Myocardial ischaemia and the inflammatory response: release of heat shock protein 70 after myocardial infarction.

OBJECTIVES: To test the hypothesis that heat shock protein (Hsp) 70 may be released into the circulation after acute myocardial infarction (AMI) by exploring the kinetics of Hsp70 release and the relations between Hsp70 and markers of inflammation and myocardial damage in AMI. DESIGN: Blood samples from 24 patients were prospectively collected through to the first day after AMI. Hsp70, interleukin (IL) 6, IL-8, and IL-10 in serum were measured by enzyme linked immunosorbent assay (ELISA). RESULTS: Median Hsp70 concentrations in AMI patients measured at arrival, six hours thereafter, and the following morning were 686, 868, and 607 pg/ml, respectively. These concentrations were all significantly different from those of the control patients with angina with a median serum Hsp70 concentration of 306 pg/ml. Peak Hsp70 correlated with creatine kinase (CK) MB (r = 0.62, p < 0.01) and cardiac troponin T (r = 0.58, p < 0.01). Furthermore, serum Hsp70 correlated with IL-6 and IL-8 at six hours (r = 0.60, p < 0.01 and r = 0.59, p < 0.01, respectively). CONCLUSIONS: In this study, Hsp70 was rapidly released into the circulation after AMI. Circulating Hsp70 is suggested as a marker of myocardial damage. In addition, Hsp70 may have a role in the inflammatory response after AMI.

Left ventricular mechanics during exercise: a Doppler and tissue Doppler study.

AIMS: To study left ventricular mechanics of exercise with Doppler and tissue Doppler. METHODS AND RESULTS: Twenty-one males (mean age, 26; height, 184 cm; weight, 84 kg), exercised on a bicycle, with increasing workload, with oxygen uptake, Doppler flow and tissue Doppler recordings during exercise. There was correlation between peak systolic LVOT flow and annulus velocity; R=0.72, (p<0.001) and between peak mitral E flow and annulus E(a) velocity; R=0.68(p<0.001). Finally there was correlation between peak LVOT and mitral flow velocity; R=0.83(p<0.001) and peak systolic and early diastolic annulus velocity R=0.69(p<0.001). All intervals of the heart cycle decreased with RR-interval. There was a linear relation between diastolic filling and RR-interval, while ejection period was less increased with RR-intervals above 600 ms, and thus not a linear relationship. There was no change in E/E(a) ratio during exercise. CONCLUSIONS: Mechanism for increased filling as well as ejection during exercise seems to be increased contraction and relaxation velocity, with no evidence of Frank-Starling mechanism. Bazett's formula gives a better heart rate correction of LVET at high heart rates than Weissler's.

High frame rate strain rate imaging of the interventricular septum in healthy subjects.

OBJECTIVE: In the present study the feasibility was assessed of a new strain rate imaging method with a very high frame rate of around 300 frames per second. METHODS: Digital radio-frequency (RF) data were obtained in nine healthy subjects using a sector of 20-30 degrees in an apical four chamber view. The RF data were analysed using a dedicated software package that displays strain rate images and profiles and calculates strain rate values. With the new method, it is possible to study events and spatial-temporal differences in the heart cycle with duration down to 3.5-3 ms, including the pre-ejection period and the isovolumic relaxation period. Since the interventricular septum (IVS) is of crucial importance for the left and right ventricular function, we assessed changes through the heart cycle of the strain rate in the IVS. RESULTS: Mean peak systolic strain rate in the healthy subjects was -1.65+/-0.13 s(-1). Mean peak diastolic strain rate during early filling was 3.14+/-0.50 s(-1) and during atrial systole 0.99+/-0.09 s(-1). We found individual differences in the strain rate patterns, but in all subjects, the ventricular contraction started simultaneously in all parts of the septum. After the ejection period, the elongation started before aortic valve closure, in the midinferior septum and propagated towards the apex. CONCLUSION: High frame rate strain rate imaging makes it possible to study rapid deformation patterns in the heart walls.

Strain rate imaging in normal and reduced diastolic function: comparison with pulsed Doppler tissue imaging of the mitral annulus.

OBJECTIVES: The pixel velocity values obtained by color Doppler tissue imaging (DTI) can be processed to velocity gradients as a measure of longitudinal strain rate with a technique termed strain rate imaging (SRI). Color mapping of strain rate does show the spatial-temporal relations of the diastolic phases. The phases of early filling and late filling during atrial systole can be seen to consist of a stretch wave in the myocardium, propagating from the base to the apex. Diastolic function is characterized by both peak strain rate and propagation velocity of this wave. The goals of this study were to establish normal values for these measurements and to study the changes with minimal diastolic dysfunction. METHODS: Twenty-eight healthy control subjects and 26 patients with hypertension and normal systolic function were studied. The patients had normal blood pressure on treatment, normal ejection fraction, minimal hypertrophy, and moderately prolonged deceleration and isovolumic relaxation times. Real-time SRI color cineloops, ordinary echocardiography and Doppler recordings, and pulsed wave DTI from the mitral ring were acquired and processed. RESULTS: Patients showed a reduction of systolic and early diastolic tissue velocities and strain rates and no significant increase in late diastolic tissue velocity and strain rate. Propagation velocity of diastolic strain during both early and late filling phases was reduced in the patients. The combination of changes in peak strain rate and propagation velocity of strain rate corresponded with changes in DTI. CONCLUSION: Diastolic deformation of the ventricle can be shown as a complex series of events, with temporal sequences in the ventricle. The peak strain rate and the propagation velocities of strain rate can describe the two main diastolic events: early and late filling. In reduced diastolic function, both are reduced during early filling. The velocities of the mitral ring are the result of this combination. This adds information about the physiology and pathophysiology of diastole.

[Myocardial injury in acute stroke assessed by troponin I]. / Myokardskade ved akutte hjerneslag bedømt med troponin I.

BACKGROUND: Acute ischaemic or haemorrhagic cerebrovascular events may produce myocardial damage. Cardiac troponin I is an indicator of cardiac cell injury with very high sensitivity and specificity. MATERIAL AND METHODS: We measured troponin I in 149 acute stroke patients admitted to the stroke unit of Trondheim University Hospital, Norway, in January to June 1999. RESULTS: 40 patients (27%) had troponin I values at 0.4 microgram/l or higher, indicating myocardial injury. 10 patients (6.7%) had troponin I values above 2.0 micrograms/l. Similarly, the mean value of CK-MB vas higher in the patients with myocardial injury, and these patients had more often ECG findings suggesting myocardial ischaemia. Patients with myocardial injury had a higher rate of previous TIA and heart failure. ECG showed atrial fibrillation in 13 of 39 patients with myocardial damage. Patients with detectable levels of troponin I had more embolic brain infarctions than thrombotic brain infarctions. Patients with myocardial injury did more often have abnormal values of CRP. 9 of 10 patients with troponin I-values above 2.0 micrograms/l had abnormal CRP values. No differences in glycosylated haemoglobin, cholesterol, heart rate, blood pressure or body temperature were found. Patients with the highest troponin I values had lower systolic blood pressure, and a higher heart rate, but these differences were not statistically significant. Patients with troponin I values above 2.0 micrograms/l had lower functional and neurological scores at admittance. Patients with myocardial injury were more often discharged to nursing homes. INTERPRETATION: Many patients with an acute stroke have at the same time a myocardial injury, determined by elevated troponin I values.

Life-threatening upper airway obstruction in a child caused by retropharyngeal emphysema.

A 2 1/2-year-old boy with acute obstructive lung disease from adenovirus infection developed cough-induced paroxysms of intense dyspnoea leading to respiratory failure. Chest x-ray and fluoroscopy demonstrated retropharyngeal air occluding the airway. The clinical management of this and similar air-leak problems is discussed.

Semiautomatic contour detection in ultrasound M-mode images.

We have developed a method for semiautomatic contour detection in M-mode images. The method combines tissue Doppler and grey-scale data. It was used to detect: 1. the left endocardium of the septum, the endocardium and epicardium of the posterior wall in 16 left ventricular short-axis M-modes, and 2. the mitral ring in 38 anatomical M-modes extracted pair-wise in 19 apical four-chamber cine-loops (healthy subjects). We validated the results by comparing the computer-generated contours with contours manually outlined by four echocardiographers. For all boundaries, the average distance between the computer-generated contours and the manual outlines was smaller than the average distance between the manual outlines. We also calculated left ventricular wall thickness and diameter at end-diastole and end-systole and lateral and septal mitral ring excursions, and found, on average, clinically negligible differences between the computer-generated indices and the same indices based on manual outlines (0.8-1.8 mm). The results were also within published normal values. In conclusion, this initial study showed that it was feasible in a robust and efficient manner to detect continuous wall boundaries in M-mode images so that tracings of left ventricular wall thickness, diameter and long axis could be derived.

Measurement of volumetric mitral and aortic blood flow based on a new freehand three-dimensional colour flow imaging method. An in vivo validation.

AIMS: To validate a new three-dimensional (3D) colour flow method used to calculate cardiac output (CO) in aortic and mitral blood flow. METHODS: The transducer was freely tilted transthoracically using a magnetic locating device recording its spatial position. Raw digital ultrasound data were recorded in healthy subjects during 10-20 heartbeats at a high frame rate ranging from 41 to 66 frames/s and analysed off-line with no loss in temporal resolution. Blood flow velocities aligned with the ultrasound beam were integrated across a moving spherical surface to calculate volumetric flow. RESULTS: The range of agreement between the 3D mitral and 3D aortic method was 0.04+/-1.32 l/min (mean+/-2 standard deviations). The range of agreement between 3D aortic flow and the two-dimensional (2D) pulsed wave Doppler method (2DPW) in the left ventricular outflow tract (LVOT) was 0.7+/-1.7 l/min, while the range of agreement between 3D mitral flow and the 2DPW method was 0.88+/-1.64 l/min. CONCLUSION: The 3D methods agreed well. The 3D volumetric flow overestimated the 2DPW method, as expected, and the range of agreement was wide. The common pitfalls in pulsed wave ultrasound methods to calculate CO were avoided, as the 3D method was angle-independent, no assumptions about the velocity profile were made, and a moving sample surface was applied. The acquisition of data was fast and easy and high temporal resolution was achieved.

Velocity profiles in mitral blood flow based on three-dimensional freehand colour flow imaging acquired at high frame rate.

AIMS: To describe the mitral blood flow velocity distribution, we applied a freehand dynamic three-dimensional (3D) colour flow method using a moving sample surface that followed the mitral apparatus during diastole. METHODS: Nineteen healthy volunteers were studied. The ultrasound data were captured from 10-20 heartbeats at high frame rate (mean 46 frames/s) while freely tilting the transducer in an apical position. A magnetic position sensor system recorded the spatial position and orientation of the probe. Blood flow velocities were integrated across a spherical surface. In volumetric blood flow measurements this would yield angle independence of the Doppler beam. Raw digital data were analysed off-line with no loss of temporal resolution. RESULTS: The ratio of the maximum velocity time integral (VTI) to the mean VTI was mean 1.3 (range 1.1-1.6). At the time of peak flow the ratio of the maximum to the mean velocity was mean 1.5 (range 1.2-2.6). CONCLUSION: The blood flow velocity profile was non-uniform. By using a single sample volume in Doppler measurements of the maximum VTI errors ranging from 10 to 60% may be introduced in calculations of stroke volumes.

Stroke unit treatment. 10-year follow-up.

BACKGROUND AND PURPOSE: We have previously shown that treatment in our combined acute and rehabilitation stroke unit (SU) improves the outcome during the first 5 years after onset of stroke compared with that for stroke patients treated in general wards (GW). The aim of the present trial was to examine the effects of SU care after 10 years of follow-up. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the SU and 110 to GW. No significant differences existed in baseline characteristics between the groups. The outcome after 10 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state as assessed by the Barthel Index, in which a Barthel Index score of >/=60 was classified as independent or partly independent and a score of >/=95 was classified as independent. RESULTS: After 10 years, 21 (19.1%) of the patients randomized to the SU and 9 (8.2%) of the patients randomized to the GW were at home (P=0.0184). Eighty-three (75.5%) of the patients from the SU and 96 (87.3%) of the patients from the GW were dead (P=0.0082), and 6 (5.4%) and 5 (4.5%), respectively, were in an institution (eg, nursing home; NS). Twenty-two (20.0%) of the SU patients and 9 (8. 2%) of the GW patients had a Barthel Index score of >/=60 (P=0.0118), and 14 (12.7%) and 6 (5.4%), respectively, had a score of >/=95 (P=0.0606). CONCLUSIONS: For the first time it has been shown that SU care improves survival and functional state and increases the proportion of patients able to live at home 10 years after their stroke. Treatment in combined acute and rehabilitation SU seems to have important long-term effects on outcome for stroke patients.

[Acute stroke--who dies in a stroke unit?]. / Akutt hjerneslag--hvem dør i en slagenhet?

Stroke unit care increases the proportions of patients able to live at home, improves functional outcome, reduces the need for institutional care, and reduces mortality. We have evaluated the data on the 69 patients who died in our stroke unit with an acute stroke, among the first 1,000 patients treated. The patients who died were older and had lower functional scores (median Barthel Index score 0 versus 70) and neurological scores (median Scandinavian Stroke Scale score 6 versus 48) at admittance. Early progression of the stroke was also more frequent in the group of patients who died. No differences in blood pressure, heart rate and body temperature were found between the groups, aside from increased diastolic pressure and heart rate in patients who died with an embolic infarction and increased systolic pressure in patients who died with an intracerebral haemorrhage.

Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important?

BACKGROUND AND PURPOSE: We have previously shown that treatment of acute stroke patients in our stroke unit (SU) compared with treatment in general ward (GWs) improves short- and long-term survival and functional outcome and increases the possibility of earlier discharge to home. The aim of the present study was to identify the differences in treatment between the SU and the GW and to assess which aspects of the SU care which were most responsible for the better outcome. METHODS: Of the 220 patients included in our trial, only 206 were actually treated (SU, 102 patients; GW, 104 patients). For these patients, we identified the differences in the treatment and the consequences of the treatment. We analyzed the factors that we were able to measure and their association with the outcome, discharge to home within 6 weeks. RESULTS: Characteristic features in our SU were teamwork, staff education, functional training, and integrated physiotherapy and nursing. Other treatment factors significantly different in the SU from the GW were shorter time to start of the systematic mobilization/training and increased use of oxygen, heparin, intravenous saline solutions, and antipyretics. Consequences of the treatment seem to be less variation in diastolic and systolic blood pressure (BP), avoiding the lowest diastolic BP, and lowering the levels of glucose and temperature in the SU group compared with the GW group. Univariate analyses showed that all these factors except the level of glucose were significantly associated with discharge to home within 6 weeks. In the final multivariate Cox regression model, shorter time to start of the mobilization/training and stabilized diastolic BP were independent factors significantly associated with discharge to home within 6 weeks. CONCLUSIONS: Shorter time to start of mobilization/training was the most important factor associated with discharge to home, followed by stabilized diastolic BP, indicating that these factors probably were important in the SU treatment. The effects of characteristic features of an SU, such as a specially trained staff, teamwork, and involvement of relatives, were not possible to measure. Such factors might be more important than those actually measured.

Stroke unit treatment improves long-term quality of life: a randomized controlled trial.

BACKGROUND AND PURPOSE: We have previously shown that treatment of acute stroke patients in the combined acute and rehabilitation stroke unit in our hospital improves survival and functional outcome compared with treatment in general wards. The primary aim of the present trial was to examine whether the treatment in our stroke unit had an effect on different aspects of quality of life (QoL) for stroke patients 5 years after the onset of stroke. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the stroke unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The patients alive after 5 years were assessed by the Nottingham Health Profile (NHP) and the Frenchay Activities Index (FAI), which were the scales used as primary outcome measures for QoL. As secondary outcome measures we used a global score for the NHP and a simple visual analogue scale (VAS). RESULTS: After 5 years, 45 of the patients treated in the stroke unit and 32 of those treated in general wards were alive. All surviving patients were assessed by the FAI. Thirty-seven (82.2%) of the stroke unit patients and 25 (78.1%) of the general wards patients were assessed by the NHP; 38 (84.4%) and 28 (87.5%), respectively, were assessed by the VAS. Patients treated in the stroke unit had a higher score on the FAI (P=0.0142). Assessment with the NHP showed better results in the stroke unit group for the dimensions of energy (P=0.0323), physical mobility (P=0.0415), emotional reactions (P=0.0290), social isolation (P=0.0089), and sleep (P=0.0436), although there was no difference in pain (P=0.3186). The global NHP score and VAS score also showed significantly better results in the stroke unit group (NHP, P<0.01; VAS, P<0.001). Patients who were independent in activities of daily living had significantly better QoL assessed by these scales than patients who were dependent. CONCLUSIONS: Our study shows for the first time that stroke unit care improves different aspects of long-term QoL for stroke patients.

Stroke unit treatment. Long-term effects.

BACKGROUND AND PURPOSE: We have previously shown that treatment in our combined acute and rehabilitation Stroke Unit improves outcome during the first year after onset of stroke compared with stroke patients treated in general wards. The aim of the present trial was to examine the long-term effects of the stroke unit care. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the Stroke Unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The outcome after 5 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state assessed by Barthel Index. RESULTS: After 5 years, 38 (34.5%) of the patients randomized to the Stroke Unit and 20 (18.2%) of the patients randomized to the general wards were at home (P = .006). Sixty-five (59.1%) of the patients from the Stroke Unit and 78 (70.9%) of the patients from the general wards were dead (P = .041), while 7 (6.4%) and 12 (10.9%), respectively, were in an institution (e.g., nursing home) (P = NS). Functional state was significantly better for patients treated in the Stroke Unit. CONCLUSIONS: For the first time it is shown that stroke unit care improves long-term survival and functional state and increases the proportion of patients able to live at home 5 years after the stroke. Combined acute and rehabilitation stroke units appear to be an effective way of organizing treatment for acute stroke patients.

Hemodynamics in white coat hypertension compared to ambulatory hypertension and normotension.

Hemodynamic alterations associated with the blood pressure response in subjects with white coat hypertension may provide insight into the pathophysiologic mechanisms of this condition. Systemic arterial hemodynamics were investigated with a recently validated method based on noninvasive estimates of aortic root pressure and flow in 28 subjects with white coat hypertension (diastolic pressure > or = 90 mm Hg measured by the general practitioner [GP arterial pressure] and ambulatory daytime pressures < 140/90 mm Hg), in 23 subjects with previously untreated, ambulatory hypertension (GP diastolic pressure > or = 90 and < 115 mm Hg and ambulatory daytime diastolic pressure > or = 90 mm Hg), and in 32 normotensive subjects. The groups did not differ significantly concerning age, gender, body surface area, heart rate, stroke index and cardiac index, but total peripheral resistance index was increased and total arterial compliance reduced in the white coat group and the hypertensive group compared to the normotensive group. The subjects in the white coat group with a systolic arterial pressure during echocardiography that was > 5 mm Hg higher than the ambulatory daytime systolic pressure (n = 19) had increased cardiac index, increased total peripheral resistance, and decreased total arterial compliance compared to the normotensive group. The subjects in this group with a hemodynamic pattern characterized by a high ratio of cardiac index/peripheral vascular resistance were significantly younger than the subjects with the opposite pattern. Thus, the blood pressure increase in subjects with white coat hypertension is associated with increased cardiac output, increased peripheral vascular resistance, and reduced total arterial compliance, but the hemodynamic pattern may be influenced by age.

[Acute stroke. Patients treated in a stroke unit in Trondheim]. / Akutt hjerneslag. Pasienter behandlet ved slagenheten i Trondheim.

Treatment in a stroke unit raises the proportion of stroke patients who are able to live at home, improves functional outcome, reduces the need for institutional care, and brings down mortality. We have evaluated the data on the first 800 patients treated in our stroke unit. Nine patients were incorrectly registered as acute stroke victims and were excluded from the analysis. Hence, 791 patients (429 men, 362 women; mean age 72.3 years range 35-101 years) fulfilled the criteria for acute stroke or TIA. In the group of 654 patients who had suffered an acute stroke, 85 patients (13%) had intracerebral haemorrhage, 439 (67.1%) nonembolic infarction, and 130 (19.9%) embolic infarction. The majority of the patients were discharged to home (55.4%), while 23.6% were discharged to a rehabilitation institution, and 6.1% were discharged to nursing homes. 48 (6.1%) of the patients died during the stay in hospital. The mean time spent in the stroke unit was 12.1 days.

[Hemopericardium with cardiac tamponade. Case reports from a coronary care unit]. / Hemoperikard med hjertetamponade. Kasuistikker fra en hjerteovervåkingsavdeling.

We describe three patients with cardiac tamponade who had been admitted to a coronary care unit, two because of rupture of the free wall during acute myocardial infarction and one because of proximal aortic dissection. Pericardiocentesis was performed in the coronary care unit after the diagnosis had been made by echocardiography. One of the patients with acute infarction and the one with proximal aortic dissection, who also underwent surgery, survived. We discuss various aspects of acute cardiac tamponade with hemopericardium.

Regurgitant volume in aortic regurgitation from a parameter estimation procedure.

The regurgitant volume and regurgitant orifice area as well as total peripheral resistance and arterial compliance were estimated in a cardiovascular hydromechanical simulator and in 10 patients with aortic regurgitation. A parameter estimation procedure based on a simple model of the cardiovascular system, Doppler measurements of the regurgitant jet, aortic systolic flow, and systolic and diastolic blood pressures was used. In the cardiovascular simulator the estimated regurgitant orifice area was compared with the size of a hole in the disk of a mechanical aortic valve. In the patients the regurgitant fraction was compared with semiquantitative grading from echocardiography routinely performed in our laboratory. In the hydromechanical simulator, the estimated regurgitant orifice area of 26.5 +/- 3.5 (SD) mm2 (n = 9) was not different from the true value of 24 mm2. In the patients there was a fair relationship between the estimated regurgitant fraction and the semiquantitative grading. The estimated regurgitant orifice areas varied between 1.6 and 31.2 mm2. The estimated mean values of total peripheral resistance and arterial compliance were 1.67 +/- 0.55 mmHg.s.ml-1 and 1.30 +/- 0.42 ml/mmHg, respectively.

Leukemic blasts with markers of four cell lineages in Down's syndrome ("megakaryoblastic leukemia").

Among 16 patients with Down's syndrome (DS) and acute leukemia admitted to our department during a ten year period, 6 were diagnosed as acute megakaryoblastic leukemia (AMkL). The diagnosis was based on clinical and hematologic criteria, confirmed in three patients with the use of monoclonal antibodies (MoAb) specific for megakaryocytic antigens. In these three, and in a fourth patient, the leukemic blasts were positive for other myeloid, lymphoid and erythroid markers in MoAb testing. We suggest that AMkL in DS is a mixed lineage leukemia with blasts presenting a variety of cell surface antigens, indicating origin from an early progenitor cell with the capability of megakaryocytic differentiation. Of the 6 patients with AMkL, 4 treated with standard AML protocols are in complete continuing remission (CCR) with observation periods from 57+ to 148+ months.

[Dystrophy caused by upper airway obstruction]. / Dystrofi forårsaket av øvre luftveisobstruksjon.

We describe three infants whose main symptoms were poor weight gain, delayed motor development and recurrent respiratory infections. Obstructive sleep apnea was diagnosed, and all three improved after adenotomy or adenotonsillectomy. Obstructive sleep apnea is an important differential diagnosis in infants showing retarded development and failure to thrive.