P206 IMPACT OF AGE, GENDER AND HEART FAILURE ON MORTALITY TRENDS AFTER ACUTE MYOCARDIAL INFARCTION IN ITALY

Background

The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

Methods

This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In–hospital mortality rate (I–MR) and 1–year post–discharge mortality rate (1–Y–MR) were assessed.

Results

Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization (Figure 1). Both I–MR and 1–Y–MR significantly decreased over time (from 8.87% to 6.72%; mean annual change − 0.23%; confidence intervals (CI): − 0.26% to − 0.20% and from 12.24% to 10.59%; mean annual change − 0.18%; CI: − 0.24% to − 0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes (Figure 2). In AMI patients complicated by HF, both I–MR and 1–Y–MR were markedly high, regardless of age and gender.

Conclusions

This contemporary, nationwide study suggests that I–MR and 1–Y–MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.

Advanced/metastatic bladder cancer: current status and future directions

In 2015 bladder cancer was the fourth most frequent malignancy and the eighth cause of death for cancer. At diagnosis, about 30% of bladder cancer (BC) patients present a muscle-invasive bladder cancer (MIBC) and 5% a metastatic bladder carcinoma (MBC). For fit MBC patients, combination chemotherapy (CC) is the standard of care for first-line treatment. CC includes both the treatment with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) either the classical or the dose-dense MVAC regimen, and the doublet therapy with cisplatin and gemcitabine (CG). Median progression free survival (PFS) was 7 months and median overall survival (OS) was 15 months. The present review provides an update on the management of MBC, with focus on target therapies, immune checkpoint inhibition, looking for prognostic and predictive factors.

Penile cancer: prognostic and predictive factors in clinical decision-making

Penile cancer (PC) is a typical tumor of non-industrialized countries. The incidence is 20-30 times higher in Africa and South America, considering the elevated prevalence of sexually transmitted diseases. Histologically, PC includes squamous cell carcinoma (SCPC), the most frequent, and nonsquamous carcinoma (NSCPC). Early diagnosis is the goal, whereas later diagnosis relates to poor functional outcomes and worse prognosis. The 5-year survival rate is 85% for patients with histologically regional negative lymph nodes, compared to 29%-40% for those with histologically regional positive lymph nodes. To date no new drugs are approved, and there are few new data about molecular mechanisms underlying tumorigenesis. The SCPC remains a rare tumor and the current therapeutic algorithm is based principally on retrospective analysis and less on prospective trials. In this review article, biomarkers of prognosis and efficacy of current treatments are summarized with a focus on those that have the potential to affect treatment decision-making in SCPC.

Eculizumab treatment in patients with COVID-19: preliminary results from real life ASL Napoli 2 Nord experience

OBJECTIVE

SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-related pneumonia, referred to as COVID-19 (Coronavirus Disease 19), is a public health emergency as it carries high morbidity, mortality, and has no approved specific pharmacological treatments. In this case series, we aimed to report preliminary data obtained with anti-complement C5 therapy with eculizumab in COVID-19 patients admitted to intensive care unit (ICU) of ASL Napoli 2 Nord.

PATIENTS AND METHODS

This is a case series of patients with a confirmed diagnosis of SARS-CoV2 infection and severe pneumonia or ARDS who were treated with up to 4 infusions of eculizumab as an off-label agent. Patients were also treated with anticoagulant therapy with Enoxaparin 4000 IU/day via subcutaneous injection, antiviral therapy with Lopinavir 800 mg/day + Ritonavir 200 mg/day, hydroxychloroquine 400 mg/day, ceftriaxone 2 g/day IV, vitamine C 6 g/day for 4 days, and were on Non-Invasive Ventilation (NIV).

RESULTS

We treated four COVID-19 patients admitted to the intensive care unit because of severe pneumonia or ARDS. All patients successfully recovered after treatment with eculizumab. Eculizumab induced a drop in inflammatory markers. Mean C Reactive Protein levels dropped from 14.6 mg/dl to 3.5 mg/dl and the mean duration of the disease was 12.8 days.

CONCLUSIONS

Eculizumab has the potential to be a key player in treatment of severe cases of COVID-19. Our results support eculizumab use as an off-label treatment of COVID-19, pending confirmation from the ongoing SOLID-C19 trial.

Association of left bundle branch block with new onset abnormal wall motion in treated hypertensive patients with left ventricle hypertrophy: the LIFE Echo Sub-study

AIMS

We aimed to investigate whether left bundle branch block (LBBB) is related to new-onset left ventricle (LV) wall motion abnormalities during treatment in hypertensive patients with electrocardiographic (ECG) defined left ventricular hypertrophy (LVH).

METHODS AND RESULTS

960 patients with essential hypertension and ECG-LVH participating in the LIFE Echo Sub-study were investigated at baseline and annually with echocardiography, during randomized antihypertensive therapy. After excluding patients with LV wall motion abnormalities at baseline and patients developing new-onset LBBB during study time, we investigated 784 patients. The participants with (n = 32) and without (n = 752) LBBB were similar regarding most baseline variables. Logistic regression models controlling for LV mass index, Framingham risk score, and randomized treatment assignment were used to assess the odds ratio of developing new-onset abnormal LV wall motion on annual follow-up echocardiograms. The likelihood of developing new global LV wall motion abnormalities in patients with LBBB was not higher compared to those without LBBB except at year 5 (p = .002). The likelihood of developing new segmental LV wall motion abnormalities in patients with LBBB was however higher compared to patients without LBBB after 1 year (OR = 3.1, 95% CI = 0.7-14.2, p = .173); 2 years (OR = 6.9, 2.1-22.4, p = .003); 3 years (OR = 5.3, 2.0-14.3, p < .001), 4 years (OR = 4.0, 1.6-10.3, p = .003 and 5 years (OR = 4.1, 1.0-16.2, p = .394) of treatment.

CONCLUSION

Among patients with ECG-LVH, undergoing antihypertensive treatment, the presence of LBBB independently identifies individuals with ∼3- to 7-fold greater odds of developing new segmental abnormal LV wall motion. These findings suggest that LBBB may be a marker for progressive myocardial disease.

Detection of preclinical impairment of myocardial function in rheumatoid arthritis patients with short disease duration by speckle tracking echocardiography

BACKGROUND

Subclinical cardiac involvement diagnosis is important for long term management of rheumatoid arthritis (RA) patients. Recently, 2D speckle tracking echocardiography (STE) allows non invasive and angle-independent measurement of left ventricular (LV) dimensions and regional myocardial strain (ε). The aim of this study was to assess whether STE can be useful to detect subclinical cardiac involvement in RA patients.

METHODS

We studied 22 RA patients (10 M, 12 F, aged 46 ± 12 years) without clinical evidence of coronary artery disease (CAD) and 20 healthy controls matched for age and sex by STE. LV end-systolic longitudinal and radial ε from apical 4-chamber view were analyzed using available software (QLAB 6.0).

RESULTS

Standard echo and Doppler parameters did not differ between the 2 groups. Tissue Doppler Imaging (TDI) showed a significant reduction of S', E' and E'/A' ratio from the basal septum and lateral mitral annulus in RA patients. LV end-systolic radial and longitudinal ε of basal-lateral, basal- and mid-septal, mid-lateral and apical segments were significantly reduced compared to controls.

CONCLUSIONS

Our data indicate that LV end-systolic radial and longitudinal ε are reduced in RA patients without CAD despite normal standard echo. Non invasive evaluation of LV function by STE appears to be useful to detect subclinical cardiac involvement in comparison to conventional 2D echoDoppler, representing a promising new modality to follow-up RA patients for cardiac involvement.

Effects of long-term disease-modifying antirheumatic drugs on endothelial function in patients with early rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with enhanced atherosclerosis and impaired endothelial function early after the onset of the disease and cardiovascular (CV) disease represents one of the leading causes of morbidity and mortality. It is well known that disease modifying antirheumatic drugs (DMARDs) are able to improve the course of the disease and the quality of life of these patients, but little is known about the effects of DMARDs on CV risk and endothelial dysfunction. Our goal was to examine the effects of long-term therapy with DMARDs on endothelial function and disease activity in early RA (ERA). Twenty-five ERA patients (mean age 52 ± 14.6 years, disease duration 6.24 ± 4.10 months) without evidence of CV involvement were evaluated for disease activity score (DAS-28), 2D-echo derived coronary flow reserve (CFR), common carotid intima-media thickness (IMT) and plasma asymmetric dimethylarginine (ADMA) levels at baseline and after 18 months of treatment with DMARDs (10 patients with methotrexate and 10 with adalimumab). DMARDs significantly reduced DAS-28 (6.0 ± 0.8 vs. 2.0 ± 0.7; P < 0.0001) and improved CFR (2.4 ± 0.2 vs. 2.7 ± 0.5; P < 0.01). Common carotid IMT and plasma ADMA levels did not show significant changes. The present study shows that DMARDs, beyond the well known antiphlogistic effects, are able to improve coronary microcirculation without a direct effect on IMT and ADMA, clinical markers of atherosclerosis. Treatment strategies in ERA patients with high inflammatory activity must be monitored to identify beneficial effects on preclinical markers of vascular function.

[Cardiac involvement in rheumatoid arthritis]

Rheumatoid arthritis (RA) is a systemic disease of unknown etiology characterized by a chronic inflammatory process mainly leading to destruction of synovial membrane of small and major diarthrodial joints. The prevalence of RA within the general adult population is about 1% and female subjects in fertile age result mostly involved. It's an invalidating disease, associated with changes in life quality and a reduced life expectancy. Moreover, we can observe an increased mortality rate in this population early after the onset of the disease. The mortality excess can be partially due to infective, gastrointestinal, renal or pulmonary complications and malignancy (mainly lung cancer and non-Hodgkin lymphoma). Among extra-articular complications, cardiovascular (CV) involvement represents one of the leading causes of morbidity and mortality. Every cardiac structure can be affected by different pathogenic pathways: heart valves, conduction system, myocardium, endocardium, pericardium and coronary arteries. Consequently, different clinical manifestations can be detected, including: pericarditis, myocarditis, myocardial fibrosis, arrhythmias, alterations of conduction system, coronaropathies and ischemic cardiopathy, valvular disease, pulmonary hypertension and heart failure. Considering that early cardiac involvement negatively affects the prognosis, it is mandatory to identify high CV risk RA patients to better define long-term management of this population.

Noninvasive quantification of coronary endothelial function by SPECT imaging in children with a history of Kawasaki disease

PURPOSE

The feasibility of coronary function estimation by single photon emission computed tomography (SPECT) has been recently demonstrated. The aim of this study was to apply SPECT imaging in patients with previous Kawasaki disease (KD) to assess the coronary functional status at long-term follow-up of the acute phase of the disease.

METHODS

Sixteen children with a history of KD underwent 99mTc-sestamibi imaging at rest and during the cold pressor test (CPT). Myocardial blood flow (MBF) was estimated by measuring first transit counts in the pulmonary artery and myocardial counts from SPECT images. Coronary endothelial function was expressed as the ratio of the CPT to rest MBF.

RESULTS

Six KD patients without coronary artery lesions served as controls and ten with coronary artery aneurysms during the acute phase of the disease were separated into two groups: group 1 (n=4) with regressed and group 2 (n=6) with persistent aneurysm at follow-up. The estimated coronary endothelial function was higher in controls compared to patients with coronary artery aneurysms (2.5±0.3 vs 1.7±0.7, p<0.05). A significant difference in coronary endothelial function among groups was found (F=5.21, p<0.02). Coronary endothelial function was higher in patients of group 1 than in those of group 2 (1.9±0.6 vs 1.4±0.7, p<0.02).

CONCLUSION

SPECT may be applied as a noninvasive method for assessing coronary vascular function in children with a history of KD, demonstrating an impaired response to the CPT, an endothelial-dependent vasodilator stimulus. These findings reinforce the concept that coronary endothelial dysfunction may represent a long-term sequela of KD.

Are coronary revascularization and myocardial infarction a homogeneous combined endpoint in hypertension trials? The Losartan Intervention For Endpoint reduction in hypertension study

OBJECTIVE

Construction of prognostically relevant endpoints for clinical trials in hypertension has increasingly included coronary revascularization with myocardial infarction (MI) as manifestations of coronary artery disease. However, whether coronary revascularization and MI predict other cardiovascular events similarly is unknown.

METHODS

We examined risks of cardiovascular death, all-cause death, and stroke following MI or coronary revascularization in hypertensive patients with left ventricular hypertrophy (LVH) enrolled in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE). We studied 9113 patients after excluding those who died within 7 days after MI or underwent coronary revascularization within 24 h after MI.

RESULTS

In multivariate Cox regression adjusting for participating countries, time-varying systolic blood pressure, and Framingham risk score, hazard ratios for cardiovascular death, all-cause death, and stroke were, respectively, 4.5 (P<0.0001), 2.9 (P<0.0001), and 1.9 (P=0.003) in 321 patients with MI as first event. In similar models, coronary revascularization as first event (n=202) was not associated with increased risks of cardiovascular death, all-cause death, and stroke (P=0.06-0.86).

CONCLUSION

During follow-up of hypertensive patients with LVH, occurrence of MI but not coronary revascularization as first cardiovascular event significantly increased risk of subsequent cardiovascular death, all-cause death, and stroke. In view of differences in prognostic implications, when the goal is to have a prognostically relevant composite endpoint for trials in hypertensive patients, caution should be used in combining coronary revascularization with MI.

Subclinical impairment of coronary flow velocity reserve assessed by transthoracic echocardiography in young renal transplant recipients

BACKGROUND

In renal transplant recipients (RTR) an increased risk to develop cardiovascular injury is present. Transthoracic Doppler echocardiographic assessment of coronary flow velocity reserve (CFVR), a sensitive and minimally invasive technique, was recently employed to detect both macrovascular and microvascular coronary artery disease (CAD) in different clinical settings. The prevalence of coronary involvement in young adult RTR is still unknown. The aim of the study was to investigate the presence of early cardiovascular damage in asymptomatic young adult RTR.

METHODS

Transthoracic Doppler echocardiographic-derived CFVR and common carotid intima-media thickness (IMT) were assessed in 25 asymptomatic young adult RTR (mean age 25.7+/-7.0 years; range 17.3-43.9) without CAD and 25 healthy controls.

RESULTS

CFVR was lower in young adult RTR compared to controls (2.8+/-0.6 vs. 3.5+/-0.8; P<0.001), meanwhile left ventricular wall motion and common carotid IMT were comparable in both groups. We found a negative correlation between CFVR and age (r=-0.50; P=0.018) and months on dialysis (r=-0.54; P<0.01).

CONCLUSIONS

Young adult RTR showed a reduced CFVR reflecting an impaired coronary microcirculation, which is significantly related to the age and duration of dialysis; coronary microvascular damage is detectable in the absence of changes in common carotid IMT. Non-invasive evaluation of CFVR by transthoracic stress echocardiography could be a reliable method for identification of early coronary microvascular involvement in young adult RTR.

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

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

Prevalence and Prognostic Significance of Wall-Motion Abnormalities in Adults Without Clinically Recognized Cardiovascular Disease

Background— Left ventricular wall motion (WM) abnormalities have recognized prognostic significance in patients with coronary or other heart diseases; however, whether abnormal WM predicts adverse events in adults without overt cardiovascular disease has not been assessed. Our objective was to determine whether echocardiographic WM abnormalities predict subsequent cardiovascular events in a population-based sample.

Methods and Results— Participants (n=2864, mean age 60±8 years, 64% women) without clinically evident cardiovascular disease in the second Strong Heart Study examination who had complete echocardiographic WM assessment were studied. Echocardiographic assessment revealed that 5% of participants (n=140) had focal hypokinesia, and 1.5% (n=42) had WM abnormalities. Relationships between WM abnormalities and fatal and nonfatal cardiovascular events (including myocardial infarction, stroke, coronary artery disease, and heart failure; n=554) and cardiovascular death (n=182) during 8±2 years follow-up were examined. In Cox regression, after adjustment for age, gender, waist/hip ratio, systolic blood pressure, and diabetes mellitus, segmental WM abnormalities were associated with a 2.5-fold higher risk of cardiovascular events and a 2.6-fold higher risk of cardiovascular death (both P <0.0001). In similar multivariable models, global WM abnormalities were associated with a 2.4-fold higher risk of cardiovascular events ( P =0.001) and a 3.4-fold higher risk of cardiovascular death ( P =0.003).

Conclusions— Echocardiographic left ventricular WM abnormalities in adults without overt cardiovascular disease are associated with 2.4- to 3.4-fold higher risks of cardiovascular morbidity and mortality, independent of established risk factors.

Electrocardiographic and echocardiographic detection of myocardial infarction in patients with left-ventricular hypertrophy. The LIFE Study

BACKGROUND

Left-ventricular hypertrophy (LVH) is a recognized risk factor for myocardial infarction (MI). However, detection of MI by standard electrocardiographic (ECG) criteria may be hampered in patients with LVH. In this setting of hypertensive LVH, the accuracy of two-dimensional (2D) echocardiography in detecting incident MI is unknown. Thus, we compared the accuracy of 2D echocardiography with Minnesota-code ECG criteria in detecting incident MI, adjudicated during serial evaluation in patients with hypertension and LVH.

METHODS

In the ECG substudy of the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) Study, complete baseline wall-motion (WM) evaluation was obtained in 904 hypertensive patients with ECG LVH who did not have a left-bundle branch block. Electrocardiography and echocardiograms obtained at annual follow-up visits were evaluated for ECG Q-waves by Minnesota codes and WM abnormalities, respectively (mean follow-up, 4.8+/-0.9 SD years). Occurrence of incident clinical MI during follow-up was adjudicated by an expert end-point committee.

RESULTS

In two logistic models adjusting for confounders, incident MI was independently associated with either incident Q-waves by the Minnesota code (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.4-15.3) or incident and worsened WM abnormalities (OR, 11.9; 95% CI, 4.5-32.0), and the association was stronger for WM abnormalities than for Q-waves (P < .0001). Detection of incident MI by ECG or 2D echocardiography was obtained with sensitivities of 29% and 68% and specificities of 95% and 84%, respectively.

CONCLUSIONS

Wall-motion abnormalities on serial 2D ECGs recognize incident MI better than do Minnesota-code ECG criteria during follow-up of patients with hypertension and LVH.

Coronary flow reserve in hypertensive patients with hypercholesterolemia and without coronary heart disease

BACKGROUND

Coronary flow reserve (CFR) may be reduced both in arterial hypertension and in hypercholesterolemia. The aim of the study was to assess an association between CFR and levels of plasma total cholesterol (TC) in untreated arterial hypertension.

METHODS

We studied 54 consecutive, untreated hypertensive outpatients free of coronary heart disease. Twenty of them had normal TC and 34 high TC (>/=200 mg/dL). Standard echocardiograms and transthoracic Doppler interrogation of the distal left anterior descending artery were obtained. Coronary diastolic peak velocities were measured both at rest and after low-dose dipyridamole. The CFR was calculated as dipyridamole/resting velocities ratio.

RESULTS

The two groups had similar age, body mass index, heart rate, and diastolic blood pressure (BP). Patients with high TC had higher systolic BP (P < .05), triglycerides (P < .02), LDL-cholesterol, and TC/HDL-cholesterol ratio (both P < .0001) than controls. Left ventricular (LV) mass index, relative wall thickness, and fractional shortening did not differ between the two groups. Coronary diastolic peak velocities were similar at rest but lower after dipyridamole in patients with high TC (P < .02). As a consequence, CFR was reduced (P < .002). In multiple linear regression analyses, adjusting for age, heart rate, systolic BP, smoking, and relative wall thickness, TC (beta = -0.338) or high LDL-cholesterol (beta = -0.301) (both P < .001) were predictors of lower CFR independently of the concomitant effect of potential confounders.

CONCLUSIONS

In hypertensive patients free of coronary artery disease, the degree of impairment in coronary vasodilator capacity is independently associated with plasma cholesterol and LDL-cholesterol.

[Multiple organ resection in advanced gastric carcinoma: experience of 7 years]

In this work we report our experience on multiorgan resections (MOR) for local advanced gastric cancer. From 1998 to 2004 in our Department 79 patient underwent total or partial resection of stomach associated with removal of various other organs. The results we report come from the evaluation of perioperative mortality and morbidity rates and further analysis of median survival time and quality of residual life. In conclusion, we affirm the utility of major surgery in advanced gastric cancer only in conditions that guarantee an acceptable rate of major complications.

Transthoracic Doppler echocardiography of mammary artery grafts to assess graft function

BACKGROUND

Transthoracic Doppler echocardiography of internal mammary artery grafts (MAGs) has been tested by the supraclavicular approach, but little information is available about the parasternal approach.

OBJECTIVE

To evaluate the usefulness of parasternal transthoracic Doppler echocardiography to assess the patency of left and right MAGs.

PATIENTS AND METHODS

Forty-eight patients with previous MAGs were divided into two groups on the basis of coronary angiography: 42 patients had patent MAGs and six patients had severe MAG stenosis. Doppler echocardiography of MAGs was performed on all patients, both at baseline and after low-dose dipyridamole infusion. Systolic and diastolic time-velocity integrals and their ratios were obtained, and MAG flow reserve was calculated.

RESULTS

Patients with patent MAGs had a predominant diastolic flow, while a prominent systolic pattern was found in the presence of MAG stenosis. In patients with stenosis, baseline Doppler analysis showed a lower diastolic peak velocity (DPV) (P<0.01), diastolic time-velocity integral (P<0.05), and diastolic and systolic time-velocity integral ratios (both P<0.005), and a reduced MAG flow reserve (P<0.001). In the overall population, when adjusting for clinical variables, a multilinear regression analyis underscored MAG flow reserve (beta=0.38, P<0.01) and baseline DPV (beta=0.29, P<0.05) as independent determinants of MAG stenosis (cumulative R2=0.25, P<0.005).

CONCLUSIONS

Doppler echocardiographic evaluation of MAGs is a reliable, noninvasive tool to assess MAG patency and functional status of the vessel. MAG blood flow reserve and baseline DPV are independent determinants of MAG stenosis.

Transthoracic coronary flow reserve and dobutamine derived myocardial function: a 6-month evaluation after successful coronary angioplasty

After percutaneous transluminal coronary angioplasty (PTCA), stress-echocardiography and gated single photon emission computerized tomography (g-SPECT) are usually performed but both tools have technical limitations. The present study evaluated results of PTCA of left anterior descending artery (LAD) six months after PTCA, by combining transthoracic Doppler coronary flow reserve (CFR) and color Tissue Doppler (C-TD) dobutamine stress.

Six months after PTCA of LAD, 24 men, free of angiographic evidence of restenosis, underwent standard Doppler-echocardiography, transthoracic CFR of distal LAD (hyperemic to basal diastolic coronary flow ratio) and C-TD at rest and during dobutamine stress to quantify myocardial systolic (S_m) and diastolic (E_m and A_m, E_m/A_m ratio) peak velocities in middle posterior septum. Patients with myocardial infarction, coronary stenosis of non-LAD territory and heart failure were excluded. According to dipyridamole g-SPECT, 13 patients had normal perfusion and 11 with perfusion defects. The 2 groups were comparable for age, wall motion score index (WMSI) and C-TD at rest. However, patients with perfusion defects had lower CFR (2.11 ± 0.4 versus 2.87 ± 0.6, p < 0.002) and septal S_m at high-dose dobutamine (p < 0.01), with higher WMSI (p < 0.05) and stress-echo positivity of LAD territory in 5/11 patients. In the overall population, CFR was related negatively to high-dobutamine WMSI (r = -0.50, p < 0.01) and positively to high-dobutamine S_m of middle septum (r = 0.55, p < 0.005).

In conclusion, even in absence of epicardial coronary restenosis, stress perfusion imaging reflects a physiologic impairment in coronary microcirculation function whose magnitude is associated with the degree of regional functional impairment detectable by C-TD.

Nebivolol improves coronary flow reserve in hypertensive patients without coronary heart disease

OBJECTIVE

To examine the effects of nebivolol, a beta-blocker with nitroxide-mediated vasodilating properties, on coronary flow reserve (CFR) in patients with uncomplicated arterial hypertension.

DESIGN, SETTING AND PATIENTS

Fourteen newly diagnosed, never-treated, World Health Organization grade I-II hypertensive patients (male/female, 10/4; mean age, 47 years), free of coronary heart disease, underwent standard Doppler echocardiography and determination of CFR in the distal left anterior descending artery by low-dose dipyridamole (0.56 mg/kg intravenously in 4 min) at baseline and after 4 weeks of treatment with 5 mg nebivolol once daily.

RESULTS

At baseline, nine patients had left ventricular (LV) hypertrophy (LV mass index > or = 51 g/m). After 4 weeks of therapy, the blood pressure was decreased from 148 +/- 8.1/101.4 +/- 4.6 mmHg to 140.7 +/- 7.0/91.1 +/- 7.4 mmHg and end-systolic stress was also significantly reduced. Heart rate was reduced (P <0.01), whereas LV end-diastolic diameter and stroke volume tended to increase (P=0.07 and P=0.09, respectively). No changes were detected in the LV mass index, relative wall thickness, fractional shortening and LV diastolic properties. Both resting and dipyridamole rate-pressure products were lower after nebivolol but dipyridamole-induced changes were not influenced by the therapy. In contrast, nebivolol therapy did not alter coronary velocities at rest, but caused a greater increase in coronary velocities after dipyridamole (P <0.03), leading to a greater CFR (2.12 +/- 0.33 versus 1.89 +/- 0.31, P <0.0001). Nebivolol induced an absolute increase of 8% in the CFR in nine of 14 patients (64.3%).

CONCLUSIONS

In hypertensive patients free of coronary artery disease, 4-week nebivolol therapy induces a significant increase of the CFR. Nebivolol preserves coronary flow at rest despite the reduction of metabolic (O2 consumption) and hemodynamic (diastolic blood pressure) determinants. The increase of hyperemic coronary velocities appears due to the reduction of coronary resistance.

Usefulness of pulsed tissue Doppler for the assessment of left ventricular myocardial function in overt hypothyroidism

BACKGROUND

The aim of this study was to assess the role of tissue Doppler (TD) in the identification of left ventricular (LV) myocardial regionl abnormalities in overt hypothyroidism.

METHODS

Fourteen women with newly diagnosed, never treated overt hypothyroidism and 14 healthy women, matched for age, underwent standard echocardiography and pulsed TD, by placing the sample volume at the basal posterior septum and lateral mitral annulus, in the apical 4-chamber view. The myocardial systolic (SM) and diastolic velocities (Em, Am and their ratio) and time intervals (relaxation time [RTm], pre-contraction time [PCTm], contraction time) were measured.

RESULTS

The two groups were comparable for body surface area, blood pressure and heart rate. At standard echocardiography, patients with overt hypothyroidism had a significantly greater septal thickness and LV mass index, a longer LV pre-ejection period (PEP), deceleration time and isovolumic relaxation time (IVRT) and a lower E peak velocity and E/A ratio. TD showed a significantly longer PCTm and RTm and a lower Em and Em/Am ratio of both the septum and mitral annulus in overt hypothyroidism. The ratio of the standard Doppler E to Em of the mitral annulus was 5.5 +/- 1.2 in controls and 5.3 +/- 1.7 in overt hypothyroidism (p = NS). In the overall population, PEP, IVRT, PCTm and RTm were correlated negatively with FT3 and FT4, and positively with thyroid-stimulating hormone. After adjusting for age, body surface area and heart rate in separate multivariate analyses, the associations of TD PCTm with the thyroid hormones and thyroid-stimulating hormone were greater than the homologous associations of standard Doppler PEP.

CONCLUSIONS

Standard echocardiography confirms itself as a satisfactory diagnostic technique for the identification of LV global dysfunction in overt hypothyroidism. Pulsed TD may be useful to determine the severity of LV myocardial dysfunction in relation to the degree of hormonal impairment.

Coronary flow reserve in hypertensive patients with appropriate or inappropriate left ventricular mass

OBJECTIVE

To assess the association between coronary flow reserve (CFR) and levels of left ventricular mass (LVM) exceeding the compensatory needs in arterial hypertension. DESIGN, SETTINGS AND PATIENTS: The association between the excess of LV mass and CFR was assessed in a population of 40 consecutive hypertensive outpatients free of coronary heart disease, 22 with appropriate and 17 with inappropriately high LVM (i.e. LVM exceeding 128% of the value predicted by sex, stroke work and height in m(2.7)). The CFR (the ratio between dipyridamole and basal diastolic peak velocity) of the distal left anterior descending artery was measured by transthoracic Doppler echocardiography.

RESULTS

Patients with inappropriate LVM had similar age, body mass index (BMI), baseline blood pressure (BP) and coronary velocities, but lower LV systolic function, post-dipyridamole diastolic peak velocities (P < 0.05) and lower CFR (P < 0.002) than patients with appropriate LVM. CFR was negatively related to the extent of the excess of LVM (beta = -0.44, P < 0.005), independently of potential combined effect of age, BMI and post-dipyridamole diastolic BP. Impairment of CFR (i.e. < 2) was better discriminated by identification of clear-cut inappropriate LVM (P < 0.004) than by the presence of LV hypertrophy (i.e. LV mass index > or = 51 g/m(2.7); P = 0.057).

CONCLUSIONS

In hypertensive patients free of coronary artery disease, the degree of reduction in CFR is associated with the excess of LVM beyond the values compensatory for individual haemodynamic load. This relation is also independent of the presence of LV hypertrophy.

Left bundle branch block with and without coronary artery disease: which value for a tissue Doppler-derived post-systolic motion?

BACKGROUND

An asynchronous contraction occurring during a prolonged relaxation period, defined as post-systolic motion (PSM), has been described as being a consequence of coronary occlusion but also in other conditions including isolated left bundle branch block (LBBB). The aim of this study was to characterize PSM of the interventricular septum at pulsed tissue Doppler in LBBB with or without stenosis of the left anterior descending coronary artery (LAD).

METHODS

Forty-two patients with chronic, complete LBBB and tissue Doppler-derived septal PSM were divided into two groups on the basis of their coronary angiography: 27 without LAD stenosis and 15 with LAD stenosis (> or = 50%). Standard Doppler echocardiography and tissue Doppler of both the middle posterior septum and lateral mitral annulus were performed in the apical 4-chamber view.

RESULTS

Standard Doppler diastolic indexes were comparable between the two groups. Septal tissue Doppler showed lower myocardial systolic (Sm) and atrial peak velocities (both p < 0.05), a higher PSM (p < 0.005), and a longer relaxation time (p < 0.02) and pre-contraction time (p < 0.05) in patients with LAD stenosis. A Sm/PSM ratio < 1 was detected in 86% of patients with LAD stenosis and in 22% without LAD stenosis (sensitivity 73%, specificity 77%, positive predictive value 64%, negative predictive value 84%). Tissue Doppler of the mitral annulus showed a significantly longer relaxation time and pre-contraction time and a lower atrial velocity in the presence of LAD stenosis. In the overall population, PSM was positively associated with ejection fraction and negatively with age and septal thickness. In a multiple linear regression analysis, only LAD stenosis (beta = 0.42, p < 0.005) and ejection fraction (beta = 032, p = 0.03) were independent predictors of PSM (cumulative r2 = 0.27, p < 0.002).

CONCLUSIONS

Tissue Doppler may be useful to distinguish septal myocardial asynchrony in LBBB with and without LAD stenosis.

[Non-invasive assessment of coronary flow reserve with transthoracic echocardiography: physiopathology, methodology and clinical value]

The assessment of coronary flow reserve with transthoracic Doppler echocardiography, measured as the ratio between hyperemic and baseline coronary flow velocities, is a new tool for the evaluation of coronary artery disease and coronary microcirculation. Color-guided pulsed Doppler allows almost optimal identification of flow velocities at the middle and distal left anterior descending artery and good visualization of the right coronary artery. The development of ultrasound technology (second harmonic, contrast agents, dedicated softwares) is responsible for great feasibility (until 98% for the left anterior descending artery and 40-50% for the right coronary artery) and very good reproducibility of this tool. Doppler-derived coronary flow reserve has excellent concordance with that obtainable with intravascular Doppler flow wire. Diagnosis of stenosis and restenosis after stent implantation in the middle and/or proximal left anterior descending artery and of stenosis of the right coronary artery is very accurate. In the absence of stenosis of epicardial coronary arteries, the reduction in coronary flow reserve implies a damage of coronary microcirculation, which can be a determinant of angina pectoris and signs of myocardial ischemia in arterial hypertension, diabetes mellitus and coronary X syndrome. Further progress may be expected by using myocardial contrast agents for quantitation of regional myocardial coronary flow reserve.

Noninvasive assessment of left and right internal mammary artery graft patency using transthoracic color Doppler echocardiography

BACKGROUND

The aim of this study was to evaluate the patency of left and right internal mammary artery grafts respectively on the left anterior descending and right coronary artery by noninvasive transthoracic color Doppler echocardiography.

METHODS

Thirty eight patients (34 males, 4 females, mean age 59 +/- 2 years), with a history of coronary artery bypass grafting for a total of 42 mammary artery grafts, were studied by means of color Doppler echocardiography at baseline and after vasodilation with dipyridamole infusion (0.56 mg/kg i.v. over 4 min). The evaluated echocardiographic parameters included: systolic (SPV) and diastolic peak velocities (DPV), systolic (SVI) and diastolic velocity-time integrals (DVI), and the DPV/SPV and DVI/SVI ratios. We also calculated the dipyridamole infusion to baseline ratio of the diastolic peak velocities (DPVdip/DPVbaseline), the index of internal mammary artery graft blood flow reserve and the percent DPV increment as an index of graft stenosis.

RESULTS

On the basis of coronary angiography, two groups were selected: group A (36 mammary grafts) with patent grafts and group B (6 mammary grafts) with moderate or severe stenosis of the grafts. Group A had a predominant diastolic pattern with a DPV of 0.24 +/- 0.13 m/s, whereas group B had a predominant systolic pattern with a reduced DPV of 0.12 +/- 0.03 m/s (p < 0.01). Dipyridamole induced an increase in the DPV respectively of 86.8 +/- 64.4% in group A and 13.8 +/- 15.9% in group B (p < 0.001). Statistical analysis (Mann-Whitney test) revealed a significant difference between the two groups for the baseline DPV (p < 0.01), DVI (p < 0.05), DPV/SPV ratio (p < 0.005), DVI/SVI ratio (p < 0.05), and for the after dipyridamole infusion values: DPV (p < 0.0001), DVI (p < 0.005), DPV/SPV ratio (p < 0.001), and DVI/SVI ratio (p < 0.05). Multivariate analysis showed that the percent DPV increment, the DPVdip/DPVbaseline ratio and the baseline DPV were independent determinants of the stenosis as evaluated at angiography (beta = -0.38, p < 0.01; beta = -0.37, p < 0.01, and beta = -0.33, p < 0.05, respectively; cumulative r2 = 0.25, standard error 0.30 m/s, p < 0.005).

CONCLUSIONS

The echocardiographic evaluation of the mammary grafts is a simple, noninvasive method for the assessment of the graft patency and of the functional status of the vessel. The percent DPV increment and baseline DPV were independent determinants of mammary graft stenosis.

Coronary flow reserve and myocardial diastolic dysfunction in arterial hypertension

The aim of this study was to assess the relation between coronary blood flow and left ventricular (LV) myocardial diastolic dysfunction in arterial hypertension. The study population included 30 hypertensive patients who were free of coronary artery disease and pharmacologic therapies. They underwent standard Doppler echocardiography and color tissue Doppler of the middle posterior septum at baseline and with high-dose dobutamine, and second-harmonic Doppler flow analysis of the distal left anterior descending coronary artery at baseline and after vasodilation by dipyridamole (0.56 mg/kg IV in 4'). Coronary flow reserve (CFR) was estimated as the ratio of hyperemic and baseline diastolic flow velocities. According to CFR, hypertensives were divided into 2 groups: 15 patients with normal CFR (>/=2) and 15 patients with reduced CFR (<2). The 2 groups were comparable for sex, age, body mass index, baseline heart rate, and blood pressure. LV mass index was greater in hypertensives with reduced CFR (p <0.01). By color tissue Doppler, baseline and high-dose dobutamine septal systolic velocities did not differ between the 2 groups. The ratio between myocardial velocities in early diastole and at atrial contraction (E(m)/A(m) ratio) was lower in patients with reduced CFR, both at baseline (p <0.05) and with high-dose dobutamine (p <0.00001). After adjusting for age, body mass index, LV mass index, and both high-dose dobutamine diastolic blood rate and heart rate by a multiple linear regression analysis, E(m)/A(m) ratio at high-dose dobutamine was independently associated with CFR in the overall population (beta 0.62, p <0.0005) (cumulative R(2) 0.38, p <0.0005). In conclusion, this study provides evidence of an independent association between CFR and myocardial diastolic function. In hypertensive patients without coronary artery stenosis, CFR alteration may be a determinant of myocardial diastolic dysfunction or diastolic impairment that should be taken into account as possibly contributing to coronary flow reduction.

Positive association between circulating free insulin-like growth factor-1 levels and coronary flow reserve in arterial systemic hypertension

BACKGROUND

The reduction of coronary flow reserve (CFR) found in arterial hypertension may be due to changes in afterload, left ventricular (LV) structure, and metabolic factors. Also, insulin-like growth factor-1 (IGF-1) may be associated with the magnitude of CFR in relation to its modulating action on cardiac and endothelial function.

METHODS

A total of 44 newly diagnosed, untreated hypertensive patients, who were free of diabetes mellitus and coronary artery disease, underwent M-mode analysis, second-harmonic Doppler echocardiographic assessment of CFR (dipyridamole infusion 0.56 mg/kg intravenously in four patients), determination of circulating free IGF-1, and insulin resistance. Based on CFR levels, hypertensive subjects were divided into two groups: 18 with normal CFR (> or = 2) and 26 with impaired CFR (<2).

RESULTS

Patients with normal CFR had lower diastolic blood pressure, heart rate, and LV mass index but higher free circulating IGF-I than patients with reduced CFR (P < .001). Insulin resistance was not significantly different between the two groups. In a first multilinear regression analysis that included demographic and echocardiographic variables, insulin resistance was independently associated with CFR (standardized beta coefficient = -0.31, P < .05) in the overall population. However, in a subsequent model which included also IGF-1, the relationship between insulin resistance and CFR disappeared, whereas IGF-1 was the main independent determinant of CFR (beta = 0.51, P < .0002).

CONCLUSIONS

Free IGF-1 circulating levels are independently associated with CFR in hypertensive individuals free of overt coronary artery disease. A possible beneficial effect exerted by IGF-1 on coronary blood flow may be supposed in arterial hypertension.

Right ventricular diastolic dysfunction in arterial systemic hypertension: analysis by pulsed tissue Doppler

AIMS

This study analyses right ventricular longitudinal function in arterial systemic hypertension by pulsed tissue Doppler.

METHODS AND RESULTS

Thirty normotensives and 30 hypertensives, free of cardiac drugs, underwent standard Doppler echocardiography and pulsed tissue Doppler of right ventricular lateral tricuspid annulus and left ventricular lateral mitral annulus. By tissue Doppler, systolic and diastolic measurements were obtained. Hypertensives had higher left ventricular mass and impaired Doppler diastolic indexes, without changes of global systolic function. Tissue Doppler showed reduction of right ventricular E/A ratio and prolongation of relaxation time in comparison with controls (both P<0.00001). In the overall population, the length of tissue Doppler derived right ventricular relaxation time was positively related to right ventricular anterior wall thickness while right ventricular E/A ratio was positively related to E/A ratio of left ventricular mitral annulus (both P<0.00001). These relations remained significant even after adjusting for clinical and echocardiographic confounders by separate multivariate models.

CONCLUSIONS

Arterial systemic hypertension is associated to right ventricular longitudinal diastolic dysfunction. This dysfunction involves the prolongation of active relaxation, which is independently associated with the degree of right ventricular hypertrophy and the impairment of passive wall properties, which is mainly due to ventricular interaction occurring under left ventricular pressure overload conditions.

The usefulness of pulsed tissue Doppler for the clinical assessment of right ventricular function

Standard Doppler echocardiographic evaluation of the right ventricular (RV) function has several limitations because of a difficult technical approach. The purpose of the present review was to investigate, even in the light of such problems, the usefulness of pulsed tissue Doppler (TD) during the assessment of RV transverse and longitudinal function on the basis of the regional velocities and time intervals. TD-derived (systolic and diastolic) velocities of the RV free wall and of the lateral tricuspid annulus have been used to establish reference values in healthy subjects and in different cardiac diseases. Some studies have shown the usefulness of myocardial systolic velocities for the detection of RV systolic failure at rest and of right coronary artery stenosis during stress. The myocardial early diastolic velocities, combined to Doppler standard tricuspid inflow measurements, represent reliable indexes of right chamber hemodynamics, the ratio between the Doppler tricuspid E velocity and the TD-derived early diastolic velocity of the lateral tricuspid annulus being positively related to the mean right atrial pressure after heart transplantation. Even the assessment of RV regional time intervals may have clinical implications. In particular, the relaxation time of the lateral tricuspid annulus, very short or even absent in healthy subjects increases progressively with the pulmonary systolic artery pressure and its length is strongly influenced also by the increasing RV wall thickness in septal hypertrophic cardiomyopathy and in hypertensive left ventricular hypertrophy. The interaction between the two ventricles is identified by assessing the TD velocities of the RV tricuspid annulus which are often associated with the corresponding velocities of the mitral annulus in different pathologies. On the grounds of these studies, the clinical use of pulsed TD merits consideration. Longitudinal follow-up of TD RV patterns will be useful to evaluate the progression from early RV wall dysfunction until the development of global RV failure and the possible beneficial effect of cardiac drugs on RV function as determined by TD evaluation.

Right ventricular myocardial diastolic dysfunction in different kinds of cardiac hypertrophy: analysis by pulsed Doppler tissue imaging

BACKGROUND

Right ventricular (RV) chamber involvement has been demonstrated in hypertrophic cardiomyopathy (HCM) as well as in hypertensive left ventricular hypertrophy (LVH) but little is known about RV myocardial dysfunction occurring in these two pathologies. The aim of this study was to compare Doppler tissue imaging (DTI) of the right ventricle in HCM and LVH in relation to DTI of the left ventricle and Doppler standard of the RV and left ventricular (LV) inflow.

METHODS

Thirty controls, 20 hypertensives with LVH, and 23 patients with HCM involving the interventricular septum underwent Doppler echocardiography and pulsed DTI of the LV lateral mitral annulus and the RV lateral tricuspid annulus.

RESULTS

Patients with HCM had a higher blood pressure, septal thickness and LV mass in comparison with the other two groups. The RV wall thickness did not differ between HCM and LVH. The fractional shortening, but not the tricuspid annular plane excursion, was higher in HCM. After adjusting for the mean blood pressure, the Doppler-derived global LV and RV diastolic functions were more impaired in HCM than in LVH. Also the majority of DTI LV and RV diastolic measurements were altered more in HCM. At the RV tricuspid annulus, myocardial diastolic indexes were impaired in HCM and LVH in comparison with controls but the deceleration and relaxation times distinguished also HCM and LVH, being much longer in HCM (p < 0.0001). In the overall population, the RV myocardial relaxation time was positively related to the septal wall thickness and the RV wall thickness, even after adjusting for age, heart rate, diastolic blood pressure, fractional shortening and DTI mitral relaxation time.

CONCLUSIONS

The impairment of RV myocardial relaxation is much more evident in HCM than in LVH, its degree being independently associated with the extent of both the septal and RV wall thickness. Pulsed DTI may be useful to distinguish the extent of RV myocardial dysfunction in different types of cardiac hypertrophy.

Association between myocardial right ventricular relaxation time and pulmonary arterial pressure in chronic obstructive lung disease: analysis by pulsed Doppler tissue imaging

This study assessed right ventricular function in chronic obstructive lung disease and pulmonary hypertension by Doppler tissue imaging. Doppler echocardiography of the right ventricle and Doppler tissue imaging of the tricuspid annulus were performed in 63 subjects: 20 healthy controls, 20 with lung disease, and 23 with both lung disease and pulmonary hypertension. Two-dimensional tricuspid systolic plane excursion was lower in patients with pulmonary hypertension than in the other 2 groups. Doppler tricuspid inflow measurements distinguished patients in both of the diseased groups from the control subjects, but they did not differentiate patients with pulmonary hypertension from those without it. The ratio of peak E-wave to peak A-wave velocities derived by Doppler tissue imaging was significantly lower and the myocardial acceleration time longer in both groups of lung disease than in the control group. Only myocardial relaxation time distinguished the 3 groups (all P <.01); a gradual increase in time occurred, with the shortest time seen in controls, a longer time in patients with chronic obstructive lung disease without pulmonary hypertension, and the longest time in patients with lung disease and pulmonary hypertension. In the overall population including subjects with at least minimal tricuspid regurgitation, myocardial relaxation time was positively related to pulmonary systolic pressure. In conclusion, Doppler tissue imaging distinguishes subsets of patients affected by lung disease with or without pulmonary hypertension and identifies patients with different levels of pulmonary artery systolic pressure.

Impact of myocardial diastolic dysfunction on coronary flow reserve in hypertensive patients with left ventricular hypertrophy

BACKGROUND

The aim of the study was to assess the possible association, in hypertensive patients, between left ventricular myocardial diastolic dysfunction and coronary flow reserve (CFR) in relation to the presence of left ventricular hypertrophy (LVH).

METHODS

Twenty-eight untreated hypertensives (22 males, 6 females, mean age 53.1 years), free of coronary artery disease, were enrolled in the study. Standard Doppler echocardiography, color Doppler tissue imaging of the posterior septum during dobutamine stress and second harmonic Doppler of the distal left anterior descending coronary vessel, at baseline and after maximal hyperemia induced by dipyridamole, were performed. CFR was estimated as the ratio between hyperemic and baseline diastolic velocities. Hypertensives were divided into two groups according to the left ventricular mass index: 15 without LVH (left ventricular mass index < 51 g/m2.7) and 13 with LVH (left ventricular mass index > 51 g/m2.7). The two groups were comparable for sex prevalence, age, body mass index, baseline heart rate and blood pressure.

RESULTS

Color Doppler tissue imaging did not show any significant difference of both the baseline and high-dobutamine septal systolic peak velocities between the two groups. The ratio between myocardial early and atrial peak velocities (Em/Am ratio) was lower in patients with LVH, either at baseline (p < 0.01) or at high-dose dobutamine (p < 0.0001). Also, CFR was lower in the presence of LVH (p < 0.01). After adjusting for age, body mass index, left ventricular mass index, diastolic blood pressure and high-dose dobutamine heart rate by a multiple linear regression analysis, the high-dose dobutamine Em/Am ratio was an independent contributor of CFR in the overall hypertensive population (beta = 0.65, p < 0.0001) (cumulative r2 = 0.38, p < 0.0001).

CONCLUSIONS

The combined use of second harmonic Doppler and color Doppler tissue imaging identifies, in arterial hypertension, an association between myocardial diastolic properties and CFR, independent of the presence of LVH. In hypertensive patients free of coronary artery stenosis, left ventricular myocardial diastolic dysfunction may be a determinant in the impairment of the coronary microvessel vasodilation capacity or a marker of silent ischemia involving the microvascular circulation.

Long-term prognostic value of dipyridamole and dobutamine stress echocardiography in patients with known or suspected coronary artery disease

BACKGROUND

Pharmacological stress echocardiography (PSE) is increasingly used for cardiac risk stratification. Our study was undertaken to assess the long-term prognostic significance of PSE in patients with known or suspected coronary artery disease.

METHODS

We studied 622 consecutive patients who underwent PSE with either dobutamine or dipyridamole. Outcome was finally assessed in 448 patients for a mean period of 32.9 months. Death and hard events (death and myocardial infarction) were considered as endpoints.

RESULTS

PSE was positive for ischemia in 192 patients (42.9%). During the follow-up, 53 hard events occurred, including 28 deaths and 25 acute non-fatal myocardial infarctions. With multivariate analysis, peak ejection fraction < 40% appeared to be the strongest predictor of cardiac-related deaths and of hard endpoints (chi2 28.4 and 32.0, respectively). Peak wall motion score index revealed a strong predictive value of the same events (chi2 8.6 and 16.3, respectively). An ischemic pattern at PSE predicted a 2.4 higher cardiac mortality rate over a 5-year follow-up (9.4 vs 3.9%, p < 0.01; log rank 5.68), while patients with a peak ejection fraction < 40% had a cardiac-related mortality 4 times higher (16.3 vs 4.1%, p < 0.00001; log rank 21.16). Hard events occurred in 6.7% of patients with a negative test vs 18.8% of patients with a positive test (p < 0.001; log rank 15.8), while hard event rate was 8.4% in patients with a peak ejection fraction > 40% vs 27.5% in patients with a peak ejection fraction < 40% (p < 0.00001; log rank 38.64).

CONCLUSIONS

The ischemic response to PSE showed a sustained prognostic value for cardiac events, especially in patients considered at either intermediate or high risk on the basis of recognized clinical risk factors. However, only the evaluation of both descriptors of global left ventricular performance and of the extension of induced ischemia may better help to select patients at higher risk of cardiac death.

Involvement of right ventricle in left ventricular hypertrophic cardiomyopathy: analysis by pulsed Doppler tissue imaging

AIMS

This study uses pulsed Doppler tissue imaging to analyse right ventricular myocardial function and its interaction with left ventricle in hypertrophic cardiomyopathy involving ventricular septum.

METHODS AND RESULTS

Thirty-four patients with septal hypertrophic cardiomyopathy and 30 normal subjects, comparable for sex, age, body mass index and heart rate, underwent complete standard Doppler echocardiography and pulsed Doppler tissue imaging of both posterior septum and right ventricular free wall, calculating myocardial velocities and both systolic and diastolic time intervals. Except for peak velocity A, the other Doppler tricuspid inflow measurements were significantly impaired in hypertrophic cardiomyopathy, without changes of tricuspid annular systolic excursion. Right ventricular Doppler tissue imaging showed longer right ventricular myocardial relaxation time in hypertrophic cardiomyopathy than in controls (P<0.00001), without a significant difference from other myocardial diastolic and systolic measurements. In the overall population, Doppler measurements of right and left ventricular inflow were not significantly associated, while (with the exception of myocardial deceleration time) all the other myocardial systolic and diastolic measurements derived by tissue imaging were directly related to the homologous septal myocardial indexes. In addition, a significant inverse relation was found between septal wall thickness and myocardial relaxation index (right-left myocardial relaxation time/right ventricular relaxation time x 100).

CONCLUSIONS

This study shows the usefulness of pulsed Doppler tissue imaging to detect impairment of right ventricular myocardial function and to provide evidence about ventricular interaction in forms of hypertrophic cardiomyopathy which involve interventricular septum.

[Food ileus caused by a phytobezoar of the small intestine]

One case of small bowel obstruction due to phytobezoar is reported. The various aetiological factors are discussed. The clinical features are not typical and small bowel obstruction can be initially recurrent until a complete intestinal occlusion. The diagnosis is not easy, and is nearly always made during urgent laparotomy. Surgical treatment consists of phytobezoar removal by enterotomy. The recognition of high-risk patients and their education to prevent phytobezoar are emphasized.

[Heterotopic pancreas in a gastric site]

The authors describe two cases of heterotopic pancreas tissue involving the stomach. After some general comments on the frequency and anatomopathological aspects of this disease, they discuss the clinical features and modern technics for the diagnosis of heterotopic pancreas tissue, with special emphasis on gastroscopic detection and execution of aimed biopsy specimen collection. Last, they discuss the indications for surgical treatment of the disease.

[Intrathoracic goiters]

Reference is made to the nosographical classification of intrathoracic goitre and the difficulties associated with its diagnosis. Particular attention is devoted to the correct surgical technique required. Surgery is mandatory in mediastinal cases on account of the slow and gradual progression of the swelling and exacerbation of the symptoms, and also because complications may supervene (cancer, intraparenchymal haemorrhage, etc.). The approach routes are discussed, along with the conditions requiring resort to a complementary route--usually median sternotomy--in addition to cervicotomy.

[Cephalic zoster with involvement of the 5th, 7th, 8th, 9th and 10th cranial nerves]

A case of cephalic zoster with involvement of the 5th, 7th, 8th, 9th and 10th left cranial nerves is described. The anatomopathological findings are surveyed. These show that lesions are often found in several areas of the nervous system. The pathogenesis of these forms is examined, with particular reference to the mechanism of involvement of several cranial nerves. It is felt that this is primarily due to reactivation of the virus in several ganglia.