobutamine stress echocardiography (DSE) has been used as a screening tool for coronary artery disease after heart transplantation and in the identification of patients at risk for development of cardiac events. However, the safety profile of high-dose dobutamine in heart transplant patients has not been systematically examined. Accordingly, we studied the safety profile and hemodynamic responses to escalating doses of dobutamine to determine the influence of denervation. DESIGN: We assessed the hemodynamic responses, heart rate (HR), and arterial BP indexes (mean arterial pressure, systolic BP [SBP], diastolic BP [DBP], and pulse pressure) to dobutamine in 87 heart transplant patients ([mean +/- SD] age, 51 +/- 1 years) and compared the results with 97 nontransplant patients (age, 63.0 +/- 1 years) who served as innervated control subjects. MEASUREMENTS AND RESULTS: The baseline HR (84 +/- 2 vs 69 +/- 1 beats/minute, respectively; p < 0.001) and peak HR response (144 +/- 2 vs 117 +/- 2 beats/minute, respectively; p < 0.001) were significantly higher in heart transplant patients than in the nontransplant patients. SBP was lower in heart transplant patients than in nontransplant patients at baseline (131 +/- 2 vs 138 +/- 2 mm Hg, respectively; p < 0.02) and at peak (150 +/- 3 vs 158 +/- 3 mm Hg, respectively; p < 0.03). However, baseline DBP was higher in transplant patients than in nontransplant patients (86 +/- 1 vs 77 +/- 1 mm Hg, respectively; p < 0.001). The decrease in DBP was similar in both groups (15 mm Hg). The dose-response curve for HR was shifted leftward in heart transplant patients. Heart transplant patients attained a higher absolute HR at each infusion stage and higher rates of increase, but the decrease in DBP was not significantly different in the two groups. CONCLUSIONS: These results show that there is augmented chronotropic response and expected decline in DBP in response to dobutamine infusion in heart transplant patients. This increase in myocardial oxygen demand and a decrease in coronary perfusion pressure may be important mechanisms in the development of ischemic abnormalities that are detectable as regional dysynergy on echocardiography.

Echocardiographic evaluation of patients with a left ventricular device.

Limited donor heart availability is primarily responsible for the renewal of interest in mechanical left ventricular assist devices (LVADs) as a bridge to transplantation. Donor availability is unlikely to increase significantly in the near future. Experience to date has shown that many patients can be maintained long enough to undergo transplantation, and LVADs may be acceptable as alternate therapy in some who may not be candidates for transplantation. However, criteria for noninvasive evaluation of patients on LVADs have not been developed. In a prospective study using serial echocardiography, we found that aortic valve opening, aortic forward flow, nonlaminar flow in the left ventricle, and mismatch of Doppler derived cardiac output at the pulmonic valve and device output are associated with device malfunction. Echocardiography was diagnostic in five of six patients with clinical instability unrelated to the device. These findings suggest that echocardiography is helpful in the routine evaluation of patients on LVADs.

Acquired atrial septal defect as a complication of endocarditis--a case report.

Bacterial endocarditis predominantly involves cardiac valves and is associated with many potential complications. Valvular dysfunction resulting from disruption of the structural integrity of valves are not infrequent. This report illustrates a rare case of endocarditis involving the interatrial septum which subsequently produced destruction of the structure resulting in an acquired atrial septal defect.

Dobutamine stress echocardiography early after heart transplantation predicts development of allograft coronary artery disease and outcome.

OBJECTIVES: This study sought to determine the prognostic significance of serial dobutamine stress echocardiography (DSE) in new heart transplant recipients and to examine the relation between persistent wall motion abnormalities and the eventual development of coronary artery disease (CAD) as assessed by angiography. BACKGROUND: Allograft CAD is a major cause of graft failure. However, clinical diagnosis of the early disease remains difficult. The reasons for this include the diffuse nature of the disease and its predilection for the microvasculature, which are not easily detected by coronary angiography. Identifying patients at risk for the development of angiographic CAD early after transplantation may allow such patients to be targeted for aggressive treatment options to prevent subsequent cardiac events and early graft failure. METHODS: Twenty-two new heart transplant recipients were selected to undergo serial DSE at the time of their regularly scheduled endomyocardial biopsy. In addition, patients underwent scheduled annual coronary angiography. DSE was performed in 5-min stages with infusion of intravenous dobutamine at 5, 10, 20, 30 and 40 microg/kg body weight per min. RESULTS: Twenty-two patients had 91 DSE studies and 45 coronary angiograms. The patients were categorized into three groups based on the echocardiographic results. Group 1 (n = 7) had normal serial stress echocardiographic studies. Group 2 (n = 4) had transient inducible wall motion abnormalities. Group 3 (n = 11) developed persistent wall motion abnormalities. During a mean follow-up time of 32 +/- 11 months (range 5 to 50), 8 (73%) of 11 patients in Group 3 developed events. The events included angiographic CAD (n = 7), myocardial infarction (MI) (n = 1) and cardiac death (n = 3). The patient who developed an MI had a normal coronary angiogram. No cardiac event or angiographic disease occurred in either Group 1 or 2 patients. CONCLUSIONS: These results suggest that dobutamine-induced wall motion abnormalities, which are persistent in new heart transplant recipients, are predictive of the development of angiographic CAD, MI or death.

Role of dobutamine stress echocardiography in heart transplant patients.

The objective of this focused review is to describe the rationale, methods, and potential clinical applications of dobutamine stress echocardiography (DSE) in heart transplant recipients. More than 500 studies in 150 heart transplant patients who underwent this procedure (1991-96) are reviewed. Relevant studies from the medical literature that have assessed the utility of DSE in the diagnosis of transplant coronary artery disease (TCAD) are discussed, the predictive ability of DSE for development of TCAD is determined, and the prognostic value of this test in the heart transplant population is evaluated. The protocol of DSE used in the laboratory for this study is presented and discussed with reference to other major studies that have determined the sensitivity, specificity, and positive and negative predictive accuracies. Since many noninvasive cardiac tests have not been consistently optimal to detect TCAD, a substantial number of patients undergo routine surveillance with coronary angiography to define the presence and magnitude of TCAD. Recent studies with DSE have shown it to be valuable in the noninvasive diagnosis of TCAD and to have an accuracy unmatched by other widely used imaging modalities. Other important evolving indications for DSE in heart transplant patients, such as prediction of prognosis and occurrence of cardiac events, are briefly discussed. Based on this study and the currently available literature, DSE appears to be a highly reproducible noninvasive test which can be serially employed in the routine surveillance of coronary artery disease in heart transplant patients.

Factors associated with elevated impedance with a nonthoracotomy defibrillation lead system.

Peak current flow across the heart determines the success of defibrillation and is inversely dependent on impedance between defibrillation electrodes. Factors associated with elevated impedance in patients with implantable defibrillators using nonthoracotomy lead systems have not been well described. Clinical and echocardiographically derived variables were analyzed in 41 patients in whom implantation of a nonthoracotomy lead system was attempted. Lead impedance was measured at end-expiration with 5-J monophasic shocks. Successful defibrillation with or without addition of a subcutaneous patch with < or = 20 J with a monophasic waveform was required for nonthoracotomy lead placement. Patients were divided into 2 groups based on impedance: low (< or = 47 ohms, n = 30) and high (>47 ohms, n = 11). Twenty-four patients had successful defibrillator implantation using a transvenous lead alone, 13 required placement of a subcutaneous patch, and 4 required epicardial patch placement. The mean left ventricular end-diastolic and end-systolic volumes were significantly smaller (p = 0.01 for both) in patients in the low- versus high-impedance groups and were significantly correlated with impedance (r = 0.44, p <0.005 for both). Impedance was not significantly different between patients with successful defibrillation using a transvenous lead alone compared with those who required either subcutaneous or epicardial patches. Thus, impedance using a nonthoracotomy lead system with monophasic shocks is significantly correlated with both end-systolic and end-diastolic volumes, but elevated impedance does not predict increased defibrillation energy requirements.

Dobutamine stress echocardiography predicts cardiac events in heart transplant patients.

BACKGROUND: Cardiac transplantation is an accepted treatment modality for end-stage heart failure. Coronary artery disease remains a major cause of mortality in the long term after heart transplantation. Despite the high prevalence of coronary artery disease in heart transplant recipients, currently used noninvasive tests as well as invasive tests are highly unreliable in predicting prognosis. We sought to test the hypothesis that the abnormalities induced by dobutamine stress echocardiography (DSE) may be of prognostic value in predicting acute cardiac events and mortality in heart transplant patients. METHODS AND RESULTS: We prospectively studied 86 survivors of orthotopic heart transplantation and followed them for a mean period of 2 years after the DSE. The patients' median age was 51 +/- 10 years, and mean duration since transplant was 57.7 +/- 29 months (range, 3 to 120 months, mean +/- SD). DSE was performed by a standard protocol (dobutamine 5, 10, 20, 30, and 40 micrograms.kg-1.min-1 at 5-minute stages). DSE was defined as positive for development of new or worsening regional wall motion abnormality or failure of augmentation. Nine patients were excluded from analysis (5 because of acute allograft rejection and 4 because of poor acoustic window). Thus, data from 77 patients were analyzed. Fifty-seven of 77 (74%) had positive DSE. After 24 months of follow-up, 19 of 57 patients with abnormal DSE (33%) experienced 22 major cardiac events. In contrast, no event occurred in patients with normal DSE. Of the 19 with cardiac events, there were 7 episodes of heart failure (including 3 deaths), 4 had unstable angina, and 5 died of cardiac causes. Three patients had myocardial infarction, and 3 others died of noncardiac causes. Among the variables examined, the baseline left ventricular ejection fraction was lower (44 +/- 3.8 versus 51 +/- 1.4) and peak wall motion score index was higher (2.01 +/- 0.4 versus 1.44 +/- 0.4) in the patients group with cardiac events than in those without events. CONCLUSIONS: These results suggest that DSE has significant value in predicting prognosis in post-heart transplant patients. Further studies are needed to define the role of DSE as a routine test for predicting prognosis in cardiac transplant recipients.

Cardiac complications in noncardiac surgery: relative value of resting two-dimensional echocardiography and dipyridamole thallium imaging.

Although perfusion imaging studies are extensively used as a preoperative screening test for risk stratification of patients undergoing noncardiac surgery, no single cardiac noninvasive test has been shown to be ideal for risk stratification. We investigated the relative impact of transthoracic two-dimensional echocardiography (ECHO) compared with dipyridamole thallium scintigraphy (DT) in predicting major cardiac complications in patients undergoing non-cardiac surgery. Eighty-seven consecutive patients undergoing 96 procedures (56 vascular, 40 general) underwent preoperative evaluation first with DT and then with ECHO before surgery. Complications were prospectively defined as myocardial infarction (MI), cardiac death (of MI, heart failure, or arrhythmia), or need of revascularization before surgery. DT showed one or more reversible defects in 44 (51%) patients, whereas ECHO demonstrated a reduced left ventricular ejection fraction (LVEF) in 25 (29%) patients. Major postoperative cardiac complications occurred in 10 patients: 5 deaths (2 ventricular fibrillation, 3 fatal MIs) and 5 nonfatal MIs. Four additional patients required urgent revascularization (coronary bypass graft surgery in 3 and percutaneous transluminal coronary angioplasty in 1). Of the 20 patients with both abnormal DT and ECHO, 11 (55%) had major complications, compared with none of the 26 (0%; p < 0.01) with an abnormal DT but normal LVEF. The sensitivity of DT and ECHO were not significantly different (79% [95% Cl, 52% to 93%] vs 86% [60% to 96%], respectively), although the specificity of DT was lower (51% [40% to 62%] vs 81% [70% to 88%]; p < 0.05). The positive predictive value of DT was significantly improved from 22% (12% to 35%) to 52% (32% to 72%) when both DT and ECHO were abnormal. The results were not significantly different when the 4 patients who underwent revascularization were excluded. In conclusion, (1) in spite of similar sensitivity of ECHO and DT, ECHO appears to be relatively more specific in predicting major CC, and (2) when ECHO and DT are both abnormal, the risk of CC related to noncardiac surgery is significantly increased. Use of the combination of DT and ECHO before major noncardiac surgery can improve the identification of patients at risk for complications.

Cardiac complications in noncardiac surgery: value of dobutamine stress echocardiography versus dipyridamole thallium imaging.

OBJECTIVES: The objective of this study was to determine the relative value of dobutamine stress echocardiography (DSE) and dipyridamole thallium imaging (DT) in the preoperative assessment of cardiovascular risk before noncardiac surgery. DESIGN: Prospectively DSE was performed in patients who had undergone DT as a part of their preoperative evaluation. SETTING: A large urban veterans' affairs medical center. PARTICIPANTS: Thirty-seven patients undergoing major noncardiac surgery were assessed for complications during a 1-month follow-up period. INTERVENTIONS: Both DSE and DT were performed before surgery. The medium interval between the two tests were 15.5 days. MEASUREMENTS: Left ventricular wall motion was assessed at baseline and peak dobutamine dose in a standard fashion. Wall motion was scored and indexed using a 16-segment model. A positive DSE was defined as failure of augmentation, new or worsening of baseline wall motion abnormalities in two or more contiguous segments. Myocardial perfusion studies after DT were performed according to conventional method. A positive DT was defined as a reversible perfusion defect, increased lung uptake, and/or transient left ventricular dilatation. Complications were defined as myocardial infarction or cardiac death occurring as a result of the operation, or need for revascularization before surgery. RESULTS: DSE was positive in 19 patients, whereas DT was positive in 25 patients. Fourteen patients had both an abnormal DSE and DT. Five patients had major postoperative cardiac complications: fetal myocardial infarction (1); fatal cardiac arrest (1); and severe coronary artery disease necessitating coronary artery bypass surgery (2) or percutaneous transluminal coronary angioplasty (1). DSE was positive in all 5 (100%), whereas DT was positive in 4 of 5 (80%) patients with complications. The sensitivity for each test was comparable: for DSE it was 100% (95% C.I. 56% to 100%) and for DT 80% (37% to 96%). Specificity for DSE (60%, 43%-74%) was somewhat higher than DT (38%, 24% to 54%), although this did not reach statistical significance (p = 0.06). CONCLUSIONS: The ability of DSE to predict major cardiac complications related to noncardiac surgery appears to be similar to DT and may be used as an alternative to DT imaging in the preoperative risk assessment of patients undergoing noncardiac surgery.

Left atrial appendage contractile function in atrial fibrillation. Influence of heart rate and cardioversion to sinus rhythm.

BACKGROUND: A high incidence of embolic phenomena is associated with atrial fibrillation (AF) and the left atrial appendage (LAA) is frequently the source of the emboli. Thrombus formation may be due to stasis within the fibrillating and inadequately emptying LAA. Because LAA emptying in AF may be the result of mechanical compression by the adjacent left ventricle, it is possible that left ventricular diastolic filling duration will importantly influence passive emptying of the LAA. We hypothesized that the magnitude of emptying of the LAA in AF is related to the duration of left ventricular diastolic filling which is determined by the ventricular response rate in AF. OBJECTIVE: The objective of our study was to determine the relationship of ventricular response rate in AF to LAA emptying and to assess the influence of sinus rhythm and heart rate on LAA emptying immediately after direct current cardioversion to sinus rhythm. METHODS: To study this, we used transesophageal echocardiography to measure LAA ejection fraction ([LAAmax-LAAmin]/LAAmax x 100%) and evaluated its relationship to left ventricular response rate (VRR) in 26 patients with AF (mean age, 65 +/- 7 [1 SD] years). RESULTS: There was a strong inverse relationship between LAA ejection fraction and VRR in AF (r = -0.73; p < 0.001). LAA ejection fraction during AF was 26 +/- 10%, and immediately after successful cardioversion, it increased to 46 +/- 12% (p < 0.001). However, during sinus rhythm there was no relationship between LAA ejection fraction and VRR (r = 0.06; p = NS) in the subgroup of patients who were successfully converted to sinus rhythm. There were poor relationships between LAA ejection fraction and peak transmitral flow velocity (r = -0.41; p = NS) or pulmonary venous flow velocity (r = -0.03; p = NS) in AF. CONCLUSION: These results indicate that the magnitude of LAA emptying in AF is strongly and inversely influenced by ventricular rate. Direct current cardioversion to sinus rhythm is associated with an increase in the magnitude of LAA emptying that is not influenced by heart rate. The magnitude of LAA emptying may be an important factor in the formation of thromboemboli in AF. The extent to which controlling the VRR in chronic AF will prevent stasis and LAA thrombus formation remains to be determined.

Noninvasive detection of transplant coronary artery disease by dobutamine stress echocardiography.

Coronary artery disease has emerged as the leading cause of late morbidity and mortality in heart transplant recipients. The incidence of allograft coronary artery disease has been reported to be as high as 40% to 50% by 5 years. Coronary angiography remains the standard approach for surveillance of coronary artery disease in this patient population. However, the detection and surveillance of allograft coronary disease by noninvasive methods remains a challenge. The purpose of this study was to determine the value of dobutamine stress echocardiography as a noninvasive screening test to rule out the presence of anatomically significant allograft coronary artery disease and to assess its prognostic power. Dobutamine stress echocardiography was carried out according to a standard protocol in which dobutamine was infused at 5, 10, 20, 30, and 40 micrograms/kg/min intravenously at 5-minute stages with 12-lead electrocardiogram and blood pressure monitoring. Left ventricular wall motion was analyzed at baseline and at peak dobutamine dose. Mean age (+/- standard error of the mean) of the study population was 50.5 +/- 1.5 years, and mean duration (+/- standard error of the mean) since transplantation was 57 +/- 5 months. The sensitivity, specificity, and positive and negative predictive accuracy of dobutamine stress echocardiography were 95%, 55%, 69%, and 92%, respectively. In the 12-month follow-up study 12 patients with abnormal dobutamine stress echocardiographic findings had 15 major cardiac events whereas no event occurred in patients with normal dobutamine stress echocardiograms.(ABSTRACT TRUNCATED AT 250 WORDS)

Ischemia-induced regional wall motion abnormality is improved after coronary angioplasty: demonstration by dobutamine stress echocardiography.

OBJECTIVES: The purpose of this study was to examine whether dobutamine stress echocardiography can detect reversal of ischemia-induced left ventricular regional wall motion abnormality immediately after percutaneous transluminal coronary angioplasty. BACKGROUND: Although angioplasty is routinely performed as a means of coronary revascularization, at present there is a question whether this results in an immediate improvement in ischemia-induced left ventricular regional function. METHODS: Thirty-five patients underwent dobutamine stress echocardiography 24 h before and 24 to 48 h after angiographically successful coronary angioplasty. Only patients with normal wall motion at rest were included. Dobutamine infusion was begun at 5 micrograms/kg per min and increased at 5-min intervals (10, 20, 30, 40 micrograms/kg per min). Echocardiographic images were stored into cine loops and analyzed off line with simultaneous comparison of images acquired at baseline, 5 micrograms/kg per min, peak infusion and recovery. Echocardiographic images were interpreted independently, without knowledge of other data, by two experienced cardiologists using the 16-myocardial segment model. RESULTS: Before angioplasty, dobutamine stress echocardiography induced wall motion abnormalities in 31 patients (88%). Wall motion score at peak dobutamine infusion improved in 28 (90%) of the 31 patients after angioplasty. Wall motion score at peak dobutamine infusion for the group improved from 20 +/- 3 before angioplasty to 17 +/- 2 after angioplasty (p < 0.001). There was no change in the rate-pressure product achieved for the group before and after angioplasty (20,038 +/- 6,415 beats/min x mm Hg before versus 20,775 +/- 5,435 after angioplasty, p = NS). Before angioplasty, dobutamine stress echocardiography induced angina in 13 patients (37%), whereas angina occurred only once after angioplasty. Electrocardiographic changes diagnostic of ischemia occurred seven times, all before angioplasty. CONCLUSIONS: We conclude that dobutamine stress echocardiography is an excellent method to demonstrate an immediate improvement in stress-induced regional left ventricular dysfunction in the distribution of the vessel undergoing successful angioplasty.