[The "Appropriatezza ECO Milano" project. Assessment of appropriateness of indications, prescriptions and clinical utility of two-dimensional Doppler echocardiography among inpatients and outpatients of Milan, Italy]

BACKGROUND

The value of echocardiography in the diagnosis and follow-up of most cardiovascular diseases is well established, even though the ever-increasing demand for the use of this technique is not always justifiable. The "Appropriatezza ECO Milano" project was developed among hospitals in Milan (Italy) to foster a rational use of echocardiography. The aim of this study was to evaluate and improve appropriateness of requests for two-dimensional color Doppler echocardiography, considering indications, prescription behaviors and clinical utility in both the outpatient and inpatient settings.

METHODS

Following several meetings, a consensus was reached whereby a multicenter, observational study would be undertaken. We assessed the value of each request in agreement with the 2003 American College of Cardiology/American Heart Association/American Society of Echocardiography guidelines. An ad hoc Microsoft Access database was developed to collect study data, which refer to May 2007. Eleven hospitals participated in the study.

RESULTS

4130 echocardiographic examinations were considered (2300 performed in men and 1830 performed in women; mean age 64 +/- 16 years); 1701 examinations were performed in hospitalized patients and 2429 in outpatients. The incidence of pathological findings was higher in hospitalized patients (73%) than in outpatients (53%) (Pearson chi2 = 29, p<0.001). A higher additional clinical value was found in hospitalized vs non-hospitalized patients (48 vs. 35%, Pearson chi2 = 99; p <0.001). In both settings, the majority of echocardiographic examinations were requested by cardiologists (inpatients 36%, outpatients 54%). The most appropriate examinations were performed more frequently in class I or class IIA hospitalized patients (73%) than in outpatients (52%) (Pearson chi2 = 277, p<0.001). Furthermore, the least accurate the indication, the less the clinical utility found in examinations requested from hospitals and outpatient clinics (64 vs 61% in class I patients, Pearson chi2 = 413, p<0.001; 5 vs 11% in class III patients, Pearson chi2 = 584, p<0.001). Conclusions. Our data confirm an inadequate level of appropriateness of requests for two-dimensional color Doppler examinations in either inpatients or outpatients. After over 10 years of passively observing and recording this trend, a timely resolution of these issues is topical in order to improve the implementation of criteria and to guarantee cost-effective and high-quality cardiovascular care.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

[Clinical course of hypertrophic cardiomyopathy in a non selected population. The Experience of the Italian Multicenter Cardiomyopathy Study]

BACKGROUND

Most of the information available on the clinical course and prognosis of hypertrophic cardiomyopathy (HCM) is based on data generated from international referral centres and as a result, it constitutes a potentially biased perspective of the disease process in this complex and diverse condition. A multicentric study was therefore set up with the aim of providing information on unselected patient populations with HCM.

METHODS

The study group comprised 330 patients from 5 non-referral hospitals (mean age 42 +/- 16 years, M/F 226/104, 74-22%-obstructive, 299-91%-in NYHA class I-II) who were followed up regularly for 9.5 +/- 5.6 years.

RESULTS

The vast majority of patients (n = 272, 82%) remained asymptomatic or mildly symptomatic during the follow-up period, whereas the remaining patients (n = 58, 18%) experienced clinical deterioration or died. Of the 18 patients (5%) who died of cardiovascular causes related to hypertrophic cardiomyopathy, 14 had progressive congestive heart failure and only 4 died suddenly. The annual mortality rate for cardiovascular disease was 0.57%, while the mortality rate due to sudden cardiac death was only 0.1%. The cumulative survival rate was 98, 95 and 93%, at 5, 10 and 15 years of follow-up respectively. Atrial fibrillation proved to be a relatively common (n = 81, 24%) and particularly unfavourable clinical feature, with higher mortality rate for cardiovascular causes related to hypertrophic cardiomyopathy. Syncope occurred in 47 patients (14%) but did not appear to have prognostic significance.

CONCLUSIONS

In an unselected population, hypertrophic cardiomyopathy had a relatively benign prognosis that was inconsistent with its prior characterization as a generally progressive disorder, based primarily on the experience of selected referral institutions. Sudden unexpected cardiac death was distinctly uncommon, although a sizable proportion of patients, particularly the subset prone to atrial fibrillation, did experience clinical deterioration.

Pulmonary venous flow velocity patterns in 143 normal subjects aged 20 to 80 years old. An echo 2D colour Doppler cooperative study

In order to find out the normal values and to evaluate the effects of age, heart rate, sex, and haemodynamic and standard echocardiographic parameters on pulmonary venous flow velocity obtained by the transthoracic approach. Doppler pulmonary venous flow parameters were measured in 143 healthy subjects aged from 20 to 80 years. Doppler pulmonary venous flow parameters which had the best correlation with age were: the peak velocity of the systolic wave (r = 0.39) and its integral (r = 0.5), the peak velocity of the diastolic wave (r = -0.6) and its integral (r = -0.44); the systolic (r = 0.68) and diastolic fractions (r = -0.68); the systolic/diastolic peak velocity ratio (r = 0.73) and the systolic/diastolic integral ratio (r = 0.7). The atrial reversal wave did not correlate with age; the atrial reversal wave was more difficult and probably less reliable to measure than the systolic and diastolic waves. The correlations of pulmonary venous flow parameters with mitral flow parameters were also examined. This study showed that, in healthy subjects, despite an increase in the early and atrial waves from the annulus to the tips of the mitral leaflets, there is a similar association between pulmonary venous flow and mitral flow measured at the annulus or at the tips of the mitral leaflets. The intra-observer reproducibility of all the pulmonary venous flow parameters considered were found to be excellent. Moderate inter-observer variability was observed for the systolic, diastolic and atrial reversal wave peak velocities and integrals; however, the systolic/diastolic ratio improved the precision of the measurements. Multivariate analysis showed that age is the principal determinant of the Doppler parameters of pulmonary venous flow: heart rate, sex, body surface area, the size of the left atrium in systole and the left ventricular ejection fraction all influence the Doppler parameters of pulmonary venous flow, even if only slightly.

Left ventricular diastolic parameters in 288 normal subjects from 20 to 80 years old

Left ventricular diastolic indexes are influenced by several variables. In order to evaluate the relationship of these indexes to age, heart rate, sex and to standard echo parameters, 288 normal subjects aged from 20 to 80 years, divided into six age groups, underwent a two-dimensional colour Doppler examination. Doppler examination was performed from the apical four chamber view to evaluate transmitral flow; isovolumic relaxation time (IVRT) was measured from an apical five chamber view. In order to obtain a sufficient number of subjects for an adequate statistical analysis, seven hospitals were involved in the study. Univariate analysis showed that age influences the peak velocity of the E (r = -0.46) and A waves (r = 0.46), the E/A ratio (peak velocities) (r = -0.69), the A wave integral (r = 0.48) and the E/A integral ratio (r = -0.57), the early and late filling fractions (r = -0.48 and r = 0.51 respectively), and the E wave deceleration (r = -0.43) and deceleration time (r = 0.36). In subjects older than 70 years an inversion of the E/A wave ratio was observed. Multivariate analysis confirmed that age has an important influence on left ventricular diastolic indexes but also demonstrated that heart rate has a significant influence. Sex, ejection fraction (EF), and the dimensions of the mitral annulus and the left ventricular posterior wall had less influence on left ventricular diastolic indexes. The mean values of E and A wave acceleration, deceleration and peak velocity were used to depict left ventricular filling morphology in various age groups for three different heart rate values. The conclusions of the study, are: (1) normal left ventricular diastolic parameters were obtained as mean values at seven different hospitals (2) when evaluating left ventricular diastolic function parameters it is important to take into account age and heart rate; E/A inversion in older subjects should be considered the normal mitral flow pattern.

Prognostic value of exercise EKG testing in asymptomatic normotensive subjects. A prospective matched study

We prospectively studied 135 asymptomatic normotensive subjects with exercise-induced ST ischemic depression of 1 mm or more and compared them with 379 controls. At least two controls with negative responses on the exercise electrocardiographic (EKG) test were selected for each case and were matched for age, sex, work, community, and coronary-risk-factors index. The end points considered were the following coronary events: angina pectoris, myocardial infarction, and sudden death. After a median follow-up period of 6.0 years for the cases and 6.4 years for the controls, the relative risk was 5.55 (95 per cent confidence limits, 2.75 to 11.22). Coronary events occurred significantly earlier in the cases than in the controls. Our data also suggest that the exercise EKG response is a particularly good prognostic indicator for myocardial infarction. In addition, our analysis has confirmed the predictive roles of age, smoking, blood pressure, and the coronary-risk-factors index and suggests that the exercise EKG response is an additional independent risk indicator for coronary events.