Direct visualization of septal perforator coronary arterial blood flow during perflutren microsphere contrast echocardiography

A 62-year-old female with supraventricular tachycardia underwent a contrast echocardiogram to assess left ventricular structure and function due to sub-optimal images on conventional imaging. Multi-pulse, phase inversion, low mechanical index imaging was used (left ventricular opacification), combined with bolus dosing of a perflutren microsphere (Definity). In the parasternal short-axis view, during contrast imaging, flow within a septal coronary artery could be directly visualized. The corresponding coronary angiogram demonstrated prominent septal perforators arising from the LAD artery. By exploiting the non-linear oscillation properties of microbubbles and the linear oscillation properties of tissue, at low MI, contrast-specific imaging has the ability to enhance the contrast signal while suppressing the myocardial signal. This form of contrast imaging has high temporal and spatial resolution, enabling visualization of relatively small structures in real time. Clinical relevance of this finding includes the ability to enhance coronary blood flow evaluation, which would have utility in those studies where spectral Doppler is being used to evaluate coronary blood flow and coronary flow reserve and it may be beneficial in the identification of septal perforator arteries that should be injected with alcohol during percutaneous septal ablation for the management of hypertrophic obstructive cardiomyopathy.

Acute effects of smoking light cigarettes on coronary microvascular functions

BACKGROUND

To date, there has been no study comparing the possible acute effects on coronary microvascular functions of smoking light cigarettes (those with low tar and nicotine yield) and regular cigarettes.

METHODS

Twenty healthy volunteers (8 women and 12 men; mean age, 25.8 +/- 5.8 years) were included in a single-blind, open-label, cross-over study to compare the effects of smoking light cigarettes (containing 0.6 mg nicotine, 8 mg tar, 9 mg carbon monoxide) and smoking regular cigarettes (containing 0.9 mg nicotine, 12 mg tar, 12 mg carbon monoxide) on coronary flow reserve (CFR). For each participant, CFR values were measured at baseline, after smoking 2 regular or light cigarettes, and 15 days later after smoking 2 cigarettes of the other kind.

RESULTS

After smoking 2 cigarettes, CFR values declined from 2.8 +/- 0.56 (baseline) to 2.31 +/- 0.51 after smoking light cigarettes (P = .003), and from 2.8 +/- 0.56 (baseline) to 2.21 +/- 0.45 after smoking regular cigarettes (P < .001). After smoking light and regular cigarettes, CFR values were similar (P = .678).

CONCLUSIONS

Light cigarette smoking has similar acute detrimental effects on coronary microvascular function and CFR as does regular cigarette smoking.

Non-invasive assessment of coronary flow reserve and ADMA levels: a case-control study of early rheumatoid arthritis patients

OBJECTIVE

Plasma concentration of asymmetric dimethylarginine (ADMA), a major endogenous inhibitor of nitric oxide synthase, is considered a novel risk factor for endothelial dysfunction associated with enhanced atherosclerosis. Coronary microcirculation abnormalities have been demonstrated in patients with early rheumatoid arthritis (ERA) without any signs or symptoms of coronary artery disease (CAD). The aim of the study was to compare the ERA and control groups with ADMA, intima-media thickness (IMT) and coronary flow reserve (CFR) levels. It assessed whether ERA patients have more cardiovascular risk (endothelial dysfunction and coronary microvascular abnormalities), and evaluated whether any difference in IMT/CFR between ERA and controls can be explained by any difference in ADMA levels between the groups.

METHODS

The study involved 25 ERA patients (female/male 21/4; mean age 52.04 +/- 14.05 years; disease duration <or=12 months) and 25 healthy volunteers with no history or current signs of CAD or other traditional risk factors. Dipyridamole trans-thoracic stress echocardiography was preformed to evaluate CFR, and carotid ultrasound to measure the IMT of the common carotid arteries. Blood samples were obtained in order to assess ADMA levels before the patients had received any biological or non-biological DMARDs, or steroid therapy.

RESULTS

CFR was significantly reduced in the ERA patients (2.5 +/- 0.5 vs 3.5 +/- 0.8; P <0.01). In particular, 6/25 (24%) had a CFR of <2 consistent with potentially dangerous coronary flow impairment. Common carotid IMT was significantly greater in the ERA patients, although still within the normal range (0.68 +/- 0.1 vs 0.56 +/- 0.11 mm; P <0.01). There was a significant correlation between CFR and plasma ADMA levels in the ERA population (r = -0.53; P <0.01). IMT was negatively associated with CFR (P <0.05).

CONCLUSIONS

Plasma ADMA levels were significantly higher in the ERA patients. A statistically significant negative effect of ADMA levels on CFR value was observed. The effect of ADMA levels on IMT is not significant.

Hypoadiponectinemia in lipodystrophic HIV individuals: a metabolic marker of subclinical cardiac damage

BACKGROUND AND AIM

To evaluate cardiovascular abnormalities in highly active antiretroviral therapy (HAART) treated HIV patients with no signs or symptoms of cardiovascular impairment, and to assess the relative role of multiple concomitant risk factors.

METHODS AND RESULTS

Forty-four consecutive HIV subjects (mean age 41+/-6 yrs) were enrolled. Inclusion criteria were HIV infection, CD4+cell count>150/ml, HAART treatment for at least 4 years. Metabolic serum levels, morphological and functional echocardiographic parameters were assessed in all subjects. Sixteen healthy age and sex matched subjects with no cardiovascular risk factors were recruited as controls. HIV patients showed increased left ventricular mass index with reduced mid-wall fractional shortening (mFS) when compared to controls (50.2+/-10.5 vs. 38.6+/-14.4, p=0.05 and 18.3+/-0.6 vs. 21.9+/-0.7, p<0.05, respectively). Twenty-nine patients were lipodystrophic (LD) and showed a longer HAART period (p=0.0004) and greater use of protease inhibitors (PI) (p=0.001). Coronary flow reserve (CFR) was significantly reduced in HIV patients as compared to controls (p<0.0001), as it was in LD subjects when compared to non-lipodystrophic ones (NLD) (p<0.001). Adiponectin concentrations were found to be significantly lower in LD subjects than in NLD ones (7.8+/-0.8 vs. 13.8+/-1.2 microg/ml, p=0.01), and showed a direct correlation with CFR. In multiple regression analysis, insulin, HDL and adiponectin accounted for 63% of CFR variations.

CONCLUSIONS

Left ventricular hypertrophy, depressed mFS and reduced CFR represent the main signs of subclinical cardiac damage in HIV subjects treated with HAART. Hypoadiponectinemia in these subjects seems to be a metabolic risk factor of cardiovascular impairment.

Additive prognostic value of coronary flow reserve in patients with chest pain syndrome and normal or near-normal coronary arteries

In patients with angiographically normal coronary arteries and chest pain, pharmacologic stress echocardiography can identify a subgroup of patients with a less benign prognosis. Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can currently be combined with wall motion analysis during vasodilator stress echocardiography. The aim of this study was to assess the prognostic value of CFR response in patients with normal coronary arteries and normal wall motion during stress. We selected 394 patients (171 men, 61 +/- 11 years of age) who underwent dipyridamole stress echocardiography (0.84 mg/kg over 6 minutes) with 2-dimensional echocardiography and CFR evaluation of the LAD by Doppler. All had angiographically nonsignificant (<50% quantitatively assessed) stenosis in any major vessel, normal left ventricular function (wall motion score index 1), and test negativity for conventional wall motion criteria. Images were independently read by a core laboratory for wall motion and a core laboratory for CFR. Mean CFR was 2.5 +/- 0.6 and 87 patients (22%) had an abnormal CFR <2. During a median follow-up of 51 months, 31 events occurred, namely 4 deaths and 27 nonfatal myocardial infarctions (3 ST-elevated myocardial infarctions and 24 non-ST-elevated myocardial infarctions). Kaplan-Meier survival estimates for hard events showed a better outcome for those patients with a normal CFR compared with those with an abnormal CFR (96% vs 55%, p = 0.001, at 48 months of follow-up). In conclusion, in patients with angiographically normal or near-normal coronary arteries and preserved at-rest regional and global left ventricular function at baseline and during stress, CFR adds incremental value to the prognostic stratification achieved with clinical and angiographic data.

Coronary no-reflow phenomenon: from the experimental laboratory to the cardiac catheterization laboratory

Coronary no-reflow occurs commonly during acute percutaneous coronary intervention, particularly in patients with acute myocardial infarction and those with degenerated vein grafts. It is associated with a guarded prognosis, and thus needs to be recognized and treated promptly. The pathophysiology originates during the ischemic phase and is characterized by localized and diffuse capillary swelling and arteriolar endothelial dysfunction. In addition, leukocytes become activated and are attracted to the lumen of the capillaries, exhibit diapedesis and may contribute to cellular and intracellular edema and clogging of vessels. At the moment of perfusion, the sudden rush of leukocytes and distal atheroemboli further contributes to impaired tissue perfusion. Shortening the door-to-balloon time, use of glycoprotein IIb/IIIa platelet receptor inhibitors and distal protection devices are predicted to limit the development of no-reflow during percutaneous interventions. Distal intracoronary injection of verapamil, nicardipine, adenosine, and nitroprusside may improve coronary flow in the majority of patients. Hemodynamic support of the patient may be needed in some cases until coronary flow improves.

Clinical value of echocardiographic assessment of coronary flow reserve after left anterior descending coronary artery stenting in an unselected population

BACKGROUND

Transthoracic Doppler echocardiography is a valuable tool to measure coronary flow reserve (CFR) and detect in-stent restenosis (ISR) after percutaneous coronary angioplasty in selected series of patients.

OBJECTIVES

To assess the usefulness of coronary flow reserve measured by echocardiography in detecting significant (> or =70%) ISR of the left anterior descending coronary artery in a large unselected population.

METHODS

Two hundred and twenty-three patients (age 61 +/- 10 years; 168 men) treated with left anterior descending stenting underwent CFR measurement by transthoracic Doppler echocardiography and venous adenosine infusion 24-72 h before control coronary angiography. Coronary-active drugs were continued, and patients with multiple risk factors and old anterior-apical myocardial infarction were included.

RESULTS

Significant ISR occurred in 56 patients (25%). Patients with ISR had higher basal coronary flow velocity (27 +/- 10 cm/s vs. 24 +/- 7 cm/s; P < 0.002) and lower CFR (1.5 +/- 0.5 vs. 2.7 +/- 0.6; P < 0.0001) than those without ISR. A linear relation was found between ISR and CFR (r = -0.73; P < 0.0001) and remained significant after adjustment for blood pressure and heart rate (r = -0.74; P < 0.0001). A CFR less than two identified significant ISR (sensitivity 88%, specificity 88%, area under the curve = 0.943; P < 0.001). In a multivariate model of CFR prediction, myocardial infarction and heart rate were slightly contributory (ss = -0.19, P < 0.01; ss = -0.16, P < 0.03, respectively), whereas ISR had a large influence (ss = -0.66; P < 0.0001). The inverse correlation between ISR and CFR persisted in patients with myocardial infarction (r = -0.64; P < 0.0001) and in those treated with beta-blockers (r = -0. 71; P < 0.0001).

CONCLUSION

Echocardiographic measurement of CFR detects significant left anterior descending ISR in unselected patients with multiple risk factors, old anterior-apical myocardial infarction, and taking beta-blockers.

Coronary flow reserve is impaired in hypertensive patients with subclinical renal damage

BACKGROUND

Renal dysfunction is relatively common in patients with primary hypertension (PH). A reduction in coronary vasodilator capacity has recently been reported in patients with renal damage undergoing coronary angiography. We investigated the relationship between coronary flow reserve (CFR) and early renal abnormalities in patients with PH and normal serum creatinine.

METHODS

Seventy-six untreated patients were studied. Albuminuria was measured as the albumin-to-creatinine ratio and glomerular filtration rate (eGFR) was estimated by the Cockroft-Gault formula. Chronic kidney disease (CKD) was defined as an eGFR <60 ml/min/1.73 m(2) and/or in the presence of microalbuminuria. Coronary blood flow velocities (cm/s) were measured by Doppler ultrasound at rest and after adenosine administration. CFR was defined as the ratio of hyperemic-to-resting diastolic peak velocities.

RESULTS

Prevalence of reduced eGFR, microalbuminuria, CKD, and left ventricular (LV) hypertrophy was 8, 10, 16, and 31%, respectively. Overall, 10% of patients showed impaired CFR (i.e., <2.0). Patients with CKD were more likely to be older (P < 0.05) and of female gender (P < 0.01) and showed higher LV mass index (LVMI) (P < 0.05), lower CFR (P < 0.05; analysis of covariance, P < 0.05), and CFR/LVMI (P < 0.05) than patients with normal renal function. Conversely, patients with impaired CFR showed a significantly higher prevalence of reduced eGFR (chi(2) 5.2, P < 0.05), microalbuminuria (chi(2) 10.2, P < 0.01), and CKD (chi(2) 9.2.1, P < 0.01). Even after adjustment for gender, the presence of CKD entailed a sevenfold higher risk of having impaired CFR (confidence interval 1.17-40.9, P < 0.05).

CONCLUSION

Early renal abnormalities are associated with reduced CFR in PH.

Coronary blood flow responses to physiological stress in humans

Animal reports suggest that reflex activation of cardiac sympathetic nerves can evoke coronary vasoconstriction. Conversely, physiological stress may induce coronary vasodilation to meet an increased metabolic demand. Whether the sympathetic nervous system can modulate coronary vasomotor tone in response to stress in humans is unclear. Coronary blood velocity (CBV), an index of coronary blood flow, can be measured in humans by noninvasive duplex ultrasound. We studied 11 healthy volunteers and measured beat-by-beat changes in CBV, blood pressure, and heart rate during 1) static handgrip for 20 s at 10% and 70% of maximal voluntary contraction; 2) lower body negative pressure at -10 and -30 mmHg for 3 min each; 3) cold pressor test for 90 s; and 4) hypoxia (10% O(2)), hyperoxia (100% O(2)), and hypercapnia (5% CO(2)) for 5 min each. At the higher level of handgrip, mean blood pressure increased (P < 0.001), whereas CBV did not change [P = not significant (NS)]. In addition, during lower body negative pressure, CBV decreased (P < 0.02; and P < 0.01, for -10 and -30 mmHg, respectively), whereas blood pressure did not change (P = NS). The dissociation between the responses of CBV and blood pressure to handgrip and lower body negative pressure is consistent with coronary vasoconstriction. During hypoxia, CBV increased (P < 0.02) and decreased during hyperoxia (P < 0.01), although blood pressure did not change (P = NS), suggesting coronary vasodilation during hypoxia and vasoconstriction during hyperoxia. In contrast, concordant increases in CBV and blood pressure were noted during the cold pressor test, and hypercapnia had no effects on either parameter. Thus the physiological stress known to be associated with sympathetic activation can produce coronary vasoconstriction in humans. Contrasting responses were noted during systemic hypoxia and hyperoxia where mechanisms independent of autonomic influences appear to dominate the vascular end-organ effects.

Diffuse, marked, reversible impairment in coronary microcirculation in stress cardiomyopathy: a Doppler transthoracic echo study

The aim of the study was to assess coronary flow reserve (CFR) in tako-tsubo cardiomyopathy (TC).

METHODS AND RESULTS

Thirty consecutive patients (5 males; age 68+/-12 years) meeting diagnostic criteria for TC were evaluated with transthoracic dipyridamole (0.84 mg/kg over 6 min) stress echo and pulsed Doppler CFR assessment on mid-distal left anterior descending (LAD) and posterior descending of right coronary artery (PD). Wall motion score index (WMSI) was evaluated at base-line and during stress. All patients were followed up clinically and-on day 1, day 7 (+/-2 days), and at 6 months-by repeat stress echo. Thirty gender- matched controls were also studied. CFR was obtained in all patients on LAD and in 25 on PD. All showed a transient apical ballooning in the acute phase (day 1 of admission), with progressive recovery of function at follow-up (WMSI, day 1 = 1.7+/-0.2; day 7 = 1.4+/-0.14; 6 months = 1.0+/-0.1; P<0.001 versus day 1 and versus day 7). When compared to controls (3.1+/-0.5), CFR on LAD was reduced on day 1 (1.8+/-0.24, P<0.001) (upon admission), and it showed early recovery in the subacute (pre-discharge) assessment on day 7. CFR values remained stable at 6-month follow-up (2.6+/-0.3).

CONCLUSION

TC is characterized by a profound, diffuse coronary microcirculatory disturbance in the acute phase, with early reversal to near-normal values within a few days, paralleling the functional recovery in regional wall motion.

Facial fractures in road cyclists

BACKGROUND

Despite the safety devices worn by bicycle riders and the road safety measures designed to protect them, road cycling is still associated with frequent traumas, notably to the extremities. Maxillofacial injuries are common, especially when road traffic accidents occur. There is a paucity of literature on the epidemiology of bicycle-related facial fractures in New Zealand.

METHODS

A retrospective database of patients presenting to the Oral and Maxillofacial Surgery Unit at Christchurch Hospital during an 11-year period was reviewed. Variables examined included demographics, types of fracture, mode of injury, and treatment delivered.

RESULTS

Sixty-three patients were identified as having road bicycle-related facial fractures, with no increase in prevalence over the study period. Male to female ratio was 3:1, with 76 per cent involving patients aged between their first and third decade. Fall was the most common mechanism of injury, followed by collision. Fifty-two per cent of patients were hospitalized and 40 per cent required surgical intervention. The highest incidence of injury was during January.

CONCLUSIONS

Road bicycle-related fractures accounted for a small proportion of the workload at our unit. They predominantly affected young male adults. More than half of the patients were hospitalized and a major proportion of these required surgery.

Angiographic and physiologic assessment of coronary flow and myocardial perfusion in the cardiac catheterization laboratory

INTRODUCTION

For many years, coronary angiography has been used to define coronary artery lesions. Angiographic assessment of coronary flow using the TIMI flow grade system (TFG) and the TIMI frame count (TFC) methods have played a significant role in our understanding of coronary artery disease and they have proved useful in prediction of long-term clinical outcomes after myocardial infarction. The availability of invasive techniques to assess the physiological significance of coronary artery lesions allows a more rationale approach to the management of patients, particularly those with intermediate lesions. The TIMI scores and other angiographic parameters such as the TIMI myocardial perfusion grade (TMPG) are now integrated into clinical practice, as are the use of flow wires and pressure recording wires. Other angiographic techniques, (e.g. digital subtraction angiography), which at this time are predominantly research tools, will require software integration into the imaging chain to facilitate real-time analysis.

CONCLUSION

In this article, we provide a comprehensive descriptive review of the different means of assessment of coronary flow in the cardiac catheterization laboratory, focusing on scores deducted from angiography as well as invasive haemodynamic measurements of blood flow and pressure.

Caracterização dos casos de violência contra a mulher atendidos em três serviços na cidade de Uberlândia, Minas Gerais, Brasil

Este estudo apresenta aspectos epidemiológicos e clínicos da violência contra a mulher, utilizando três fontes de dados: prontuários médicos do Hospital de Clínicas de Uberlândia, Minas Gerais, Brasil, (HCU); fichas de atendimento da ONG SOS Ação Mulher Família (ONG SOS Mulher); laudos de perícia de lesões corporais e de necropsias do Posto Médico Legal (PML). No HCU e no PML, os atendimentos foram decorrentes principalmente por agressão física, não havendo alusão à violência psicológica nos prontuários médicos e nos laudos, revelando que em serviços de atenção primária à saúde esta violência é evidenciada somente em pesquisas pós-entrevistas com as vítimas. Na ONG SOS Mulher foram observadas principalmente as violências psicológica e física. Nas três fontes pesquisadas houve baixa ocorrência da violência sexual, corroborando dados da literatura que retrata a invisibilidade desta questão, principalmente da violência sexual conjugal sofrida pelas mulheres que buscam ajuda nesses serviços. Os dados da presente pesquisa permitem concluir que os tipos de violência contra a mulher nesses três diferentes serviços públicos de saúde e social, em Uberlândia, diferenciam-se conforme as características específicas dos serviços oferecidos nessas instituições.

Cardiovascular involvement in systemic autoimmune diseases

Autoimmune diseases, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), primary antiphospholipid syndrome (APS), systemic sclerosis and systemic vasculitis, affect a large number of people in whom one of the leading causes of morbidity and mortality is cardiovascular disease. Cardiovascular disease is associated with the development of accelerated atherosclerosis. It seems to occur at a younger age than in the general population, is often asymptomatic and, in addition to traditional risk factors, also involves specific risk factors as chronic inflammation, the duration and activity of the autoimmune disease, and immunosuppressive therapy. The early phases of cardiovascular involvement in patients with autoimmune diseases may be clinically silent, with only a microcirculation disorder present. There are various means of detecting morphological cardiac damage: coronary angiography remains the gold standard for diagnosing coronary stenosis, but new, non invasive and more reliable methods have been introduced into clinical practice in order to detect subclinical microcirculation abnormalities.

The prognostic value of Doppler echocardiographic-derived coronary flow reserve is not affected by concomitant antiischemic therapy at the time of testing

BACKGROUND

When wall motion abnormality is the diagnostic end point, concomitant antiischemic therapy heavily modulates the prognostic value of dipyridamole echocardiography test (DET). A negative test result is less benign, and a positive test result is more malignant if performed under therapy. Recently, coronary flow reserve (CFR) was added to wall motion in dual imaging DET. The aim of the study was to determine whether antianginal medications affect the prognostic value of Doppler echocardiographic-derived CFR in patients with known or suspected coronary artery disease undergoing DET.

METHODS

In a prospective, multicenter, observational study, we evaluated 1,779 patients (1,072 males; 64 +/- 11 years) who underwent high-dose dipyridamole (0.84 mg/kg for 6 minutes) stress echo with CFR evaluation of left anterior descending (LAD) artery by Doppler.

RESULTS

Seven hundred thirty-three (41%) patients were on antiischemic therapy at time of testing (nitrates and/or calcium antagonists and/or beta-blockers). Mean CFR was 2.3. +/- 0.6. At individual patient analysis, 1,141 patients had normal (CFR >2.0) and 638 had abnormal (CFR <or=2.0) CFR on LAD. During a median follow-up of 36 months, 263 events occurred as follows: 36 deaths and 59 ST-elevation myocardial infarctions (STEMIs) and 168 non-STEMIs (NSTEMIs). Survival was highest in patients with normal CFR and lowest in patients with abnormal CFR (87% vs 34%, P = .0001). Survival was comparable in patients with normal CFR on and off therapy and in patients with abnormal CFR on and off therapy. At multivariable analysis, hypertension (hazard ratio [HR] 1.5, 95% CI 1.0-1.9, P = .010), DET positivity for regional wall motion abnormalities (HR 5.7, 95% CI 4.3-7.4, P = .000), an abnormal CFR on LAD (HR 3.3, 95% CI 2.5-4.4, P = .000) were independent prognostic predictors of hard cardiac events.

CONCLUSION

Ongoing antiischemic therapy at the time of testing does not modulate the prognostic value of Doppler echocardiographic-derived coronary flow reserve.

Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC)

Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

A floor of mouth teratoid cyst with tract in a newborn--case report and English literature review unraveling erroneous quotes and citations

Dysontogenetic cysts are thought to fall into one of three classes: epidermoids, dermoids or teratoids. Floor of mouth teratoid cysts are the least common presentation reported. Over the last 70 years, fewer than 20 histologically proven cases have been described in the English literature. We report an infant presenting with this lesion in association with a midline tract. The cyst was identified at birth and interfered with feeding. It was surgically excised with no recurrence at 10 month point of follow-up. A literature search revealed that confusing terminology and indirect quotation disseminated false beliefs regarding the epidemiology. Contrary to most reports, floor of mouth teratoid cysts are most commonly encountered in childhood with only a handful of cases in older age groups.

Relation between the assessment of microvascular injury by cardiovascular magnetic resonance and coronary Doppler flow velocity measurements in patients with acute anterior wall myocardial infarction

OBJECTIVES

We studied the relation between presence and severity of microvascular obstruction (MO), measured by cardiovascular magnetic resonance (CMR) and intracoronary Doppler flow measurements, for assessment of myocardial reperfusion in patients with acute anterior myocardial infarction (MI) treated by primary percutaneous coronary intervention (PCI).

BACKGROUND

Cardiovascular magnetic resonance has been used to detect and quantify MO in patients after acute MI but has never been compared with coronary blood flow velocity patterns.

METHODS

Twenty-seven patients with first anterior ST-segment elevation MI successfully treated with primary PCI were included. Coronary blood flow velocity was measured during recatheterization 4 to 8 days after primary PCI. These measurements were related to MO determined by late gadolinium-enhanced (LGE) CMR performed the day before recatheterization.

RESULTS

Early systolic retrograde flow was observed in 0 of 8 patients without MO on LGE CMR and in 10 (53%) of 19 patients with MO (p = 0.01). The extent of MO correlated with the diastolic-systolic velocity ratio (r = 0.44; p = 0.02), diastolic deceleration time (r = -0.61; p = 0.001), diastolic deceleration rate (r = 0.75; p < 0.0001), and coronary flow velocity reserve of the infarct-related artery (r = -0.44; p = 0.02). Furthermore, multivariate regression analyses, including extent of MO, infarct size, and transmural necrosis on LGE CMR, revealed that extent of MO was the only independent factor related to early systolic retrograde flow and diastolic deceleration rate.

CONCLUSIONS

Assessment of microvascular injury by LGE CMR corresponds well to evaluation by intracoronary Doppler flow measurements. By means of CMR, quantification of myocardial function, infarct size, and microvascular injury can accurately be performed with a single noninvasive technique in patients with acute MI.

Beta-blockers and coronary flow reserve: the importance of a vasodilatory action

Coronary flow reserve (CFR) is the maximal increase in coronary blood flow (CBF) above its resting level for a given perfusion pressure when coronary vasculature is maximally dilated. Normally, hyperaemic CBF reaches values at least 2- to 3-fold greater than resting CBF. Reduction of CFR is mainly due to epicardial coronary artery stenosis or to coronary microvascular dysfunction. CFR can be determined by several techniques that measure CBF itself (e.g. positron emission tomography) or CBF velocities (Doppler methods) from which coronary flow velocity reserve is calculated. Hyperaemic coronary vasodilation can be obtained by pharmacological agents (e.g. adenosine and dipyridamole), but also by the cold pressure test. Long-term antihypertensive treatment induces significant improvement of CFR, which is parallel to the regression of left ventricular (LV) hypertrophy. First- and second-generation beta-adrenergic receptor antagonists (beta-blockers) have shown contradictory influences on CFR. This can be explained by the interaction of the effects on CBF at rest, generally reduced by these drugs, and after hyperaemia, when minimal coronary resistance appears to be either increased or reduced. Third-generation beta-blockers (e.g. carvedilol and nebivolol), which have vasodilating capacity, improve hyperaemic CBF. This occurs as a result of a reduction in minimal resistance, which can be attributed to alpha-adrenergic blockade and/or to a nitric oxide-mediated effect. This improvement is clearly beneficial in patients with coronary artery disease and indicates an improved coronary microvascular function. Changes of CFR due to vasodilating beta-blockers improve microvascular angina pectoris or silent ischaemia in patients without epicardial artery stenosis, and are also helpful in predicting the response or the further improvement of LV function to treatment.

Impact of individual and cumulative coronary risk factors on coronary flow reserve assessed by dobutamine stress echocardiography

Traditional cardiovascular risk factors have been shown to cause microvascular dysfunction. Most studies that have evaluated microcirculation rely on invasive measurement tools. We used dobutamine stress echocardiography, a validated method to measure coronary flow velocity (CFV) and coronary flow reserve (CFR), in a previously unstudied population without known significant coronary artery disease to determine the impact of traditional risk factors on CFR. Consecutive patients who had no evidence of regional wall motion abnormalities at rest or during dobutamine stress echocardiography were studied. Left anterior descending artery CFV was measured at baseline and at peak dobutamine stress and CFR was calculated as the ratio of peak stress CFV to baseline CFV. Fifty-nine consecutive patients (28 men) with mean age of 66.8+/-14.5 years were studied. CFR was lower in patients with diabetes mellitus (DM) compared with those without (1.7+/-0.74 vs 2.48+/-0.98, p<0.007), in patients with hypertension compared with those without (2+/-0.8 vs 2.6+/-0.9, p<0.02), and in obese patients compared with nonobese patients (1.6+/-0.5 vs 2+/-0.6, p<0.02). CFR was further impaired in the presence of DM with hypertension, DM with obesity, DM with a wide pulse pressure (>50 mm Hg), and obesity with a wide pulse pressure. In a multivariate model, DM, obesity, and wide pulse pressure were significantly associated with variation in CFR (p<0.0008). In conclusion, CFR was abnormal in patients with DM, hypertension, and obesity. CFR impairment is exaggerated as the number of risk factors increases. Despite a negative dobutamine stress echocardiographic result, aggressive risk factor assessment and control should be implemented in patients with coronary risk factors due to an underlying abnormal CFR.

Effects of cognac on coronary flow reserve and plasma antioxidant status in healthy young men

Background

The cardioprotective effects of certain alcoholic beverages are partly related to their polyphenol content, which may improve the vasodilatory reactivity of arteries. Effect of cognac on coronary circulation, however, remains unknown. The purpose of this randomized controlled cross-over study was to determine whether moderate doses of cognac improve coronary reactivity as assessed with cold pressor testing (CPT) and coronary flow reserve (CFR) measument.

Methods

Study group consisted of 23 subjects. Coronary flow velocity and epicardial diameter was assessed using transthoracic echocardiography at rest, during CPT and adenosine infusion-derived CFR measurements before drinking, after a moderate (1.2 ± 0.1 dl) and an escalating high dose (total amount 2.4 ± 0.3 dl) of cognac. To explore the bioavailability of antioxidants, the antioxidant contents of cognac was measured and the absorption from the digestive tract was verified by plasma antioxidant capacity determination.

Results

Serum alcohol levels increased to 1.2 ± 0.2‰ and plasma antioxidant capacity from 301 ± 43.9 μmol/l to 320 ± 25.0 μmol/l by 7.6 ± 11.8%, (p = 0.01) after high doses of cognac. There was no significant change in flow velocity during CPT after cognac ingestion compared to control day. CFR was 4.4 ± 0.8, 4.1 ± 0.9 (p = NS), and 4.5 ± 1.2 (p = NS) before drinking and after moderate and high doses on cognac day, and 4.5 ± 1.4, and 4.0 ± 1.2 (p = NS) on control day.

Conclusion

Cognac increased plasma antioxidant capacity, but it had no effect on coronary circulation in healthy young men.

Trial Registration

NCT00330213

Factors predicting coronary flow reserve impairment in patients evaluated for chest pain: an ultrasound study

OBJECTIVE

To evaluate the impact of multiple cardiovascular risk factors on coronary flow reserve (CFR) in a large patient population with acute chest pain referred for coronary angiography.

METHODS

Three hundred and ninety-four consecutive patients (mean age 59 +/- 10 years) were enrolled in the study. Blood flow velocity was measured, using transthoracic echocardiography, in the middle-distal tract of the left anterior descending coronary artery (LAD) at rest and during infusion of high-dose dipyridamole in 6 min. CFR was calculated as the ratio of hyperaemic to basal peak diastolic flow velocity. All patients underwent coronary angiography within 48-72 h of CFR evaluation and a LAD stenosis was considered significant for lumen diameter narrowing > or =70%.

RESULTS

Out of 394 patients, 11 patients (3%) were excluded because of inadequate quality of the spectral Doppler envelope. In the group of 269 patients with LAD stenosis <70%, CFR was significantly reduced in 64 patients with >2 risk factors compared to 205 patients with < or =2 risk factors (2.24 +/- 0.48 vs. 2.52 +/- 0.53, P < 0.005). On multiple logistic regression analysis, age, hypertension and diabetes mellitus were related to reduced CFR. In 114 patients with significant LAD disease, CFR was not reduced in patients with multiple cardiovascular risk factors. On multiple logistic regression analysis, the percentages of stenosis and diabetes mellitus were independent determinants of CFR.

CONCLUSIONS

In patients with acute chest pain, the occurrence of multiple cardiovascular risk factors adversely affected CFR in an additive manner, in absence of significant angiographic stenosis. Diabetes mellitus was a powerful coronary risk factor decreasing CFR both in patients with or without significant LAD disease.

Effects of cardiac resynchronization therapy on coronary blood flow: evaluation by transthoracic Doppler echocardiography

BACKGROUND

Relatively limited and conflicting data are available on the effects of cardiac resynchronization therapy (CRT) on coronary blood flow (CBF).

AIMS

To investigate changes in the left anterior descending coronary artery (LAD) flow under different CRT pacing modes by means of transthoracic Doppler echocardiography (TTE).

METHODS

Twenty-two responders to CRT (67+/-11 years) with idiopathic dilated cardiomyopathy underwent TTE assessment of LAD flow and Tissue Velocity Imaging during 4 programming modes: intrinsic conduction (IC), right ventricular pacing (RV), simultaneous biventricular pacing (BVP), BVP with left ventricular (LV) pre-activation.

RESULTS

Mean coronary flow velocity (CFV) was increased by simultaneous BVP (p=0.0063 vs. IC) and BVP with LV pre-activation (p<0.0001 vs. IC; p=0.027 vs. simultaneous BVP). Peak CFV and LAD flow velocity/time integral were highest during BVP with LV pre-activation. A reduction in septal-to-lateral delay and an increase in peak systolic velocity in the basal septum were observed during simultaneous BVP and BVP with LV pre-activation.

CONCLUSIONS

In CRT responders with idiopathic dilated cardiomyopathy, an increase in LAD flow, assessed by TTE, was observed during simultaneous BVP and BVP with LV pre-activation. This was associated with an improvement in regional myocardial contraction and a decrease in intraventricular dyssynchrony.

Feasibility and diagnostic power of transthoracic coronary Doppler for coronary flow velocity reserve in patients referred for myocardial perfusion imaging

Background

Myocardial perfusion imaging (MPI), using single photon emission computed tomography (SPECT) is a validated method for detecting coronary artery disease. Transthoracic Doppler echocardiography (TTDE) of flow at rest and during adenosine provocation has previously been evaluated in selected patient groups. We therefore wanted to compare the diagnostic ability of TTDE in the left anterior descending coronary artery (LAD) to that of MPI in an unselected population of patients with chest pain referred for MPI. Our hypothesis was that TTDE with high accuracy would identify healthy individuals and exclude them from the need for further studies, enabling invasive investigations to be reserved for patients with a high probability of disease.

Methods

Sixty-nine patients, 44 men and 25 women, age 61 ± 10 years (range 35–82), with a clinical suspicion of stress induced myocardial ischemia, were investigated. TTDE was performed at rest and during adenosine stress for myocardial scintigraphy.

Results

We found that coronary flow velocity reserve (CFVR) determined from diastolic measurements separated normal from abnormal MPI findings with statistical significance. TTDE identified coronary artery disease, defined from MPI, as reversible ischemia and/or permanent defect, with a sensitivity of 60% and a specificity of 79%. The positive predictive value was 43% and the negative predictive value was 88%. There was an overlap between groups which could be due to abnormal endothelial function in patients with normal myocardial perfusion having either hypertension or diabetes.

Conclusion

TTDE is an attractive non-invasive method to evaluate chest pain without the use of isotopes, but the diagnostic power is strongly dependent on the population investigated. Even in our heterogeneous clinical cardiac population, we found that CFVR>2 in the LAD excluded significant coronary artery disease detected by MPI.

Reduced coronary flow reserve and parasympathetic dysfunction in patients with cardiovascular syndrome X

OBJECTIVE

Although cardiovascular syndrome X was described many years ago, its causes are still unclear. Many studies have addressed the autonomic function, whereas others have investigated the coronary reserve. The purpose of this study was to investigate the correlations between parasympathetic dysfunction and coronary flow reserve deficiency.

BASIC METHODS

Eleven consecutive women suffering from cardiovascular syndrome X were enrolled in the study. All the patients underwent the analysis of heart rate and blood pressure variability, the cold face test and noninvasive evaluation of the coronary flow reserve by transthoracic echocardiography. Comparison was made with healthy volunteers.

RESULTS

Seven patients (64%) showed vagal impairment in the analysis of heart rate and blood pressure variability and a pathological response to the cold face test, whereas four patients (36%) did not show significant differences from the control group. In these three groups, patients with and without vagal impairment and controls, there was a difference in the mean diastolic coronary velocity reserve (1.94+/-0.48; 3.73+/-0.95, 2.88+/-0.55, P=0.0005) and in maximal diastolic velocity reserve (2.00+/-0.48, 3.26+/-0.64, 2.65+/-0.57, P=0.0047). Post-hoc analysis demonstrated that the mean and maximal diastolic velocity reserves of the patients with vagal impairment seemed to be reduced compared with those of the other groups (P<0.05), which were similar.

CONCLUSIONS

This study confirmed that syndrome X patients represent a heterogeneous group. More than half of the patients exhibited vagal dysfunction. In these patients, coronary flow reserve was abnormal compared with controls and other syndrome X patients without vagal impairment.

Endothelial dysfunction: a key to the pathophysiology and natural history of peripheral arterial disease?

Dysfunctional endothelium plays a crucial role in all stages of atherosclerosis and thus the accurate assessment of this organ is a valuable tool, especially if such assessments are clinically relevant. In peripheral arterial disease (PAD), which affects about 27 million of individuals in Europe and North America, increased plasma markers of endothelial dysfunction and reduced endothelium-mediated vasoreactivity, are associated with both the severity and the extent of atherosclerosis in the arteries of the lower limbs, is exacerbated by acute exercise, may help identify subjects with subclinical coronary artery disease, and portends a worse outcome. As a result, endothelial dysfunction is a promising target for therapeutic interventions in PAD. Large clinical trials are needed to verify whether affected individuals with depressed endothelial function benefit from specific treatments.

Semi-automated analysis of coronary flow Doppler images: validation with manual tracings

Coronary flow velocity reserve (CFVR) is conventionally obtained by manual tracings of Doppler profiles, as ratio of stress vs baseline diastolic peak velocity. When <1.9, this parameter evidences reduced coronary flow and possible microcirculatory disease. Our goals were: 1) to develop a novel technique for semi-automated detection of Doppler flow velocity profile, allowing the automated computation of CFVR and other parameters; 2) to validate this technique in comparison with conventional measurements obtained by manual tracing; 3) to test for differences between normal (N) subjects and patients with rheumatoid arthritis (RA). Linear correlation and Bland-Altman analyses showed that the proposed method was highly accurate and repeatable compared to the manual measurements. Comparison between N and RA groups evidenced significant differences in some of the automated parameters.

Evaluation of left main coronary artery stenosis by transthoracic echocardiography

OBJECTIVE

We sought to demonstrate left main coronary artery (LM) stenosis by transthoracic echocardiography.

BACKGROUND

Evaluation of LM stenosis was done mostly by transesophageal echocardiography in patients with coronary artery disease.

METHODS

A total of 1456 patients with coronary artery disease were studied, of which 801 patients (55%) had adequate coronary flow assessment. The LM and the adjacent segments of left anterior descending coronary artery and left circumflex coronary artery were evaluated by color flow and Doppler. Mosaic flow and/or peak diastolic velocity of greater than or equal to 1.5 m/s was considered abnormal. These findings were correlated with stenoses at coronary angiography. A total of 40 patients who had abnormal diastolic flow in LM by transthoracic echocardiography constituted group 1 and 56 patients with normal LM flow constituted the control group (group 2).

RESULTS

The peak diastolic velocities in LM in group 1 ranged between 1.5 and 4.4 m/s (mean 2.11 +/- 0.78 m/s). Of the 40 patients in group 1, 34 had significant LM stenosis by coronary angiography (sensitivity of 85%, positive predictive value 82.5%). The velocities in LM in group 2 ranged between 0.4 and 1.2 m/s (mean 0.66 +/- 0.25 m/s). In all, 49 of 56 patients in this group had normal LM on coronary angiography (88% specificity, negative predictive value 90.7%). The remaining 7 had distal LM stenosis. Mosaic flow in LM indicated significant LM stenosis in 85% of patients, whereas normal flow in LM did not rule out distal LM stenosis in 12% of patients.

CONCLUSIONS

LM stenosis could be assessed by transthoracic echocardiography with an acceptable degree of sensitivity and specificity.

Transthoracic echo-Doppler assessment of coronary microvascular function late after Kawasaki disease

The goal of this study was to demonstrate that Doppler transthoracic echocardiography (TTE) may represent a valuable tool for the noninvasive demonstration of coronary microvascular dysfunction in children with previous Kawasaki disease (KD) by the measurement of coronary flow reserve (CFR) during cold pressor test (CPT). Twenty-five children with previous KD (mean follow-up, 4.6 +/- 2.6 years) were included in the study-16 with no evidence of coronary artery lesions (CALs(-)) by TTE and 9 with coronary aneurysms (CALs(+)). Seventeen age-matched healthy subjects were also recruited. Diastolic peak velocity was measured by pulsed Doppler both at rest (DPV(Rest)) and during CPT (DPV(CPT)) in the anterior descending artery. CFR was calculated as DPV(CPT)/DPV(Rest). KD patients demonstrated significantly higher values of DPV(Rest) (0.21 +/- 0.05 vs 0.13 +/- 0.01 cm/sec, p < 0.0001) and DPV(CPT) (0.33 +/- 0.07 vs 0.27 +/- 0.03 cm/sec, p < 0.005). CFR was reduced in KD compared to control subjects (1.5 +/- 0.4 vs 2.1 +/- 0.2, p < 0.0001). CFR was decreased in a similar manner in both CALs(+) patients (1.4 +/- 0.4, p = 0.002 vs controls) and CALs(-) patients (1.6 +/- 0.4, p < 0.0001 vs controls). Doppler TTE at rest and during CPT may represent a valuable modality for CFR evaluation in children with a history of KD. CFR is significantly reduced in KD patients independently of the presence of CALs.

Impaired coronary flow reserve in patients with metabolic syndrome

BACKGROUND

Metabolic syndrome (MetS) is a strong predictor of cardiovascular events. Coronary flow reserve (CFR), as determined by transthoracic echocardiography, is an indicator of microvascular function. In this study, we sought to determine whether CFR is impaired in patients with MetS without clinical coronary heart disease.

METHODS

Thirty-three patients with MetS (mean age, 67+/-8 years) and 35 age- and sex-matched controls were studied prospectively. Transthoracic two-dimensional and Doppler echocardiography was performed on all patients. Baseline and hyperemic (after dipyridamole infusion) coronary flow rates were measured using pulsed Doppler echocardiography. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities.

RESULTS

There was no difference with regard to baseline systolic and diastolic coronary flow rates in patients with MetS compared with control subjects (19.9+/-3.1cm/s vs. 19.7+/-2.9cm/s, P>.05; and 27.7+/-4.2cm/s vs. 27.1+/-3.6cm/s, P>.05, respectively). Hyperemic diastolic flow and CFR were significantly lower in patients with MetS than in controls (61.7+/-9.4cm/s vs. 70.2+/-9.2cm/s, P<.0001; and 2.2+/-0.5 vs. 2.6+/-0.4, P=.001, respectively). In a logistic regression analysis that included age, sex, body mass index, hypertension, and dyslipidemia and MetS, MetS was the only predictor of a CFR<2.5 (P=.007, OR=6.1, 95% CI: 1.6-23.3).

CONCLUSION

In conclusion, CFR is impaired in patients with MetS suggesting that coronary microvascular dysfunction, an early finding of atherosclerosis, is present in this patient population. Metabolic syndrome is associated with a CFR<2.5.

Non-invasive assessment of coronary flow and coronary flow reserve by transthoracic Doppler echocardiography: a magic tool for the real world

Transthoracic Doppler echocardiography, introduced in the echo-lab in recent last years, to measure coronary flow and coronary flow reserve, is a very attractive tool, totally non-invasive, and easily available at bedside. This review summarizes the actual possibilities of this tool, its multiple potential clinical applications and diagnostic insights, and its arising prognosis value, in coronary artery disease as in various settings affecting the coronary microcirculation.

Association between serum gamma-glutamyltransferase levels and coronary microvascular function in hypertensive patients

OBJECTIVE

Serum gamma-glutamyltransferase (GGT) level is an independent risk factor for cardiovascular (CV) disease, and there is a strong association between serum GGT levels and most CV risk factors, including hypertension; however, the role of serum GGT level as an independent risk factor for target organ damage in hypertension remains controversial. Accordingly, we aimed to determine whether serum GGT level is independently and specifically associated with coronary flow reserve (CFR) impairment in hypertensive patients.

METHODS

We examined 100 never-treated and newly diagnosed hypertensive individuals, and CFR was achieved in 97 (97%) of them. They were divided into two groups based on serum GGT levels.

RESULTS

Subjects with higher GGT had significantly impaired CFR as compared to those with lower GGT (2.10 +/- 0.36 versus 2.57 +/- 0.54, P < 0.0001). After adjusting for potential confounders, including age, sex, body mass index, blood pressure, lipids and glucose, we found that serum GGT levels were independently associated with CFR impairment (beta = -0.62, P < 0.0001). We also found that GGT level was a good predictor of low CFR at the receiver-operating characteristic curve. Area under the curve was 79% [95% confidence interval: 0.70-0.88], and GGT level was significantly predictive of low CFR (P < 0.0001).

CONCLUSION

These results support a role for serum GGT level as an independent marker of target organ damage in hypertensive subjects without concomitant risk factors.

Noninvasive assessment of coronary flow reserve in the left anterior descending artery by transthoracic echocardiography before and after stenting

BACKGROUND

Noninvasive assessment of coronary flow reserve in the left anterior descending artery (LAD) by transthoracic Doppler echocardiography (TTDE) has been already validated as a new method for determining the degree of stenosis over the proximal flow.

OBJECTIVES

The aim of the study is to determine, by TTDE, the feasibility and the value of the coronary flow reserve (CFR) (defined as the maximal increase in coronary blood flow above its basal pressure for a given perfusion pressure when coronary circulation is maximally dilated) in the mid-to-distal LAD before and after percutaneous angioplasty and to demonstrate the early recovery of microvascular tone immediately after stenting.

METHODS

The study population consisted of 36 patients with significant isolated LAD stenosis (70-90%) identified by coronary angiography. CFR was recorded in the mid-to-distal LAD at rest and during hyperemia obtained after adenosine intravenous infusion before and after stenting.

RESULTS

Adequate visualization of the LAD was obtained in 25 out of 36 patients (70%). At rest the mean CFR was 1.5132 +/- 0.33 (1.1-2.58). However, after stenting the mean CFR was significantly higher: 2.18 +/- 0.55 (1.3-3.8), with P <0.01.

CONCLUSIONS

CFR can be easily determined by TTE in approximately 70% of patients. Noninvasive Doppler echocardiography shows impaired CFR in patients with LAD disease. After stenting CFR is restored, demonstrating early recovery of microvascular tone. These results are comparable to those published in the same conditions. Larger series with a long-term follow-up may allow identifying patients at high risk for restenosis after stenting.

Impaired coronary microvascular and left ventricular diastolic functions in patients with ankylosing spondylitis

BACKGROUND

It has been shown that the patients with inflammatory rheumatic diseases such as systemic lupus erythematosus and rheumatoid arthritis have an increased risk of developing atherosclerosis. However, the association of ankylosing spondylitis (AS) to atherosclerosis and related diseases is still controversial. Accordingly, we investigated coronary flow reserve (CFR) and left ventricular (LV) diastolic function in patients with AS using transthoracic Doppler echocardiography.

METHODS

CFR and LV diastolic function were studied in 40 patients with AS (38.9+/-10.2 years, 26 males) and 35 healthy volunteers (37.5+/-6.4 years, 23 males). Coronary diastolic peak flow velocities (DPFV) were measured at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline DPFV. LV diastolic function was assessed by both standard and tissue Doppler imaging.

RESULTS

Demographic features and coronary risk factors except diastolic blood pressure were similar between the groups. CFR were significantly lower in the AS group than in the control group (2.20+/-0.46 versus 3.02+/-1.50, P<0.0001). Reflecting LV diastolic function mitral A-wave and E/A ratio were borderline significant, and mitral E-wave deceleration time and isovolumic relaxation time were significantly different between the groups. Serum hsCRP and TNF-alpha levels were significantly higher in the patients with AS, and hsCRP and TNF-alpha levels independently correlated with CFR.

CONCLUSION

These findings show that CFR reflecting coronary microvascular function and LV diastolic function are impaired in patients with AS, and severity of these impairments correlate well with hsCRP and TNF-alpha. These results suggest that impaired CFR may be an early manifestation of cardiac involvement in patients with AS.

A moderate dose of red wine, but not de-alcoholized red wine increases coronary flow reserve

BACKGROUND

Red wine consumption is associated with reduced cardiovascular disease mortality. Its cardioprotective properties may be partly related to its ability to improve endothelial function. The purpose of this randomized controlled cross-over study was to determine whether moderate doses of red wine and de-alcoholized red wine improve coronary flow velocity reserve (CFR).

METHODS

Using transthoracic Doppler echocardiography, 176 CFR measurements were made in 22 healthy men before and after ingestion of a moderate (4.0+/-0.4 dl) and an escalating high dose (total amount 8.1+/-0.9 dl) of alcohol-containing red wine and de-alcoholized red wine, which contained similar amounts of phenolic substances. The difference in plasma antioxidant capacity was determined by colorimetric assay kit.

RESULTS

Red wine increased CFR from 3.8+/-1.4 to 4.5+/-1.4 (p<0.01) and 4.0+/-1.2 (p=NS) after moderate and high doses, respectively; whereas de-alcoholized red wine had no significant effects on CFR (4.0+/-0.7, 4.3+/-1.3 and 4.5+/-1.4, respectively). Plasma antioxidant capacity increased significantly after high dose of red wine (27.5+/-14.7%, p<0.001), but not after de-alcoholized red wine (0.5+/-10.5%, p=NS) despite similar amounts of phenolic substances. Differences between CFR and plasma antioxidant capacities before and after drinking had no significant association.

CONCLUSIONS

A moderate dose of red wine, but not de-alcoholized red wine increases CFR. The increase of CFR is probably mediated by other than direct antioxidant properties of polyphenols, because the simultaneous increase of CFR and plasma antioxidant capacity were not associated.

Effects of atorvastatin on coronary flow reserve in patients with slow coronary flow

BACKGROUND

Statins improve endothelial functioning in patients with coronary artery disease and hypercholesterolemia, while substantially little is known about induced changes in myocardial microcirculation. However, although previous studies have suggested that microvascular abnormalities and endothelial dysfunction is responsible for slow coronary flow (SCF), there is no study investigating possible effects of statins on coronary microvascular function in patients with SCF.

HYPOTHESIS

We prospectively investigated the effects of short-term lipid-lowering therapy with atorvastatin on coronary flow reserve (CFR) reflecting coronary microvascular function in patients with SCF assessed by transthoracic Doppler echocardiography (TTDE).

METHODS

In an open clinical trial, CFR was studied in 20 subjects with SCF. TTDE was used to assess CFR at baseline as well as after 8 weeks of atorvastatin therapy. Coronary flow was quantified according to TIMI frame count (TFC). Coronary diastolic peak flow velocities were measured at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities.

RESULTS

CFR was independently correlated with TFC. After 8 weeks of atorvastatin therapy, CFR values increased significantly (1.95 +/- 0.38 vs. 2.54 +/- 0.56, (p < 0.001). No change in hemodynamic parameters was noted during the entire study. The improvement in CFR was not correlated to the amount of lipid-lowering effect of atorvastatin.

CONCLUSIONS

These findings suggest that short-term lipid-lowering therapy with atorvastatin improved CFR, which reflects coronary microvascular functioning in patients with SCF.

Associations between left ventricular myocardial involvement and endothelial dysfunction in systemic sclerosis: noninvasive assessment in asymptomatic patients

OBJECTIVES

Systemic sclerosis (SSc) is a multisystem disorder characterized by widespread vascular lesions and fibrosis of skin and distinct internal organs. Cardiac involvement is a common finding in SSc, but often clinically occult.

AIM OF THE STUDY

To analyze possible associations of left ventricular (LV) myocardial function with coronary flow reserve (CFR) and endothelial function in asymptomatic patients with SSc.

METHODS

30 healthy patients and 33 age- and sex-comparable asymptomatic patients classified as having either diffuse (18 patients) or limited form (15 patients) of SSc underwent standard Doppler Echo, Doppler myocardial imaging, Strain rate imaging of interventricular septum and LV lateral wall, transthoracic CFR of left anterior descending coronary vessel (after dipyridamole infusion), and brachial artery vasodilatation measurement (Vivid 7, GE Medical Systems Inc).

RESULTS

LV diameters and ejection fraction were comparable between the two groups, while systolic pulmonary pressure (P < 0.001) was increased in SSc. By chest-CT, 15 SSc patients showed interstitial pulmonary fibrosis. Serological antibodies analysis detected anti-centromere pattern in 14 SSc patients, and anti Scl-70 in 19 patients. In SSc, LV myocardial early diastolic peak velocity, peak systolic strain rate and strain were both reduced in basal and middle interventricular septum, and in basal and middle LV lateral wall. Both CFR (P < 0.0001) and endothelial flow-mediated dilatation (P < 0.001) were significantly lower in SSc patients. By stepwise forward multivariate analyses, CFR (P < 0.001) and endothelial function (P < 0.001) were powerful independent determinants of middle LV strain.

CONCLUSIONS

Strain rate imaging, transthoracic CFR, and brachial artery flow-mediated dilatation are valuable noninvasive and easily repeatable tools for detecting LV myocardial and vascular involvement caused by SSc. Their combined use may be therefore useful for early identifying patients with more diffused and severe form of SSc, ideally in asymptomatic cases prior to the development of severe vasculopathy, when it may be most feasible to modify the disease process by new potential therapies.

Significance of the distal to proximal coronary flow velocity ratio by transthoracic Doppler echocardiography for diagnosis of proximal left coronary artery stenosis

OBJECTIVE

This study was designed to evaluate the significance of accelerated coronary flow velocity in the proximal left coronary artery by transthoracic Doppler echocardiography for detecting coronary stenosis.

METHODS

Seventy subjects with suspected coronary artery disease underwent successful coronary flow velocity measurement in both proximal and distal lesions by transthoracic Doppler echocardiography and coronary angiography.

RESULTS

On the basis of the coronary angiography results, 23 patients had significant (> or =50%) stenosis in the proximal left coronary artery (Group S) and 47 patients had no stenosis (Group N). The distal averaged diastolic peak velocity to proximal averaged diastolic peak velocity ratio (DAPAR) in Group S was significantly lower than that in Group N. A cutoff value of DAPAR < or = 0.5 for DAPAR predicted significant coronary stenosis with a sensitivity of 91% and a specificity of 72%.

CONCLUSION

Measurement of the DAPAR by transthoracic Doppler echocardiography is a promising method in the noninvasive diagnosis of stenosis in the proximal left coronary artery lesion.

Immediate- and late-hemodynamic coronary effects of tadalafil in men with erectile dysfunction and coronary artery disease

We investigated whether coronary flow reserve (CFR) can be modified by tadalafil, a long-acting phosphodiesterase 5 (PDE5) inhibitor, in patients with documented coronary artery disease (CAD). CFR was non-invasively evaluated in 12 men with a positive history for erectile dysfunction (ED) and angiographically documented CAD, in the distal portion of the left anterior descending coronary artery, free from critical stenosis, with contrast enhanced echocardiography at time zero (T0). Then, after 20 mg tadalafil was orally administered CFR measurement was repeated after 2 h (T1) and after 24 h (T2). Doppler curves suitable for the analysis were obtained in all patients (CFR feasibility: 100%). The peak diastolic velocity after adenosine infusion increased from 71.3+/-14.3 cm/s at T0 to 82.5+/-24.0 at T1 (P=NS) and to 89.5+/-21.1 at T2 (P=0.0010). CFR after tadalafil increased significantly from 2.6+/-0.3 at T0 to 3.1+/-0.7 at T1 (P=0.0078) and a further increment was found at T2 (3.5+/-0.9; P=0.0010 vs T0). Our study shows that oral administration of tadalafil exerts a long standing, potentially beneficial effect on coronary microvasculature in patients with ED.

Impaired coronary microvascular function in familial Mediterranean fever

BACKGROUND

Patients with inflammatory rheumatic diseases have an increased risk of developing atherosclerosis. However, the question of whether patients with familial Mediterranean fever (FMF) are at risk of atherosclerosis and related diseases remains controversial.

OBJECTIVE

We aimed to use transthoracic Doppler echocardiography to investigate coronary flow reserve (CFR) and left ventricular (LV) diastolic function in patients with FMF.

METHODS

CFR and LV diastolic function were studied in 33 patients with FMF (16 men, 17 women; mean age, 36.7+/-12.0 years) and 35 healthy volunteers (20 men, 15 women; mean age, 36.8+/-5.2 years). Coronary diastolic peak flow velocities (DPFV) were measured at baseline and after dipyridamole infusion. LV diastolic function was assessed by standard and tissue Doppler imaging.

RESULTS

CFR was significantly lower in the FMF group than in the control group (2.27+/-0.38 versus 3.02+/-0.50, P<0.0001). Significant between-group differences were found regarding LV diastolic function mitral E/A ratio, mitral E-wave deceleration time, and lateral A(m). Serum high sensitivity C-reactive protein (hsCRP) levels were significantly higher in the patients with FMF, and hsCRP values independently correlated with CFR.

CONCLUSIONS

Coronary microvascular function and LV diastolic function are impaired in patients with FMF. The severity of these impairments is correlated with hsCRP. Impaired CFR may be an early manifestation of cardiac involvement in patients with FMF.