Differential effects of coronary artery stenosis on myocardial function: the value of myocardial strain analysis for the detection of coronary artery disease.

BACKGROUND: Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to assess the predictive value of two-dimensional longitudinal strain in the detection of longitudinal LV dysfunction and the identification of coronary artery disease (CAD) in patients hospitalized with angina. METHODS: Two-dimensional strain software was extended to allow the analysis of numerous longitudinal strain traces in the entire left ventricle and generate a histogram of peak systolic strain (PSS) values for the left ventricle and for each coronary territory. In each histogram, the value of the 10% worst strain values (PSS(10%)) was determined. Global strain, segmental PSS, and PSS(10%) were analyzed in 97 patients hospitalized with angina and had normal LV function, who underwent coronary angiography, and 51 patients with low probability of CAD. Echocardiography was performed 2.9 ± 2 days after admission. RESULTS: Sixty-nine patients had significant CAD on coronary angiography. Significant differences were observed in all strain parameters between patients with and without CAD. PSS(10%) showed the best accuracy in detecting CAD, with an area under the receiver operating characteristic curve of 0.85. The areas under the curve for global strain and segmental PSS were 0.80 and 0.76, respectively. The optimal cutoff for PSS(10%) was -13.9%, with sensitivity and specificity of 86% and 75%, respectively. PSS(10%) was better than segmental PSS in the detection of CAD in each coronary territory. CONCLUSIONS: In patients hospitalized with angina who have significant CAD on coronary angiography, longitudinal systolic function is impaired. Histogram analysis improved the accuracy of longitudinal strain analysis in detecting global and regional impaired function.

Accuracy and long-term prognostic value of pacing stress echocardiography compared with dipyridamole tl201 emission computed tomography in patients with a permanent pacemaker and known or suspected coronary artery disease.

OBJECTIVES: Myocardial ischemia is difficult to assess by noninvasive methods in patients with a permanent pacemaker. Pacing stress echocardiography (PASE) has been used successfully in the detection of coronary artery disease (CAD). However, there are no data comparing PASE and other methods. METHODS: We compared agreement and accuracy of PASE and radionuclide tomography (SPECT) in detecting CAD in 58 patients, mean age 75 +/- 7 years, with a permanent pacemaker and known or suspected CAD. Thirty-nine patients underwent coronary angiography. The prognostic value of these tests was determined by prediction of cardiac events and cardiac death. RESULTS: PASE and SPECT were positive in 39 and 43 patients, respectively. The agreement between the tests was 75%; kappa value 0.64. The sensitivity was 87 and 96% and the specificity 78 and 57%, respectively. With median follow-up of 51 months, there were 24 cardiac events and 8 cardiac deaths. Multivariable analysis determined that positive PASE was the only independent predictive factor associated with cardiac events and cardiac death. CONCLUSIONS: PASE is a feasible and effective method for detection of significant CAD in patients with permanent-pacemaker and allows effective risk stratification. PASE merits further study in larger prospective comparative studies.

Blood transfusion for acute decompensated heart failure--friend or foe?

BACKGROUND: In acute coronary syndromes (ACSs), blood transfusion (BT) has been associated with worse outcomes. The impact of BT among patients with acute decompensated heart failure (ADHF) remains unknown. METHODS: Propensity score analysis of patients with ADHF with and without BT in a national heart failure (HF) survey was used in this study. RESULTS: Of the 4,102 enrolled patients, 2,335 had ADHF, of whom 166 (7.1%) received BT. These patients were older (75.6% vs 73.6%, P = .04), more likely to be females (54.8% vs 43.9%, P = .007), more likely to have diabetes (59.0% vs 51.1%, P = .04) and renal dysfunction (59.0% vs 40.2%, P < .001), and more likely to receive inotropes (16.9% vs 8.0%, P < .001), but they had similar rates of ACS (41.0% vs 39.4%, P = .69) and prior HF (64.5% vs 70.0%, P = .23). Nadir hemoglobin levels were commonly <10 g/dL in BT patients (92.7% vs 8.0%); 15 BT patients had bleeding complications, of which 10 are major bleeding. Major predictors for BT were ACS (OR 1.85, 95% CI 1.15-2.96), inotropes use (OR 2.36, 95% CI 1.22-4.55), and nadir hemoglobin (OR 0.18 per 1 g/dL increase, 95% CI 0.14-0.22). In-hospital, 30-day, 1-year, and 4-year unadjusted mortality rates were higher for BT patients (10.8% vs 5.2%, P = .02; 11.0% vs 8.5%, P = .27; 39.6% vs 28.5%, P = .03; 69.5% vs 59.5%, P = .01, respectively). However, in 103 propensity-matched pairs (c-statistic 0.97), short-term mortality tended to be lower with BT (8.7% vs 14.6%, P = .20; 9.7% vs 18.4%, P = .08; 38.8% vs 42.7%, P = .59; and 72.8% vs 76.7%, P = .52, respectively). CONCLUSIONS: Acute decompensated HF patients receiving BT had worse clinical features and unadjusted outcomes, but BT per se seemed to be safe and perhaps even beneficial.

Clinical and hemodynamic effects of bosentan dose optimization in symptomatic heart failure patients with severe systolic dysfunction, associated with secondary pulmonary hypertension--a multi-center randomized study.

OBJECTIVE: To evaluate the effects of bosentan on echo-derived hemodynamic measurements, and clinical variables in symptomatic heart failure (HF) patients. METHOD: Multi- center, double-blind, randomized (2:1), placebo-controlled study comparing bosentan (8-125 mg b.i.d.) to placebo in patients with New York Heart Association class IIIb-IV HF, left ventricular ejection fraction <35% and systolic pulmonary artery pressure (SPAP) >40 mm Hg. Primary and secondary endpoints were change from baseline to 20 weeks in SPAP and cardiac index, respectively. Safety endpoints were treatment emergent adverse events (AEs), change in body weight, hemoglobin, hematocrit, systolic blood pressure and diuretic use. RESULTS: Ninety-four patients enrolled: 60 to bosentan, 34 to placebo. There was no significant difference between the 2 arms in SPAP change (0.1 +/- 11.5 mm Hg , 95% confidence limit (CL) -5.4 to 5.2, p = 0.97), cardiac index shift (0.12 +/- 0.45, 95% CL -0.09 to 0.33 , p = 0.24 ) or any of the other 22 echocardiographic measurements obtained. Therapy-duration was longer in the placebo arm, while more patients in the bosentan arm experienced adverse and serious AEs. CONCLUSION: In HF patients with left ventricular dysfunction and secondary pulmonary hypertension, bosentan did not provide any measurable hemodynamic benefit, and was associated with more frequent AEs, requiring drug discontinuation.

Cardiac abnormalities as a new manifestation of nonalcoholic fatty liver disease: echocardiographic and tissue Doppler imaging assessment.

Nonalcoholic fatty liver disease (NAFLD) is linked to the metabolic syndrome. The aim of the present study is to determine the effect of the metabolic syndrome on left ventricular (LV) geometry and function using as a model patients with NAFLD. Thirty-eight patients with NAFLD, less than 55 years of age and with a normal exercise test, were compared with an age and sex-matched control group. Patients with diabetes mellitus, hypertension, and body mass index>40 were excluded. A complete echocardiographic study including tissue Doppler imaging (TDI) was performed. The following parameters were assessed by echo Doppler: peak velocities of early (E) and late (A) diastolic filling, E/A ratio, flow propagation velocity (Vp). Using TDI early diastolic velocity (E'), and systolic velocity (S') of mitral annulus were obtained. The patients with NAFLD had a significantly higher body mass index (31.4+/-5 vs. 26.4+/-4 kg/m, P=0.01), higher glucose (100.6+/-13 vs. 83.0+/-10 mg/dL, P=0.01), and triglyceride levels (126.5+/-44 vs. 206.5+/-67 mg/dL, P<0.001). Increased thickness of the intraventricular septum, posterior wall (11.03+/-2.2 vs. 8.9+/-2.9 mm, P=0.001; 8.5+/-1.7 vs. 9.7+/-2.3 mm, P=0.04), and larger LV mass and LV mass/height (160.7+/-58.7 vs.115.3+/-35.4 g, P=0.001 and 92.6+/-29.5 vs. 69.2+/-19.8 g/m, P=0.001, respectively) were found in NAFLD group. LV systolic function was similar in both groups. Patients with NAFLD had a lower E (73.6+/-11.0 vs. 86.4+/-20.0 cm/s, P<0.006) and E/A ratio (1.0+/-0.3 vs. 1.76+/-0.8 P<0.0001). Moreover, the Vp and the E' on TDI were significantly lower compared with the control group (49.0+/-9.7 vs. 74.7+/-18.4 cm/s, P<0.0001 and 10.3+/-2.0 vs. 13.8+/-1.7 cm/s, P<0.0001, respectively). On multivariate analysis the E' on TDI was the only independent parameter associated with NAFLD. In conclusion, patients with NAFLD in the absence of morbid obesity, hypertension, and diabetes have mildly altered LV geometry and early features of left ventricular diastolic dysfunction. Early diastolic velocity on TDI was found to be the only index that could identify the patients with NAFLD and metabolic syndrome.

Fatal ventricular arrhythmia as a complication of transesophageal echocardiography.

AIM: To report a case of serious ventricular arrhythmia during transesophageal echocardiography. METHODS AND RESULTS: A 58-year-old woman with previous mitral and tricuspid valve replacement and permanent pacemaker implantation suffered from recurrent fever and Staphylococcus aureus bacteremia. Transesophageal echocardiography was performed as part of the assessment for infective endocarditis. During this procedure the patient developed sustained ventricular tachycardia and subsequently ventricular flutter. She was successfully resuscitated. Subsequently the procedure was undertaken under general anesthesia with no complications. CONCLUSION: The increasing use of TEE in a wider spectrum of patients, many of whom are seriously ill, may result in serious side-effects.

Dipyridamole-induced abnormal Tl-201 lung uptake in patients with normal myocardial perfusion: a marker of increased left ventricular filling pressures.

BACKGROUND: The mechanism of dipyridamole-induced abnormal increased T1-201 lung uptake in patients without coronary artery disease is poorly understood. The purpose of this study was to evaluate the relation between dipyridamole-induced abnormal T1-201 lung uptake and left ventricular (LV) diastolic indexes using Doppler, color M-mode and Tissue Doppler modalities at rest, and at dipyridamole stress echocardiograpy (DSE) in patients with normal myocardial perfusion and LV function. METHODS AND RESULTS: 18 consecutive patients (mean age 64 +/- 7 years) with normal myocardial perfusion and increased lung T1-201 uptake on dipyridamole stress-redistribution single photon emission computed tomography (SPECT) were included in our study. These patients were compared with 18 age-matched control patients with normal perfusion and normal T1-201 lung uptake. All patients underwent DSE. A good correlation was found between the T-201 lung uptake, the peak early velocity of mitral inflow (E, r = 0.57) and estimated pulmonary capillary wedge pressure (PCWP = 1.24[E/Ea] + 1.9, r = 0.68). In patients with increased L/H ratio compared to control group, the E and the PCWP were significantly higher at baseline 81 +/- 18 vs 68 +/- 11 (cm/s) and 13 +/- 3 vs 10.2 +/- 2 (mmHg). An additional significant increase of E to 91 +/- 23 (cm/s (P = 0.001)) and PCWP to 14.8 +/- 3 (P = 0.005) after dipyridamole administration was seen; in contrast to a nonsignificant change observed in control group. For the detection of a dipyridamole induced PCWP >12 mmHg, a L/H ratio of >/=50% had a sensitivity of 72% and a specificity of 83%, resulting in a positive and a negative predictive value of 81% and 75%, respectively. CONCLUSIONS: A dipyridamole-induced abnormal T1-201 lung uptake in patients with normal myocardial perfusion and systolic function is predictive of elevated filling pressures at rest and in response to dipyridamole administration, probably reflecting an intrinsic resting diastolic dysfunction and a further abnormal response to vasodilatation.

Peripheral arterial tonometry: a diagnostic method for detection of myocardial ischemia induced during mental stress tests: a pilot study.

BACKGROUND: Mental stress testing is considered a reliable method for diagnosing patients with coronary heart disease (CHD) who may be at risk for future events. It has been shown recently that myocardial ischemia induced during mental stress tests is specifically associated with peripheral arterial vasoconstriction. HYPOTHESIS: The study was undertaken to test the diagnostic capability of peripheral arterial tonometry (PAT) to detect peripheral arterial vasomotor changes. METHODS: We monitored pulsatile finger blood volume changes using a specially designed finger plethysmograph, PAT that can detect peripheral arterial vasomotor changes. Equilibrium radionuclide angiography (ERNA) was simultaneously performed in 18 male patients at rest and during a mental arithmetic stress test with harassment. All patients had previously diagnosed coronary disease and positive exercise tests. Myocardial ischemia was diagnosed by ERNA when global ejection fraction fell > or = 8% during mental stress or new (or worsened) focal wall motion abnormalities occurred. Peripheral arterial tonometry tracings were considered abnormal when the pulse wave amplitude decreased by > or = 20% from baseline. RESULTS: In 18 patients there were 16 usable studies. In eight patients, both ERNA and PAT were abnormal, and in six patients the tests were negative by both methods. In two cases, the results were discordant. Therefore, when considering an abnormal PAT tracing as indicative of mental stress-driven myocardial ischemia, concordance of the two methods was 88%. CONCLUSION: The use of PAT may facilitate both clinical testing and research during mental stress.

High fasting glucose levels as a predictor of worse clinical outcome in patients with coronary artery disease: results from the Bezafibrate Infarction Prevention (BIP) study.

BACKGROUND: A high fasting glucose level may be a marker not only for microvascular complications, but also for macrovascular complications. We evaluated the clinical significance of a high fasting glucose level (> or =110 mg/dL), detected either at baseline or during follow-up, in the Bezafibrate Infarction Prevention (BIP) study. METHODS: The BIP study was a secondary prevention prospective double-blind study comparing bezafibrate to placebo. A total of 3122 patients with documented coronary artery heart disease who were aged 45 to 74 years and had a total cholesterol level between 180 and 250 mg/dL, low-density lipoprotein cholesterol level < or =180 mg/dL, a high-density lipoprotein cholesterol level < or =45 mg/dL, a triglyceride level < or =300 mg/dL, and a fasting glucose < or =160 mg/dL were randomized to receive 400 mg of bezafibrate daily or placebo. RESULTS: The primary end point of the BIP study was fatal myocardial infarction, non-fatal myocardial infarction, or sudden death. Secondary end points included hospitalization for unstable angina, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting. At baseline, 330 patients (11%) had diabetes mellitus, and 293 patients (9%) had an impaired fasting blood glucose level (IFG). During 6.2 years of follow-up, diabetes mellitus developed in 186 patients (6%), IFG developed in 366 patients (12%), and 62% of patients remained with normal fasting glucose levels (NFG). Patients with diabetes mellitus and IFG both at baseline or developing during follow-up had a significantly higher rate of secondary end points than paients with NFG (P <.0001). Bezafibrate treatment reduced secondary end points only in patients with NFG (P =.04). CONCLUSION: Diabetes mellitus and IFG were common in the BIP study and were predictive of a worse clinical outcome that was not attenuated with bezafibrate treatment.

[Preoperative cardiac risk evaluation in non cardiac surgery].

Cardiovascular complications are important causes of morbidity with major non cardiac procedures. Preoperative risk stratification relies on the identification of the cardiac problem, its stability, its severity and previous treatment. The approach to risk stratifying preoperative patients should be performed by accepted guidelines used for patients with suspected coronary artery disease (CAD) or known CAD and not as an "obligatory test" prior to operation. Risk stratification is based on clinical predictors, stress testing, including cardiac imaging if necessary, and the kind of operation. Most of the tests are noninvasive and some invasive tests conducted are intended to identify myocardial ischemia and critical lesions of the coronary arteries. Most of the patients are able to undergo elective procedures without any problem with the perioperative cardiac event rate of up to 2% considered as an accepted goal. The use of invasive diagnostic and therapeutic methods, such as cardiac catheterization, PCI, CABG, has to be restricted only to patients who are at very high risk. The partial reduction of the cardiac event rate in the short term and monitoring for 24 hours after operation is most important, as well as the administration of beta blockers, starting prior to surgery. Furthermore, long term follow-up for cardiac events in these patients in essential, as the clinical predictors and cardiac tests performed for preoperative risk stratification are also used for long term prognosis.

A prospective national survey of management and clinical outcome of acute myocardial infarction in Israel, 2000.

BACKGROUND: Little information is available on the clinical practice and implementation of guidelines for treating acute myocardial infarction patients in Israel. OBJECTIVE: To assess patient characteristics, hospital course, management, and 30 day clinical outcome of all AMI patients hospitalized in Israel during a 2 month period in 2000. METHOD: We conducted a prospective 2 month survey of consecutive AMI patients admitted to 82 of 96 internal medicine departments and all 26 cardiac departments operating in Israel in 2000. Data were collected uniformly by means of a hospital and 30 day follow-up form. RESULTS: During the survey 1,683 consecutive patients with a discharge diagnosis of AMI were included. Their mean age was 66 years; 73% were male. The electrocardiographic pattern on admission revealed ST elevation, non-ST elevation and an undetermined ECG in 63%, 34% and 4% of patients respectively. Aspirin and heparin were given to 95% of patients. Beta-blockers and angiotensin-converting enzyme inhibitors were given to 76% and 65% of patients respectively. Among hospital survivors, 45% received lipid-lowering drugs. Thrombolytic therapy was administered in 28% of patients, coronary angiography was used in 45%, and 7% of patients underwent primary percutaneous coronary intervention. The 7 and 30 day mortality rates were 7% and 11% respectively. CONCLUSIONS: This nationwide survey shows that one-third of the AMI patients in Israel are elderly (> or = 75 years). The survey suggests that clinical guidelines for the management of patients with AMI are partially implemented in the community. Data from large surveys representing the "real world" practice are of utmost importance for the evaluation of clinical guidelines, research and educational purposes.