Risk factors for atherosclerosis in healthy employees-a multidisciplinary approach.

BACKGROUND: The aim of the study was to investigate the prevalence of early atherosclerosis in healthy workers and the relationship between classical, psychological, and immunological risk factors and atherosclerosis, as well as their predictive value. METHODS: One hundred healthy managers and 50 office workers aged 35-65 were studied. In all subjects, individual, family, and occupational stress/coping risk factors were evaluated, including plasma levels of biochemical (total cholesterol, LDL, HDL, TG, glucose) and inflammatory-immunological (aCL, anti-beta(2) GPI, oxLDL, HSP, HSCRP) parameters. Carotid artery intima-media thickness (IMT) and atherosclerotic plaques in carotid arteries were assessed with computer analysis of B-mode ultrasound images. RESULTS: In 107 persons (71%) no changes were found in ultrasound images and in 43 individuals (29%) the presence of plaque was shown. The mean IMT value was 0.0618+/-0.013 mm. Cross-domain analysis showed that core predictors for IMT were age, LDL level, smoking, and occupation (being a manager) (beta=0.33, 0.30, 0.23, and 0.20, respectively); the core predictors for plaque were age, total cholesterol level, and an occupational stressor home-work balance (Wald=7, 6.7, and 5.6, respectively). Immunological factors were not independent predictors. CONCLUSIONS: In atherosclerosis, not only traditional risk factors (age, lipid disorders, and lifestyle) but also occupational stress factors may play a role. Immunological factors do not seem to play a role in the development of atherosclerosis in a population of healthy workers. The interplay between occupational stress and atherosclerotic changes requires further investigation.

Advantages of exercise echocardiography in comparison to dobutamine echocardiography in the diagnosis of coronary artery disease in hypertensive subjects.

OBJECTIVE: The aim of the study was to compare the efficacy and safety of two stress echocardiography methods, exercise and dobutamine, in the diagnosis of coronary artery disease in hypertensive patients with angina. PATIENTS AND METHODS: A total of 197 treated hypertensive patients, age 53 +/- 9 years (65 women) with no history of myocardial infarction referred for coronary angiography were prospectively investigated with exercise electrocardiography (ECG), exercise and dobutamine echocardiography. RESULTS: Sensitivity of the exercise ECG, exercise echocardiography and dobutamine echocardiography did not differ (77%, 82% and 75%). Negative predictive value of exercise ECG was significantly lower than exercise echocardiography (64% vs 79%, P < 0.01). Specificity and positive predictive value of exercise ECG were markedly lower than exercise and dobutamine echocardiography (57%, 96%, 98% and 72%, 97%, 98%, P < 0.0001 for both stress echocardiography vs ECG). Specificity and sensitivity of diagnostic methods were not influenced by the presence of echocardiographic left ventricular hypertrophy. Dobutamine infusion in comparison to exercise was more often associated with substantial arterial blood pressure rise or fall (7% vs 2%, P < 0.05) and with simple ventricular ectopy (15,7% vs 6,1%, P < 0.05). CONCLUSIONS: In hypertensive patients with the symptoms of angina, both stress echo methods are significantly more specific than the exercise ECG test. Maximal exercise is associated with less frequent side effects than infusion of dobutamine, so exercise echocardiography may be preferred in the diagnosis of angina in hypertensive patients.

Transesophageal echocardiographic findings in patients with anterior and posterior circulation infarcts.

OBJECTIVES: The aim of this study was to assess the role of transesophageal echocardiography in detecting the source of cerebral embolism in ischemic stroke patients and to evaluate the difference in occurrence of heart abnormalities in anterior and posterior circulation infarcts. MATERIAL AND METHODS: The study group included 104 patients, 51 males and 53 females with ischemic stroke without significant atherosclerosis in the carotid arteries. Age of the patients ranged from 14 to 82 years (mean 55). The clinical picture of stroke suggested the embolic etiology, 34 of them had atrial fibrillation. Transthoracic and transesophageal echocardiography were performed in all patients. All patients were separated as anterior or posterior circulation infarcts. The control group consisted of 100 patients aged from 14 to 73 years (mean 53) without stroke history. RESULTS: Transesophageal echocardiography (TEE) examination revealed left atrial thrombus in 12%, left atrial spontaneous contrast in 16%, interatrial communication in 31%, mitral valve prolapse in 20%, atrial septal aneurysm in 14%, ventricular thrombus in 6% and aortic atheromas of 5 mm or more in size in 7% of stroke patients. In the control group left atrial spontaneous contrast was found in 10%, interatrial communication in 17%, mitral valve prolapse in 4%, atrial septal aneurysm in 8%, neither atrial nor ventricular thrombi were found. At least one abnormal TEE finding was present in 70 (67%) of stroke patients. Abnormal TEE findings were more often seen in patients with anterior circulation infarct than in those with posterior circulation infarcts, although the difference was not statistically significant. Left atrial thrombus and mitral valve prolapse occurred statistically significantly more often in stroke patients than in the control group. CONCLUSIONS: Echocardiographic examination is often abnormal in patients with ischemic stroke. The study did not reveal the statistically significant difference in the prevalence of abnormal transesophageal echocardiography findings between patients with anterior and posterior circulation infarcts.

Systolic anterior motion of the mitral chordae tendineae: prevalence and clinical and Doppler-echocardiographic features.

The objective of this investigation was to determine the prevalence and clinical associations of systolic anterior motion (SAM) of the mitral chordae (chordal SAM) in patients without evidence of hypertrophic cardiomyopathy. Although SAM of the mitral valve is thought to be a specific marker of hypertrophic obstructive cardiomyopathy, little is known about the clinical significance of chordal SAM either as an isolated echocardiographic finding (ICSAM) or in patients with mitral valve prolapse (MVP). A retrospective search of the clinical echocardiographic database was made to identify studies demonstrating chordal SAM with no other echocardiographic features of hypertrophic cardiomyopathy. The prevalence of chordal SAM was also ascertained in a group of 97 normal control subjects. Clinical, demographic, and two-dimensional and Doppler echocardiographic characteristics were compared between patients with and without MVP. Chordal SAM was identified in 3.9 percent of clinical studies but was rarely seen in normal volunteers (1 percent). Of the 57 patients with chordal SAM, 21 had systemic or cardiovascular conditions other than MVP associated with SAM (including 7 with aortic insufficiency and 8 with secondary concentric left ventricular hypertrophy), 18 (32 percent) had MVP, and 19 (33 percent) had no associated cardiovascular or systemic condition. These 19 patients with ICSAM were similar to patients with MVP and SAM with respect to age (44 +/- 8 vs 41 +/- 17 years), blood pressure, left ventricular wall thickness, ejection fraction, left atrial size, degree of mitral insufficiency, and left ventricular outflow tract velocity. Indications for the echocardiographic studies were similar between the two groups (chest pain, syncope, arrhythmia, cardiac source of embolus, and suspected MVP), but more patients in the ICSAM group were men (16 of 19 vs 8 of 18; p < 0.05). In conclusion, patients with ICSAM and CSAM associated with MVP are virtually indistinguishable by clinical, demographic, or Doppler-echocardiographic features. The syndrome of ICSAM deserves further study as a potentially clinically significant echocardiographic variant of the floppy mitral valve/MVP syndrome.

Resolution of an aortic mobile mass with anticoagulation without evidence of arterial embolism.

The prognostic significance of aortic mobile debris detected by transesophageal echocardiography (TEE) in patients without history of embolism has not been established. A mobile aortic arch mass was found by TEE in a 59-year-old man with coronary artery disease, and with rheumatic mitral valve disease, and with no embolic symptoms. The patient was anticoagulated for 6 weeks and the mass was no longer seen on repeated TEE. He had no embolic symptoms during 9 months of follow-up. Different therapeutic approaches to mobile aortic debris are discussed and anticoagulant treatment of asymptomatic cases is advocated.

Surgery as an effective nonpharmacological mode of treatment of atrial fibrillation resistant to standard therapy.

There are two surgical methods for atrial fibrillation (AF) treatment: Maze and corridoring procedures. The first one prevents AF occurrence by performing multiple atriotomies. During the second procedure a corridor between a sino-atrial and the AV node is created together with an electrical isolation of the atria. During 1992 and 1993 seven patients, aged 27-55, mean 43-years-old, with recurrent, resistant to standard therapy AF were referred for surgical treatment to our department. Additional diagnoses include: concealed WPW syndrome in 1 patient, atrial septal defect (ASD) in 3 patients, coronary artery disease in 1 patient. Maze procedure was performed solely in 1 patient, in another together with 2 accessory pathways ablation, in 3 patients with ASD closure and in 1 patient with 2 bypass grafts. In one patient corridoring procedure was performed. Normal sinus rhythm was restored in every patient from 7 to 26 days after the procedure. No surgical complications were noted during the postoperative period. Mechanical function of the atria was documented with echo Doppler 2-6 weeks after the operation. No evidence for AF recurrence was noted within 3-14 months (mean 5 months) of follow-up. The preliminary results of Maze and corridoring procedures are encouraging.

Spontaneously appearing microbubbles associated with prosthetic cardiac valves detected by transesophageal echocardiography.

During transesophageal echocardiographic studies in patients with prosthetic cardiac valves, we have noticed the presence of bright, highly mobile echoes (termed microbubbles because of their similarity to saline contrast bubbles) that move rapidly away from the valve. These echoes are distinct from spontaneous echo contrast. The purpose of this study was to determine the frequency with which microbubbles are detected in association with prosthetic valves. No microbubbles were detected in association with bioprosthetic valves. Thus analysis was limited to 198 studies performed in 138 patients with left-sided mechanical valves. Microbubbles were detected in 69 (35%) studies. No differences were found between studies with and without microbubbles with regard to patient characteristics or the indication for the study. Among the 173 individual valves studied, microbubbles were more frequently detected in association with mitral valves (34 of 82, 41%) versus aortic valves (14 of 91, 15%; p 0.0001). Microbubbles were more frequently detected with disc-type mitral valves (30 of 42, 17%) in comparison to Starr-Edwards mitral valves (4 of 39, 10%; p 0.0001). Microbubbles were more often detected with abnormal valves (28 of 76, 37%) than normal valves (20 of 97, 21%), p 0.02. We conclude that bright, highly mobile echoes (microbubbles) distinct from spontaneous echo contrast are frequently detected during transesophageal echocardiography in association with mechanical prosthetic valves. Although the cause and clinical significance of these microbubbles are unknown, it is important to distinguish these echoes from valvular masses such as thrombus or vegetations.

[The importance of transoesophageal echocardiography in establishing of the source of cerebral embolism]. / Znaczenie echokardiograficznego badania przezprzelykowego w ustaleniu zródla zatoru mózgowego.

Transesophageal echocardiography becomes widely used in patients suspected of cerebral embolism. This examination is characterized by higher than transthoracic echocardiography sensitivity for detection of left atrial thrombus. Patent foramen ovale and atrial septal aneurysm have been recognized more often in patients with embolic stroke than in control group. Another potential source of embolism is aortic atheroma especially when protruding or ulcerated. Transesophageal echocardiography allows for identification of embolic source in more than 50% of examined patients.

Transesophageal echocardiographic assessment of the effects of age, gender, and hypertension on thoracic aortic wall size, thickness, and stiffness.

Aging is associated with progressive arterial stiffening and widening of the pulse pressure, resulting in a high prevalence of systolic hypertension. The contribution of increased aortic thickness to this process and to essential hypertension has been poorly characterized. With transesophageal echocardiography, aortic thickness and diameter can be measured. Thus, the influence of aging, gender, and hypertension on the geometry and stiffness of the descending thoracic aorta in humans can be determined in vivo. In 83 patients undergoing transesophageal echocardiography for clinical indications, recordings of the descending thoracic aorta were made. There were 53 normotensive subjects (33 men and 20 women, mean age 46 years, range 14 to 79 years) and 25 hypertensive subjects (8 men and 17 women, mean age 67 years, range 50 to 80 years). Measurements of diastolic and systolic aortic thickness and aortic diameter were made, and three measures of the elastic properties of the aorta were calculated: (1) Peterson's elastic modulus, (2) Young's modulus, and (3) the stiffness index (beta). Aortic thickness averaged 1.1 +/- 0.1 mm in both normotensive men and women. Normotensive women had a significantly greater thickness/diameter ratio than men (0.06 +/- 0.01 vs 0.05 +/- 0.01, p < 0.01), but there were no differences in stiffness between men and women. Age was highly positively correlated with thickness (r = 0.74, p < 0.001), diameter (r = 0.67, p < 0.001), beta (r = 0.79, p < 0.001), Peterson's modulus (r = 0.78, p < 0.001), and Young's modulus (r = 0.81, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison between the automatized impedance cardiography and pulsed-wave Doppler echocardiography methods for measurements of stroke volume (SV) and systolic time intervals (STI).

Stroke volume (SV) and systolic time intervals (STI) were measured automatically using impedance cardiography signals (ICG) and compared with those obtained by pulsed-wave Doppler echocardiography using the apex approach. The comparison was made in 9 healthy male subjects, mean age 24.9 +/- 12.2 years, using recordings of 10 heart cycles simultaneously obtained by the two methods. During measurements the subjects rested in the supine position. There were no differences between mean values of SV determined by the two methods as well as between mean values of ejection time (ET) (p > 0.8 and p > 0.9, respectively). The pre-ejection period (PEP) estimated by ICG was 22 ms longer than that determined by echocardiography (p < 0.001). The relationship between SV values measured by impedance cardiography (SVA) vs those calculated by echocardiography (SVE) was found to be close to the line of identity in the range of measurements. The regression equation for SV was: SVA = 0.784.SVE + 15 (r = 0.69, p < 0.001, SEE = 10.7 ml). We conclude that automatic determination of SV and ET from ICG signals provides results comparable in absolute values with those obtained by the pulsed wave Doppler ultrasonocardiography using the apex approach for subjects remaining in the supine position.

Echocardiographic evaluation of pulmonary artery distensibility.

The aim of this study was to verify the hypothesis that pulmonary artery (PA) distensibility may modify the pattern of right ventricular ejection. Pulmonary artery distensibility was evaluated with M-mode measurements of right pulmonary artery diameter from suprasternal notch simultaneous with pulmonary pressure measurements. Pulmonary artery pressure was measured in 19 subjects, 29 to 75 years old (mean age, 49 years). Pulmonary artery systolic pressure was 22 to 108 mm Hg (mean, 52 mm Hg). Pulmonary artery pressure strain modulus (Ep) was calculated as follows: PADD x (PASP-PADP)/PADD-PADS (PADS-PA diameter in systole, PADD-PA diameter in diastole, PASP-PA systolic pressure, PADP-PA diastolic pressure) was 6 +/- 8 10(5) dynes/cm2. Right ventricular outflow tract velocity was recorded with pulsed Doppler echocardiography and acceleration times (AT) and ejection times (ET) were measured. Log Ep was correlated with pulmonary artery systolic and mean pressure (r = 0.90 and r = 0.87, p < 0.0001) but not with age (r = 0.30, p = NS). Acceleration time and AT/ET ratio were correlated with log Ep (r = 0.73 and r = 0.76, p < 0.001) and with pulmonary artery mean pressure (r = 0.91 and r = 0.89, p < 0.0001). When pulmonary artery pressure was included in multiple analyses, the relationships between Doppler indices and elastic modulus did not prove to be significant. These findings emphasize the independence of Doppler right ventricular outflow tract velocity indexes used for noninvasive evaluation of pulmonary hypertension from pulmonary artery distensibility in a clinical setting.

Comparison of transthoracic and transesophageal echocardiography in evaluation of 47 Starr-Edwards prosthetic valves.

OBJECTIVES: Our objectives were to characterize by transesophageal echocardiography the normal appearance of the Starr-Edwards prosthetic heart valve and to compare the utility of transesophageal and transthoracic echocardiography in detection of valve abnormality. BACKGROUND: The Starr-Edwards prosthetic heart valve, the first mechanical valve to be used, has demonstrated excellent durability. METHODS: Fifty transthoracic and transesophageal echocardiographic studies on 37 patients with 47 Starr-Edwards prosthetic valves were analyzed retrospectively. Six cases of surgically confirmed infective endocarditis were studied. RESULTS: Vegetation or abscess formation, or both, was identified by transesophageal echocardiography in all six cases of infective endocarditis but was found in only one of these cases by transthoracic echocardiography. Thrombus was detected by transesophageal echocardiography in 9 of 11 patients with transient ischemic attacks or stroke and in 2 patients by transthoracic echocardiography with 3 confirmed at surgery. In 26 of the 30 patients with a mitral Starr-Edwards valve, the valve demonstrated a trivial or mild "closing volume" early systolic or holosystolic leak on transesophageal echocardiography alone. Transthoracic evaluation identified significant mitral regurgitation in six of the eight patients who had this finding on transesophageal echocardiography. Serial studies were performed to assess response to treatment or need for surgical intervention in eight patients. Seventeen valves have been implanted for 12 years; six of these had significant leakage without apparent cause, a finding not observed more recently implanted valves. CONCLUSIONS: These observations demonstrated the unique utility of transesophageal echocardiography in patients with Starr-Edwards prosthetic valve dysfunction, endocarditis or thrombus formation, and of the clear superiority of transesophageal echocardiography over transthoracic echocardiography in these situations.

Evaluation of aortic distensibility with transesophageal echocardiography.

Distensibility of the descending aorta was evaluated during routine transesophageal echocardiography (TEE) in 50 subjects (16 to 80 years, average age 53). M-mode measurements of aortic systolic (SD) and diastolic diameter (DD) were taken distal to the left subclavian artery. Simultaneously, cuff brachial artery systolic (SBP) and diastolic (DBP) pressures were measured. Aortic pressure strain modulus (Ep), calculated as brachial artery pulse pressure/aortic strain, averaged 1.19 +/- 0.95 10(6) dynes/cm2. Elasticity index beta, defined as 1n (SBP/DBP)/aortic strain, averaged 3.77 +/- 2.12. Both Ep and beta were correlated with age (r = 0.65, p less than 0.001; and r = 0.70, p less than 0.0001). In 20 subjects aortic pulse wave velocity was assessed at the same time using simultaneous high fidelity recordings of carotid and femoral artery pressure waveforms. Aortic pulse wave velocity averaged 818 +/- 231 cm/sec and was correlated with Ep (r = 0.60, p less than 0.01) and with age (r = 0.55, p less than 0.05). Intraobserver and interobserver variability for aortic diameter measurement ranged from 0.2 to 0.5 mm.

[Primary arterial hypertension. Treatment with captopril and function of the left heart ventricle, concentration of catecholamine in blood and activity of renin]. / Pierwotne nadcsnienie tetnicze. leczenie kaptoprylem a czynnosc lewej komory serca, stezenie katecholamin we krwi i aktywnosc reniny.

We evaluated the effect of captopril treatment on left ventricular mass (LVM) and function in sustained mild-to-moderate primary hypertension. In 16 men aged 34.5 +/- 6.4 yrs. M-mode echo and pulsed wave Doppler recordings were obtained prior to and after 2 months captopril treatment (50-150 mg daily). No significant changes in heart rate, systolic blood pressure, ejection fraction, fractional shortening, cardiac output, LVM and Doppler-derived indices of mitral inflow were observed. Diastolic blood pressure measured during examination fell from 102.2 +/- 13.3 to 90.3 +/- 9 mmHg (p less than 0.026). No consistent correlations between catecholamines and indexes of left ventricular function were found. Two-month captopril therapy in mild-to-moderate hypertension results in diastolic blood pressure lowering with no effect on LVM or left ventricular function.

Factors influencing transmitral flow velocity in normal and hypertensive subjects.

Transmitral flow velocity and its determinants were examined with Doppler echocardiography in 53 hypertensive and 32 age-matched healthy normotensive men. Early and late maximal transmitral velocity, and early and late flow velocity integral were evaluated. In comparison with normal subjects, hypertensive patients were characterized by decreased maximal early velocity (66.3 +/- 12.3 versus 72.3 +/- 11.5 cm/sec, p less than 0.05), normalized early flow integral (67 +/- 7% versus 73 +/- 5%, p less than 0.001), increased maximal late flow velocity (45 +/- 10 cm/sec, p less than 0.001), and normalized late flow integral (29 +/- 7% versus 21 +/- 5%, p less than 0.001). Abnormally high late transmitral flow was found in 47% of the hypertensive group. Multiple regression analysis revealed that in normal subjects transmitral flow indexes were determined by age, relative wall thickness, and systolic blood pressure, but not by heart rate. A strong relationship of Doppler transmitral flow indexes with age was confirmed in hypertensive patients; however, relative wall thickness influenced transmitral flow velocity only weakly and systolic blood pressure did not affect transmitral flow. Left ventricular mass and diastolic blood pressure did not influence mitral filling velocity in either group. The altered pattern of mitral inflow found in a large number of hypertensive subjects is not related to elevated arterial blood pressure or to altered left ventricular geometry.

Pathophysiology of isolated systolic hypertension in elderly patients: Doppler echocardiographic insights.

Systemic hemodynamics were evaluated with aortic pulsed wave Doppler echocardiography in 79 elderly subjects with isolated systolic hypertension participating in the Systolic Hypertension in the Elderly Program (SHEP) and were compared with the values in 39 normal age-matched subjects. Cardiac output was elevated (4.50 +/- 1.13 L/min versus 3.94 +/- 1.12 L/min, p less than 0.05) in patients with isolated systolic hypertension in comparison with values in normal elderly subjects. Systemic vascular resistance did not differ between both groups (2140 +/- 536 dyn.sec/cm-5 versus 2011 +/- 553 dyn.sec/cm-5, p = NS). The mean acceleration of blood during left ventricular ejection was similar in patients with isolated systolic hypertension in comparison with normals (12.6 +/- 5.6 m/sec2 versus 11.5 +/- 3.5 m/sec2, p = NS). Patients with isolated systolic hypertension had significantly decreased arterial compliance, as measured by the stroke volume-to-pulse pressure ratio (0.77 +/- 0.26 cm3/mm Hg versus 1.11 +/- 0.30 cm3/mm Hg, p less than 0.0001). The prevalence of aortic and mitral regurgitation as well as valvular and annular calcification did not differ between analyzed groups. Isolated systolic hypertension in elderly patients appears to be multifactorial, with reduced arterial compliance and increased cardiac output both playing a role.

Initial clinical experience with a 48 by 48 element biplane transesophageal probe.

Recent technologic advances in ultrasound have resulted in the capability of transesophageal echocardiographic imaging in both transverse and longitudinal planes. Previous biplane probes suffered from inferior images because of reduced scan elements. We evaluated the utility of a prototype 48 X 48 element biplane transesophageal probe in 23 consecutive patients. Examinations were well tolerated with no side effects. In comparison to the single transverse plane, imaging with the longitudinal plane gave superior information on prosthetic valve pathology, atrial septal abnormalities, and pathoanatomy of the ascending aorta and mitral valve. Complementary information was provided by the longitudinal plane in patients with endocarditis and vegetations and in mitral protheses. Images obtained with this 48 X 48 element biplane probe along with color and spectral Doppler information were not perceptibly inferior to those obtained by single-plane probes. In conclusion, biplane transesophageal echocardiography with a 48 X 48 element probe indicates a great potential for enhanced three-dimensional understanding of cardiac pathology and diagnostic yield in specific pathologies.