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Turer AT, Lewis GD, O'Sullivan JF, Elmariah S, Mega JL, Addo TA, Sabatine MS, de Lemos JA, Gerszten RE. Increases in myocardial workload induced by rapid atrial pacing trigger alterations in global metabolism. PLoS One 2014; 9:e99058. [PMID: 24932507 PMCID: PMC4059652 DOI: 10.1371/journal.pone.0099058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 05/09/2014] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To determine whether increases in cardiac work lead to alterations in the plasma metabolome and whether such changes arise from the heart or peripheral organs. BACKGROUND There is growing evidence that the heart influences systemic metabolism through endocrine effects and affecting pathways involved in energy homeostasis. METHODS Nineteen patients referred for cardiac catheterization were enrolled. Peripheral and selective coronary sinus (CS) blood sampling was performed at serial timepoints following the initiation of pacing, and metabolite profiling was performed by liquid chromatography-mass spectrometry (LC-MS). RESULTS Pacing-stress resulted in a 225% increase in the median rate·pressure product from baseline. Increased myocardial work induced significant changes in the peripheral concentration of 43 of 125 metabolites assayed, including large changes in purine [adenosine (+99%, p = 0.006), ADP (+42%, p = 0.01), AMP (+79%, p = 0.004), GDP (+69%, p = 0.003), GMP (+58%, p = 0.01), IMP (+50%, p = 0.03), xanthine (+61%, p = 0.0006)], and several bile acid metabolites. The CS changes in metabolites qualitatively mirrored those in the peripheral blood in both timing and magnitude, suggesting the heart was not the major source of the metabolite release. CONCLUSIONS Isolated increases in myocardial work can induce changes in the plasma metabolome, but these changes do not appear to be directly cardiac in origin. A number of these dynamic metabolites have known signaling functions. Our study provides additional evidence to a growing body of literature on metabolic 'cross-talk' between the heart and other organs.
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Affiliation(s)
- Aslan T Turer
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Gregory D Lewis
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - John F O'Sullivan
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Sammy Elmariah
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jessica L Mega
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Tayo A Addo
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Marc S Sabatine
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - James A de Lemos
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Robert E Gerszten
- Department of Internal Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Myocardial ischemia induced by rapid atrial pacing causes troponin T release detectable by a highly sensitive assay: insights from a coronary sinus sampling study. J Am Coll Cardiol 2011; 57:2398-405. [PMID: 21658559 DOI: 10.1016/j.jacc.2010.11.066] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 10/19/2010] [Accepted: 11/18/2010] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The purpose of this study was to assess whether: 1) very small increases in troponin T, measured by a new highly sensitive cardiac troponin T (hs-cTnT), may reflect ischemia without necrosis; and 2) serial changes can discriminate ischemia from other causes of cardiac troponin T (cTnT) release. BACKGROUND A new hs-cTnT assay offers greater sensitivity than current assays. METHODS Nineteen patients referred for diagnostic catheterization underwent cannulation of the coronary sinus (CS). Serial CS and peripheral plasma samples were obtained at multiple time points during and after incremental rapid atrial pacing. cTnT was quantified using both a standard and a pre-commercial highly sensitive assay. Ischemia was determined by the presence of significant coronary artery disease (CAD) and myocardial lactate release with pacing. RESULTS cTnT concentrations in CS blood increased from a median of 6.8 pg/ml prior to pacing to 15.6 pg/ml 60 min after termination of rapid atrial pacing (p < 0.0001), changes that were mirrored at 180 min in peripheral blood (5.1 to 11.8 pg/ml, p < 0.0001). Although peripheral cTnT concentrations tended to be higher at 180 min following pacing for patients with CAD and lactate elution (n = 7) when compared with those without either marker (n = 5) (25.0 pg/ml vs. 10.2 pg/ml, p = 0.10), relative (1.7-fold vs. 5.2-fold) and absolute (6.8 pg/ml vs. 8.8 pg/ml, p = 0.50) changes were not different between groups. CONCLUSIONS Brief periods of ischemia, without frank infarction, cause low-level cTnT release, and small increases are common after periods of increased myocardial work, even among patients without objective evidence of myocardial ischemia or obstructive CAD. Additional research is needed before hs-cTnT assays are widely adopted in the management of subjects with chest pain syndromes.
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Krüger D, ElMokhtari NE, Wieckhorst A, Simon-Herrmann G, Simon R. Intravascular ultrasound study and evidence of pathological coronary flow reserve in patients with isolated coronary artery aneurysms. Clin Res Cardiol 2010; 99:157-64. [DOI: 10.1007/s00392-009-0100-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Accepted: 12/08/2009] [Indexed: 10/20/2022]
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4
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Evidence of pathological coronary flow patterns in patients with isolated coronary artery aneurysms. Coron Artery Dis 2008; 19:249-55. [DOI: 10.1097/mca.0b013e3283030b4b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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5
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Modi SA, Siegel RJ, Birnbaum Y, Atar S. Systematic overview and clinical applications of pacing atrial stress echocardiography. Am J Cardiol 2006; 98:549-56. [PMID: 16893716 DOI: 10.1016/j.amjcard.2006.02.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Revised: 02/27/2006] [Accepted: 02/27/2006] [Indexed: 11/23/2022]
Abstract
Pacing atrial stress echocardiography (PASE) has been studied over the past 3 decades for the evaluation of myocardial ischemia. Published studies suggest that PASE may be used as an alternative to exercise or pharmacologic stress imaging. The recent introduction of improved pacing electrodes, together with use of accelerated and shortened pacing protocols and improvements in transthoracic echocardiographic imaging techniques, makes PASE an appealing stress imaging method. A critical analysis of the diagnostic accuracy of PASE shows equivalence with other imaging stress modalities. PASE has been found to be highly feasible and accurate technique that may expedite the diagnosis and risk stratification of patients with coronary artery disease. This review addresses the history, hemodynamics, protocols, accuracy, clinical utility, and cost-effectiveness of PASE as well as elucidating its place among other stress modalities.
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Affiliation(s)
- Shreyas A Modi
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA
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Høilund-Carlsen PF, Marving J, Gadsbøll N, Rasmussen S, Lønborg-Jensen H, Nielsen MD, Christensen NJ, Jensen BH. Acute effects of smoking on left ventricular function and neuro-humoral responses in patients with known or suspected ischaemic heart disease. Clin Physiol Funct Imaging 2004; 24:216-23. [PMID: 15233836 DOI: 10.1111/j.1475-097x.2004.00551.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Systolic left ventricular function was examined by radionuclide ventriculography in 12 habitual smokers with known or suspected ischaemic heart disease, aged 33-69 years, before, during, and after smoking of two cigarettes in a row and was repeated on a non-smoking control day. Plasma concentrations of adrenaline, noradrenaline, renin, and angiotensin II were determined on the smoking day, before and immediately after smoking. During smoking, there were significant increases in heart rate (+27%), rate-pressure product (+23%), and cardiac output (+14%) in the face of a significant increase in left ventricular end-systolic volume (+5%) and significant decreases in ejection fraction (-6%) and stroke volume (-8%). Blood pressure was virtually unchanged, and total peripheral resistance remained constant. Plasma adrenaline increased by 100%, renin decreased by 21%, and noradrenaline and angiotensin II did not change. The humoral changes were not correlated to changes in any of the haemodynamic variables. Areas of myocardial hypokinesis emerged or widened during smoking in 11 of 12 patients. Thus, in patients with known or suspected ischaemic heart disease, smoking was associated with an acute decrease in systolic ventricular function and development of widespread hypokinesis despite adrenaline stimulation.
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Buffon A, Rigattieri S, Santini SA, Ramazzotti V, Crea F, Giardina B, Maseri A. Myocardial ischemia-reperfusion damage after pacing-induced tachycardia in patients with cardiac syndrome X. Am J Physiol Heart Circ Physiol 2000; 279:H2627-33. [PMID: 11087214 DOI: 10.1152/ajpheart.2000.279.6.h2627] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The presence of myocardial ischemia in syndrome X (chest pain, "ischemia-like" electrocardiogram changes, and normal coronary angiograms) is uncertain possibly because, when focally distributed, it may not cause contractile dysfunction or lactate production. We measured lipid hydroperoxides (ROOHs) and conjugated dienes (CDs), two sensitive, independent markers of ischemia-reperfusion oxidative stress, in paired aortic and great cardiac vein blood samples before and after pacing-induced tachycardia in nine patients with syndrome X. Diagnostic ischemic S-T segment changes during pacing were followed by a consistent increase in ROOH and CD levels in the great cardiac vein (from 4.83 +/- 1.18 micromol/l at baseline to 7.88 +/- 1.12 micromol/l and from 0.038 +/- 0.002 to 0.051 +/- 0.003 arbitrary units, respectively, P < 0.01). In controls, ROOH and CD levels did not change after pacing. The large postpacing cardiac release of lipid peroxidation products, consistently observed in all patients and similar to that previously observed after ischemia caused by percutaneous transluminal coronary angioplasty, is consistent with an ischemic origin of syndrome X.
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Affiliation(s)
- A Buffon
- Institute of Cardiology, Università Cattolica del Sacro Cuore, Rome 00168, Italy.
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9
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Krüger D, Stierle U, Herrmann G, Simon R, Sheikhzadeh A. Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms ("dilated coronopathy"). J Am Coll Cardiol 1999; 34:1461-70. [PMID: 10551693 DOI: 10.1016/s0735-1097(99)00375-7] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The purpose of our study was to evaluate the clinical significance of isolated coronary artery ectasias or aneurysms (CEA). BACKGROUND It has been postulated that altered coronary blood flow in CEA predisposes patients to the development of myocardial ischemia (CI) and infarction. METHODS Sixty-seven patients with bilateral nonobstructive CEA without associated cardiac defects ("dilated coronaropathy") were derived from 16,341 cardiac catheterizations between 1986 and 1997. Ectasias were defined as luminal dilation of 1.5- to 2.0-fold, aneurysms of >2.0-fold of normal limits. Eleven of 25 patients presented with myocardial infarction due to an occlusion of the infarct vessel. In 42 patients without infarction (study group), exercise-induced CI was investigated. RESULTS A corresponding CI was documented in 32 of 42 patients in a coronary sinus lactate study (reduced lactate extraction 5.6 +/- 4.1%) and in 29 of 40 patients in an ergometry (0.25 +/- 0.06 mV ST depressions). The results differed significantly from a control group of 29 patients without heart disease (p < 0.001). Nitroglycerin (0.8 mg) provoked a further significant deterioration of CI in the 32 of 42 developing a frank cardiac lactate production (-2.6 +/- 6.8%, p < 0.001). The metabolic extent of CI was significantly correlated to the coronary diameters of the proximal and middle segments of left anterior descending artery and the middle segment of left circumflex artery (r = 0.87, p < 0.001). Stigmata of an impaired coronary blood flow such as delayed antegrade filling, segmental backflow phenomenon and local deposition of dye were found significantly more often with increasing coronary diameters (p < 0.04). CONCLUSIONS "Dilated coronaropathy" is an entity of nonobstructive, ischemic coronary artery disease. Nitroglycerin is of no therapeutic benefit but leads to an aggravation of exercise-induced CI.
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Affiliation(s)
- D Krüger
- University Hospital Lübeck, Germany
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10
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Abstract
Coronary flow reserve (CFR) is a critical measurement in the assessment of the coronary circulation. The development of this physiologic variable in animal and human studies is reviewed. Human studies documenting the limitations of coronary angiography, especially in the setting of severe diffuse coronary artery disease, are analyzed. Furthermore, the important variables that must be accounted for when CFR is measured are examined. With this background, the application of CFR in a variety of clinical settings and the development and use of the Doppler FloWire for its measurement are discussed.
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Affiliation(s)
- J D Joye
- Department of Medicine, Allegheny University, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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11
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Kamp O, De Cock CC, Küpper AJ, Roos JP, Visser CA. Simultaneous transesophageal two-dimensional echocardiography and atrial pacing for detecting coronary artery disease. Am J Cardiol 1992; 69:1412-6. [PMID: 1590229 DOI: 10.1016/0002-9149(92)90892-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study describes a new technique for assessing wall motion abnormalities, combining transesophageal echocardiography (TEE) and transesophageal atrial pacing in 71 patients. Stable capture was reached in 70 patients (99%). In 3 patients (4%) pacing was discontinued prematurely because of discomfort. TEE during pacing was performed in 52 patients with and in 18 patients without coronary artery disease (CAD). In 43 of 52 patients with CAD, regional wall motion abnormalities occurred (sensitivity 83%). No wall motion abnormalities occurred in 17 of 18 patients without CAD (specificity 94%, positive predictive value 98%). Wall motion abnormalities related to another vascular region were observed in 17 of 22 patients with previous myocardial infarction (sensitivity 77%, specificity 100%, positive predictive value 100%). Simultaneous 12-lead electrocardiography during atrial pacing was performed in 57 patients and yielded positive results in 21 of 40 patients with (sensitivity 52%) and in 3 of 17 patients without (specificity 82%, positive predictive value 88%) CAD. Exercise stress testing was performed in 66 patients. Twenty-four of 48 patients with CAD had a positive exercise electrocardiogram (sensitivity 50%); a false-positive exercise electrocardiogram was observed in 3 of 18 patients (specificity 83%, positive predictive value 89%). It is concluded that TEE during transesophageal atrial pacing is a feasible and promising alternative technique for the assessment of CAD, with a higher sensitivity than simultaneous 12-lead and exercise electrocardiography.
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Affiliation(s)
- O Kamp
- Department of Cardiology, Free University Hospital, Amsterdam, The Netherlands
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12
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De Marco T, Deedwania P, Chatterjee K. Systemic and coronary hemodynamic effects of bepridil in patients with depressed left ventricular function. Am J Cardiol 1992; 69:31D-36D. [PMID: 1553889 DOI: 10.1016/0002-9149(92)90956-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To assess the effects of oral bepridil therapy (10-14 days) on cardiac performance and myocardial energetics in the presence of depressed left ventricular function, systemic and coronary hemodynamic effects and neurohumoral effects were evaluated in 7 patients with coronary artery disease and reduced ejection fraction at control, submaximal, and maximal pacing rates during atrial pacing stress. After bepridil therapy, arterial, right atrial, and left ventricular filling pressures as well as systemic vascular resistance and left ventricular stroke work index did not change, suggesting no deleterious effects of bepridil on cardiac performance in patients with reduced ejection fraction. Rate-pressure product, myocardial oxygen consumption, coronary sinus blood flow, myocardial lactate extraction, and catecholamine balance remained unchanged. Development of angina during pacing showed a variable response to bepridil. We conclude that despite its potential negative inotropic effect, bepridil does not exert deleterious effects on hemodynamics or left ventricular performance. The mechanism for its beneficial antianginal effect may be due to favorable redistribution of myocardial blood flow to ischemic zones; no clear effect on anginal threshold or sympathetic tone could be demonstrated in these patients.
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Affiliation(s)
- T De Marco
- Department of Medicine, University of California, San Francisco 94143-0124
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13
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Dhainaut J, Schremmer B, Lanore J. The coronary circulation and the myocardial oxygen supply/uptake relationship: A short review. J Crit Care 1991. [DOI: 10.1016/0883-9441(91)90034-q] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Perin E, Petersen F, Massumi A. Rate-related left bundle branch block as a cause of non-ischemic chest pain. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 22:45-6. [PMID: 1995174 DOI: 10.1002/ccd.1810220111] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A case is presented of rate-dependent left bundle branch block associated with chest pain in a patient with angiographically normal coronary arteries. Lactate extraction showed no evidence of myocardial ischemia. It appears that in this case, chest pain was associated with sudden ventricular asynergy rather than myocardial ischemia.
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Affiliation(s)
- E Perin
- Department of Adult Cardiology, Texas Heart Institute, St. Luke's Episcopal Hospital, Houston 77030
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15
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Iliceto S, Caiati C, Ricci A, Amico A, D'Ambrosio G, Ferri GM, Izzi M, Lagioia R, Rizzon P. Prediction of cardiac events after uncomplicated myocardial infarction by cross-sectional echocardiography during transesophageal atrial pacing. Int J Cardiol 1990; 28:95-103. [PMID: 2365537 DOI: 10.1016/0167-5273(90)90013-u] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Atrial pacing can safely be utilized shortly after myocardial infarction. To evaluate the prognostic value of wall motion abnormalities induced by such pacing 83 consecutive patients with recent uncomplicated myocardial infarction underwent transthoracic cross-sectional echocardiography during transesophageal atrial pacing and upright bicycle exercise stress test. Patients were followed-up for 14 +/- 5 months. During the atrial pacing and the echocardiography, patients were defined at high risk if abnormalities of wall motion were detected in left ventricular regions remote from the infarcted area. Then, during the exercise stress test, high risk patients were those with ST segment depression greater than or equal to 1 mm. On the other hand, patients were considered to be at low risk if they had no abnormalities of wall motion during atrial pacing in remote regions or, in the case of the stress test, if they did not develop ST depression greater than or equal to 1 mm. Of the 83 patients, 21 had major cardiac events during the period of follow-up. Cardiac events occurred in 15/23 (65%) and 5/60 (8%, P less than 0.001) patients assigned to the groups adjudged to be at high and low risk, respectively, on the basis of echocardiographic results. Exercise testing was less reliable in identifying patients at risk of future cardiac events. Major events occurred in only 6 of the 19 patients with a positive stress test (32%, P less than 0.05 vs positive stress echocardiography) and in 14 of the 64 patients with a negative exercise stress test (22%, P = NS vs positive exercise stress test, P less than 0.05 vs negative atrial pacing echocardiography).
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Affiliation(s)
- S Iliceto
- Division of Cardiology, University of Bari, Italy
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16
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Martínez Martínez JA, Mele E, Suárez L. The prognostic value of right atrial pacing after acute myocardial infarction. Int J Cardiol 1990; 28:43-9. [PMID: 2365531 DOI: 10.1016/0167-5273(90)90007-r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We performed right atrial pacing in 90 consecutive patients 10 to 30 days (mean 16.8 days) after acute myocardial infarction. Right atrial pacing was normal in 28 patients, depression of the ST segment occurred in 27 patients, systolic blood pressure fell below control values in 20 patients and, in 15 patients, right atrial pacing was non-diagnostic. Follow-up was from 12 to 28 months (mean = 17.3). Global mortality was 11.1%, with none of the patients with normal tests dying, 11% of those with ST depression, 30% of those with induced hypotension (P less than 0.01) and 7.1% of those in whom pacing was non-diagnostic. Patients with high clinical risk at discharge in Peel Class III-IV, showed 41.2% mortality during the period of follow-up. None of those had shown normal responses to pacing, but those dying included 50% of the patients with ST depression and 66.7% of those in whom right atrial pacing induced hypotension. Development of new angina during the period of follow-up was more frequent among the patients with ST depression (33.3%) (P less than 0.001). Thus, our results showed that right atrial pacing was useful in predicting mortality after acute myocardial infarction. In patients at high risk, we observed that a fall of systolic blood pressure was the best predictor of mortality.
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Affiliation(s)
- J A Martínez Martínez
- Division of Cardiology, Hospital José de San Martin, University of Buenos Aires, Argentina
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Ogawa T, Ishii M, Iida K, Iida K, Ajisaka R, Yamaguchi I, Sugishita Y, Ito I. Mechanisms of stress-induced ST elevation and negative T-wave normalization studied by serial cardiokymogram in patients with a previous myocardial infarction. Am J Cardiol 1990; 65:962-6. [PMID: 2327356 DOI: 10.1016/0002-9149(90)90997-f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Seventeen patients with a previous myocardial infarction were studied during pacing to characterize the clinical correlates of ST elevation, to analyze the relation between ST elevation and negative T-wave normalization and to investigate the mechanism of these electrocardiographic changes. Myocardial ischemia was evaluated by measurement of blood lactate, and wall motion was analyzed using cardiokymographs concurrently and serially. Results show that ST elevation and negative T-wave normalization were most marked in leads containing abnormal Q waves, that ST elevation greater than or equal to 1 mm during pacing was associated with a significant increase in left ventricular end-diastolic pressure and deterioration of left ventricular wall motion and that the magnitude of ST elevation and negative T-wave normalization was significantly correlated, but the latter appeared earlier and more markedly. In addition, there was no significant correlation between the extent of either ST elevation or negative T-wave normalization and myocardial lactate production. Thus, ST elevation and negative T-wave normalization are caused by abnormal left ventricular wall motion rather than myocardial ischemia. Negative T-wave normalization is a more sensitive marker of abnormal wall motion than ST elevation in patients with a previous myocardial infarction.
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Affiliation(s)
- T Ogawa
- Department of Internal Medicine, University of Tsukuba, Japan
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18
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Abstract
The examination of a patient with angina pectoris begins with clinical assessment. Certain clinical findings that are present only during angina, such as mitral regurgitation due to ischemia-induced papillary muscle dysfunction, may clarify an otherwise uncertain diagnosis. Electrocardiography is a useful and relatively inexpensive test for detecting evidence of ischemia in patients with suspected angina. The presence of cardiomegaly on the chest roentgenogram has adverse prognostic implications. Exercise stress testing is important in the diagnosis of coronary artery disease and also provides prognostic information. Patients should be classified into high-, intermediate-, or low-risk subsets by noninvasive techniques. Although relatively easy and inexpensive, treadmill exercise stress testing cannot be performed in all patients, and sometimes it will yield equivocal results. In these cases, radionuclide testing (with thallium scintigraphy or radionuclide angiography) can be helpful and also can identify high-risk patients. Some patients will require coronary angiography.
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Bedotto JB, Eichhorn EJ, Popma JJ, Dehmer GJ. Effects of intravenous isradipine on left ventricular performance during rapid atrial pacing in coronary artery disease. Am J Cardiol 1990; 65:189-94. [PMID: 2136968 DOI: 10.1016/0002-9149(90)90083-d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The effects of isradipine, a new dihydropyridine calcium antagonist, were evaluated in 24 patients referred for elective cardiac catheterization because of suspected coronary artery disease. Hemodynamics and left ventricular (LV) function (by digital subtraction angiography) were measured at baseline and during rapid atrial pacing (mean peak heart rate 135 beats/min), which induced chest pain or electrocardiographic changes in all patients. After a control pacing period, intravenous isradipine (0.01 mg/kg, n = 16) or placebo (n = 8) was administered in a double-blind fashion and all variables were measured again at baseline and during pacing to the same maximum heart rate. Before isradipine was given, pacing had no effect on systolic blood pressure, while increasing diastolic blood pressure (68 +/- 8 to 87 +/- 11 mm Hg, p less than 0.0001) and LV end-diastolic pressure measured in the immediate postpacing period (13 +/- 5 to 18 +/- 6 mm Hg, p less than 0.03) and decreasing LV end-diastolic volume index (59 +/- 18 to 40 +/- 12 ml/m2, p less than 0.001), stroke volume index (37 +/- 11 to 23 +/- 10 ml/m2, p less than 0.0001), ejection fraction (0.64 +/- 0.07 to 0.53 +/- 0.12, p less than 0.0003) and percent regional shortening in 4 of 5 myocardial wall segments. During pacing after isradipine, systolic and diastolic blood pressures were lower, ejection fraction was higher and percent regional shortening decreased in only 2 of 5 myocardial segments. In comparison to placebo, isradipine increased baseline heart rate, ejection fraction and stroke volume index while it decreased arterial pressure and end-systolic volume index before the second pacing period.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J B Bedotto
- Cardiac Catheterization Laboratory, Dallas Veterans Administration Medical Center, Texas 75216
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20
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Young LH, Zaret BL, Barrett EJ. Physiologic hyperinsulinemia stimulates lactate extraction by heart muscle in the conscious dog. Metabolism 1989; 38:1115-9. [PMID: 2682138 DOI: 10.1016/0026-0495(89)90049-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The effect of physiologic hyperinsulinemia on the net balance of lactate, glucose, and free fatty acids across the heart was studied in eight normal postabsorptive conscious dogs. After obtaining basal measurements of myocardial substrate balance, arterial plasma insulin was increased from 8 +/- 1 to 68 +/- 14 microU/mL while blood glucose was maintained constant (64 +/- 1 mg/dL) using the hyperinsulinemic euglycemic clamp. Myocardial lactate uptake increased nearly fourfold, from 5.8 +/- 1.8 to 22.4 +/- 2.9 mumol/min (P less than .005). Despite a small increase in arterial lactate concentration from 0.46 +/- 0.08 to 0.79 +/- 0.11 mmol/L (P less than .02), the lactate extraction fraction increased from 23% +/- 7% to 54% +/- 2% (P less than .001) indicating an increased efficiency of lactate extraction. Euglycemic hyperinsulinemia led to a comparable increase in myocardial glucose uptake (6.7 +/- 2.3 to 18.2 +/- 3.7 mumol/min, P less than .05). Arterial free fatty acid concentrations fell from 1.06 +/- 0.13 to 0.35 +/- 0.06 mmol/L (P less than .001) with a concomitant decline in the myocardial uptake of free fatty acids from 18.5 +/- 5.3 to 5.8 +/- 2.9 mumol/min (P less than .05). These results indicate that physiologic hyperinsulinemia increases lactate as well as glucose uptake in normal heart muscle.
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Affiliation(s)
- L H Young
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510
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Camici P, Ferrannini E, Opie LH. Myocardial metabolism in ischemic heart disease: basic principles and application to imaging by positron emission tomography. Prog Cardiovasc Dis 1989; 32:217-38. [PMID: 2682779 DOI: 10.1016/0033-0620(89)90027-3] [Citation(s) in RCA: 211] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The human heart in the fasting state extracts FFA, glucose, lactate, pyruvate, and ketone bodies from the systemic circulation. Of these substrates, FFA utilization accounts for the greater part of oxygen consumption and energy production. The oxidative use of lipid (FFA) and carbohydrate (glucose and lactate) fuels is reciprocally regulated through the operation of Randle's cycle. Feeding, by increasing both insulin and glucose concentration, shifts myocardial metabolism towards preferential carbohydrate usage, both for oxidative energy generation and for glycogen synthesis. During conditions of reduced oxygen supply, the oxidation of all substrates is decreased while anaerobic metabolism is activated. In patients with coronary artery disease and stable angina pectoris, lactate release in the CS can be demonstrated during pacing stress. However, this occurs in only 50% of patients, and no relationship can be demonstrated between lactate production and the severity of ischemia. In patients with chronic angina, a significant release of alanine in the CS and an increased myocardial uptake of glutamate could be demonstrated at rest and following pacing. These two phenomena result from increased transamination of excess pyruvate to alanine with glutamate serving as NH2 donor. In addition, release of citrate (a known inhibitor of glycolysis) in the CS can be demonstrated following pacing in patients with stable angina. The introduction of PET has made it possible to study regional myocardial perfusion and metabolism in humans noninvasively. Two basically different patterns of myocardial glucose utilization have been observed in patients with coronary artery disease studied at rest using 18F-flurodeoxyglucose. In patients with stable angina on exercise but studied at rest, regional myocar- dial glucose utilization was homogeneously low and comparable with that of a group of normals. In contrast, in patients with unstable angina, myocardial glucose utilization at rest was increased even in the absence of symptoms and ECG signs of acute ischemia. In patients with stable angina, a prolonged increase in glucose uptake could be demonstrated in the post-ischemic myocardium in the absence of perfusion abnormalities, and a state of chronic metabolic ischemia is proposed. PET imaging has also allowed prospective differentiation between viable and nonviable segmental function in patients with recent myocardial infarction and in those undergoing coronary artery surgery; in both cases viable segments have relatively maintained glucose uptakes, whereas nonviable segments have depressed glucose uptakes.
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Affiliation(s)
- P Camici
- CNR Institute of Clinical Physiology, University of Pisa, Italy
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22
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Hogg KJ, Hornung RS, Hillis WS, Gupta S, Grant P, Singh SP. Pharmacodynamics of amlodipine: hemodynamic effects and antianginal efficacy after atrial pacing. Am Heart J 1989; 118:1107-13. [PMID: 2530869 DOI: 10.1016/0002-8703(89)90837-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The hemodynamic effects and antianginal efficacy of 10 mg amlodipine administered intravenously were assessed for 45 minutes in 18 subjects with stable angina pectoris. After amlodipine the heart rate was increased from 75 +/- 12 beats/min to 80 +/- 15 beats/min (p less than 0.05) for at least 15 minutes, with a decrease in systemic vascular resistance of 1091 +/- 205 to 815 +/- 390 dynes/sec/cm5 and a decrease in mean arterial pressure at 30 minutes from 99 +/- 11 to 91 +/- 10 (p less than 0.05). There was no change in dp/dt or dp/dt/IP or in cardiac output, wedge pressure, or pulmonary artery pressure. In the parallel placebo group (n = 8) there was no change in any of the hemodynamic parameters. Time to pacing-induced angina was increased in the treated group (n = 12) from 6 +/- 3.2 minutes before the dose to 8.2 +/- 4 minutes after the dose (p less than 0.01) compared to the control subjects who were given saline solution, in whom the time increased from 7 +/- 1.5 minutes before the dose to 7.5 +/- 2.2 minutes after the dose (n = 9). The double product at an equivalent pacing time to the initial onset of angina was reduced after therapy from 15,590 +/- 1490 to 14,100 +/- 1193 with a reduction in ST segment shift from 11.9 +/- 9.4 mm2 to 6.2 +/- 5.6 mm2 (p less than 0.05). Amlodipine after intravenous use has a vasodilator effect and also increases the anginal threshold without deleterious negative inotropic effects.
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Affiliation(s)
- K J Hogg
- Department of Materia Medica, University of Glasgow, Stobhill General Hospital, Scotland
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23
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Matthews RV, Haskell RJ, Ginzton LE, Laks MM. Usefulness of esophageal pill electrode atrial pacing with quantitative two-dimensional echocardiography for diagnosing coronary artery disease. Am J Cardiol 1989; 64:730-5. [PMID: 2801523 DOI: 10.1016/0002-9149(89)90755-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Noninvasive diagnosis of coronary artery disease (CAD) is difficult in patients who are unable to exercise. In this study esophageal pill electrode atrial pacing was used as a myocardial stress not requiring exercise, and changes in ejection fraction and pressure volume ratio during pacing with 2-dimensional echocardiography were quantitatively analyzed. All patients had completed a Bruce protocol treadmill exercise test and had undergone coronary arteriography. Of 26 patients, 22 were successfully paced (85%). Comparable rate-pressure products were obtained for treadmill exercise (23,500 +/- 5,900 mm Hg/min) and pacing (24,100 +/- 4,400 mm Hg/min; difference not significant). Of the 22 patients completing the study 8 had normal coronary arteries (group I) and 14 had CAD (group II). The change in ejection fraction with pacing in group I patients was not significant (3 +/- 8%). In group II ejection fraction decreased with pacing (-8 +/- 13%; p = 0.025). The pressure/volume ratio increased in group I with pacing (3.8 +/- 1.8 mm Hg/min/m2; p = 0.05) and was unchanged in group II (0.3 +/- 1.8 mm Hg/min/m2; difference not significant). Using an ejection fraction decrease with pacing or a failure to increase pressure/volume ratio with pacing as criterion for the presence of CAD, similar predictive accuracies were obtained when compared to treadmill exercise testing. Esophageal pill electrode atrial pacing with quantitative 2-dimensional echocardiography may be a useful noninvasive, nonexercise method to detect CAD.
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Affiliation(s)
- R V Matthews
- Heart Institute, Hospital of the Good Samaritan, Los Angeles, California 90017
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24
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Stratmann HG, Kennedy HL. Evaluation of coronary artery disease in the patient unable to exercise: alternatives to exercise stress testing. Am Heart J 1989; 117:1344-65. [PMID: 2567110 DOI: 10.1016/0002-8703(89)90417-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Exercise stress testing is a well-established method for the diagnostic, prognostic, and functional assessment of patients with known or suspected CAD. A variety of alternative tests have been described in patients unable to perform leg exercise. Atrial pacing and dipyridamole imaging have been evaluated most extensively, and results compare favorably with those of exercise testing for diagnosing the presence of CAD. Both tests may be used to assess prognosis after myocardial infarction, and dipyridamole imaging may be useful in patients undergoing preoperative evaluation. The use of the cold pressor test and isometric handgrip exercise have also been described. However, the value of both tests is limited by a relatively low sensitivity for detecting the presence of CAD. Other testing modalities--arm ergometry, intravenous infusion of beta-adrenergic agonists, and transthoracic pacing--show promise but require further assessment to confirm their value.
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Affiliation(s)
- H G Stratmann
- Department of Cardiology, St. Louis Veterans Administration Medical Center, MO 63125
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25
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De Marco T, Chatterjee K, Rouleau JL, Parmley WW. Abnormal coronary hemodynamics and myocardial energetics in patients with chronic heart failure caused by ischemic heart disease and dilated cardiomyopathy. Am Heart J 1988; 115:809-15. [PMID: 3354409 DOI: 10.1016/0002-8703(88)90883-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Coronary sinus blood flow, transmyocardial oxygen extraction, myocardial oxygen consumption, and transmyocardial lactate extraction were determined, along with systemic hemodynamics, in 34 patients with chronic stable angina without heart failure (group 1), in 66 patients with heart failure associated with coronary artery disease (group 2), and in 28 patients with heart failure caused by dilated cardiomyopathy without coronary artery disease (group 3). Compared with group 1 patients, in patients with heart failure in groups 2 and 3, resting coronary sinus blood flow was 30% and 24% higher, respectively (p less than 0.05), myocardial oxygen consumption was 25% higher (p less than 0.01), and coronary sinus oxygen content was 33% lower (p less than 0.01). The rate-pressure product was not different between the three groups. In eight patients with heart failure (five in group 2 and three in group 3), myocardial lactate production was observed without angina. Thus in patients with chronic heart failure resulting from either chronic coronary artery disease or dilated cardiomyopathy, resting coronary blood flow and myocardial oxygen consumption tend to increase probably because of an increase in myocardial oxygen requirements. Silent myocardial ischemia may also occur in both the presence and absence of coronary artery disease in patients with chronic heart failure. The abnormal coronary hemodynamics and myocardial metabolic function may play a role in causing progressive deterioration in cardiac function in dilated cardiomyopathy.
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Affiliation(s)
- T De Marco
- Department of Medicine, University of California, San Francisco 94143
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26
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Andersen K, Vik-Mo H. Detection of left ventricular ischemia during atrial pacing: simultaneous assessment by echocardiography and invasive hemodynamic measurements. Int J Cardiol 1988; 18:173-85. [PMID: 3343073 DOI: 10.1016/0167-5273(88)90163-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The ability of cross-sectional echocardiography to detect myocardial ischemia induced by atrial pacing was assessed during cardiac catheterization in 11 patients with coronary arterial disease. Angina pectoris was precipitated in all patients with increase in left ventricular end-diastolic pressure after pacing by 5 +/- 6 (mean +/- standard deviation) mm Hg (P less than 0.01). Regional left ventricular dysfunction occurred during pacing in all patients as determined by quantitative echocardiographic assessment of wall motion. Simultaneously, systolic reduction in parasternal short-axis area decreased (from 42 +/- 13 to 28 +/- 9%, P less than 0.01) with concomitant decrease in ejection fraction as determined in the apical four-chamber view (from 49 +/- 5 to 40 +/- 8%, P less than 0.01). In conclusion, echocardiography may detect pacing-induced myocardial ischemia through detection of regional and global left ventricular dysfunction. Inadequate regional perfusion may be indicated by echocardiography even in patients without apparent evidence of ischemia as determined by invasive hemodynamic measurements.
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Affiliation(s)
- K Andersen
- Department of Clinical Physiology, Haukeland Hospital, University of Bergen, Norway
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27
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Chappuis FP, Widmann TF, Nicod P, Peterson KL. Densitometric regional ejection fraction: a new three-dimensional index of regional left ventricular function--comparison with geometric methods. J Am Coll Cardiol 1988; 11:72-82. [PMID: 3275707 DOI: 10.1016/0735-1097(88)90169-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Densitometric regional ejection fraction obtained by computer analysis of digital subtraction ventriculography was evaluated as a new, quantitative, three-dimensional index of regional left ventricular performance. Eighteen patients with coronary artery disease and seven control subjects had right anterior oblique ventriculography at rest and immediately after rapid atrial pacing using central venous injection of contrast material. Regional left ventricular ejection fraction was determined by densitometry in six segments drawn around the end-diastolic center of gravity, and compared with two conventional indexes of segmental wall motion: area and radial regional ejection fraction. Densitometric, area or radial regional ejection fraction was classified as abnormal if it fell at least 2 standard deviations below the corresponding mean value in the normal group. The densitometric method did not require outlining of the end-systolic left ventricular silhouette and was the easiest and fastest to perform of all three techniques. In addition, intra- and interobserver reproducibilities were higher with the densitometric method (r = 0.97 and 0.95) than with either the area (r = 0.84 and 0.82) or the radial method (r = 0.82 and 0.76). Regional left ventricular dysfunction as assessed by the densitometric, area and radial techniques allowed the detection of coronary artery disease in 50, 50 and 44% of the patients at rest and in 83, 67 and 61% of the patients in the post-pacing period, respectively. Post-pacing regional left ventricular dysfunction accurately predicted the presence or absence of greater than 70% diameter stenosis in the supplying coronary artery in 75, 67 and 56% of the cases, respectively. Thus, densitometric analysis of digital subtraction ventriculography allows a fast and reproducible three-dimensional determination of regional left ventricular ejection fraction. Using this technique, pacing-induced regional dysfunction can be detected in most patients with coronary artery disease and corresponds well with the location of significant coronary artery lesions.
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Affiliation(s)
- F P Chappuis
- Division of Cardiology, University of California San Diego Medical Center 92103
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28
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Crake T, Canepa-Anson R, Shapiro L, Poole-Wilson PA. Continuous recording of coronary sinus oxygen saturation during atrial pacing in patients with coronary artery disease or with syndrome X. BRITISH HEART JOURNAL 1988; 59:31-8. [PMID: 3342147 PMCID: PMC1277069 DOI: 10.1136/hrt.59.1.31] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Coronary sinus oxygen saturation was measured continuously during incremental atrial pacing in 34 patients undergoing cardiac catheterisation. In eleven patients with normal coronary arteriograms, negative exercise tests, and no ST segment depression on the electrocardiogram, an increase in the rate of atrial pacing transiently decreased coronary sinus oxygen saturation but within 20 s oxygen saturation returned to the control value. In six patients with coronary artery disease ST segment depression developed during atrial pacing. The coronary sinus oxygen saturation fell and remained reduced until pacing was discontinued. The size of the fall of coronary sinus oxygen saturation increased with increasing heart rate. In seven patients with coronary artery disease the ST segments were unaltered during atrial pacing and coronary sinus oxygen saturation did not fall. Ten patients with syndrome X were studied. In six ST segment depression developed on atrial pacing. In five, three of whom developed ST segment depression, the changes in coronary sinus oxygen saturation during atrial pacing were similar to those observed in patients without any evidence of coronary artery disease. In three, all of whom developed ST segment depression, coronary sinus oxygen saturation gradually increased throughout the period of atrial pacing. In two patients coronary sinus oxygen saturation fell in a manner similar to that observed in patients with obstructive coronary artery disease who developed ST segment depression on pacing. Thus regulation of coronary blood flow in normal persons in response to an increase of heart rate is rapid. Oxygen extraction across the coronary bed can increase by up to 30% and a persistent increase in oxygen extraction is an indicator of myocardial ischaemia. The term "syndrome X" does not describe a homogeneous group of patients but in the majority coronary sinus oxygen saturation does not fall despite symptoms and changes on the electrocardiogram, indicating that inadequate coronary blood flow is not the dominant mechanism.
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Affiliation(s)
- T Crake
- Cardiothoracic Institute, London
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29
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Thomassen AR, Bagger JP, Nielsen TT, Pedersen EB. Atrial natriuretic peptide during pacing in controls and patients with coronary arterial disease. Int J Cardiol 1987; 17:267-79. [PMID: 2960626 DOI: 10.1016/0167-5273(87)90075-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
At rest, during cardiac catheterization, aortic plasma levels of immunoreactive atrial natriuretic peptide did not differ between 10 controls with atypical chest pains and normal coronary arteries and 9 patients with stable angina pectoris and coronary arterial disease (55.2 +/- 19.8 vs. 64.8 +/- 19.8 pg/ml, NS). Nor did atrial natriuretic peptide values differ between the two groups during or after atrial pacing (150 beats/minute), which induced electrocardiographic and metabolic signs of acute myocardial ischaemia in the patients with coronary arterial disease but in none of the controls. Pacing, when carried out for more than 300 seconds, induced an increase of plasma atrial natriuretic peptide that correlated with duration of pacing (r = 0.80, P less than 0.001), and similarly in controls and patients with coronary arterial disease. In a second part of the study, which included 2 controls and 2 patients with coronary arterial disease, post-pacing coronary sinus concentrations of atrial natriuretic peptide were 10-20 times higher than peripheral levels (415- greater than 890 pg/ml). The concentration of atrial natriuretic peptide rose as blood from the caval veins (34 +/- 7 pg/ml) entered the right atrium (56 +/- 24 pg/ml), but thereafter was unchanged in the pulmonary artery (51 +/- 3 pg/ml) and the aorta (46 +/- 9 pg/ml). In conclusion, the results gave no evidence for ischaemic heart disease without congestive cardiac failure to be associated with altered levels of atrial natriuretic peptide. It was confirmed that atrial pacing stimulates the secretion of atrial natriuretic peptide which is produced by the heart and released via the coronary sinus into the circulation.
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Affiliation(s)
- A R Thomassen
- Department of Cardiology B, Aarhus Kommunehospital, Denmark
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30
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Picano E, Lattanzi F, Masini M, Distante A, L'Abbate A. Usefulness of a high-dose dipyridamole-echocardiography test for diagnosis of syndrome X. Am J Cardiol 1987; 60:508-12. [PMID: 3630933 DOI: 10.1016/0002-9149(87)90295-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study assesses whether the high-dose dipyridamole-echocardiography test (DET, 2-D echocardiographic and 12-lead electrocardiographic monitoring during dipyridamole infusion, up to 0.84 mg/kg over 10 minutes) can help to identify patients with syndrome X. DET was performed in 10 control subjects (group A) and in 19 patients with syndrome X (group B). Patients in group B had chest pain on effort, a positive exercise stress response (more than 0.1 mV of ST-segment depression), negative ergonovine test response and normal left ventricular function and coronary angiographic findings. During DET no subject in group A showed transient asynergy or ST-segment depression and none had chest pain; in group B, no patient had transient asynergy, 13 (68%) had chest pain and 16 (84%) had more than 0.1 mV of ST-segment depression. Percent fractional shortening was not significantly different in the 2 study groups, either basally (group A, 35 +/- 7; group B, 37 +/- 8) or at peak hyperkinesia during DET (group A, 48 +/- 8; group B, 54 +/- 10). Thus, dipyridamole-induced chest pain and ST-segment depression in patients with syndrome X are not associated with impaired regional or global left ventricular function. This entity of echocardiographically silent myocardial ischemia during DET may be a clue to noninvasive detection of syndrome X.
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31
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De Marco T, Daly PA, Liu M, Kayser S, Parmley WW, Chatterjee K. Enalaprilat, a new parenteral angiotensin-converting enzyme inhibitor: rapid changes in systemic and coronary hemodynamics and humoral profile in chronic heart failure. J Am Coll Cardiol 1987; 9:1131-8. [PMID: 3033043 DOI: 10.1016/s0735-1097(87)80318-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Systemic and coronary hemodynamic, metabolic and humoral effects of a new intravenous angiotensin-converting enzyme inhibitor, enalaprilat, were evaluated in 14 patients with chronic heart failure. Onset of hemodynamic action occurred within 15 minutes and persisted for 6 hours. At the time of peak effect, there was a significant reduction in mean arterial pressure (-21%) and pulmonary capillary wedge pressure (-33%). Systemic vascular resistance decreased by 32% and stroke volume index increased by 20%. These systemic hemodynamic changes indicate improved left ventricular function. There was a substantial sustained reduction in rate-pressure product initially without a change in coronary sinus blood flow or myocardial oxygen consumption. There was also reduced myocardial oxygen extraction and augmented coronary sinus oxygen saturation at 30 minutes and 1 hour. In three patients, abnormal myocardial lactate extraction, present before enalaprilat, changed to uptake after enalaprilat, indicating amelioration of myocardial ischemia that was not clinically manifest. Systemic catecholamine levels and myocardial catecholamine balance did not change. Plasma renin activity increased and plasma aldosterone decreased. These findings suggest that enalaprilat produces inhibition of the angiotensin-converting enzyme and consequent beneficial systemic hemodynamic changes in heart failure. In some patients with heart failure, silent myocardial ischemia at rest can occur and can be alleviated with enalaprilat. Decreased myocardial oxygen extraction, increased coronary sinus oxygen saturation and lack of expected decrease in coronary sinus blood flow despite reduced rate-pressure product suggest transient coronary vasodilation by enalaprilat.
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32
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Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 1987; 59:23C-30C. [PMID: 2950748 DOI: 10.1016/0002-9149(87)90192-5] [Citation(s) in RCA: 343] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The development of an ischemic event, whether silent or painful, represents the cumulative impact of a sequence of pathophysiologic events. Each ischemic episode is initiated by an imbalance between myocardial oxygen supply and demand that may ultimately be manifested as angina pectoris. This sequence of events can be termed the ischemic cascade. The significance of this concept resides in the fact that it redirects the focus from the end result--angina--to the more fundamental, underlying pathophysiologic factors that precede it. Specifically, these events include diminished left ventricular compliance, decreased myocardial contractility, increased left ventricular end-diastolic pressure, ST-segment changes and, occasionally, angina pectoris.
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33
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Khuri SF, Warner KG, Marston W, Josa M, Sharma G, Tow D, Hunt H, Schonmetzler HK. Intraoperative assessment of the physiologic significance of coronary stenosis in humans. J Thorac Cardiovasc Surg 1986. [DOI: 10.1016/s0022-5223(19)35934-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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34
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Iliceto S, D'Ambrosio G, Sorino M, Papa A, Amico A, Ricci A, Rizzon P. Comparison of postexercise and transesophageal atrial pacing two-dimensional echocardiography for detection of coronary artery disease. Am J Cardiol 1986; 57:547-53. [PMID: 3953437 DOI: 10.1016/0002-9149(86)90832-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Two-dimensional (2-D) echocardiography during transesophageal atrial pacing (TAP) was recently proposed as an alternative to exercise 2-D echocardiography for the diagnosis of coronary artery disease (CAD). To compare these 2 methods, 78 consecutive patients with good-quality echocardiographic (echo) examinations at rest were studied. Two-dimensional echocardiography was performed immediately after supine bicycle exercise and at peak atrial pacing obtained with transesophageal atrial stimulation. Twenty patients were excluded: 16 because of poor quality of 2-D echo images after exercise and 4 because of inadequate TAP studies (atrial capture not achieved in 2 and intolerance in 2). Of the remaining 58 patients, 39 had significant CAD (at least 75% diameter stenosis of at least 1 major coronary artery) and 19 had no significant CAD. The 2 test responses were considered positive if a wall motion abnormality was detected during pacing or after exercise. Sensitivity and specificity were 82% and 95% after exercise and 90% and 84% during TAP. In patients with significant CAD but without wall motion abnormalities at rest, sensitivity was 75% during pacing and 56% after exercise. In patients with significant CAD, the wall motion score index decreased significantly with both types of stress; during pacing wall motion score index was significantly lower than after exercise. Thus, 2-D echo during TAP appears to be a feasible and reliable alternative to postexercise echo for the detection of CAD.
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35
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Mirvis DM, Ramanathan KB, Wilson JL. Regional blood flow correlates of ST segment depression in tachycardia-induced myocardial ischemia. Circulation 1986; 73:365-73. [PMID: 3943169 DOI: 10.1161/01.cir.73.2.365] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Tachycardia produces subendocardial ischemia and ST segment abnormalities after coronary obstruction. To determine whether a quantitative relationship exists between these ST shifts and transmural blood flow, 19 dogs were studied. Coronary obstruction was produced by ameroid constriction of the left circumflex artery, and tachycardia was generated by atrial pacing at 90 to 210 beats/min. ST shifts were studied by body surface isopotential mapping with an 84-electrode torso grid, and blood flow was quantitated by serial radiolabeled microsphere injections. Isopotential maps at each paced rate, 40 msec into the ST segment, were classified as normal or ischemic based on spatial patterns of voltages. Pacing after 3 weeks of ameroid constriction reduced endocardial/epicardial flow ratios in 11 dogs from 1.16 +/- 0.22 at rest to 0.41 +/- 0.18 at 210 beats/min. Abnormal ST depression developed in these dogs at a rate of 184.0 +/- 16.5 beats/min. Endocardial/epicardial ratios with ST depression (0.45 +/- 0.15) were lower than at those without ST depression (1.05 +/- 0.19; p less than .01). Logistic regression analysis demonstrated that ST depression corresponded to an endocardial/epicardial ratio of 0.67 or less (p less than .01). With this model, 95.5% of data sets were correctly classified. Neither heart rate nor perfusion bed size were significant independent predictors of an ischemic electrocardiographic response. The magnitude of abnormal ST segment shift was significantly correlated (r = .87) with the transmural flow ratio. Thus development of electrocardiographic changes indicative of ischemia corresponds to a predictable degree of flow redistribution and the magnitude of the ST shift is correlated with the intensity of the flow abnormality.
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36
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Iliceto S, Sorino M, D'Ambrosio G, Papa A, Favale S, Biasco G, Rizzon P. Detection of coronary artery disease by two-dimensional echocardiography and transesophageal atrial pacing. J Am Coll Cardiol 1985; 5:1188-97. [PMID: 3989131 DOI: 10.1016/s0735-1097(85)80024-3] [Citation(s) in RCA: 73] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Two-dimensional echocardiography was performed at rest and during rapid transesophageal atrial pacing in 85 patients undergoing coronary arteriography for evaluation of chest pain. Transesophageal atrial pacing was performed with 10 ms pulses of 6 to 27 mA intensity; the rate was progressively increased up to 150 beats/min. Four patients were excluded: two because atrial capture was not achieved and two because of chest discomfort induced during transesophageal atrial pacing. Of the remaining 81 patients, 56 had significant coronary artery disease (greater than or equal to 75% stenosis of at least one major coronary vessel) and 25 had no significant coronary artery disease; 25 of the 56 patients with coronary artery disease had no wall motion abnormalities at rest. The test was considered positive if wall motion abnormalities were detected during pacing. Wall motion abnormalities occurred in 3 of 25 patients without coronary artery disease (specificity 88%) and in 51 of 56 patients with coronary artery disease (sensitivity 91%). Wall motion abnormalities developed in 20 of the 25 patients with coronary artery disease and normal regional wall motion at rest (sensitivity 80%); sensitivity for one, two and three vessel disease was 85% (17 of 20 patients), 94% (15 of 16 patients) and 95% (19 of 20 patients), respectively. In patients without coronary artery disease, wall motion score was 18 at rest and 17.7 +/- 0.9 during pacing (p = NS). In patients with coronary artery disease, wall motion score decreased from 15.2 +/- 3.6 at rest to 11.6 +/- 4.1 during pacing (p less than 0.001). In patients with coronary artery disease and normal regional wall motion at rest, wall motion score decreased from 18 at rest to 14.4 +/- 3.1 during pacing (p less than 0.001). Thus, two-dimensional echocardiography during transesophageal atrial pacing appears both sensitive and specific in detecting patients with coronary artery disease. This new procedure is a feasible and reliable alternative to exercise two-dimensional echocardiography.
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37
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Josephson MA, Hopkins J, Singh BN. Hemodynamic and metabolic effects of diltiazem during coronary sinus pacing with particular reference to left ventricular ejection fraction. Am J Cardiol 1985; 55:286-90. [PMID: 3969863 DOI: 10.1016/0002-9149(85)90362-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To determine the systemic and coronary hemodynamic effects of diltiazem at rest and during pacing, 14 patients with stable angina pectoris undergoing coronary angiography were studied before and after 0.165 mg/kg (n = 7) and 0.25 mg/kg (n = 7) of intravenously administered diltiazem. Hemodynamic variables, metabolic measurements and left ventricular (LV) ejection fraction (EF) were obtained at rest and during coronary sinus (CS) pacing before and during diltiazem administration. Lactate production during control pacing turned into extraction after diltiazem (p less than 0.05). At rest, systemic resistance was reduced by 21% (p greater than 0.01) and mean arterial pressure by 12% (p less than 0.01); cardiac index increased from 2.4 +/- 0.4 to 2.6 +/- 0.4 liters/min/m2 (p less than 0.01), with no significant change in heart rate. The mean pulmonary artery pressure increased from 17 +/- 2 to 19 +/- 3 mm Hg (p less than 0.01), but other hemodynamic variables were not affected. Diltiazem given during pacing reduced the mean aortic pressure (from 112 +/- 15 to 104 +/- 15 mm Hg, p less than 0.05), but other hemodynamic variables were not affected significantly. LVEF decreased 16%, from 0.63 +/- 0.9 to 0.53 +/- 0.8 with CS pacing (p less than 0.01); when the pacing was performed after diltiazem administration the 8% decrease in LVEF from 0.64 +/- 0.09 to 0.59 +/- 13 was less marked (p less than 0.01). Diltiazem had no significant effect on LVEF at rest. The overall data suggest that the ischemic manifestations of CS pacing are attenuated by diltiazem in doses of the drug that exert no significant depressant effect on LV function in patients with coronary artery disease.
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Cannon RO, Bonow RO, Bacharach SL, Green MV, Rosing DR, Leon MB, Watson RM, Epstein SE. Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation 1985; 71:218-26. [PMID: 3965167 DOI: 10.1161/01.cir.71.2.218] [Citation(s) in RCA: 202] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thirty-three patients with chest pain despite angiographically normal coronary arteries underwent both coronary flow studies during pacing and resting and exercise gated blood pool scintigraphy. During atrial pacing after administration of ergonovine, those patients developing their typical chest pain demonstrated significantly lower great cardiac vein flow (97 +/- 31 vs 150 +/- 33 ml/min, p less than .001), higher coronary resistance (1.27 +/- 0.43 vs 0.77 +/- 0.18 mm Hg/ml/min, p less than .005), and less lactate consumption (30.5 +/- 22.0 vs 69.7 +/- 41.1 mM . ml/min, p less than .005) and a higher left ventricular end-diastolic pressure after pacing (20 +/- 4 vs 12 +/- 1, p less than .001) compared with those without pain and in the absence of significant luminal narrowing of the epicardial coronary arteries. The 26 patients with abnormal vasodilator reserve demonstrated reduced left ventricular ejection fraction during exercise (58 +/- 8%) compared with the seven patients with appropriate vasodilator reserve (66 +/- 4%, p less than .05) and with a group of 52 control patients of similar age and sex distribution and free of known heart disease (66 +/- 10%, p less than .001). In addition, 12 of the 26 patients with abnormal vasodilator reserve demonstrated exercise-induced regional wall motion abnormalities. Many of these patients also manifested impaired left ventricular diastolic filling at rest compared with the control subjects (peak filling rate 2.6 +/- 0.7 vs 3.2 +/- 0.7 end-diastolic volume/sec, p less than .005). Thus, patients with chest pain resulting from abnormal vasodilator reserve demonstrate abnormalities of left ventricular systolic and diastolic function suggestive of myocardial ischemia.
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Cannon RO, Leon MB, Watson RM, Rosing DR, Epstein SE. Chest pain and "normal" coronary arteries--role of small coronary arteries. Am J Cardiol 1985; 55:50B-60B. [PMID: 3969858 DOI: 10.1016/0002-9149(85)90613-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To study the mechanism of chest pain in patients with insignificant epicardial coronary artery disease, 50 patients underwent great cardiac vein (GCV) flow, oxygen content and lactate determinations at rest and during pacing, and left ventricular end-diastolic pressure (LVEDP) measurements at rest and after pacing. Twenty-four patients having typical chest discomfort during pacing demonstrated significantly lower increase in flow from baseline (36 +/- 18% versus 86 +/- 24%, p less than 0.001) and decrease in coronary resistance (-17 +/- 12% versus -43 +/- 7%, p less than 0.001) compared with 26 patients without pacing-induced chest pain, despite no significant difference in myocardial oxygen consumption (MVO2) between the 2 groups. Lactate consumption at a heart rate (HR) of 150 beats/min was significantly less (28.3 +/- 21.5 versus 51.3 +/- 35.8 mM X ml/min, p less than 0.001) and the increase in LVEDP from rest to after pacing was significantly greater (5 +/- 2 versus 1 +/- 2 mm Hg, p less than 0.001) in the chest pain group. After administration of ergonovine, 0.15 mg intravenously, to 46 of these patients, 31 had typical pain either at rest (1 patient) or during pacing. This group had significantly lower increase in flow (38 +/- 20% versus 107 +/- 38%, p less than 0.001), and decrease in coronary resistance (-16 +/- 12% versus -45 +/- 11%, p less than 0.001) compared with the 15 patients not having chest pain, despite no significant difference in MVO2 between the 2 groups. Patients with chest pain also had lower lactate consumption at a HR of 150 beats/min (39.2 +/- 23.6 versus 65.3 +/- 46.3 mM X ml/min, p less than 0.01), greater arterial-GCV oxygen difference (12.5 +/- 1.3 versus 11.6 +/- 1.0 ml O2/100 ml, p less than 0.05), and a more marked increase in LVEDP from rest to after pacing (11 +/- 3 versus 5 +/- 2 mm Hg, p less than 0.001). Quantitative coronary arteriography demonstrated no significant luminal narrowing of the epicardial coronary arteries in response to ergonovine. These data are consistent with the hypothesis that some patients with chest pain and angiographically normal epicardial coronary arteries have dynamic abnormalities of the small coronary arteries or coronary microcirculation that cause abnormal vasodilator reserve or vasoconstriction, resulting in myocardial ischemia and angina pectoris.
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Ihlen H, Myhre E, Smith HJ. Potential deleterious haemodynamic effects of glyceryl trinitrate on myocardial ischaemia in man. Heart 1984; 52:510-5. [PMID: 6437422 PMCID: PMC481673 DOI: 10.1136/hrt.52.5.510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The potential adverse effects of glyceryl trinitrate on myocardial ischaemia were studied using low and high dose infusions in 10 patients with coronary heart disease. Cardiac venous flow was measured by the thermodilution technique and blood was sampled for metabolic studies. Angina pectoris was provoked by atrial pacing before drug infusion and the same heart rate was regained with low and high doses of glyceryl trinitrate. Both doses reduced myocardial ischaemia equally. The low dose of glyceryl trinitrate reduced mean systolic aortic pressure from 145(23) to 128(23) mm Hg and the high dose further to 103(9) mm Hg. Myocardial oxygen uptake decreased owing to a combined reduction in preload and afterload with the low dose and was substantially more reduced with the high dose owing to a further afterload reduction. Transmural perfusion gradient did not change with the low dose of glyceryl trinitrate but fell significantly with the high dose. This fall in myocardial perfusion probably accounts for the lack of further reduction in ischaemia with the high dose. Thus the adverse effects of glyceryl trinitrate infusion are small and do not increase myocardial ischaemia.
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Wasserman AG, Johnson RA, Katz RJ, Leiboff RH, Bren GB, Varghese PJ, Ross AM. Detection of left ventricular wall motion abnormalities for the diagnosis of coronary artery disease: a comparison of exercise radionuclide and pacing intravenous digital ventriculography. Am J Cardiol 1984; 54:497-501. [PMID: 6475766 DOI: 10.1016/0002-9149(84)90237-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Intravenous digital ventriculography before and after pacing was compared with equilibrium gated nuclear ventriculography at rest and after exercise. Specifically, the relative abilities of the 2 techniques to detect resting and stress-related wall motion abnormalities were tested. Twelve normal patients and 28 patients with coronary artery disease (CAD) were tested. Neither technique produced a new wall motion abnormality in a patient with normal coronary arteries. Six patients with CAD had a history of a myocardial infarction (MI); an abnormality at rest was present in all 6 by both techniques. Of the 22 patients with CAD and a normal baseline ventriculogram, a wall motion abnormality developed in 18 during digital ventriculography with pacing; a wall motion abnormality developed in 15 with exercise nuclear ventriculography. Wall motion abnormalities by nuclear ventriculography (performed in the left anterior oblique projection) tended to be apical; digital ventriculography (performed in the right anterior oblique projection) more often produced an abnormality of the anterior or inferior wall, which could be predictive of coronary anatomy. Thus, the 2 techniques are substantially equivalent for the detection of wall motion abnormalities in CAD.
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Martin JL, Wilson JR, Ferraro N, Laskey WK, Kleaveland JP, Hirshfeld JW. Acute coronary vasoconstrictive effects of cigarette smoking in coronary heart disease. Am J Cardiol 1984; 54:56-60. [PMID: 6741839 DOI: 10.1016/0002-9149(84)90303-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
To investigate the effect of cigarette smoking on the coronary vasculature, coronary sinus flow and myocardial oxygen delivery were measured at rest and during incremental atrial pacing in 10 patients with coronary artery disease. Measurements were then repeated while the patients smoked 2 unfiltered, high-nicotine cigarettes. Although smoking significantly increased the heart rate at rest and double product, coronary sinus flow did not change significantly (141 +/- 32 vs 146 +/- 28 ml/min). At the lowest equivalent pacing rate before and during smoking, the double products were comparable. However, coronary sinus flow was reduced by smoking (146 +/- 28 vs 159 +/- 28 ml/min, p less than 0.01) and coronary vascular resistance was increased (0.96 +/- 0.15 vs 0.83 +/- 0.13 mm Hg ml-1 min, p less than 0.02). The double products were also comparable at the peak pacing rate before and during smoking. Nonetheless, the coronary sinus flow was again lower (167 +/- 23 vs 227 +/- 41 ml/min, p = 0.02) and the coronary vascular resistance was higher (0.77 +/- 0.10 vs 0.63 +/- 0.09 mm Hg ml-1 min, p less than 0.01) during smoking. The transmyocardial arteriovenous oxygen difference was unchanged by smoking; therefore, myocardial oxygen delivery was reduced in proportion to the reductions in coronary sinus flow. Thus, cigarette smoking appears to acutely alter the ability of the coronary vasculature to regulate flow in accordance with the oxygen requirements of the myocardium.
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