Prognostic implications of restrictive left ventricular filling in acute myocardial infarction: a serial Doppler echocardiographic study

A Noninvasive Method for Assessing Impaired Diastolic Suction in Patients With Dilated Cardiomyopathy

BACKGROUND

Diastolic suction is a major determinant of early left ventricular filling in animal experiments. However, suction remains incompletely characterized in the clinical setting.

METHODS AND RESULTS

First, we validated a method for measuring the spatio-temporal distributions of diastolic intraventricular pressure gradients and differences (DIVPDs) by digital processing color Doppler M-mode recordings. In 4 pigs, the error of peak DIVPD was 0.0+/-0.2 mm Hg (intraclass correlation coefficient, 0.95) compared with micromanometry. Forty patients with dilated cardiomyopathy (DCM) and 20 healthy volunteers were studied at baseline and during dobutamine infusion. A positive DIVPD (toward the apex) originated during isovolumic relaxation, reaching its peak shortly after mitral valve opening. Peak DIVPD was less than half in patients with DCM than in control subjects (1.2+/-0.6 versus 2.5+/-0.8 mm Hg, P<0.001). Dobutamine increased DIVPD in control subjects by 44% (P<0.001) but only by 23% in patients with DCM (P=NS). DIVPDs were the consequence of 2 opposite forces: a driving force caused by local acceleration, and a reversed (opposed to filling) convective force that lowered the total DIVPD by more than one third. In turn, local acceleration correlated with E-wave velocity and ejection fraction, whereas convective deceleration correlated with E-wave velocity and ventriculo:annular disproportion. Convective deceleration was highest among patients showing a restrictive filling pattern.

CONCLUSIONS

Patients with DCM show an abnormally low diastolic suction and a blunted capacity to recruit suction with stress. By raising the ventriculo:annular disproportion, chamber remodeling proportionally increases convective deceleration and adversely affects left ventricular filling. These previously unreported mechanisms of diastolic dysfunction can be studied by using Doppler echocardiography.

Tissue Doppler echocardiographic evidence of atrial mechanical dysfunction in coronary artery disease

BACKGROUND

Atrial function is an integral part of cardiac function which is often neglected. The presence of coronary artery disease (CAD) may impair atrial function. This study investigated if atrial mechanical dysfunction was present in patients with CAD by tissue Doppler echocardiography (TDI).

METHODS

Echocardiography with TDI was performed in 118 patients with CAD, and compared with 100 normal controls with comparable age and heart rate. Regional atrial function was assessed at the left (LA) and right (RA) atrial free wall and inter-atrial septum (IAS). The peak regional atrial contraction velocity of (V(A)) and the timing of mechanical events were compared.

RESULTS

The V(A) in the LA (5.0+/-2.6 Vs 7.7+/-2.6 cm/s), IAS (4.8+/-1.7 Vs 5.7+/-1.5 cm/s) and RA (6.8+/-3.1 Vs 9.2+/-2.9 cm/s) were significantly decreased in patients with CAD when compared with controls (all p<0.001). Patients with impaired systolic function (ejection fraction<or=50%) had significantly lower V(A) in the LA and IAS than those with ejection fraction>50% (both p<0.001); and were lower in those with restrictive filling pattern (RFP) than non-RFP of diastolic dysfunction (both p<0.05). The V(A) in all the subgroups was lower than controls. In contrast, transmitral atrial velocity was unable to reveal any abnormality except in the subgroup with a RFP. The LA dimension, area and volume were increased in the disease groups, but were largely unchanged in the RA despite abnormal V(A). The physiological inter-atrial delay for the onset and peak atrial contraction between the RA and LA were unaffected by CAD.

CONCLUSIONS

The atrial contractile function in both atria was impaired in the presence of CAD, especially in the LA. This was detected even in patients with preserved systolic function or mild diastolic dysfunction such as non-RFP. Direct assessment of atrial velocity by TDI may better reflect atrial mechanical function than transmitral atrial velocity.

Diastolic wall motion abnormality after myocardial infarction: relation to neurohormonal activation and prognostic implications

BACKGROUND

Systolic wall motion abnormality (WMA) after acute myocardial infarction (AMI) is a major determinant of outcome; the presence and importance of diastolic WMA after AMI are unknown. We therefore sought to detect diastolic WMA using color kinesis and to assess its relation to neurohormonal activation and its prognostic importance in a consecutive population with a first AMI.

METHODS

Complete color-encoded color kinesis and 2-dimensional and Doppler echocardiography were performed in 149 consecutive patients with documented first AMI within 24 hours of their admission. N-terminal pro-brain natriuretic peptide was measured 3 days after AMI. Study end point was cardiac death or readmission for heart failure.

RESULTS

Diastolic area of WMA exceeded the systolic area in all but 5 patients (97%) and was significantly correlated with brain natriuretic peptide (unadjusted beta = .67, P < .0001; adjusted for systolic function, age, Killip class, and overall diastolic function beta = .27, P = .007). Diastolic WMA was also correlated with the number of diseased vessels on coronary angiography (beta = .59, P < .0001). During follow-up, 25 patients died and 11 were readmitted because of recurrent heart failure. On univariate analysis, the area of diastolic WMA was a predictor of the composite end point (hazard ratio 1.07 [95% CI 1.05-1.09], P < .0001) and remained a predictor on multivariate Cox analysis after adjustment of well-known risk factors, left ventricular systolic and overall diastolic functions (hazard ratio 1.09 [95% CI 1.06-1.15], P < .001).

CONCLUSION

The extent of diastolic WMA can be assessed early after AMI using color kinesis. Diastolic WMA is associated with neurohormonal activation and angiographic severity of coronary artery disease and provides independent prognostic information.

Left ventricular hypertrophy and preclinical impaired glucose tolerance and diabetes mellitus contribute to abnormal left ventricular diastolic function in hypertensive patients

BACKGROUND

Impaired left ventricular diastolic function is not uncommon in patients with either diabetes mellitus or hypertension. This study was carried out to assess the contribution of left ventricular hypertrophy, high blood pressure, preclinical impaired glucose tolerance and diabetes mellitus to left ventricular diastolic function in patients attending a hypertension clinic.

METHODS

Echocardiography, 24-h ambulatory blood pressure monitoring and oral glucose tolerance tests were carried out in 152 consecutive hypertensive patients who had no evidence of ischaemic heart disease and were not known to be diabetic. From echocardiography, E/A (peak velocity of early/atrial filling waves of the transmitral flow) at rest and at peak standardized isometric exercise using handgrip, left ventricular mass index and deceleration time of the E wave were derived.

RESULTS

Patients with impaired glucose tolerance and diabetes mellitus had lower E/A than the euglycaemic subjects both at rest (P=0.0073) and during isometric exercise (P<0.0001). E/A significantly reduced during isometric exercise in patients with impaired glucose tolerance and diabetes but not in euglycaemic patients. Deceleration time was shortened with a worsening degree of glucose intolerance in all the patients (P=0.0005), in those with left ventricular hypertrophy (P=0.0006) and in those without left ventricular hypertrophy (P=0.033). When adjusted for age, gender, race, body mass index, smoking history, ambulatory blood pressure findings, cholesterol and triglyceride levels and antihypertensive medications taken, E/A at isometric exercise was related to results of glucose tolerance tests and was inversely proportional to left ventricular mass index (P<0.0001). No significant differences were found whether patients were taking antihypertensive medications or not.

CONCLUSION

In hypertensive patients, left ventricular diastolic function is determined by left ventricular mass index and the status of preclinical glucose intolerance, independent of age, gender, race, body mass index, blood pressure level, nocturnal drop in blood pressure or lipid level. These findings were not prejudiced by antihypertensive medications.

Usefulness of four echocardiographic risk assessments in predicting 30-day outcome in acute myocardial infarction

One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p <0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's class > or =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).

Left ventricular diastolic function in normotensive subjects 2 months after acute myocardial infarction is related to glucose intolerance

BACKGROUND

Both glucose intolerance and myocardial infarction are independently associated with impaired left ventricular (LV) function. This study was carried out to relate LV diastolic function in normotensive subjects 2 months after acute myocardial infarction (AMI) to glucose tolerance status.

METHODS

Left ventricular ejection fraction (LVEF), LV mass index, peak velocity of the early phase/atrial contraction wave, deceleration time of E wave, and isovolumic relaxation time were measured during echocardiograph/Doppler cardiography in 200 normotensive patients 2 months after AMI. Twenty-nine patients were known to be diabetic on admission with AMI. Glucose tolerance test was carried out in the 171 patients who are not known to be diabetic.

RESULTS

Independent of LVEF, restrictive LV filling (peak velocity of the early phase/atrial contraction wave > 1 but < 2 associated with deceleration time of E wave < or = 140 milliseconds) was found in 72% of the known-diabetic patients, 70% of the 20 preclinical diabetic patients, 23% of the 35 patients with impaired glucose tolerance, 13% of the 15 patients with stress hyperglycemia, and 7% of the euglycemic patients (P < .01). In the rest of these patients, LV filling was nonrestrictive. No significant difference was observed in LVEF and LV mass index between patient groups.

CONCLUSION

Independent of LVEF, the pattern of abnormal LV filling in normotensive subjects 2 months after AMI is a function of the severity of glucose intolerance, restrictive in the majority of the diabetic patients and nonrestrictive in the majority of the euglycemic patients, impaired glucose tolerance, and stress hyperglycemia. After AMI, abnormal LV filling occurs even in the absence of detectable systolic dysfunction or left ventricular hypertrophy.

Prediction of Prognosis in the UM-X7.1 Hamster Model of Congestive Heart Failure Using the Tei Index

BACKGROUND

Cardiac function is difficult to evaluate in small animal models of heart disease. The Doppler Tei index is a simple and non-invasive measure that can express global cardiac function even in small animal models of congestive heart failure. However, its ability to predict prognosis has not been evaluated.

METHODS AND RESULTS

We tested the hypothesis that cardiac functional indices, such as the Tei index, can predict the prognosis of hamsters with cardiac dysfunction. The Tei index, defined as the sum of the isovolume contraction and relaxation time divided by ejection time, and the percent fractional shortening of the left ventricle was measured in 48 anesthetized male hamsters (19.7+/-0.4 weeks old) with cardiac dysfunction (UM-X7.1), using Doppler and 2-dimensional echocardiography. The hamsters were separated into 2 groups based on the median Tei index (0.50) and % fractional shortening (FS) (21%). Kaplan-Meier analysis determined the survival rates of the groups. Both the Tei index and %FS enabled significant distinction of better and poorer survival (p < 0.01), and the survival curves were less overlapped when the animals were separated according to the Tei index.

CONCLUSION

The Tei index can predict prognosis in a small animal model of heart failure.

Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index

BACKGROUND

Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI.

METHODS

In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a - b)/ b , where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission.

RESULTS

Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 +/- 0.16 vs 0.50 +/- 0.11, P < .0001). When Tei index > or = 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively.

CONCLUSION

In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.

Predictors of Cardiovascular Death in Patients with a Left Ventricular Restrictive Filling Pattern of the Mitral Inflow

The survival, clinical and echocardiographic variables and the predictors of cardiovascular death were determined for a group of 168 patients (mean age 63+/-13 years; 65 females; mean left ventricular ejection fraction 32+/-10%) with restrictive filling of the left ventricle and depressed systolic function after a mean follow-up period of 2.7+/-1 years. Shorter deceleration time (DT) of the mitral inflow was the only variable significantly different between survivors and nonsurvivors (p<0.05) and the only predictor of death found by multivariate logistic regression analysis (odds ratio 2.2, 95% confidence interval 1.7-3.6). In this patient population, a DT of the early wave of the mitral inflow <140 ms identified the patients with the highest risk of cardiac death. DT is a practical echocardiographic parameter for risk stratification of patients with significant left ventricular systolic dysfunction and restrictive filling of the left ventricle.

Echocardiographic predictors of prognosis after first acute myocardial infarction

We prospectively studied 490 patients who had a first myocardial infarction and performed a complete 2-dimensional echocardiographic study <or=48 hours of admission. In addition to left ventricular ejection fraction, multiple echocardiographic parameters of left ventricular systolic and diastolic performances were found to be independent predictors of 2-year mortality rate and congestive heart failure.

Long-term prognostic significance of left atrial volume in acute myocardial infarction

OBJECTIVES

The aim of this study was to evaluate the significance of increased left atrial (LA) volume determined within the first 48 h of admission as a long-term predictor of outcome in patients with acute myocardial infarction (MI).

BACKGROUND

The LA volume reflects left ventricular (LV) diastolic properties. Whereas other LV Doppler diastolic characteristics are influenced by acute changes in LV function, LA volume is stable and reflects diastolic properties before MI.

METHODS

Clinical and echocardiographic parameters were prospectively collected in 395 consecutive patients with acute MI. Patients with LA volume index (LAVI) >32 ml/m(2) (normal + 2 standard deviations) were compared with those with LAVI <==32 ml/m(2). Independent clinical and echocardiographic prognostic risk factors for five years' mortality were determined by the Cox proportional hazard model.

RESULTS

Left atrial volume index >32 ml/m(2) was found in 63 patients (19%) who had a higher incidence of congestive heart failure on admission (24% vs. 12%, p < 0.01), a higher incidence of mitral regurgitation, increased LV dimensions, and reduced LV ejection fraction when compared with patients with LAVI <==32 ml/m(2). Their five-year mortality rate was 34.5% versus 14.2% (p < 0.001). Significant independent risk predictors of five years' mortality were age (10 years) (odds ratio [OR] 1.45; 95% confidence interval [CI]1.14 to 1.86), Killip class >/=2 on admission (OR 2.30; 95% CI 1.29 to 4.09), LAVI >32 ml/m(2) (OR 2.22; 95% CI 1.25 to 3.96), diabetes (OR 1.94; 95% CI 1.15 to 3.28), and LV restrictive filling pattern (OR 1.89; 95% CI 1.09 to 3.31).

CONCLUSIONS

In patients with acute MI, increased LA volume, determined within the first 48 h of admission, is an independent predictor of five-year mortality with incremental prognostic information to clinical and echocardiographic data.

Is left ventricular diastolic function an independent marker of prognosis after acute myocardial infarction?

BACKGROUND

In addition to clinical risk markers, indices of left ventricular (LV) systolic function are valuable prognostic markers after acute myocardial infarction (MI). Previous studies have also suggested that LV diastolic function may contribute with prognostic information. The present study assessed whether this assumption applies to a large population of patients with acute MI who underwent thrombolytic therapy.

METHODS AND RESULTS

520 out of 608 patients participating in the ATTenuation by Adenosine of Cardiac Complications (ATTACC) study, with an ST-elevation acute MI underwent two-dimensional and Doppler echocardiographic examination at 4 (range 2-10) days after admission. During the follow-up period of 31 (S.D. +/- 11) months, cardiovascular death occurred in 57 (11%) patients, nonfatal acute MI occurred in 77 (15%), and 124 (24%) patients suffered a combined cardiovascular end-point (either nonfatal acute MI or cardiovascular death). Univariate regression analysis showed that all indices of LV systolic function predicted cardiovascular death and combined cardiovascular end-points. Regarding LV diastolic function only a restrictive filling pattern predicted cardiovascular death. In a multistep multivariate regression analysis in which the variables were introduced in a hierarchic order age, history of systemic hypertension, wall motion score index (WMSi), and history of previous MI and diabetes mellitus were independent predictors of cardiovascular death. A history of systemic hypertension or congestive heart failure were independent predictors of nonfatal acute MI, while a history of systemic hypertension, wall motion score index and diabetes mellitus independently predicted combined cardiovascular end-points.

CONCLUSIONS

The results of this study confirmed that clinical risk indicators and LV systolic function were the most important independent predictors of cardiovascular death and combined cardiovascular end-points. LV diastolic function assessed by Doppler-echocardiography did not provide additional prognostic information.

Hyperbaric oxygen treatment does not affect left ventricular chamber stiffness after myocardial infarction treated with thrombolysis

BACKGROUND

It has been shown that transient increase in left ventricular stiffness, assessed by Doppler-derived early filling deceleration time, occurs during the first 24 to 48 hours after myocardial infarction but returns to normal within several days. It has been reported that hyperbaric oxygen treatment has a favorable effect on left ventricular systolic function in patients with acute myocardial infarction treated with thrombolysis. However, there are no data on the effects of hyperbaric oxygen on diastolic function after myocardial infarction.

METHODS

To assess acute and short-term effects of hyperbaric oxygen on left ventricular chamber stiffness, we studied 74 consecutive patients with first acute myocardial infarction who were randomly assigned to treatment with hyperbaric oxygen combined with streptokinase or streptokinase alone. After thrombolysis, patients in the hyperbaric oxygen group received 100% oxygen at 2 atm for 60 minutes in a hyperbaric chamber. All patients underwent 2-dimensional and Doppler echocardiography 1 (after thrombolysis), 2, 3, 7, 21, and 42 days after myocardial infarction.

RESULTS

Patient characteristics, including age, sex, risk factors, adjunctive postinfarction therapy, infarct location, and baseline left ventricular volumes and ejection fraction, were similar between groups (P >.05 for all). For both groups, deceleration time decreased nonsignificantly from day 1 to day 3 and increased on day 7 (P <.001, for both groups), increasing nonsignificantly subsequently. The E/A ratio increased in the entire study group throughout the time of study (P <.001, for both groups). The pattern of changes of deceleration time was similar in both groups (P >.05 by analysis of variance), as was in subgroups determined by early reperfusion success.

CONCLUSIONS

These data in a small clinical trial do not support a benefit of hyperbaric oxygen on left ventricular diastolic filling in patients with acute myocardial infarction treated with thrombolysis.

Genesis of the restrictive filling pattern: pericardial constraint or myocardial restraint

BACKGROUND

Restrictive filling pattern has been predictive of heart failure in patients with cardiomyopathy and after myocardial infarction, and is similar to the filling pattern in constrictive pericarditis and amyloid heart disease. The purpose of this study was to determine the role of both myocardial restraint and pericardial constraint in a chronic left ventricular dysfunction model with restrictive filling.

METHODS

After instrumentation, a flat balloon containing a high-fidelity pressure catheter was inserted through a pericardial incision in 12 dogs with chronic left ventricular dysfunction. Intracardiac volume (ICV) was manipulated by inferior venal caval balloon occlusion and volume loading while hemodynamics, echo-assessed chamber size, and transmitral Doppler were obtained at the same atrial paced rate with an intact pericardium and after pericardiectomy.

RESULTS

With an intact pericardium, deceleration time increased with reduced ICV (130 +/- 35 vs 153 +/- 47 milliseconds, P <.05) and shortened with increased ICV (107 +/- 45 milliseconds, P <.05). The filling fraction at one-third of diastole decreased with reduced ICV (45.6 +/- 29.3 vs 24.2 +/- 15.8%, P <.01) and increased with increased ICV (60.1 +/- 14.8%, P <.05). Deceleration time could be predicted from intrapericardial pressure, the transmural left ventricular chamber stiffness constant, and filling fraction at one-third of diastole. After pericardiectomy, deceleration time also shortened with increased ICV (141 +/- 26 vs 112 +/- 38 milliseconds, P <.01). However, filling fraction at one-third of diastole was markedly reduced at paced baseline (19.9 +/- 14.4%, P <.01) and with increased ICV (15.5 +/- 11.8%, P <.001) as compared with an intact pericardium.

CONCLUSIONS

Pericardial constraint and myocardial restraint play a role in restrictive filling pattern. Pericardial constraint becomes evident with redistribution of diastolic filling to later in diastole after pericardiectomy.

Prediction of heart failure post myocardial infarction: comparison of ejection fraction, transmitral filling parameters, and the index of myocardial performance

Following an acute myocardial infarction (MI), the development of congestive heart failure (CHF) has been associated with a reduced ejection fraction (EF), pseudonormal or restrictive diastolic filling, and an increased index of myocardial performance (IMP).

STUDY OBJECTIVES

To determine the comparative predictive value of EF, transmitral filling parameters, and IMP for the development of CHF following a first MI.

DESIGN AND SETTING

A retrospective analysis of consecutive echocardiographic and Doppler studies in patients admitted for their first acute MI from the years 1988 through 1992. We studied 109 patients following their first MI with two-dimensional and Doppler within 24 hours of MI. We divided patients into those who developed CHF within 15 days (43 patients) and without CHF (66 patients).

RESULTS

Patients who developed CHF had greater LV dilatation, lower EF (27.7%+/- 10.2% vs 45.6%+/- 13.2%, P < 0.001), higher E/A, shorter deceleration times (DCT; 157 +/- 69 msec vs 248 +/- 105 msec, P < 0.001), and increased IMP. Utilizing multiple logistic regression, EF (strongest predictor), DCT, and IMP were predictive of CHF. Nineteen patients in the no CHF group developed late CHF and had lower EFs (30.5%+/- 13.1% vs 50.5%+/- 9.8%, P < 0.001), higher E/A and shorter DCTs (161 +/- 39 msec vs 283 +/- 103 msec, P < 0.001). EF, DCT, and E/A were predictive of late CHF in patients without initial CHF. For patients admitted with a first MI, the EF, DCT, and to a lesser extent IMP predicted who would ultimately develop CHF. An EF < 40% or a DCT < 200 msec correctly predicted CHF in 60 of 62 patients.

CONCLUSION

We conclude that the early and ultimate development of CHF following a first MI were associated with an moderately reduced EF < 40%, pseudonormal diastolic filling indices, and an increased IMP.

Doppler-derived mitral deceleration time as a strong prognostic marker of left ventricular remodeling and survival after acute myocardial infarction

OBJECTIVES

The goal of this study was to assess the impact of left ventricular (LV) diastolic filling on remodeling and survival after acute myocardial infarction (AMI).

BACKGROUND

Little is known regarding the link between LV filling, its changes over time, and six-month remodeling and late survival in uncomplicated AMI.

METHODS

Doppler mitral profile, end-diastolic volume index (EDVi) and end-systolic volume index (ESVi), ejection fraction (EF), and wall motion abnormalities (%WMA) were evaluated in 571 patients from the GISSI-3 Echo substudy at baseline, pre-discharge, and six months after AMI. Patients with baseline early mitral deceleration time (DT) 130 ms were assigned to the restrictive group (n = 147), and those with DT >130 ms to the nonrestrictive group (n = 424).

RESULTS

Restrictive group patients had greater baseline ESVi and %WMA and lower EF than nonrestrictive group, and six-month greater LV dilation (EDVi, ESVi: p < 0.001 for EDVi and ESVi), smaller decrease in %WMA decrease (p < 0.01), and larger EF impairment (p < 0.008). Among the restrictive group, patients (n = 56) with pre-discharge persistent restrictive filling (n = 56) showed six-month greater LV enlargement (p < 0.001) and EF impairment (p < 0.009) than those (n = 91) with reversible restrictive filling. Baseline %WMA and EDVi, together with pre-discharge persistent restrictive filling, predicted severe (>20%) LV dilation. Four-year survival was 93% in nonrestrictive patients versus 88% in the restrictive group (p < 0.06), and 93% in pre-discharge reversible restrictive versus 79% in persistent restrictive (p < 0.0003). The single best predictor of mortality, by Cox analysis, was pre-discharge persistent restrictive filling (chi-square 14.88).

CONCLUSIONS

Left ventricular dilation may occur even after uncomplicated AMI and may be paralleled by an improvement in LV filling. However, a baseline restrictive filling that persists at pre-discharge identifies more compromised patients at higher risk for six-month remodeling and four-year mortality.

The prognostic significance of exercise-induced atrial arrhythmias

OBJECTIVES

The purpose of the study was to determine if atrial ectopy (AE) or atrial arrhythmias during exercise are predictive of an increased risk of cardiac events and death.

BACKGROUND

Although stress-induced atrial arrhythmias are common during exercise testing, there is a paucity of data regarding the correlation with underlying heart disease and cardiovascular outcomes. Atrial arrhythmias may reflect underlying left atrial enlargement and diastolic dysfunction, which are prognostic of mortality. We hypothesized that these stress-induced arrhythmias are associated with long-term adverse cardiac events.

METHODS

Exercise echocardiography was performed in 5,375 patients (age 61 +/- 12 years) with known or suspected coronary artery disease. An abnormal result was defined as exercise-induced atrial fibrillation (AF)/atrial flutter, supraventricular tachycardia (SVT), or AE.

RESULTS

A total of 311 (5.8%) patients died (132 [2.5%] from cardiac causes) over a period of 3.1 +/- 1.7 years. In addition, 193 (3.6%) patients experienced a myocardial infarction (MI) and 531 (9.9%) patients required revascularization. During exercise testing, 1,272 (24%) patients developed AE, 185 (3.4%) developed SVT, and 43 (0.8%) developed AF. The five-year cardiac death rate was not statistically different between groups (none [3.8%], AE [4.3%], SVT [3.7%], AF [0%], p = 0.43). The five-year rate of MI was significantly different between groups (none [5.7%], AE [8.3%], SVT [0%], AF [9.0%], p = 0.005). The five-year rate of revascularization between groups was not significantly different (none [14.2%], AE [17.0%], SVT [11.8%], AF [14.8%], p = 0.50). A composite of all five-year adverse end points was similar between groups (none [22.7%], AE [27.8%], SVT [17.7%], AF [25.7%], p = 0.10). In stepwise multivariate analysis, AE was not predictive of myocardial infarction when taking into account traditional clinical variables and exercise test results.

CONCLUSIONS

In this large cohort of patients, the occurrence of AE was predictive of an increased risk of MI. However, the association did not persist after adjustment for clinical and exercise variables known to predict adverse long-term cardiovascular outcomes. The rate of long-term cardiac death or revascularization was not influenced by the development of stress-induced atrial arrhythmias.

Myocardial global performance index as a predictor of in-hospital cardiac events in patients with first myocardial infarction

OBJECTIVE

We sought to assess the ability of a Doppler index of global myocardial performance (MPI), measured at entry, to predict inhospital cardiac events in a series of patients with first acute myocardial infarction (AMI).

METHODS

A complete 2-dimensional and Doppler echocardiographic examination was performed within 24 hours of arrival at the coronary care department in 96 patients (81 men and 15 women; mean age 58 +/- 9 years) with first AMI. Patients were divided a posteriori into 2 groups according to their inhospital course: group 1 comprised 75 patients with an uneventful course and group 2 comprised 21 patients with a complicated inhospital course (death, heart failure, arrhythmias, or post-AMI angina).

RESULTS

There were no significant differences between the 2 groups with regard to history of hypertension, diabetes mellitus, hypercholesterolemia, site and size of infarction, and conventional parameters of diastolic function. However, patients with complications were significantly older (63 +/- 10 vs 55 +/- 8 years, P =.005) and had higher wall-motion score index and left ventricular end-systolic volume compared with patients without events (1.84 +/- 0.27 vs 1.52 +/- 0.30, P =.001; and 66 +/- 29 vs 47 +/- 21 mL, P =.009, respectively), whereas the ejection fraction was reduced (40 +/- 10% vs 52 +/- 10%, P =.0001). The mean value of the MPI was significantly higher in patients with cardiac events than in those without events (0.65 +/- 0.20 vs 0.43 +/- 0.16, P =.0001). A MPI >/= 0.47 showed a sensitivity of 90% and specificity of 68% for identifying patients with events, on the basis of the receiver operator curve. In a multivariable model, the MPI at admission remained independently predictive of inhospital cardiac events (odds ratio 15.6, 95% confidence interval 2.4-99, P =.003).

CONCLUSION

These data suggest that in the acute phase of AMI, the MPI measured at entry may be useful to predict which patients are at high risk for inhospital cardiac events.

Noninvasive estimation of left ventricular filling pressure by e/e′ is a powerful predictor of survival after acute myocardial infarction

OBJECTIVES

The aim of this study was to assess the prognostic value of a noninvasive measure of left ventricular diastolic pressure (LVDP) early after acute myocardial infarction (MI).

BACKGROUND

The early diastolic velocity of the mitral valve annulus (e') reflects the rate of myocardial relaxation. When combined with measurement of the early transmitral flow velocity (E), the resultant ratio (E/e') correlates well with mean LVDP. In particular, an E/e' ratio >15 is an excellent predictor of an elevated mean LVDP. We hypothesized that an E/e' ratio >15 would predict poorer survival after acute MI.

METHODS

Echocardiograms were obtained in 250 unselected patients 1.6 days after admission for MI. Patients were followed for a median of 13 months. The end point was all-cause mortality.

RESULTS

Seventy-three patients (29%) had an E/e' >15. This was associated with excess mortality (log-rank statistic 21.3, p < 0.0001) and was the most powerful independent predictor of survival (risk ratio 4.8, 95% confidence interval 2.1 to 10.8, p = 0.0002). The addition of E/e' >15 improved the prognostic utility of a model containing clinical variables and conventional echocardiographic indexes of left ventricular systolic and diastolic function (p = 0.001).

CONCLUSIONS

E/e' is a powerful predictor of survival after acute MI. An E/e' ratio >15 is superior, in this respect, to other clinical or echocardiographic features. Furthermore, it provides prognostic information incremental to these parameters.

Prognostic Importance of Predischarged Troponin T Levels in Acute Anterior Myocardial Infarction

The baseline cardiac troponin T (cTnT) level strongly predicts short-term mortality in acute coronary syndromes, but the added value of predischarged (7th day) measures to predict short-term outcome and left ventricular (LV) remodeling in patients with ST elevation myocardial infarction (MI) is controversial. Baseline, peak and predischarged cTnT results were evaluated in 52 patients (15 females, 37 males, mean age, 54.4 +/- 8.8 years) with first acute anterior MI. There were 4 deaths (all cardiac origin) during the 30 day follow up period. Kaplan-Meier analysis revealed patients with a predischarged serum cTnT level higher than the median level (1.2 ng/mL) had a higher mortality rate than those with submedian levels (P < 0.05). Additionally, the highest correlation rate was found between predischarged cTnT values and LV ejection fraction (LV-EF, r = -0.58, P < 0.002). There were no differences between the groups in the 7th day left ventricular diastolic parameters, but the 30th day isovolumetric relaxation time and mitral E wave deceleration time were shorter (146.9 +/- 30.1 vs 129 +/- 23.4 msec, P = 0.025 and, 185.8 +/- 51.8 vs 144.6 +/- 58.1 msec, P = 0.012) in patients with higher predischarged cTnT level. High levels of predischarged cTnT levels in patients admitted with first acute anterior MI defines a subgroup. These patients have poor systolic and diastolic functions and are at increased risk of short term mortality. This group of patients may have benefit from early intensive treatment strategies before discharge.

Prognostic Value of Global Myocardial Performance Indices in Acute Myocardial Infarction *

STUDY OBJECTIVES

Assessment of global myocardial performance by a single index (ie, the myocardial performance index [MPI]) has been suggested as an appealing alternative to the individual assessment of systolic and diastolic left ventricular (LV) function We sought to test the prognostic value of MPI in comparison to clinical characteristics and echocardiographic parameters of LV filling and ejection in acute myocardial infarction (AMI).

PATIENTS

Four hundred seventeen consecutive patients with AMI were examined within 24 h of hospital admission.

INTERVENTIONS

Doppler echocardiographic measures of systolic, diastolic, and global myocardial performance were assessed within 24 h of hospital admission. In addition to MPI (ie, the sum of the isovolumic time intervals divided by ejection time), we determined the isovolumic/heterovolumic time ratio, which expresses the time "wasted" by the myocardium to generate and decrease LV pressure without moving blood.

RESULTS

The end points of the study at 30 days were death (4.7%), congestive heart failure (23%), and recurrent infarction (4.8%), and occurred in 109 patients, who were compared as group B to 314 patients without an event (group A). Multivariate analysis identified only age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02 to 1.07), LV ejection fraction (LVEF) < or = 40% (OR, 3.82; 95% CI, 2.15 to 6.87), and E-wave deceleration time (EDT) of < or = 130 ms (OR, 2.29; 95% CI, 1.0 to 5.21) as independent predictors of adverse events.

CONCLUSION

LVEF and EDT are powerful and independent echocardiographic predictors of poor outcome following AMI, and are superior to indexes of global LV performance. Both parameters should be taken into consideration when deciding about the management of these patients.

Early changes in left ventricular volume and function are predictors for long-term remodeling in patients with acute transmural myocardial infarction and preserved systolic function

BACKGROUND

We sought to describe the degree of long-term left ventricular (LV) remodeling after acute transmural myocardial infarction with preserved LV systolic function, and to evaluate whether Doppler echocardiographic parameters in the early phase could predict this process.

METHODS

A total of 60 patients without heart failure and with LV ejection fraction > or = 0.40 (mean 0.48 +/- 0.054), were followed up with Doppler echocardiographic examinations at baseline, 3 months, and 1 and 2 years.

RESULTS

There was a significant increase in LV end-diastolic volume index of 7% (P =.006) and LV end-systolic volume index of 8% (P =.03), and no change in ejection fraction. This remodeling was confined to 7 patients (12%) with a significant increase in LV end-diastolic volume index above 20 mL/m(2). There was also a significant increase in the deceleration time of both the early mitral filling wave (Delta early mitral filling wave = 58 milliseconds, P <.0005) and the diastolic forward component of pulmonary venous flow (Delta diastolic forward component of pulmonary venous flow = 61 milliseconds, P <.0005), and a shift in filling pattern with increasing prevalence of abnormal relaxation. Changes in end-diastolic volume index were predicted by baseline early mitral filling wave less than 100 milliseconds, but the most powerful predictors of 2-year remodeling were volume changes at 3 months.

CONCLUSION

Twelve percent of patients with Q-wave infarction and ejection fraction > or = 0.40 experienced significant LV dilatation at 2 years, and this late remodeling was partly related to baseline filling characteristics.

Impact of early changes in left ventricular filling pattern on long-term outcome after acute myocardial infarction

BACKGROUND

In patients with heart failure due to chronic ischemic heart disease improvement of diastolic function indicates improved survival and a reduced morbidity, but whether this is also the case after acute myocardial infarction is not known.

METHODS

To assess the prognostic importance of changes in left ventricular filling pattern, assessed with mitral deceleration time and colour M-mode flow propagation velocity, on cardiac death and readmission due to heart failure serial Doppler echocardiography was carried out in 103 patients with a first myocardial infarction. Based on echocardiography on hospital admission and after 1 month, patients were divided into three groups: group A (n=29) comprised patients with normal filling at either examination, group B (n=29) comprised patients with improvement of initially abnormal filling, and group C (n=45) patients with deterioration or no change of an abnormal filling pattern.

RESULTS

One-year survival free of cardiac death or hospitalisation for heart failure was 97% in group A, 86% in group B and 64% in group C (P<0.0001). In Cox analysis persistence of abnormal filling or deterioration of left ventricular filling was still a predictor of the combined endpoint (risk ratio 4.4, 95% CI 1.8-12.0, P=0.003) after adjustment of LV filling on admission, left ventricular systolic function and clinical variables. Serial analyses of left ventricular systolic function demonstrated a significant improvement after 1 year in ejection fraction in groups A and B, whereas ejection fraction remained unchanged in group C.

CONCLUSION

Patients with a persistently abnormal or a deterioration of left ventricular filling pattern as opposed to improved or normal filling are at increased risk of cardiac death and readmission due to heart failure after acute myocardial infarction.

Left atrial volume: a powerful predictor of survival after acute myocardial infarction

BACKGROUND

After acute myocardial infarction (AMI), diastolic function assessed by Doppler echocardiography provides important prognostic information that is incremental to systolic function. However, Doppler variables are affected by multiple factors and may change rapidly. In contrast, left atrial (LA) volume is less influenced by acute changes and reflects subacute or chronic diastolic function. This may be of importance when one assesses risk in patients with AMI.

METHODS AND RESULTS

Three hundred fourteen patients with AMI who had a transthoracic echocardiogram with assessment of left ventricular (LV) systolic and diastolic function and measurement of LA volume during admission were identified. The LA volume was corrected for body surface area, and the population was divided according to LA volume index of 32 mL/m2 (2 SDs above normal). LA volume index was >32 mL/m2 in 142 (45%). The primary study end point was all-cause mortality. During follow-up of 15 (range 0 to 33) months, 46 patients (15%) died. LA volume index was a powerful predictor of mortality and remained an independent predictor (hazard ratio 1.05 per 1-mL/m2 change, 95% CI 1.03 to 1.06, P<0.001) after adjustment for clinical factors, LV systolic function, and Doppler-derived parameters of diastolic function.

CONCLUSIONS

Increased LA volume index is a powerful predictor of mortality after AMI and provides prognostic information incremental to clinical data and conventional measures of LV systolic and diastolic function.

Clinical efficacy of Doppler-echocardiographic indices of aortic valve stenosis: a comparative test-based analysis of outcome

OBJECTIVES

This study was designed to assess which hemodynamic index best accounts for clinical severity of aortic stenosis (AS) and to analyze the value of low-dose dobutamine testing.

BACKGROUND

Pressure gradient and valve area are suboptimal because they depend on flow rate, correlate poorly with symptoms, and provide limited prognostic information. Recently, new indices and low-dose inotropic stimulation have been introduced, but their clinical value remains uncertain.

METHODS

A total of 307 consecutive patients with AS were included in an ambispective study design (71 +/- 12 years old; peak jet velocity: 3.7 +/- 1.1 m/s). Clinical and Doppler-echocardiographic data were obtained, as well as results of low-dose dobutamine infusion (47 patients). Using receiver-operator-characteristic curve analysis, we evaluated jet velocity, pressure gradient, valve area, resistance, stroke-work loss (SWL), and dobutamine-induced increase in area for predicting 1) symptomatic status at entry, 2) early (</=3 months) cardiovascular death or aortic valve replacement, and 3) long-term outcome. Logistic regression and Cox models were designed multivariate and adjusted by bootstrapping.

RESULTS

Only 28% of patients were alive without valve replacement at the end of the follow-up period (22 +/- 4 months). The decision for valve replacement was made by the referring physician, blinded to the SWL, valve resistance, and dobutamine results. Non-flow-corrected indices performed better than valve area and valve resistance. Among them, SWL best predicted the defined end points. Odds/hazard ratios associated with a SWL Delta = 17% were 5.14 for presenting AS symptoms, 4.68 for early events, and 2.31 for late outcome. A cutoff value of SWL >25% best discriminated clinical end points. Other independent predictors of prognosis were symptomatic status and left ventricular ejection fraction. Dobutamine testing added no value to baseline models.

CONCLUSIONS

Non-flow-corrected indices show the highest clinical efficacy in aortic stenosis. Among these, SWL best predicts symptomatic status and outcome and therefore should be incorporated to aid patient management in unclear situations.

Myocardial viability independently influences left ventricular diastolic function in the early phase after acute myocardial infarction

BACKGROUND

After acute myocardial infarction, a broad range of left ventricular (LV) end-diastolic pressure (LVEDP) is expected because of chamber remodeling. However, intrinsic characteristics of the infarcted tissue (necrosis or viability) may also play a role. We aimed to evaluate whether myocardial viability (Mviab) has an influence on LVEDP.

METHODS

One hundred twenty-three consecutive patients with acute myocardial infarction underwent low-dose dobutamine echocardiography (5-10 microg/kg/min) to assess Mviab. Mviab was quantitatively evaluated by the variation of Delta wall motion score index. Patients underwent left heart catheterization with recording of LVEDP and a complete echocardiographic examination with measurement of LV volumes, ejection fraction, and mass.

RESULTS

The overall population (81% male; mean age 58 +/- 10 years) was divided into 2 groups according to the presence (group 1; 66 patients) or absence (group 2; 57 patients) of Mviab. LVEDP was higher in patients without Mviab (16 +/- 8 vs 20 +/- 7 mm Hg; P =.02). The multivariate analysis showed that Delta wall motion score index correlated with LVEDP (P =.01) independent of wall motion score index and LV end-systolic volume.

CONCLUSIONS

After acute myocardial infarction, LVEDP shows wide variability and is independently associated with Mviab.

Long-term, dose-dependent effects of spironolactone on left ventricular function and exercise tolerance in patients with chronic heart failure

OBJECTIVES

This study was designed to assess the effects of spironolactone (SP) on left ventricular (LV) function and exercise tolerance in patients with chronic heart failure (CHF).

BACKGROUND

In severe heart failure (HF), SP improves survival, but the underlying mechanisms are not clear.

METHODS

We randomized 106 outpatients with HF to SP (12.5 to 50 mg/day) (group 1) or control (group 2). Complete echocardiography and cardiopulmonary exercise testing were performed at baseline and 12 months after randomization.

RESULTS

Left ventricular end-systolic volume at baseline and at follow-up was 188 +/- 94 ml and 171 +/- 97 ml in group 1 and 173 +/- 71 ml and 168 +/- 79 ml in group 2 (treatment group-by-time interaction, p = 0.03). Left ventricular ejection fraction at baseline and at follow-up was 33 +/- 7% and 36 +/- 9% in group 1 and 34 +/- 7% and 34 +/- 9% in group 2 (treatment group-by-time interaction, p = 0.02). At baseline, 9 patients in group 1 and 3 patients in group 2 had a restrictive mitral filling pattern, a marker of severe diastolic dysfunction; at follow-up, 3 patients in group 1 and no patient in group 2 improved their pattern. No patient in group 1 and 4 patients in group 2 worsened their pattern (chi-square, p = 0.02). Peak oxygen consumption increased significantly in patients treated with 50 mg of SP and decreased in group 2 (17.7 +/- 5.2 vs. 18.5 +/- 5.9 and 19.1 +/- 5.6 vs. 17.9 +/- 5.3, respectively; analysis of variance, p = 0.01).

CONCLUSIONS

Spironolactone improves LV volumes and function; furthermore, it improves exercise tolerance at the highest administered dose. Our data might explain the mortality reduction during aldosterone antagonism in patients with HF.

Prognostic significance of left ventricular diastolic dysfunction in essential hypertension

OBJECTIVES

We sought to assess the prognostic value of alterations in left ventricular (LV) diastolic function in patients with essential hypertension.

BACKGROUND

Alterations in LV diastolic function are frequent in patients with hypertension, even in the absence of LV hypertrophy, but their prognostic significance has never been investigated.

METHODS

In the setting of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale (PIUMA) study, we followed, for up to 11 years (mean: 4.4 years), 1,839 Caucasian hypertensive patients (50 +/- 12 years, 53% men, blood pressure (BP) 156/98 mm Hg) without previous cardiovascular events, who underwent Doppler echocardiography and 24-h BP monitoring before therapy. The early/atrial (E/A) mitral flow velocity ratio was calculated and corrected for age and heart rate (HR).

RESULTS

During follow-up, there were 164 major cardiovascular events (2.04 per 100 patient-years). The incidence of cardiovascular events was 2.47 and 1.65 per 100 patient-years in patients with an age- and HR-adjusted E/A ratio below (n = 919) and above (n = 920) the median value, respectively (p < 0.005 by the log-rank test). In Cox analysis, controlling for age, gender, diabetes, cholesterol, smoking, LV mass and 24-h systolic BP (all p < 0.05), a low age- and HR-adjusted E/A ratio conferred an increased risk of cardiovascular events (odds ratio 1.57, 95% confidence interval [CI] 1.11 to 2.18, p < 0.01). A 21% excess risk was found for each 0.3 decrease of the adjusted E/A ratio (95% CI from +2% to +43%; p = 0.03).

CONCLUSIONS

Impaired LV early diastolic relaxation, detected by pulsed Doppler echocardiography, identifies hypertensive patients at increased cardiovascular risk. Such association is independent of LV mass and ambulatory BP.

Pseudonormal mitral filling pattern predicts hospital re-admission in patients with congestive heart failure

OBJECTIVES

We sought to investigate whether pseudonormal (PN) filling was associated with death or hospital admission in patients with congestive heart failure (CHF).

BACKGROUND

The high mortality rate associated with CHF is related to many clinical and echocardiographic variables. In particular, a short mitral deceleration time and restrictive diastolic filling predict death and/or hospital admission. We hypothesized that differentiating patients with nonrestrictive filling might identify an intermediate PN group that may be associated with intermediate risk.

METHODS

A total of 115 patients admitted to the hospital for exacerbation of CHF symptoms underwent pre-discharge Doppler echocardiography to determine mitral inflow (before and after preload reduction) and pulmonary venous return. Patients were followed up for one year, and all-cause mortality and re-admission data were analyzed.

RESULTS

The classification of filling patterns was: abnormal relaxation (AR) in 46 (40%) patients, pseudonormal (PN) filling in 42 (36.5%) patients and restrictive filling pattern (RFP) in 27 (23.4%) patients. When comparing the RFP group with the AR group, all-cause mortality was higher (38.4% vs. 17.4%, p = 0.033), hospital admission was higher (70.3% vs. 54.3%, p = 0.073), death/hospital admission was higher (77.8% vs. 56.5%, p = 0.02), CHF hospital admission was higher (40.7% vs. 15.2%, p = 0.01) and death/CHF hospital admission was higher (62.9% vs. 26.1%, p = 0.0005). Mortality in the PN group was not significantly different from that in the two other groups, but re-admissions were higher than the AR group (76.2% vs. 54.3%, p = 0.006), as was death/re-admission (78.6% vs. 56.5%, p = 0.004) and death/CHF re-admission (47.6% vs. 26.1%, p = 0.03). Re-admissions in the PN and RFP groups were comparable.

CONCLUSIONS

In a general hospital population of older patients with CHF, PN filling was associated with hospital admission rates similar to those seen with restrictive filling. The combined end point of death/CHF hospital admission was similar for restrictive filling and AR. Measurement of these variables is easy to add to routine clinical echocardiography and may provide important prognostic information in a wide range of patients with CHF.

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Plasma nitric oxide level in heart failure secondary to left ventricular diastolic dysfunction

Nitric oxide (NO) is a free radical that is elevated in the plasma of patients with systolic heart failure. However, its relation to diastolic function is unknown. This study investigated the relation between the level of stable end-products of plasma NO (NOx level) and diastolic function in patients with heart failure. We performed echocardiographic Doppler studies in 76 patients (mean age of 66 +/- 10 years, 75% men) with congestive heart failure. Left ventricular (LV) diastolic dysfunction was classified as either a restrictive (RFP) or nonrestrictive filling pattern (non-RFP). Same day venous total nitrite plus nitrate levels were measured by chemiluminscence. Both patients with isolated diastolic heart failure (ejection fraction >50%) (77 +/- 9 micromol/L, n = 33) and systolic failure (ejection fraction < or = 50%) (115 +/- 17 micromol/L, n = 43) had significantly higher plasma NOx levels than controls (37 +/- 2 micromol/L, both p <0.001). RFP coexists mostly in patients with systolic heart failure (15 of 18), and these patients had a higher NOx level than patients with systolic failure and a non-RFP (n = 28) (163 +/- 35 vs 88 +/- 16 micromol/L, p <0.05). Patients who were not on oral nitrate drugs had insignificant lower plasma NOx levels than those on regular nitrate therapy, although it was still higher than controls. Plasma NOx level did not correlate with LV ejection fraction. Stepwise multiple regression analysis confirmed that the presence of RFP was the only independent predictor of NOx, and hence NO production. Plasma NOx level is elevated in patients with isolated diastolic heart failure. In addition, in patients with LV systolic failure, the severity of LV diastolic dysfunction determines the amount of NO production.

Prognostic value of left ventricular diastolic function and association with heart rate variability after a first acute myocardial infarction

OBJECTIVE

To study the prognostic value of left ventricular (LV) diastolic function and its relation with autonomic balance expressed by heart rate variability (HRV) in patients after a first acute myocardial infarction.

DESIGN

The study population consisted of 64 consecutive patients with first acute myocardial infarction and 31 control subjects. Long and short term HRV indices were evaluated by 24 hour Holter monitoring, and LV systolic and diastolic function were assessed by two dimensional and Doppler echocardiography before discharge. Patients were divided into two groups: those with restrictive LV filling characteristics (deceleration time </= 140 ms) and those with non-restrictive LV filling characteristics (deceleration time > 140 ms).

RESULTS

Both long and short term HRV indices were significantly reduced in patients with restrictive LV filling compared with the non-restrictive group and control subjects. Mitral deceleration time and isovolumetric relaxation time correlated weakly but significantly with all indices of HRV whereas ejection fraction correlated weakly with the long term HRV indices. The mean follow up time was 14.9 (8.7) months. Multivariate analysis showed that mitral deceleration time (chi(2) = 6.4, p < 0.001) and ejection fraction </= 40% (chi(2) = 4.4, p < 0.05) were independent predictors of cardiac death and readmission to hospital with congestive heart failure.

CONCLUSIONS

A restrictive LV filling pattern was found to be the strongest predictor of adverse outcome independent of HRV and ejection fraction during follow up after a first acute myocardial infarction. Patients with restrictive LV filling characteristics had more reduced HRV than those with non-restrictive diastolic filling.

New method of on-line quantification of regional wall motion with automated segmental motion analysis

We have recently developed an automated segmental motion analysis (A-SMA) system, based on an automatic "blood-tissue interface" detection technique, to provide real-time and on-line objective echocardiographic segmental wall motion analysis. To assess the feasibility of A-SMA in detecting regional left ventricular (LV) wall motion abnormalities, we performed 2-dimensional echocardiography with A-SMA in 13 healthy subjects, 22 patients with prior myocardial infarction (MI), and 9 with dilated cardiomyopathy (DCM). Midpapillary parasternal short-axis and apical 2- and 4-chamber views were obtained to clearly trace the blood-tissue interface. The LV cavity was then divided into 6 wedge-shaped segments by A-SMA. The area of each segment was calculated automatically throughout a cardiac cycle, and the area changes of each segment were displayed as bar graphs or time-area curves. The systolic fractional area change (FAC), peak ejection rate (PER), and filling rate (PFR) were also calculated with the use of A-SMA. In the control group, a uniform FAC was observed in real time among 6 segments in the short-axis view (60% +/- 10% to 78% +/- 9%), or among 5 segments in either the 2-chamber (59% +/- 12% to 75% +/- 16%) or 4-chamber view (58% +/- 13% to 72% +/- 12%). The variations of FAC, PER, and PFR were obviously decreased in infarct-related regions in the MI group and were globally decreased in the DCM group. We conclude that A-SMA is an objective and time-saving method for assessing regional wall motion abnormalities in real time. This method is a reliable new tool that provides on-line quantification of regional wall motion.

Color M-mode and pulsed wave tissue Doppler echocardiography: powerful predictors of cardiac events after first myocardial infarction

To assess the association between color M-mode flow propagation velocity and the early diastolic mitral annular velocity (E(m)) obtained with tissue Doppler echocardiography and to assess the prognostic implications of the indexes, echocardiography was performed on days 1 and 5, and 1 and 3 months after a first myocardial infarction in 67 consecutive patients. Flow propagation velocity correlated well with E(m) (r = 0.72, P <.0001). The ratio of peak E-wave velocity (E) to flow propagation velocity also correlated well with E/E(m) (r = 0.87, P <.0001). The positive predictive value of E/FPV > or =1.5 to identify patients with Killip class > or =II was 90%, and the negative predictive value 92%. The corresponding values for E/E(m) > or =10 were 70% and 90%. Cox proportional hazards analysis identified E/flow propagation velocity > or =1.5 (relative risk, 12.4 [95% confidence interval, 4.1-37.3]), E/E(m) > or =10 (relative risk, 11.5 [95% confidence interval, 3.8-34.7]), and Killip class > or =II (relative risk, 7.8 [95% confidence interval, 1.6-40.4]) to be predictors of the composite end point of cardiac death and readmission because of heart failure. Thus flow propagation velocity and E(m) are closely related after myocardial infarction and appear to have similar prognostic information.

Short early filling deceleration time on day 1 after acute myocardial infarction is associated with short and long term left ventricular remodelling

OBJECTIVE

To assess the relations between early filling deceleration time, left ventricular remodelling, and cardiac mortality in an unselected group of postinfarction patients.

DESIGN AND PATIENTS

Prospective evaluation of 131 consecutive patients with first acute myocardial infarction. Echocardiography was performed on day 1, day 2, day 3, day 7, at three and six weeks, and at three, six, and 12 months after infarction. According to deceleration time on day 1, patients were divided into groups with short (< 150 ms) and normal deceleration time (⩾ 150 ms).

SETTING

Tertiary care centre.

RESULTS

Patients with a short deceleration time had higher end systolic and end diastolic volume indices and a higher wall motion score index, but a lower ejection fraction, in the year after infarction. These patients also showed a significant increase in end diastolic (p < 0.001) and end systolic volume indices (p = 0.007) during the follow up period, while ejection fraction and wall motion score index remained unchanged. In the group with normal deceleration time, end diastolic volume index increased (p < 0.001) but end systolic volume index did not change; in addition, the ejection fraction increased (p = 0.002) and the wall motion score index decreased (p < 0.001). One year and five year survival analysis showed greater cardiac mortality in patients with a short deceleration time (p = 0.04 and p = 0.02, respectively). In a Cox model, which included initial ejection fraction, infarct location, and infarct size, deceleration time on day 1 was the only significant predictor of five year mortality.

CONCLUSIONS

A short deceleration time on day 1 after acute myocardial infarction can identify patients who are likely to undergo left ventricular remodelling in the following year. These patients have a higher one year and five year cardiac mortality.

Short early filling deceleration time on day 1 after acute myocardial infarction is associated with short and long term left ventricular remodelling

OBJECTIVE

To assess the relations between early filling deceleration time, left ventricular remodelling, and cardiac mortality in an unselected group of postinfarction patients.

DESIGN AND PATIENTS

Prospective evaluation of 131 consecutive patients with first acute myocardial infarction. Echocardiography was performed on day 1, day 2, day 3, day 7, at three and six weeks, and at three, six, and 12 months after infarction. According to deceleration time on day 1, patients were divided into groups with short (< 150 ms) and normal deceleration time (>/= 150 ms).

SETTING

Tertiary care centre.

RESULTS

Patients with a short deceleration time had higher end systolic and end diastolic volume indices and a higher wall motion score index, but a lower ejection fraction, in the year after infarction. These patients also showed a significant increase in end diastolic (p < 0.001) and end systolic volume indices (p = 0.007) during the follow up period, while ejection fraction and wall motion score index remained unchanged. In the group with normal deceleration time, end diastolic volume index increased (p < 0.001) but end systolic volume index did not change; in addition, the ejection fraction increased (p = 0.002) and the wall motion score index decreased (p < 0.001). One year and five year survival analysis showed greater cardiac mortality in patients with a short deceleration time (p = 0.04 and p = 0.02, respectively). In a Cox model, which included initial ejection fraction, infarct location, and infarct size, deceleration time on day 1 was the only significant predictor of five year mortality.

CONCLUSIONS

A short deceleration time on day 1 after acute myocardial infarction can identify patients who are likely to undergo left ventricular remodelling in the following year. These patients have a higher one year and five year cardiac mortality.

Early patency of the infarct-related artery after myocardial infarction preserves diastolic filling

A patent infarct-related artery (IRA) following myocardial infarction has been associated with lower mortality, increased systolic function, decreased left ventricular remodeling, and electrical stability. The purpose of this study was to determine whether coronary artery patency early after myocardial infarction is associated with greater early diastolic filling than a closed artery. Radionuclide ventriculograms were performed at a central laboratory on 167 patients who received alteplase for an acute myocardial infarction and had infarct artery patency determined by cardiac catheterization. The peak early filling rate (PEFR) was assessed by 4 different methods: (1) PEFR (EDV/s)--normalized to the end-diastolic volume; (2) PEFR (SV/s)--normalized to the stroke volume; (3) PEFR (ml/s/m(2))--an absolute diastolic filling rate; and (4) PEFR (PER)--normalized to the peak ejection rate. Patients with a closed IRA (n = 16, Thrombolysis In Myocardial Infarction [TIMI] 0 or 1 flow) and patients with an open IRA (n = 151, TIMI 2 or 3 flow) had similar ages, ejection fractions, and cardiac volumes. However, among patients with an occluded IRA, the PEFR was decreased by 12% to 18% by the 4 measures of diastolic filling (3 of 4 methods, p <0.05). PEFR (EDV/s) was 1.69 +/- 0.9 in the occluded group versus 2.06 +/- 0.4 EDV/s in the open artery group (p = 0.005). By multivariate analysis, IRA patency was an independent predictor of the PEFR by all 4 methods. Early coronary artery patency after an acute myocardial infarction preserves diastolic filling. Improved diastolic function may in part explain part of the long-term benefits of a patent IRA after thrombolytic therapy when there is no documented improvement in the ejection fraction.

Prognostic implications of restrictive left ventricular filling in reperfused anterior acute myocardial infarction

OBJECTIVES

We sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA).

BACKGROUND

In thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment.

METHODS

In 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT < or = 130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (+/- SD) period of 32 +/- 10 months.

RESULTS

During the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor.

CONCLUSIONS

Patients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Determinants of diastolic myocardial tissue Doppler velocities: influences of relaxation and preload

Myocardial tissue Doppler echocardiography (TDE) has been proposed as a tool for the assessment of diastolic function. Controversy exists regarding whether TDE measurements are influenced by preload. In this study, left ventricular volume and high-fidelity pressures were obtained in eight closed-chest dogs during intermittent caval occlusion. The time constant of isovolumic ventricular relaxation (tau) was altered with varying doses of dobutamine and esmolol. Peak early diastolic myocardial (E(m)) and transmitral (E) velocities were measured before and after preload reduction. The relative effects of changes in preload and relaxation were determined for E(m) and compared with their effects on E. The following results were observed: caval occlusion significantly decreased E (DeltaE = 16.4 +/- 3.3 cm/s, 36.6 +/- 13.7%, P < 0.01) and E(m) (DeltaE(m) = 1. 3 +/- 0.4 cm/s, 32.5 +/- 26.1%, P < 0.01) under baseline conditions. However, preload reduction was similar for E under all lusitropic conditions (P = not significant), but these effects on E(m) decreased with worsening relaxation. At tau < 50 ms, changes in E(m) with preload reduction were significantly greater (DeltaE(m) = 2.8 +/- 0.6 cm/s) than at tau = 50-65 ms (DeltaE(m) = 1.2 +/- 0.2 cm/s) and at tau >65 ms (DeltaE(m) = 0.5 +/- 0.1 cm/s, P < 0.05). We concluded that TDE E(m) is preload dependent. However, this effect decreases with worsening relaxation.

Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study

OBJECTIVES

We sought to assess the prognostic value of left ventricular (LV) filling patterns, as determined by mitral E-wave deceleration time (DT) and color M-mode flow propagation velocity (Vp), on cardiac death and serial changes in LV volumes after a first myocardial infarction (MI).

BACKGROUND

Combined assessment of DT and Vp allows separation of the effects of compliance and relaxation on LV filling, thereby allowing identification of pseudonormal filling. This may be valuable after MI, where abnormal LV filling is frequently present.

METHODS

Echocardiography was performed within 24 h, five days and one and three months after MI in 125 unselected consecutive patients. Normal filling was defined as DT 140 to 240 ms and Vp > or =45 cm/s; impaired relaxation as DT > or =240 ms; pseudonormal filling as DT 140 to 240 ms and Vp <45 cm/s; and restrictive filling as DT <140 ms.

RESULTS

Left ventricular filling was normal in 38 patients; impaired relaxation in 38; pseudonormal in 23; and restrictive in 26. End-systolic and end-diastolic volume indexes were significantly increased during the first three months after MI in patients with pseudonormal or restrictive filling (37+/-15 vs. 47+/-19 ml/m2, p<0.0005 and 71+/-20 vs. 88+/-24 ml/m2, p<0.0005, respectively). During a follow-up period of 12+/-7 months, 33 patients died. Mortality was significantly higher in patients with impaired relaxation (p = 0.02), pseudonormal filling (p<0.00005) and restrictive filling (p<0.00005), compared with patients with normal filling. On Cox analysis, restrictive filling (p = 0.003), pseudonormal filling (p = 0.006) and Killip class > or =II (p = 0.008) independently predicted cardiac death, compared with clinical and echocardiographic variables.

CONCLUSIONS

Pseudonormal or restrictive filling patterns are related to progressive LV dilation and predict cardiac death after a first MI.

Doppler-derived mitral deceleration time as an early predictor of left ventricular thrombus after first anterior acute myocardial infarction

BACKGROUND

The relation between left ventricular (LV) diastolic function and LV thrombus has not yet been fully investigated. The aim of this study was to determine whether early assessment of Doppler-derived mitral deceleration time (DT), a measure of LV compliance and filling, may predict LV thrombus formation after acute myocardial infarction.

METHODS AND RESULTS

Two-dimensional and Doppler echocardiographic examinations were performed in 98 consecutive patients (aged 57 +/- 12 years; 8 women) with first acute myocardial infarction. The patients were studied within 24 hours and at days 3, 7, 15, and 30 after arrival to the coronary care unit. Mitral flow velocities were obtained from the apical 4-chamber view with pulsed Doppler. LV thrombus was detected in 20 of 98 patients. Patients were divided into 2 groups according to LV thrombus formation: group 1 (n = 20) with thrombus and group 2 (n = 78) without thrombus. Mitral E-wave DT was significantly shorter in group 1 than group 2 (134 ms vs 175 ms; P <.001). Patients in group 1 had significantly larger LV end-diastolic and end-systolic volumes and a higher wall motion score index than patients in group 2 (133 +/- 39 mL vs 112 +/- 41 mL, P =.03; 83 +/- 34 mL vs 59 +/- 30 mL, P =.003; and 1.8 +/- 0.3 mL vs 1.5 +/- 0.3 mL, P =.007, respectively). The LV ejection fraction was significantly lower in group 1 than in group 2 (39% +/- 13% vs 48% +/- 12%; P =.004). In a multivariate regression analysis, mitral E-wave DT was identified as an independent variable related to development of LV thrombus (P =.04).

CONCLUSIONS

Doppler-derived mitral DT is superior to conventional clinical and 2-dimensional echocardiographic assessment in estimating the risk of left ventricular thrombosis after myocardial infarction.

Prognostic value of pulmonary venous flow Doppler signal in left ventricular dysfunction: contribution of the difference in duration of pulmonary venous and mitral flow at atrial contraction

OBJECTIVES

We assessed the contribution of difference in duration of pulmonary venous and mitral flow at atrial contraction (ARd-Ad) for prognostic stratification of patients with left ventricular (LV) systolic dysfunction.

BACKGROUND

Although pulmonary venous flow (PVF) variables may supplement mitral flow patterns in evaluating left ventricular (LV) diastolic function, their value to the prognostic stratification of patients has not been investigated.

METHODS

Pulsed wave Doppler mitral and PVF velocity curves were recorded in 145 patients (mean age: 70 years) with LV systolic dysfunction secondary to ischemic or nonischemic cardiomyopathy who were followed for 15 +/- 8 months. In 38% of patients, PVF signal was enhanced by the intravenous (IV) administration of a galactose-based echo-contrast agent. Based on E-wave deceleration time < or = or >130 ms and ARd-Ad, patients were grouped into restrictive (group 1, n = 40), nonrestrictive with ARd-Ad > or =30 ms (group 2, n = 55) and nonrestrictive with ARd-Ad <30 ms (group 3, n = 50).

RESULTS

During follow-up, 29 patients died from cardiac causes and 28 were hospitalized for worsening heart failure (HF). On multivariate Cox model, ARd-Ad > or =30 ms provided important prognostic information with regard to cardiac mortality and emerged as the single best predictor of cardiac events (cardiac mortality, hospitalization). The 24-month cardiac event-free survival was best (86.3%) for group 3; it was intermediate (37.9%) for group 2; and it was worst (22.9%) for group 1 (p < 0.0002 group 1 vs. 3; p < 0.0005 group 2 vs. 3; p < 0.0003 group 1 vs. group 2).

CONCLUSIONS

Assessment of ARd-Ad exhibited an independent value in the prognostic evaluation of patients with LV systolic dysfunction. Moreover, it contributed to identify patients at low, intermediate and high risk of cardiac events.

Improvement of exercise capacity and left ventricular diastolic function with metoprolol XL after acute myocardial infarction

BACKGROUND

Left ventricular (LV) diastolic function predicts and correlates with exercise capacity. Beta-blockers improve exercise capacity and LV diastolic function in patients with severe LV systolic dysfunction in dilated cardiomyopathy. However, information on the effect of metoprolol XL on exercise capacity in relation to LV diastolic function in patients with mild to moderate LV systolic dysfunction after acute myocardial infarction is limited.

METHODS

In a randomized, double-blind, placebo-controlled study of 77 patients, a subgroup of 59 patients with mild to moderate LV systolic dysfunction after acute myocardial infarction were given metoprolol XL (n = 29) or placebo (n = 30). The effects of metoprolol XL on exercise capacity in relation to effects on LV diastolic filling were studied. Two-dimensional Doppler echocardiography and maximal symptom limited bicycle test were performed on days 5 through 7 and after 3 months.

RESULTS

Maximal exercise capacity increased in the metoprolol XL group (124 +/- 30 W vs 135 +/- 29 W) compared with placebo (125 +/- 31 W vs 126 +/- 34 W) (P <.01). E/A ratio decreased, A peak velocity increased, reverse pulmonary flow decreased, and deceleration time was significantly prolonged in the metoprolol XL group. A significant correlation was found between the changes of deceleration time (metoprolol XL: rho = 0.69, P <.0001; placebo: rho = 0.31, P = not significant) and A peak velocity (metoprolol XL: rho = 0.71, P <.0001; placebo: rho = -0.15, not significant) in relation to changes of exercise capacity.

CONCLUSION

Metoprolol XL increases exercise capacity after 3 months, and this change seems related to improvement of LV diastolic filling after acute myocardial infarction.

Relationship between serum amino-terminal propeptide of type III procollagen and changes of left ventricular function after acute myocardial infarction

BACKGROUND

The amino-terminal propeptide of type III procollagen (PIIINP) is a marker of type III collagen synthesis, which has previously been shown to correlate with infarct size in nonthrombolyzed myocardial infarction (MI) and to provide prognostic information after MI.

METHODS AND RESULTS

The relationship between PIIINP and changes of left ventricular (LV) function was studied in 47 consecutive patients with first acute MI and 16 control subjects. Serum PIIINP analysis was measured daily during hospitalization and on days 90, 180, and 360. LV function was assessed by echocardiography on days 1, 5, 90, and 360. Patients with MI were stratified according to their serum PIIINP value at day 4 (group A, </=5.0 microg/L; group B, >5.0 microg/L). On arrival, LV function and size were comparable between groups A (n=31) and B (n=16). LV ejection fraction, initially depressed (day 1: group A, 47+/-7% versus group B, 47+/-8%; P=NS), increased significantly in group A (day 360: 54+/-8%, P<0.001) but was unchanged in group B (day 360: 43+/-8%, P=NS). LV volumes increased significantly in group B (P<0. 05) but not in group A. Furthermore, patients in group B developed signs of restrictive LV diastolic filling. Multivariate regression analysis identified PIIINP >5.0 microg/L and deceleration </=140 ms as independent predictors of cardiac death or complicating heart failure during follow-up.

CONCLUSIONS

PIIINP assessed in the subacute phase of MI relates to long-term changes of LV function and provides clinical prognostic information.

Ratio of left ventricular peak E-wave velocity to flow propagation velocity assessed by color M-mode Doppler echocardiography in first myocardial infarction: prognostic and clinical implications

OBJECTIVES

To determine the ability of the ratio of peak E-wave velocity to flow propagation velocity (E/Vp) measured with color M-mode Doppler echocardiography to predict in-hospital heart failure and cardiac mortality in an unselected consecutive population with first myocardial infarction (MI).

BACKGROUND

Several experimental studies indicate color M-mode echocardiography to be a valuable tool in the evaluation of diastolic function, but data regarding the clinical value are lacking.

METHODS

Echocardiography was performed within 24 h of arrival at the coronary care unit in 110 consecutive patients with first MI. Highest Killip class was determined during hospitalization. Patients were divided into groups according to E/Vp <1.5 and > or =1.5.

RESULTS

During hospitalization 53 patients were in Killip class > or =II. In patients with E/Vp > or =1.5, Killip class was significantly higher compared with patients with E/Vp <1.5 (p < 0.0001). Multivariate logistic regression analysis identified E/Vp > or =1.5 to be the single best predictor of in-hospital clinical heart failure when compared with age, heart rate, E-wave deceleration time (Dt), left ventricular (LV) ejection fraction, wall motion index, enzymatic infarct size and Q-wave MI. At day 35 survival in patients with E/Vp <1.5 was 98%, while for patients with E/Vp > or =1.5, it was 58% (p < 0.0001). Cox proportional hazards model identified Dt <140 ms, E/Vp > or =1.5 and age to be independent predictors of cardiac death, with Dt < 140 ms being superior to age and E/Vp.

CONCLUSIONS

In the acute phase of MI, E/Vp > or =1.5 measured with color M-mode echocardiography is a strong predictor of in-hospital heart failure. Furthermore, E/Vp is superior to systolic measurements in predicting 35 day survival although Dt <140 ms is the most powerful predictor of cardiac death.

Persistent ST segment depression in precordial leads V5-V6 after Q-wave anterior wall myocardial infarction is associated with restrictive physiology of the left ventricle

OBJECTIVES

To examine the relationship between the persistence of ST segment depression in leads V5-V6 after Q-wave anterior wall myocardial infarction (MI) and the filling pattern of the left ventricle (LV).

BACKGROUND

Precordial ST segment depression predominantly in leads V5-V6 is associated with increased in-hospital morbidity and mortality after acute myocardial ischemia, perhaps due to reduced diastolic distensibility of the LV.

METHODS

We prospectively studied 19 patients after Q-wave anterior wall MI (>6 months). All patients underwent 12-lead ECG recording, symptom-limited treadmill exercise testing with single photon emission computed tomography thallium-201 imaging, transthoracic Doppler echocardiography, cardiac catheterization and measurement of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels. Patients were classified based on the presence of ST segment depression in leads V5-V6: Group I = ST segment depression <0.1 mV (n = 10); Group II = ST segment depression > or =0.1 mV (n = 9).

RESULTS

Patients in Group II had greater LV end diastolic pressures (32.4 +/- 6.5 mm Hg vs. 14.8 +/- 6.1 mm Hg; p = 0.0001), higher plasma ANP (44.4 +/- 47.1 pg/ml vs. 10.7 +/- 14 pg/ml; p = 0.04) and BNP levels (89.4 +/- 62.7 pg/ml vs. 23.6 +/- 33.1 pg/ml; p = 0.01), greater left atrium area (20.6 +/- 3.1 cm2 vs. 17.8 +/- 2.4 cm2; p = 0.05), lower peak atrial (A), higher early (E) mitral inflow velocities, a higher E/A ratio and a lower deceleration time (167 +/- 44 ms vs. 220 +/- 40 ms; p = 0.05). Lung thallium uptake during exercise was more common in Group II (78% vs. 10%, p = 0.04).

CONCLUSIONS

Persistent ST segment depression in leads V5-V6 in survivors of Q-wave anterior wall MI is associated with increased LV filling pressure and a restrictive LV filling pattern.