Prevalence and characteristics of coronary artery disease in a population with suspected ischemic heart disease using CT coronary angiography: correlations with cardiovascular risk factors and clinical presentation.

PURPOSE: This study was undertaken to describe the correlation between the distribution of coronary artery disease (CAD) in a symptomatic population with suspected ischaemic heart disease, cardiovascular risk factors (RF) and clinical presentation. MATERIALS AND METHODS: we studied 163 patients (mean age 65.5 years; 101 men and 62 women) referred for multidetector computed tomography coronary angiography (MDCT-CA) to rule out CAD. The patients had no prior history of revascularisation or myocardial infarction. We analysed how the characteristics of CAD (severity and type of plaque) can change with the increase in RF and how they are related to different clinical presentations. RESULTS: patients were divided into three groups according to the number of RF: zero or one, two or three, and four or more. The percentage of coronary arteries with no plaque, nonsignificant disease and significant disease was 55%, 41% and 4%, respectively, in patients with zero or one RF; 27%, 51% and 22%, respectively, in patients with two or three RF; and 19%, 38% and 44%, respectively, in patients with four or more RF. Plaque in patients with nonsignificant disease was mixed in 65%, soft in 18% and calcified in 17%. The percentage of coronaries with no plaque in the three RF groups was 50%, 20% and 0% in patients with typical chest pain and 46%, 24% and 12% in those with atypical pain. The percentage of significant disease in patients with typical pain was 0%, 47% and 86% and in those with atypical pain 4%, 20% and 29%. CONCLUSIONS: MDCT plays an important role in the identification of CAD in patients with suspected ischaemic heart disease. Severity and type of disease is highly correlated with RF number and assumes different characteristics according to clinical presentation.

Diagnostic accuracy of 64-slice computed tomography coronary angiography in patients with low-to-intermediate risk.

PURPOSE: Our aim was to evaluate the diagnostic accuracy of 64-slice computed tomography coronary angiography (MSCT-CA) for detecting significant stenosis (>or=50% lumen reduction) in a population of patients at low to intermediate risk. MATERIALS AND METHODS: We studied 72 patients (38 men, 34 women, mean age 53.9+/-8.0 years) with atypical or typical chest pain and stratified in the low-to intermediate risk category. MSCT-CA (Sensation 64 Cardiac, Siemens, Germany) was performed after IV administration of 100 ml of iodinated contrast material (Iomeprol 400 mgI/ml, Bracco, Italy). Two observers, blinded to the results of conventional coronary angiography (CAG), assessed the MSCT-CA scans in consensus. Diagnostic accuracy for detecting significant stenosis was calculated. RESULTS: CAG demonstrated the absence of significant disease in 70.1% of patients (51/72). No patient was excluded from MSCT-CA. There were 37 significant lesions on 1,098 available coronary segments. Sensitivity, specificity and positive and negative predictive value of MSCT-CA for detecting significant coronary artery on a per-segment basis were 100%, 98.6%, 71.2% and 100%, respectively. All patients with at least one significant lesion were correctly identified by MSCT-CA. MSCT-CA scored 15 false positives on a per-segment base, which affected only marginally the per-patient performance (only one false positive). CONCLUSIONS: We concluded that 64-slice CT-CA is a diagnostic modality with high sensitivity and negative predictive value in patients at low to intermediate risk.

A rare case of left ventricular outflow obstruction.

We report a patient with a mass originating from the anterior mitral valve leaflet causing severe left ventricular outflow tract obstruction. Noninvasive imaging provided the best diagnostic tools for diagnosis. Histological findings showed a very rare giant blood cyst of the mitral valve.

Anomalous origin of the circumflex artery and patent foramen ovale: a rare cause of myocardial ischaemia after percutaneous closure of the defect.

A 35 year old man with a history of transient ischaemic attack and atrial septal aneurysm underwent percutaneous closure of a patent foramen ovale (PFO) with a transcatheter device. After the procedure the patient developed effort angina not present previously. Transoesophageal echocardiography confirmed the absence of residual shunt but showed an abnormal linear image running behind the aortic root. Magnetic resonance imaging detected an anomalous origin of the circumflex coronary artery from the right coronary sinus. The anomalous artery was located between the aortic root and the PFO closing device, causing coronary insufficiency. This report describes a rare complication of transcatheter PFO closure.

Transthoracic three-dimensional echocardiographic reconstruction of left and right ventricles: in vitro validation and comparison with magnetic resonance imaging.

Two-dimensional (2D) echocardiographic and angiographic measurements of ventricular volumes are limited by geometric assumptions concerning cavity shape. We compared in vitro the accuracy of a three-dimensional (3D) echocardiographic system suitable for transthoracic imaging to magnetic resonance imaging (MRI) in the measurement of left and right ventricular volumes. Ventricular cast volumes from 14 excised formalin-fixed sheep hearts filled with an agarose solution were compared with data derived from 3D echocardiography and MRI. Left and right ventricular volumes from 3D echocardiographic reconstructions agreed well with actual volumes without significant underestimation or overestimation. MRI progressively underestimated left ventricular volumes as these increased and systematically underestimated right ventricular volumes. Our echocardiographic system designed for 3D transthoracic imaging combines excellent measurements of left and right ventricular volumes and the computed reconstruction of tomographic slices with the full spatial resolution of the original 2D images. Thus in this in vitro model, 3D echocardiography exhibited greater accuracy than MRI.

Heart rate variability and functional severity of congestive heart failure secondary to coronary artery disease.

To investigate the behaviour of heart rate variability (HRV) with the advancing severity of heart failure (CHF) we studied 20 normal subjects and 80 coronary artery disease (CAD) patients in sinus rhythm. CAD patients were selected consecutively in order to form four equal groups of 20 subjects with different degrees of CHF according to the New York Heart Association (NYHA) functional classification. In each subject a 24 h ECG Holter tape was recorded and subsequently analysed to obtain measures of heart rate and HRV. We used several measures of HR and both spectral and non-spectral measures of HRV. Among these we employed the width of the R-R interval distribution over 24 h at three different heights (TV, 10%Var, 50%Var). The CAD group showed significantly lower HRV counts and smaller spectral components than controls. However, these differences were due to the presence of CHF rather than to CAD. Indeed, a progressive and significant increase in heart rate and a contemporary decrease in HRV was observed with the advancing severity of CHF. Class IV patients had the smallest HR variation; the spectral composition in this group was barely detectable. The decrease in time domain measures of HRV followed the increase in NYHA Class in a progressive and regular pattern, while the low frequency and high frequency spectral power showed the largest reduction from NYHA Class I to NYHA Class II patients. No significant change was demonstrated in NYHA Class I patients as compared to Controls.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular free wall rupture during a myocardial infarct: its incidence, clinical presentation, evolution]. / Rottura della parete libera del ventricolo sinistro in corso di infarto miocardico: incidenza, presentazione clinica, evoluzione.

Of 554 patients hospitalized for acute myocardial infarction, 61 (11%) died in the Intensive Care Unit. Echocardiography (performed at admission, at discharge and in every case of modification of the clinical course) allowed the diagnosis of left ventricular free wall rupture (RPLVS) in 20. The clinical course was acute in 13 of the latter, presenting with electromechanical dissociation (DEM). Pericardiocentesis allowed survival of one patient of this group. In 6 patients RPLVS had a subacute pattern, with progressive hypotension (in 2 cases preceded by syncope): pericardiocentesis allowed temporary stabilization of 4 patients; 2 had surgical repair with 1 long-term survivor. In 1 patient RPLVS began with lipothymia, and then he stabilised spontaneously. Many physiopathological mechanisms are discussed which could explain the great clinical variability of RPLVS. Awareness that RPLVS can appear with patterns different from DEM is fundamental for the diagnosis of subacute RPLVS. Indeed, this form of RPLVS, when recognized, can be treated with an encouraging prognosis.

Heart rate variability during the acute phase of myocardial infarction.

BACKGROUND: After acute myocardial infarction (AMI), several abnormalities of the autonomic control to the heart have been described. Heart rate (HR) variability has been used to explore the neural control to the heart. A low HR variability count measured 7-13 days after AMI is significantly related to a poor outcome. Little information is available on HR variability early after AMI and its relation to clinical and hemodynamic data. METHODS AND RESULTS: We studied 54 consecutive patients (42 men and 12 women; mean age, 60.4 +/- 11 years) with evidence of AMI by collecting the 24-hour HR SD from Holter tapes recorded on day 2 or 3. We also measured HR variability in 15 patients with unstable angina and in 35 age-matched normal subjects. HR variability was lower in AMI than in unstable angina patients (57.6 +/- 21.3 versus 92 +/- 19 msec; p less than 0.001) and controls (105 +/- 12 msec; p less than 0.001). Also, HR variability was greater in non-Q-wave than in Q-wave AMI (p less than 0.0001) and in recombinant tissue-type plasminogen activator-treated patients with respect to the rest of the group (p less than 0.02). No difference was found for infarct site. HR variability was significantly related to mean 24-hour HR, peak creatine kinase-MB, and left ventricular ejection fraction (all p less than 0.0001). Patients belonging to Killip class greater than I or who required the use of diuretics or digitalis had lower counts (p less than 0.004, p less than 0.001, and p less than 0.024, respectively). Six patients died within 20 days after admission to the hospital. In these patients, HR variability was lower than in survivors (31.2 +/- 12 versus 60.9 +/- 20 msec; p less than 0.001), and a value less than 50 msec was significantly associated with mortality (p less than 0.025). CONCLUSIONS: HR variability during the early phase of AMI is decreased and is significantly related to clinical and hemodynamic indexes of severity. The causes for the observed changes in HR variability during AMI may be reduced vagal and/or increased sympathetic outflow to the heart. It is suggested that early measurements of HR variability during AMI may offer important clinical information and contribute to the early risk stratification of patients.

Evaluation of mitral stenosis by cine magnetic resonance imaging.

To evaluate the ability of cine magnetic resonance imaging (cine MRI) in the assessment of mitral stenosis (MS), we studied 20 patients (14 women and 6 men, mean age 60.6 +/- 8.5 years) with rheumatic mitral valve stenosis by using an 0.5 T magnet. Cine MRI showed several signs of MS. Mitral leaflet thickening, reduced diastolic opening, and abnormal valve motion toward the left ventricular outflow tract were all common features. MS was also characterized by an abnormal diastolic transmitral signal from blood. Both left atrial and left ventricular dimensions were similar to those obtained at two-dimensional echocardiography (2-DE) (r = 0.89 and r = 0.86, respectively; p less than 0.001). A significant relationship was also found between the maximum mitral leaflet separation measured by cine MRI in diastole and the mitral valve area as calculated using the pressure half-time method and continuous wave Doppler (r = 0.81; p less than 0.001). These data indicate the improved ability of MRI to detect and assess MS and also suggest that this technique may contribute to the noninvasive assessment of MS.

[Changes in the wall motion of left ventricle in dipyridamole-induced ischemic cardiopathy studied by nuclear magnetic resonance. A comparison with myocardial scintigraphy with 99mTc MIBI]. / Alterazioni della motilità parietale del ventricolo sinistro nella cardiopatia ischemica indotte da dipiridamolo studiate con risonanza magnetica nucleare. Confronto con la scintigrafia miocardica mediante 99mTc MIBI.

To investigate whether magnetic resonance imaging (NMR) can detect alterations in LV contractility during myocardial ischemia, ten patients aged 32-72 with coronary artery disease underwent ECG gated NMR performed at 0.5 Tesla after intravenous infusion of high dose dipyridamole (DP) (0.7 mg/Kg) over 5 minutes. LV contraction in planes similar to echo short axis projection was imaged under condition, 3' and 15-20' after infusion of DP by fast multiphasic imaging (FMI), multiple angulated cine-NMR sequence with a temporal resolution of 50 m/sec. Entity and size of perfusion defects after DP were determined by Tc 99m MIBI myocardial scintigraphy. In all patients changes in LV contractility appeared at NMR in the same site of perfusion impairments revealed with MIBI. In 8 patients the alterations lasted even more than 20' after the first NMR scan. NMR provides the opportunity of performing long-lasting assessment of ventricular wall contractility and enables to exactly localize the site and extension of kinetic changes as well as their time of onset and time duration.

Evaluation of a mobile coronary care unit protocol in patients with acute onset chest pain.

This study was designed to assess the accuracy of a diagnostic protocol of the mobile coronary care unit (MCCU) of Florence for acute chest discomfort. During 1986, 706 patients with chest pain were seen by the MCCU. Of these, 324 of 376 (95.2%) of those hospitalized and 247 of 324 (76.2%) of the nonhospitalized patients were entered in the study. The MCCU diagnosis of acute myocardial infarction (AMI) was confirmed in 120 patients (80.3%). A false positive diagnosis of AMI was made in 27 patients (6.9%), while in 37 patients AMI was not diagnosed at the first MCCU clinical examination (false negative). The sensitivity in the diagnosis of AMI was 80.5%, the specificity 91.8%, and the diagnostic accuracy 89.1%. In the recognition of acute coronary syndromes (AMI + unstable angina), sensitivity and specificity were, respectively, 94.0% and 94.4%. The protocol of the Florence MCCU provides high accuracy in the diagnosis of AMI and acute coronary insufficiency; close adherence to the protocol can decrease the number and the costs of undue hospital admissions while protecting the safety of patients.

[Magnetic resonance imaging of aortic and mitral valve insufficiency. Comparison with Doppler echocardiography and angiocardiography]. / Studio con risonanza magnetica dell'insufficienza valvolare aortica e mitralica. Confronto con ecocardiografia Doppler ed angiocardiografia.

Fourty-five subjects--10 normal volunteers and 35 patients with valvular insufficiency were examined with MRI and [20 of them with mitral (MI) and 15 with aortic (AI) insufficiency] were evaluated with MR imaging and with Doppler echocardiography (echo-Doppler); 22 of these patients were also studied with angiocardiography. The extent of regurgitation jet was classified as follows: minimal (1+), mild (2+), moderate (3+), and severe (4+), according to the max distance of regurgitant jet signal from valvular leaflets. In our series, MR imaging with FFE sequences always showed the regurgitant jet. High agreement was found between MR and echo-Doppler results (80% for MI, and 86% for AI). In 22 patients who underwent angiocardiography, we observed 73% agreement. Cine-MR imaging proved to be an accurate and sensitive technique to recognize and to evaluate severity of regurgitant valvular flow in patients with AI and MI. This technique may be useful in those patients in whom Doppler echocardiography is inadequate or impossible to perform.

[Cardiac lipoma in a patient with diffuse subcutaneous lipomatosis. Nuclear magnetic resonance diagnosis]. / Lipoma cardiaco in soggetto con lipomatosi sottocutanea diffusa. Diagnosi con risonanza magnetica nucleare.

We describe a case of left ventricular intramyocardial lipoma in a patient with diffuse subcutaneous lipomatosis. The diagnosis was suspected on the basis of a two-dimensional echocardiographic examination that revealed a hyperechogenic mass within the left ventricular wall. Magnetic resonance imaging showed a homogeneous high signal mass thus indicating the presence of a benign lipoma. This report shows the ability of two-dimensional echocardiography and magnetic resonances imaging in detecting, localizing and characterizing left ventricular lipomas without the use of more invasive studies.