Selenium Deficiency as a Risk Factor for Peripartum Cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a multifactorial disease. Although the specific aetiology and pathogenesis of PPCM are unknown, several hypotheses have been proposed, including selenium deficiency. However, the risk of PPCM from selenium deficiency was not previously quantified. This posthoc analysis of peripartum cardiomyopathy in Nigeria (PEACE) registry data aimed to determine if selenium deficiency is an independent risk factor for PPCM.

METHODS

Apparently healthy women who delivered within the previous 8 weeks and PPCM patients in Kano, Nigeria, were compared for selenium deficiency (<70µg/L) and other relevant socio-demographic and clinical characteristics. Selenium level was measured at recruitment for each subject. Independent predictors of PPCM were determined using logistic regression models.

RESULTS

159 PPCM patients and 90 age-matched controls were consecutively recruited. 84.9% of the patients and 3.3% of controls had selenium deficiency. Selenium deficiency independently increased the odds for PPCM by 167-fold while both unemployment and lack of formal education independently increased the odds by 3.4-fold.

CONCLUSION

Selenium deficiency was highly prevalent among PPCM patients in Kano, Nigeria, and significantly increased the odds for PPCM. These results could justify screening of women in their reproductive years for selenium deficiency, particularly those living in regions with high incidence of PPCM. The results also call for the setting up of a definitive clinical trial of selenium supplementation in PPCM patients with selenium deficiency, to further define its benefits in the treatment of PPCM.

Left ventricular myocardial and cavity velocity disturbances are stronger predictors of stress induced ischaemia in patients with significant coronary artery disease

Background and aim

Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for significant coronary artery disease (CAD). The aim of this study was to evaluate the accuracy of cardiac Doppler parameters in predecting CAD.

Methods

We prospectively studied 103 consecutive patients with suspected CAD based on typical symptoms, 59 proved to have CAD and 44 patients proved to have no-CAD (n=44). All patients underwent a complete stress Doppler echocardiographic examination, including tissue Doppler, long axis velocities and total isovolumic time (T-IVT) as a marker of cavity dyssynchrony, determined as [60 − (total ejection time (ET) + total filling time (FT))]. The wall motion score index (WMSI) was also calculated.

Results

CAD patients were older, had less females, less prevalent cardiac risk factors and higher CT calcium score compared to patients with no-CAD (p&lt;0.05, for all). At peak dobutamine stress the compromised LV longitudinal excursion (MAPSE), systolic septal and lateral velocities (s'), TAPSE and diastolic indices were more pronounced in the CAD patients compared to those without CAD, but LV dimension did not differ between groups (p&gt;0.05). The WMSI was higher and t-IVT more prolonged in patients with CAD (p&lt;0.01, for both). Similarly, the changes were more pronounced in patients with significant CAD compared to insignificant CAD.

On multivariate model, delta mean s' OR 2.016 (1.610–3.490, p&lt;0.001), delta E velocity OR 1.822 (1.179–2.360, p&lt;0.001), delta t-IVT OR 1.406 (1.180–2.180, p&lt;0.001), and delta FT OR 1.911 (1.401–2.710, p=0.001), were the most powerful independent predictors of the presence of CAD, particularly when significant (&gt;50%). Delta mean s' &lt;5.0 was 85% sensitive, 89% specific with AUC 0.92. Respective values for delta E velocity &lt;6.0 cm/s were 82%, 90% and 0.91; for delta t-IVT &gt;4.5, 78%, 77% and 0.81 and for delta FT ≥150ms, 76%, 78% and 0.84 in predicating significant CAD. WMSI≥0.7 was 75% sensitive, 77% specific with AUC of 0.81 in predicting significant CAD. The accuracy of DSE was higher in significant CAD compared to insignificant CAD (80% vs 74%; p=0.03).

Conclusions

Compromised LV longitudinal systolic function, lower delta E wave, prolonged t-IVT and increased WMSI were the most powerful independent predictors of the presence and significance of CAD. These finding strengthen the role of comprehensive DSE analysis in diagnosing ischaemic disturbances secondary to significant CAD.

Funding Acknowledgement

Type of funding sources: None.

Disease progression in cardiac morphology and function in heart failure: ATTR cardiac amyloidosis versus hypertensive left ventricular hypertrophy

Background

Transthyretin cardiac amyloidosis (ATTR-CA) is today more frequently recognized but the rate of progression of cardiac dysfunction is not well established. The aim of this study is to investigate the nature of cardiac structure and function changes, over time, in a retrospective cohort of ATTR-CA patients.

Methods

Fifty-one patients with ATTR-CA (mean age 78 ± 7 years, 30 females) were compared with 20 patients with heart failure but no amyloidosis (HFnCA) (mean age 76 ± 7 years, 5 females), all with septal thickness >  = 14 mm. All patients underwent DPD scintigraphy and an echocardiogram (Echo 2) which was compared with a previous echocardiographic examination (Echo 1), performed at least 3 years before.

Results

Over the follow-up period, the interventricular septal thickness (IVST) and relative wall thickness (RWT) in ATTR-CA increased from 16 (4) to 18 (5) mm and from 0.51 (0.17) to 0.62 (0.21) respectively, p < 0.001 for both, by a mean increase of 0.4 mm/year and 0.03 mm/year, (p = 0.009 and p = 0.002 compared with HFnCA), respectively. RWT > 0.45 (AUC = 0.77) and RELAPS > 2.0 (AUC 0.86) both predicted positive DPD diagnosis for ATTR-CA.

Conclusion

In ATTR-CA patients, the overtime-increase in RWT and IVST was worse than that seen in patients with heart failure but no cardiac amyloidosis. Also, RWT and relative apical sparing predicted diagnosis of ATTR-CA, thus could strengthen the use of follow-up echocardiographic findings as red flag for the diagnosis of ATTR-CA.

Uncontrolled diabetes predicts anxiety and depression in CAD patients

Background and aim

Coronary artery disease (CAD) is a major public health problem worldwide because of high incidence of comorbidity and mortality. Diabetes mellitus (DM) is associated with clustered risk factor for CAD. The aim of this study was to assess the impact of diabetes in CAD and its relationship with depression.

Methods

The study included 77 patients (mean age 64±11 years, 63% female) with CAD. Based on comorbidity patients were classified into CAD with DM (n=49) and CAD without DM (n=28). In this prospective study demographic, clinic, echocardiographic and angiographic indices were collected as well as scale of anxiety and depression.

Results

Patients with CAD and DM were older (p=0.001), had reduced left ventricular ejection fraction-EF (p=0.02), more obese (p=0.03), had higher NYHA class (p=0.04), more prevalent arterial hypertension (p=0.04), and higher anxiety and/or depression scales (p&lt;0.001) compared with patients without DM. Whereas gender was not significantly difference (p=0.11). Diabetes most closely correlated with the scale of depression (r=0.61, p&lt;0. 001).

In multivariate analysis, only diabetes OR=1.099 (95% CI 1.028 to 1.231, p&lt;0.001), predicted depression in patients with CAD. Glycemic &gt;8.9 mmol/L, predicted the scale of depression in patients with CAD (sensitivity 75%, specificity 70%, AUC=0.72, p&lt;0.001).

Conclusions

Diabetes is the most important risk factor for CAD and the uncontrolled levels are related to patient's disturbed mental health. These results constitute important knowledge for nurses serving CAD patients.

Funding Acknowledgement

Type of funding sources: None.

Obesity strongly predicts COVID-19-related major clinical adverse events in Coptic Clergy

Background and aims

The Coptic Clergy, due to their specific work involving interaction with many people, could be subjected to increased risk of infection from COVID-19. The aim of this study, a sub-study of the COVID-19-CVD international study of the impact of the pandemic on the cardiovascular system, was to assess the prevalence of COVID-19 among Coptic priests and identify predictors of clinical adverse events.

Methods

Participants were geographically divided into three groups: Group-I: Europe and USA, Group II: Northern Egypt and Group III: Southern Egypt. Participants' demographic indices, cardiovascular risk factors, possible source of infection, number of liturgies, infection management and major adverse events (MAEs), comprising death, re-infection or mechanical ventilation, were assessed.

Results

Out of the 1,570 clergy serving in 25 dioceses, 226 (14.39%) were infected. Their mean age was 49.5±12 years and mean weekly number of liturgies was 3.44±1.0. The overall prevalence rate was 14.7% and did not differ between Egypt as a whole and overseas (p=0.23). Disease prevalence was higher in Northern Egypt clergy compared to Europe and USA combined (18.4% vs 12.1%, p=0.03) and tended to be higher than in Southern Egypt (18.4% vs. 13.6%, p=0.09). Ten priests (4.42%) died of COVID-19 related complications, 2 (0.9%) had re-infection and 27 (11.9%) suffered a MAE. The clergy from Southern Egypt were more obese but the remaining risk factors were less prevalent compared to those in Europe and USA (p=0.01). In multivariate analysis, obesity OR 4.184 (2.483 to 12.14; p=0.01); age OR 1.070 (0.014 to 1.130; p=0.02), and systemic hypertension OR 0.932 (0.874 to 0.994; p=0.007) predicted MAEs. Obesity was the most powerful independent predictor of MAE in Southern Egypt and systemic hypertension in Northern Egypt (p&lt;0.05 for both).

Conclusion

Obesity is very prevalent among Coptic clergy and seems to be the most powerful independent predictor of major COVID-19-related adverse events.

Funding Acknowledgement

Type of funding sources: None. Prevalence of SARS-CoV2 among Clergy

Combined cardiac risk factors predict COVID-19 related mortality and the need for mechanical ventilation in Coptic Clergy

Background and aims

The clinical adverse events of COVID-19 among clergy worldwide have been found higher than among ordinary communities, probably because of the nature of their work. The aim of this study, was to assess the impact of cardiac risk factors on COVID-19-related mortality and the need for mechanical ventilation in Coptic clergy.

Methods

Of 1576 Coptic clergy participating in the COVID-19-Clergy study, serving in Egypt, USA and Europe, 213 had the infection and were included in this analysis. Based on the presence of systemic arterial hypertension (AH), participants were divided into two groups: Group-I, Clergy with AH (n=77) and Group-II, without AH (n=136).Participants' demographic indices, cardiovascular risk factors, COVID-19 management details and related mortality were assessed.

Results

Clergy with AH were older (p&lt;0.001), more obese (p=0.04), had frequent type 2 diabetes (DM) (p=0.001), dyslipidemia (p=0.001) and coronary heart disease (CHD) (p=0.04) compared to those without AH. COVID-19 treatment at home, hospital or in intensive care did not differ between the patient groups (p&gt;0.05 for all). Clergy serving in Northern and Southern Egypt had a higher mortality rate compared to those from Europe and the USA combined (5.22%, 6.38%, 0%; p=0.001). The impact of AH on mortality was significant only in Southern Egypt (10% vs. 3.7%; p=0.01) but not in Northern Egypt (4.88% vs. 5.81%; p=0.43).

In multivariate analysis, CHD OR 1.607 [(0.982 to 3.051); p=0.02] and obesity, OR 3.403 [(1.902 to 4.694); p=0.04]predicted COVID-19 related mortality. A model combining cardiac risk factors (systolic blood pressure (SBP) ≥160 mmHg, DM, obesity, dyslipidemia and history of CHD), was the most powerful independent predictor of COVID-19-related mortality, OR 4.813 [(2.011 to 7.017); p=0.008]. The same model also proved the best independent multivariate predictor of mechanical ventilation OR 1.444 [(0.949 to 11.88); p=0.001].

Conclusion

In Coptic clergy, the cumulative impact of risk factors is the most powerful predictor of mortality and the need for mechanical ventilation in Coptic clergy.

Funding Acknowledgement

Type of funding sources: None.

P901 Left ventricular diastolic and systolic functions are compromised in patients with hypothyroidism

Background and Aim

Long standing hypothyroidism may impair myocardial relaxation, but its effect on systolic myocardial function is still controversial. The aim of this study was to investigate left ventricular (LV) systolic and diastolic function in patients with hypothyroidism.

Methods

This study included 81 (age 42 ± 13 years, 92% female) patients with hypothyroidism, and 22 age and gender matched controls. All subjects underwent a detailed clinical examination followed by a complete biochemical blood analysis including thyroid function assessment and anthropometric parameters measurements. LV function was assessed by 2 dimensional, M-mode and Tissue-Doppler Doppler echocardiographic examination performed in the same day.

Results

Patients had lower waist/hip ratio (p &lt; 0.001), higher urea level (p = 0.002) and lower white blood cells (p = 0.011), compared to controls. All other clinical, biochemical and anthropometric data did not differ between the two groups. Patients had impaired LV diastolic function (lower E wave [p &lt; 0.001], higher A wave [p = 0.028], lower E/A ratio [p &lt; 0.001], longer E wave deceleration time [p = 0.01], and higher E/e’ ratio [p &lt; 0.001]), compared with controls. Although LV global systolic function did not differ between groups, LV longitudinal systolic function was compromised in patients (lateral mitral annular plane systolic excursion - MAPSE [p = 0.005], as were lateral and septal TDI s’ [p &lt; 0.001 for both]).

Conclusion

In patients with hypothyroidism, in addition to compromised LV diastolic function, LV longitudinal systolic function is also impaired compared to healthy subjects of the same age and gender. These findings suggest significant subendocardial function impairment, reflecting potentially micro-circulation disease, that requires optimum management.

P791 Left atrial stiffness as a predictor of cardiac events in patients with heart failure and reduced ejection fraction: the impact of diabetes

Background and Aim

Diabetes mellitus (DM) affects left ventricular remodeling in patients with heart failure (HF), but its effect on left atrial (LA) remodeling and their combined effect on survival and other clinical events (CE) remain to be elucidated. We evaluated in this study the relationship between DM and left atrial (LA) remodeling in a group of HF patients with reduced ejection fraction (HFrEF),

Methods

This studied 136 consecutive HFrEF patients (65 ± 11 years), 36 diabetics, using conventional and tissue Doppler echocardiography. LA dimension and function were measured and cavity stiffness was calculated with the formula: LA stiffness = E/e’ratio/LA strain.

Results

The age, gender, LV end-systolic dimension, LV end-diastolic dimension, LV EF and BNP level did not differ between diabetic and non-diabetic patients. Diabetic patients with HFrEF had higher NYHA functional class (p = 0.02), reduced right ventricle (RV) systolic function (p = 0.01) and increased LA stiffness (p = 0.02) .

At follow up of 55 ± 37 months, survival free from CE was 69% in non-diabetics compared with 44.4% in diabetics (X2 12.7; p&lt; 0.0001). The CE free survival was lower in patients with increased LA stiffnes, irrespective of the presence of DM: 1) Patients with HFrEF without DM and normal LA stiffness (85%); 2) Patients with HFrEF without DM and with increased LA stiffness (50%); 3) Patients with HFrEF with DM and with normal LA stiffness (71%) and patients with HFrEF with DM and with increased LA stiffness (27%) (X2 29.6; p&lt; 0.0001, Figure 1).

Conclusion

Compromised LA stiffness as surrogate of LA remodeling is associated with poor outcome in patients with heart failure and reduced EF. The presence of diabetes in patients with HFrEF and increased LA stiffness has incremental prognostic value.

Abstract P791 Figure.

P895 Relationship between left ventricular function components and cardiovascular risk factors in asymptomatic individuals

Funding Acknowledgements

none

Background and Aim

Coronary artery disease is commonly related to conventional cardiovascular (CV) risk factors. The exact role of those risk factors in early development of CV disease or left ventricular (LV) dysfunction before the development of sign and symptoms remains debated. We studied the relationship between conventional risk factors and LV systolic, diastolic and synchronous function in a population sample of asymptomatic individuals.

Methods

All participants underwent a detailed echocardiographic examination as part of a cross-sectional survey for the prevalence of coronary risk factors in randomly selected individuals from general population. LV end-systolic and end-diastolic dimensions, and LV volumes and ejection fraction (EF) were all calculated. From the spectral Doppler flow, LV early diastolic (E wave) and atrial systolic (A wave) velocities were measured and E/A ratio calculated. LV filling time (FT) was also measured from the onset of E wave to the end of A wave, and LV ejection time (ET) from the onset to the end of aortic Doppler velocity. Global LV dyssynchrony was assessed using total isovolumic time (T-IVT) as 60 – (total filling time + total ejection time), and Tei index was also calculated.

Results

The study population comprised 184 individuals (96 male and 88 female, mean age 55.9 (11.3), range 25-78 years). There was no relationship between systolic LV function expressed by EF and CV risk factors. Markers of diastolic function: LV filling velocities and E/A ratio, were correlated with age (r= -0.36, p &lt; 0.000, r= -0.57, p &lt; 0.000, respectively), with glycemia (r= -0.21, p &lt; 0.000, r= -0.14, p = 0.004,) and with systolic blood pressure (r= -0.31, p &lt; 0.000, r= -0.34, p &lt; 0.000). Markers of LV dyssynchrony, in the form of prolonged T-IVT, and raised Tei index, directly correlated with age, glycemia and systolic blood pressure (r = 0.58, p &lt; 0.000, r = 0.18, p &lt; 0.000, r = 0.33, p &lt; 0.000, respectively). However, when these correlations were adjusted for age in a multivariate analysis, the statistical significance was strongly reduced (LV filling) or completely lost (IVT and E/A).

Conclusions

In normal asymptomatic population, age, rather than CV risk factors, is the main determinant of changes in diastolic and synchronous function.

Passive leg-lifting in heart failure patients predicts exercise-induced rise in left ventricular filling pressures

AIM

The aim of this study was to assess PCWP with passive leg-lifting (PLL) and exercise, in two groups of patients presenting with normal left ventricular ejection fraction (LVEF); one group with elevated NT-proBNP (eBNP), and one with normal NT-proBNP (nBNP) plasma concentration.

METHODS AND RESULTS

Fifty-one patients with eBNP (NT-proBNP ≥ 125 ng/l) and LVEF > 50%, were investigated and compared with 34 patients with nBNP (NT-proBNP < 125 ng/l) and LVEF > 50%. Both groups underwent right heart catheterization (RHC) at rest, PLL and exercise. From RHC, mean pulmonary arterial pressure (mPAP), cardiac output (CO), and PCWP were measured. All nBNP patients had PCWP < 15 mmHg at rest, and a PCWP of < 25 mmHg with PLL and during exercise. Patients with eBNP had higher (p < 0.01) resting mPAP, PCWP, and mPAP/CO. These values increased with exercise; however, CO increased less in comparison with nBNP patients (p = 0.001). 20% of patients with eBNP had a PCWP > 15 mmHg at rest, this percentage increased to 47% with PLL and 41% had a PCWP > 25 mmHg during exercise. Of those with PCWP > 25 mmHg during exercise, 91% had a PCWP > 15 mmHg with PLL. A PCWP > 15 mmHg on PLL had a 91% sensitivity and 92% specificity in predicting exercise-induced PCWP of > 25 mmHg.

CONCLUSION

In patients presenting with eBNP, PLL can predict which patients will develop elevated PCWP with exercise. These findings highlight the role of stress assessment.

Prevalence and predictors of right ventricular diastolic dysfunction in peripartum cardiomyopathy

BACKGROUND

This study aimed to assess the prevalence of right ventricular diastolic dysfunction (RVDD) and its potential predictors in peripartum cardiomyopathy (PPCM) patients.

METHODS

This was a cross-sectional study carried out in Nigeria. RVDD was defined and graded using Doppler filling and myocardial tissue Doppler velocities obtained at tricuspid annular level.

RESULTS

Forty-three subjects with PPCM and mean age of 26.6 ± 7.0 years were recruited over 6 months. RVDD was found in 30 (69.8 %) subjects, of whom 16 (53.3 %) had grade I, 12 (40.0 %) had grade II and 2 (6.7 %) had grade III severity. RV systolic dysfunction (RVSD), defined as RV fractional area change <35 %, was found in 88.4 %, while combined RVSD and RVDD was found in 58.1 % of patients. Subjects with RVDD had significantly higher tricuspid E/e' ratio (5.1 ± 2.8 versus 3.5 ± 1.0, p = 0.012) and prevalence of pulmonary hypertension (76.7 versus 46.2 %; p < 0.05), and lower serum selenium concentration (55.6 ± 12.1 versus 72.5 ± 12.0 µg/L, p = 0.001) than those with preserved RV diastolic function. Regression analyses showed serum selenium [odds ratio (OR) = 1.14; 95 % confidence interval (CI) = 1.0-1.3; p = 0.049] and combined RVSD and pulmonary hypertension (OR = 79.2; CI = 3.9-1593.7; p = 0.004) as the only predictors of RVDD, and serum selenium <70 µg/L increased the odds of RVDD by 6.67-fold (CI = 1.18-37.78; p = 0.032).

CONCLUSIONS

Both RVDD and RVSD were common in PPCM patients. Selenium deficiency and combined RVSD and pulmonary hypertension seemed to be the only determinants of RVDD in this small cohort, a finding that needs verification in a larger sample of patients.

Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Many reports have shown an association between hypoechoic (echolucent) carotid atherosclerotic plaques and unstable features. In this meta-analysis our aim was to determine the role of carotid plaque echogenicity in predicting future cerebrovascular (CV) symptoms.

METHODS

Electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to September 2015 were systematically searched. Studies with ultrasound-based characterization of carotid artery plaque echogenicity and its association with focal neurological symptoms of vascular origin were eligible for analysis. In the meta-analysis, heterogeneity was measured using I(2) statistics and publication bias was evaluated using the Begg-Mazumdar test. In addition several comparisons between subgroups were performed.

RESULTS

Of 1387 identified reports, eight studies with asymptomatic patients and three studies with symptomatic patients were meta-analyzed. Pooled analysis showed an association between echolucent carotid plaques and future CV events in asymptomatic patients [relative risk 2.72 (95% confidence interval 1.86-3.96)] and recurrent symptoms in symptomatic patients [relative risk 2.97 (95% confidence interval 1.85-4.78)]. The association was preserved for all stenosis degrees in asymptomatic patients, whilst patients with echolucent plaques and severe stenosis were at higher risk of future events. Also, computer-assisted methods for assessment of carotid plaque echogenicity and studies analyzing ultrasound data collected after the year 2000 showed better prediction.

CONCLUSIONS

In asymptomatic and symptomatic patients, analysis of carotid plaque echogenicity could identify those at high risk of CV events.

Stress long-axis function in coronary artery spasm

In a patient with prior myocardial infarction who had complained of frequent angina repeat arteriograms proved normal coronary arteries. Both ECG exercise testing and thallium scanning excluded ischemia. Resting echocardiogram showed increased distal septal and right ventricular apical myocardial echo intensity. Dobutamine stress echo demonstrated right ventricular and posteroseptal abnormalities consistent with ischemia. Repeat angiogram with ergonovine confirmed distal right coronary spasm.

Age dependency in the timing of mitral annular motion in relation to ventricular filling in healthy subjects: Umea General Population Heart Study

AIMS

Peak left ventricular (LV) relaxation normally precedes peak filling (E), which supports the hypothesis that LV suction contributes to early-diastolic filling. The significance of similar temporal discordance in late diastole has previously not been studied. We describe the time relationships between mitral annular motion and LV filling in early and late diastole and examine the effect of normal ageing on these time intervals.

METHODS AND RESULTS

A total of 128 healthy subjects aged 25-88 years were studied. Transmitral and pulmonary venous flow reversals (Ar) were recorded by Doppler echocardiography. Mitral annular diastolic displacement-early (E(m)) and late (A(m))-were recorded by Doppler tissue imaging. With reference to electrocardiographic R and P-waves, the following measurements were made: R to peak E-wave (R-E) and E(m) (R-E(m)); onset P to peak A-wave (P-pA), A(m) (P-pA(m)), and Ar (P-pAr). The differences between [(R-E) and (R-E(m))] for early-diastolic temporal discordance (EDTD) and [(P-A) and (P-A(m))] for late-diastolic temporal discordance (LDTD) were calculated. Isovolumic relaxation time (IVRT) was also measured. Early-diastolic temporal discordance was approximately 26 ms in all age groups. Late-diastolic temporal discordance, however, was inversely related to age (r = -0.35, P < 0.001) and IVRT (r = -0.34, P < 0.001) and therefore decreased in the elderly vs. young (13 +/- 10 vs. 23 +/- 10 ms; P < 0.001). In multivariate analysis, age failed to predict LDTD in the presence of IVRT. A, A(m), and Ar were simultaneous at onset, and peak A(m) coincided with peak Ar in all age groups (r = 0.97, P < 0.001). No significant differences were noted in the RR intervals.

CONCLUSIONS

Sequential prolongation of IVRT with ageing reduces LDTD, thus converging the peaks of A(m), A, and Ar (atrial mechanical alignment)-a potential novel method to identify subjects at increased dependency on atrial contraction for late-diastolic filling.

Instantaneous effects of resynchronisation therapy on exercise performance in heart failure patients: the mechanistic role and predictive power of total isovolumic time

BACKGROUND

Cardiac resynchronisation therapy improves peak oxygen uptake (peak VO(2)) 3-9 months after device implantation. In chronic heart failure, total isovolumic time (t-IVT) is a major determinant of peak VO(2) and of cardiac output at peak dobutamine stress. In selected patients, resynchronisation can instantaneously shorten t-IVT. We sought to determine the acute effect of resynchronisation on exercise performance and determine, with pharmacological stress echocardiography, the mechanism underlying this effect.

METHODS AND RESULTS

Twenty-two patients with resynchronisation were studied within 3 months after device implantation. On a single study day, sequential cardiopulmonary exercise tests were performed during native activation (left bundle branch block) and resynchronisation (atrio-biventricular pacing) in random order. Total-IVT and cardiac output (at rest and peak dobutamine stress) were then measured in each activation mode. Resynchronisation acutely increased peak VO(2) by 1.6 (SD 1.5) ml/kg/min (p<0.001) and shortened peak stress t-IVT by 10 (SD 7) s/min (p<0.001), with the effects in individual patients showing a correlation (r = -0.46, p<0.05). Amongst all measurements during native activation, the best predictor of gain in peak VO(2) from resynchronisation was peak stress t-IVT (r = 0.71, p<0.001) with every increment of 5 s/min of peak stress t-IVT during native activation predicting an 8% gain in peak VO(2). No conventional measures during native activation at rest or on stress (including QRS duration, Tei index, tissue Doppler intraventricular delay, and resting t-IVT) added significant additional information.

CONCLUSIONS

In eligible patients, resynchronisation can acutely augment peak VO(2), possibly through a mechanism of t-IVT shortening. Under native activation, long t-IVT during peak stress is the single best predictor of acute resynchronisation-mediated increment in peak VO(2).

Can heart rate variation rule out sleep-disordered breathing in heart failure?

In patients with obstructive sleep apnoea (OSA), the very low frequency power spectral density index (VLFI) derived from analysis of heart rate correlates with the severity of obstructive apnoeas. VLFI is also associated with Cheyne-Stokes respiration/central sleep apnoea (CSR/CSA) in congestive heart failure (CHF). The present authors have tested the hypothesis that per cent VLFI, derived from a standard Holter ECG recording, can be used to detect the presence of OSA and CSR/CSA in patients with mild-to-moderate CHF. In total, 60 CHF patients underwent polysomnography with monitoring of heart rate. Data from 33 patients were analysed for per cent VLFI. Of the 60 patients, 27 were excluded due to atrial fibrillation, extensive pacing or frequent ventricular extra systoles. Receiver operator characteristic curves were constructed to establish the per cent VLFI that would optimally identify the presence or absence of sleep-disordered breathing. Using an apnoea-hypopnoea index>20 events.h-1 and setting the per cent VLFI at 2.23% yielded a sensitivity of 85%, specificity of 65%, positive predictive value of 61% and a negative predictive value of 87%. The latter increased to 100% when using an apnoea-hypopnoea cut-off of 30 events.h-1. In conclusion, these results suggest that spectral analysis of heart rate may be useful as a "rule-out test" for sleep-disordered breathing in patients with mild-to-moderate congestive heart failure.

Predictive value of asymptomatic cervical bruit for carotid artery disease in coronary artery surgery revisited

OBJECTIVE

To investigate the predictive value of asymptomatic cervical bruit for detecting internal carotid artery disease in consecutive patients undergoing coronary artery bypass grafting (CABG).

DESIGN

A prospective cohort study.

SETTING

Tertiary referral university hospitals.

PATIENTS

153 consecutive patients (mean age 57 years) undergoing CABG, without previous history of cerebrovascular events.

INTERVENTIONS

Patients underwent detailed pre-operative work-up, including coronary angiography and carotid artery duplex scanning. Internal carotid artery diameter stenosis was graded as A: normal; B: < 15%; C: 15%-50%; D: 50-80%; D+: > 80-99% and E=complete occlusion.

RESULTS

72 patients (47.1%) (95% CI: 39%, 55%) had no evidence of internal carotid artery stenosis; 81 (52.9%) (95% CI: 44.9%, 60.9%) had varying grades of disease, unilateral or bilateral. Cervical bruit was detected in 12/153 patients (7.8%) (95% CI: 3.5%, 12.1%) of whom all but one (0.7%) had varying grades of internal carotid artery disease; of these, 4 patients had bilateral cervical bruit (2.6%) (95% CI: 0.06%, 5.2%). The sensitivity, specificity, positive and negative predictive values and overall accuracy of cervical bruit for detection of > or = 50% internal carotid artery stenosis were 23.5%, 95.8%, 25%, 95.5% and 91.8%, respectively. The relative risk of > or = 50% stenosis ipsilateral to cervical bruit in 306 sides was 5.58 (95% CI: 2.0, 15.0) and the odds ratio 7.1 (95% CI: 2.0, 25.0).

CONCLUSIONS

Asymptomatic cervical bruit proved a highly specific clinical sign for detection of internal carotid artery stenosis, whether haemodynamically significant (> or = 50%) or otherwise, in patients undergoing myocardial revascularisation. This was matched by a high negative predictive value and overall accuracy for flow limiting atheroma (> or = 50% stenosis). Yet, steering carotid investigations on the basis of cervical bruit alone would result in > or = 80% internal carotid artery stenosis remaining undetected in 3% of overall patients, in whom cervical bruit is absent.

Echocardiographic features and brain natriuretic peptides in patients presenting with heart failure and preserved systolic function

OBJECTIVE

To characterise patients who appear to fulfil the diagnosis of heart failure with preserved systolic function clinically, echocardiographically, and by concentrations of brain-type natriuretic peptide (BNP).

METHODS

102 new cases of heart failure were identified over 24 months in 213 patients referred to a rapid access heart failure clinic. Patients with heart failure and preserved systolic function with contemporary markers of diastolic function were assessed to evaluate their cardiac status further.

RESULTS

Forty patients (39%) had an ejection fraction (EF) < 45% and 62 (61%) had an EF > or = 45%. Of these 62 patients, 30 (48%) fulfilled the case definition of diastolic heart failure. The remaining 32 (52%) had neither an EF < 45% nor abnormalities of diastolic function. Dobutamine stress echocardiography was performed on 26 (42%) patients with EF > or = 45%, which provided an alternative explanation for symptoms in 15 (58%) patients. Concentrations of BNP were higher in patients with diastolic abnormalities (mean (SEM) 101.4 (32.5) pg/ml v 58.4 (6.78) pg/ml, p = 0.042) and with no diastolic abnormalities (199 (37.9) pg/ml v 58.4 (6.78) pg/ml, p < 0.0001) than in patients with no heart failure.

CONCLUSION

Among ambulatory patients presenting with suspected heart failure in the community 19% have systolic dysfunction, 14% have diastolic dysfunction, and 15% seemingly have heart failure with neither systolic nor diastolic dysfunction. A new understanding, including alternative parameters of diastolic function, seems to be necessary to classify patients with heart failure and preserved systolic function.

RETRACTED: Age dependency in the timing of mitral annular motion in relation to ventricular filling in healthy subjects - A pulsed and tissue Doppler study

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Pulmonary venous flow reversal and its relationship to atrial mechanical function in normal subjects ? Ume� General Population Heart Study

AIMS

Although pulmonary venous flow reversal (Ar) is useful in the evaluation of left ventricular (LV) diastolic function, it is often difficult to study with transthoracic echocardiography (TTE). We determined the relationship between Ar and left atrial (LA) mechanical function and sought to define surrogate measurements for Ar.

METHODS AND RESULTS

A total of 130 healthy subjects, mean age 54.3+/-18.3 years, 62 women, were studied and classified into three groups: [young (Y), 25-44 years; n=44], [middle-age (M), 45-64 years; n=43] and [elderly (E), > or =65 years; n=43]. Pulmonary venous flow and LV inflow studies were performed by TTE and LV basal free-wall motion was studied by Doppler tissue imaging (DTI). All images were acquired with a superimposed electrocardiogram. RR interval was similar in all groups while LA dimension and PR interval were increased in Group E vs. Y (P<0.001). LA contraction (A(m)) on DTI, transmitral A-wave (A) and Ar were simultaneous and started 84ms after onset of P wave and this interval increased with age (P=0.02). Similarly, the time intervals from the same landmark to peak A(m), A, and Ar were prolonged with age (all, P<0.001). Despite this prolongation, peak A(m) coincided with peak Ar in every age group (r=0.97, P<0.001) and Ar acceleration and deceleration times were consistently equal.

CONCLUSION

The timing of A(m) obtained by DTI can be used to accurately estimate corresponding measurements of Ar recorded by TTE in subjects without cardiac disease.

Clinical outcome of coronary angioplasty in patients with ischaemic cardiomyopathy

OBJECTIVE

To assess the clinical outcome of successful percutaneous transluminal coronary angioplasty (PTCA) in patients with poor ventricular function.

METHODS

Analysis of angiographic, echocardiographic and clinical records of patients with severe LV dysfunction who underwent PTCA from January 1, 1995 to December 31, 1997 was undertaken. Forty-one patients aged 63+/-10 years, 36 men, all with significant coronary artery disease and impaired LV function (fractional shortening, FS<or=20%) were identified. Patients' data before and after angioplasty were analyzed.

RESULTS

Post PTCA: angiographic success was 95.2%. Major complications occurred in 19.5% and hospital mortality was 2.7%. At 6 months after PTCA:LV fractional shortening (FS) increased from 15.9+/-3.4% to 19.6+/-6.6%, P=0.02 and consequently cardiac output from 4.28+/-0.98 to 5.34+/-1.77 l/min, P<0.01. Change in at least one class of angina and cardiac functional status was observed in 46% of patients, P<0.001, and this was maintained to the end of the year. After 12 months follow-up: restenosis occurred in 10.8%; mortality was 5.4%; event-free and actuarial survivals were 62.3% and 91.9%, respectively.

CONCLUSIONS

In patients with severe LV dysfunction, continued symptomatic improvement can be achieved with successful coronary angioplasty. This is associated with significant recovery of LV systolic function and cardiac output. In order to minimize procedure-related complications, careful patient selection should be considered.

Influence of gender and reported alcohol intake on mortality in nonischemic dilated cardiomyopathy

Between 1994-1998, we retrospectively studied a cohort of 396 consecutive patients with dilated cardiomyopathy, mean age 53 +/- 15 years, 74% men. The history of alcohol intake was abstracted from the medical records. During a follow-up period of 42 +/- 26 months, 83 (76% men) patients died and 15 (80% men) underwent cardiac transplantation. Men were younger and more likely to have a history of excessive alcohol intake compared with women. Gender significantly modified the risk of alcohol consumption on mortality. Although alcohol intake increased the mortality risk in women, it was protective toward death in men (hazards ratios for death were 7.3 vs. 0.44). The effect of alcohol intake on outcome was reassessed after classifying the patients into 4 groups: group 1: life-long nondrinkers; group 2: former drinkers; group 3: moderate drinkers; and group 4: heavy drinkers. Similar findings were seen. This study demonstrated that the risk of reported alcohol intake on mortality is related to gender in patients with nonischemic heart failure. Our findings deserve further study, including a larger number of females, as a possible way to improve outcome in such patients.

Clinical depression is common and significantly associated with reduced survival in patients with non-ischaemic heart failure

Several studies have shown that depression is an important predictor of morbidity and mortality in patients with ischaemic heart failure. We have investigated whether clinically recognised depression is linked to mortality in patients with non-ischaemic heart failure due to dilated cardiomyopathy (DCM) in the Royal Brompton Hospital (RBH), a tertiary cardiac centre located in London, UK. We retrospectively examined a cohort of 396 consecutive adult patients with DCM who satisfied our inclusion and exclusion criteria identified from an echocardiographic database and the hospital medical records. Mean age was 53+/-15 years. In all, 83 patients (21%) were clinically depressed, the majority of which (60%) were taking antidepressant therapy. After a follow-up period of 48 months, 83 (21%) patients died, 15 (4%) underwent cardiac transplantation and 130 (33%) were readmitted; 29 (35%) of the deaths and 40 (31%) of the readmissions were among clinically depressed patients. After 5 years, clinically depressed patients had significantly higher mortality and readmission rates than non-depressed; 36 vs. 16% (hazards ratio for death, 3.0; 95% CI, 1.4-6.4; P=0.004), and 87 vs. 74% (hazards ratio for readmission, 0.25; 95% CI, 0.07-0.90; P=0.03), respectively. The risk of depression was greatly increased in the presence of other recognised adverse clinical variables at baseline. Depression increases the risk of death and readmission in patients with heart failure secondary to non-ischaemic DCM. The risk associated with depression appears to be greatest among patients with milder disease, those with a shorter duration of symptoms and those demonstrating a lower systolic or diastolic blood pressure, renal impairment, or a restrictive left ventricular physiology on echocardiography. Interventions targeted at reducing depression warrant further study as a possible way to improve quality of life and/or outcome in patients with heart failure.

Incremental changes in QRS duration in serial ECGs over time identify high risk elderly patients with heart failure

AIMS

To investigate the hypothesis that changes in the ECG over time may be an important and readily available marker of prognostic value in patients with heart failure.

METHODS

112 elderly patients (81 men) with stable heart failure, a mean (SD) age of 73.3 (4.4) years, left ventricular ejection fraction 38 (17)%, and peak oxygen consumption 15.1 (4.7) ml/kg/min had ECG measurements on two occasions a minimum of 12 (5) months apart.

RESULTS

During the subsequent follow up period (mean 27 (17) months) 45 patients died. QRS duration (p = 0.001) and heart rate (p = 0.03) at baseline were found by Cox proportional hazard method analysis to predict adverse outcomes in these patients. Of the changes in ECG parameters between the first and second visit, broadening of QRS duration (p = 0.001) predicted mortality. On Kaplan-Meier survival analysis, patients with < 5% change in QRS duration had fewer end points than patients with 5-20% change. A > 20% increase in QRS duration was associated with the worst prognosis. Progressive prolongation of QRS duration correlated closely with deterioration of LV systolic and diastolic function.

CONCLUSION

A single measurement of QRS duration has significant prognostic value in elderly patients with heart failure and the increase in QRS duration over time is an even better predictor of adverse out comes.

Arterial waves in humans during peripheral vascular surgery

The purpose of this study was to investigate the effect of aortic clamping on arterial waves during peripheral vascular surgery. We measured pressure and velocity simultaneously in the ascending aorta, in ten patients (70+/-5 years) with aortic-iliac disease intra-operatively. Pressure was measured using a catheter tip manometer, and velocity was measured using Doppler ultrasound. Data were collected before aortic clamping, during aortic clamping and after unclamping. Hydraulic work in the aortic root was calculated from the measured data, the reflected waves were determined by wave-intensity analysis and wave speed was determined by the PU-loop (pressure-velocity-loop) method; a new technique based on the 'water-hammer' equation. The wave speed is approx. 32% (P<0.05) higher during clamping than before clamping. Although the peak intensity of the reflected wave does not alter with clamping, it arrives 30 ms (P<0.05) earlier and its duration is 25% (P<0.05) longer than before clamping. During clamping, left ventricule (LV) hydraulic systolic work and the energy carried by the reflected wave increased by 27% (P<0.05) and 20% (P<0.05) respectively, compared with before clamping. The higher wave speed during clamping explains the earlier arrival of the reflected waves suggesting an increase in the afterload, since the LV has to overcome earlier reflected compression waves. The longer duration of the reflected wave during clamping is associated with an increase in the total energy carried by the wave, which causes an increase in hydraulic work. Increased hydraulic work during clamping may increase LV oxygen consumption, provoke myocardial ischaemia and hence contribute to the intra-operative impairment of LV function known in patients with peripheral vascular disease.

Right and left ventricular long-axis function in the fetus using angular M-mode

OBJECTIVE

Long-axis function is determined by the longitudinally oriented myocardial fibers. Postnatally, conventional M-mode is used to assess tricuspid and mitral valve ring movements in relation to the cardiac apex. During fetal life, this is precluded by variable fetal position. We assessed the feasibility of determining right and left ventricular long-axis function in the fetus.

METHODS

A prospective, pilot study. The four-chamber view obtained during routine fetal echocardiography was recorded in a cineloop to which B-mode guided M-mode echocardiography was applied using angular M-mode. This allowed retrospective and correct placement of the cursor line from cardiac apex to tricuspid or mitral valve rings. M-mode tracings of the valve ring movements in relation to the apex were derived from the originally stored loop. Data from 18 fetuses (17-29 weeks of gestation) were available for analysis. Total excursion of the valve rings was measured offline. A second cursor line was simultaneously placed in the left ventricular outflow tract during color flow mapping for timing purposes (n = 6).

RESULTS

Right and left ventricular long-axis recordings were obtained in 18 and 14 cases, respectively. Total right ventricular excursion was 5.2 mm (SD, 0.9 mm) (range, 3.9-7.2 mm). Total left ventricular free wall excursion was 4.5 mm (SD, 1.1 mm) (range, 3.0-6.8 mm). For paired data, the mean of differences (right ventricle-left ventricle) was 0.8 mm (95% confidence interval 0.5-1.2). The valve rings moved towards the apex during systole (shortening) and away from it during diastole (lengthening). Peak downward movement coincided with cessation of aortic flow and diastolic lengthening with flow through the atrioventricular valves.

CONCLUSION

Long-axis function in the fetus is feasible if M-mode angle correction is used. There was no clinically significant difference between tricuspid and mitral valve excursions. The pattern of atrioventricular valve movement is coordinate and similar to that of adults. Long-axis function offers a new avenue to study systolic and diastolic function in the fetus.

Disturbed atrioventricular electromechanical function long after Mustard operation for transposition of great arteries: a potential contributing factor to atrial flutter

OBJECTIVE

The objectives were to study atrial and ventricular electromechanical function in patients long after Mustard repair for transposition of great arteries and to identify possible causes and physiologic disturbances in those with recurrent atrial flutter.

METHODS

Electromechanical atrial and ventricular function was assessed in 22 patients (11 women) aged 27 +/- 5 years, 10 to 29 (mean 24) years after initial Mustard operation with electrocardiography and echocardiography. The study subjects involved 12 patients with documented atrial flutter and the remaining 10 without history of atrial arrhythmia served as controls. All patients were studied while in sinus rhythm.

RESULTS

There was no difference in age, gender, or age at original Mustard surgery between the 2 patient groups. The P wave and QRS duration were significantly broader in patients compared with controls (128 +/- 14 ms vs 100 +/- 10 ms, P <.05 and 120 +/- 20 ms vs 93 +/- 6 ms, P <.01). Right ventricular end diastolic dimension was not different, whereas left ventricular fraction shortening was less (20% +/- 10% vs 35% +/- 12%, P <.01) in the patient group. Left and septal total ventricular long axes amplitude were significantly lower in patients compared with controls (1.4 +/- 0.4 cm vs 1.7 +/- 0.3 cm, P <.05 and 0.6 +/- 0.2 cm vs 1.0 +/- 0.3 cm, P <.01). Right-sided total long axis excursion was equally reduced in the 2 groups (1.0 +/- 0.3 cm). Septal and right-sided but not left-sided "a" wave was smaller in the patients (1.2 +/- 1 mm vs 3 +/- 1.2 mm, P <.001 and 1 +/- 1.3 mm vs 3 +/- 0.9 mm, P <.01). Right atrial electromechanical delay was significantly longer in patients with respect to controls (110 +/- 14 ms vs 84 +/- 25 ms, P <.001), but on the left there was no difference. The P wave duration correlated closely with right atrial electromechanical delay, r = 0.79, P <.003. Significant tricuspid regurgitation was found in 9 of 12 patients but none of the controls.

CONCLUSION

Right ventricular dysfunction is present long after Mustard operation for transposition of great arteries whether flutter occurs. However, in patients with history of atrial flutter, evidence of left ventricular dysfunction, significant tricuspid regurgitation, impaired right atrial electrical and mechanical function, and reversed onset of atrial systole is also present. The consistent association of the disturbed atrial and ventricular electromechanical behavior suggests a multifactorial etiology for atrial arrhythmia.

Wasting as an independent predictor of mortality in patients with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is the most common life threatening autosomal recessive disorder in the white population. Wasting has long been recognised as a poor prognostic marker in CF. Whether it predicts survival independently of lung function and arterial blood gas tensions has not previously been reported.

METHODS

584 patients with CF (261 women) of mean (SD) age 21 (7) years were studied between 1985 and 1996, all of whom were being followed up in a tertiary referral centre. Lung function tests, body weight, arterial blood oxygen (PaO(2)) and carbon dioxide (PaCO(2)) tensions were measured. The weight was calculated as a percentage of the ideal body weight for age, height, and sex.

RESULTS

Forced expiratory volume in one second (FEV(1)) recorded at the start of the study was 1.8 (1.0) l (52 (26)% predicted FEV(1)), PaO(2) 9.8 (1.9) kPa, PaCO(2) 5.0 (0.9) kPa, and % ideal weight 92 (18)%. During the follow up period (45 (27) months) 137 patients died (5 year survival 72%, 95% CI 67 to 73). FEV(1), % predicted FEV(1), PaO(2), % ideal weight (all p<0.0001), and PaCO(2) (p=0.04) predicted survival. In multivariate analysis, % predicted FEV(1) (p<0.0001), % ideal weight (p=0.004), and PaCO(2) (p=0.02) were independent predictors of outcome. Patients with >85% ideal body weight had a better prognosis at 5 years (cumulative survival 84%, 95% CI 79 to 89) than those with < or =85% ideal weight (survival 53%, 95% CI 45 to 62), p<0.0001. Percentage predicted FEV(1) (area under curve 0.83; 95% CI 0.78 to 0.87) and % ideal weight (area under curve 0.74; 95% CI 0.68 to 0.79) were accurate predictors of survival at 5 years follow up (receiver-operating characteristic analysis).

CONCLUSIONS

Body wasting is a significant predictor of survival in patients with CF independent of lung function, arterial blood oxygen and carbon dioxide tensions.

Long axis electromechanics during dobutamine stress in patients with coronary artery disease and left ventricular dysfunction

OBJECTIVE

To dissociate the effect of inotropy from activation change during dobutamine stress on left ventricular long axis function in patients with coronary artery disease (CAD).

METHODS

25 patients with CAD and normal left ventricular cavity size and 30 with cavity dilatation-18 with normal activation (DCM-NA) and 12 with left bundle branch block (DCM-LBBB)-were compared with 20 controls. 12 lead ECG and septal long axis echograms were assessed at rest and peak dobutamine stress. Amplitude, shortening and lengthening velocities, postejection shortening, Q wave to onset of shortening (Q-OS), and A2 to onset of lengthening (A2-OL) were measured. Inotropy was evaluated from peak aortic acceleration.

RESULTS

In controls, amplitude, shortening and lengthening velocities, and peak aortic acceleration increased with stress; QRS, Q-OS, and A2-OL shortened (all p < 0.001); and contraction remained coordinate. In the group of patients with CAD and normal left ventricular cavity size, shortening velocity and peak aortic acceleration increased with stress (p < 0.005). However, amplitude and lengthening velocity did not change, QRS, Q-OS, and A2-OL lengthened (p < 0.01), and incoordination appeared. Results were similar in the group with DCM-NA. In the DCM-LBBB group, shortening velocity and peak aortic acceleration increased modestly with stress (p < 0.01) but amplitude, lengthening velocity, QRS, Q-OS, A2-OL, and incoordination remained unchanged. Overall, change in shortening velocity correlated with that in peak aortic acceleration (r(2) = 0.71), in amplitude with that in lengthening velocity (r(2) = 0.74), and in QRS with both Q-OS (r(2) = 0.69) and A2-OL (r(2) = 0.63).

CONCLUSION

The normal long axis response to dobutamine reflects both inotropy and rapid activation. In CAD, inotropy is preserved with development of ischaemia but the normal increase in amplitude is lost and prolonged activation delays the time course of shortening, causing pronounced incoordination. Overall, shortening rate uniformly reflects inotropy while lengthening rate depends mainly on systolic amplitude rather than primary diastolic involvement, even with overt ischaemia.

Assessment of cardiac risk before peripheral vascular surgery: a comparison of myocardial perfusion imaging and long axis echocardiography at rest

OBJECTIVE

To compare resting long axis echocardiography with adenosine thallium-201 emission tomography in detecting myocardial ischaemic abnormalities and surgical related risk in patients before peripheral vascular surgery.

DESIGN

A prospective and blinded pre-operative examination of resting left ventricular minor and long axes and myocardial perfusion during adenosine vasodilation using thallium-201 emission tomography.

SETTING

A tertiary referral centre for cardiac and vascular disease equipped with invasive, non-invasive and surgical facilities.

SUBJECTS

65 patients (40 male) with significant peripheral vascular disease, mean age 63+/-10 (S.D.) years, and 21 normal subjects of similar age.

RESULTS

Thallium-201 myocardial perfusion tomography was abnormal in 50/65 patients; 27 had fixed, 23 reversible abnormalities (19 of whom had both). Long axis was considered abnormal if one or more of two systolic long axis disturbances, reduced extent of total excursion <1 cm at any of the three (left, septal and posterior left ventricular) sites or prolonged shortening >1 mm after A2, and two diastolic abnormalities, delayed onset of lengthening >80 ms after A2 or reduced peak lengthening velocity <4.5 cm/s, was present. Long axis score (maximum 12) was based on the presence or absence of these four disturbances at each of the three sites. Myocardial perfusion imaging with thallium-201 classified the patients into three different groups according to their liability to low, moderate or high surgical risk (summed stress perfusion score of 36). Thirteen of 50 patients were identified as subjects at high surgical risk, with a perfusion score of 22/36 and below. Twelve of these demonstrated significantly greater impairment of systolic and diastolic long axis function, compared to those at low surgical risk, with a total long axis echo score of 6/12 or more. Seventeen of 18 patients identified as being at low surgical risk, with a perfusion score of 32/36 and above, had total long axis score of less than 6/12. The remaining 19 moderate risk patients had a wide range of long axis scores. In the 65 patients studied there were two post-operative deaths, one post-discharge death due to cerebrovascular accident, and one due to renal failure.

CONCLUSION

The combination of both systolic and diastolic long axis disturbances in patients with peripheral vascular disease can be used to predict the thallium assessment of surgical risk. Long axis echocardiography may thus have value as a screening test before non-cardiac surgery as well as providing a means of monitoring myocardial perfusion.