Regional myocardial systolic function during acute myocardial ischemia assessed by strain Doppler echocardiography

OBJECTIVES

We sought to evaluate if echocardiographic strain measurements could detect acute myocardial ischemia, and to compare this new method with myocardial velocity measurements and wall motion score index.

BACKGROUND

Tissue Doppler echocardiography (TDE) is a promising method for assessing regional myocardial function. However, myocardial velocities measured by tissue Doppler echocardiography (TDE) vary throughout the left ventricle (LV) because of tethering effects from adjacent tissue. Strain Doppler echocardiography (SDE) is a new tool for measuring regional myocardial deformation excluding the effect of adjacent myocardial tissue.

METHODS

Seventeen patients undergoing angioplasty of the left anterior descending coronary artery (LAD) were studied. Left ventricular longitudinal wall motion was assessed by TDE and SDE from the apical four-chamber view before, during and after angioplasty from multiple myocardial segments simultaneously.

RESULTS

Systolic strain values were uniformly distributed in the different nonischemic LV segments, whereas systolic velocities decreased from basis to apex. During LAD occlusion, strain measurement showed expansion in the apical septal segment in 16 of 17 patients (7.5 +/- 6.5% vs. -17.7 +/- 7.2%, p < 0.001) and reduced compression in the mid-septal segment (p < 0.05) compared with baseline. Segments not supplied by LAD remained unchanged. Tissue Doppler echocardiography showed reduced velocities in all septal segments (p < 0.05) during angioplasty even though LAD does not supply the basal septal segment. Negative systolic velocities were present in 11 of 17 patients. Wall motion score index increased during ischemia (1.3 +/- 0.4, p < 0.05).

CONCLUSIONS

The new SDE approach might be a more accurate marker than TDE for detecting systolic regional myocardial dysfunction induced by LAD occlusion.

[Time delay in the thrombolytic treatment of myocardial infarction]

INTRODUCTION

Thrombolytic treatment is central in the treatment of patients with myocardial infarction.

MATERIAL AND METHODS

A cross-sectional study was conducted to determine the time delay incurred in thrombolytic treatment of patients with myocardial infarction in Ostfold Hospital, Fredrikstad, Norway. Over a seven-month period, 317 patients were diagnosed as having myocardial infarction. 80 patients (25%) received thrombolytic therapy, 68 of whom (85%) were eligible for the study. 12 patients were excluded either because of not meeting the inclusion criteria or because of incomplete data.

RESULTS

The following median times were recorded: from onset of chest pain till first contact with the health care services, 59 minutes; from first contact till arrival at hospital, 32 minutes; from hospital arrival till initiation of treatment, 40 minutes; from onset of chest pain till initiation of treatment, 147 minutes. 38% of the patients received thrombolysis within 120 minutes of pain onset, and 35% received treatment within 30 minutes of arrival in hospital. There was no difference in time delay before contacting health care services among patients with or without a previous history of coronary heart disease, except for those who took nitroglycerine at onset of symptoms. They had the longest time delay.

INTERPRETATION

In order to reduce time delay, doctors should give better instructions to patients with a previous history of coronary heart disease and conduct regular training programmes for hospital interns and nurses. It is further assumed that prehospital ECG and direct admission to the coronary care unit, or initiation of thrombolysis in the emergency department or in the ambulance, would result in a considerable reduction in time delay.

[Reflux disease and 24-hour esophageal pH monitoring in children]

Gastrooesophageal reflux disease has a variety of symptoms in children. 24-hour pH monitoring in the lower oesophagus is the gold standard for documenting gastrooesophageal reflux. We present our experience with 24-hour pH monitoring in children. 150 pH recordings in 120 children were performed. Clinical background and results from pH monitoring were recorded, in addition to supplementary examinations and treatment. No complications were recorded, but ten recordings (8.3%) were unsuccessful. Mean age was 3.5 years (median 13 months; range one month to 15 years). 44% had a pathological reflux index. Indications for pH monitoring were dominated by regurgitation/vomiting (63%), failure to thrive (45%) and respiratory symptoms (32%). Of the supplementary examinations performed, upper gastrointestinal contrast series provided no additional information (34 children), while endoscopy (20 children) showed oesophagitis in 11. Medical treatment was prescribed in 66% of the cases based on the pH monitoring results and clinical evaluation. Five patients were given anti-reflux surgery, and ten received gastrostomy. Our experience with this recording technique is good. pH monitoring should be available in paediatric departments, as a large number of the recordings had clinical consequences for the patient.

[Fatal coronary heart disease in a young woman 20 years after radiotherapy for Hodgkin disease]

We present a case in which a 37-year-old female died of acute myocardial infarction. The patient was 20 years earlier successfully treated with radiation therapy against the mediastinum for Hodgkin's disease. Nearly half of the patients with Hodgkin's disease are younger than 40 years at the time of diagnosis. Most of them are successfully treated with radiation therapy. Radiation against mediastinum including parts of the heart can induce fibrotic changes in the coronary arteries. We conclude that the radiation therapy was the main etiologic factor behind the patient's coronary artery disease. It is important to use techniques with the lowest possible risk for damaging the coronary arteries under chest radiation therapy. It is also important to perform early checks for coronary artery disease in this category of patients when they present with chest pain.

[Gastrointestinal amyloidosis. Differential diagnosis or a complication of inflammatory bowel disease?]

A 77 year-old man developed intermittent diarrhoea and malabsorption. Endoscopic findings and preliminary histological examination indicated ulcerative colitis. Special staining of biopsies from the duodenum and colon revealed amyloid deposits. Classification of the amyloid fibril protein verified AL-amyloidosis, and the diagnosis primary idiopathic amyloidosis was made. Amyloid deposit in the gastrointestinal tract are a common feature of primary and secondary amyloidosis. The symptoms and findings are nonspecific and resemble those of chronic inflammatory bowel disease and ischemic colitis. Secondary amyloidosis can be seen as a rare complication of Crohn's disease and ulcerative colitis. Special staining is necessary to show amyloid deposit, and the distinction between primary and secondary amyloidosis requires immunohistochemistry.