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Background: In ischaemic cardiomyopathy, raised plasma concentrations of natriuretic peptides are associated with a poor long term prognosis, while the presence of contractile reserve is a favourable sign. Objective: To [...]

Heart 2003;89:1322-1326 Objective: To quantify regional left ventricular (LV) function and contractile reserve in Q wave and non-Q wave regions in patients with previous myocardial infarction. Design: An observational study. [...]

Heart 2003;89:1327-1334 Objective: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. Design: [...]

Objective: To assess the prevalence of myocardial viability by technetium-99m (Tc-99m)-tetrofosmin/fluorine-1--8-fluorodeoxyglucose (FDG) single photon emission computed tomography (SPECT) in patients with ischaemic cardiomyopathy. Design: A retrospective observational study. Setting: Thoraxcenter [...]

Heart 2004;90:97-98 Cardiac resynchronisation therapy (CRT) has recently been introduced to treat patients with drug refractory heart failure. (1 2) Studies have demonstrated immediate haemodynamic improvement after CRT, followed by [...]

The present substudy of a recently published randomized trial aimed to investigate the effect of intramyocardial bone marrow cell injection on diastolic function in patients with chronic myocardial ischemia.

AbstractDespite recent advancements in perioperative care and guideline recommendations, patients undergoing vascular surgery remain at risk for perioperative cardiovascular complications. In this review, the results are summarized of the most recent studies on the effectiveness and safety of perioperative statin use for the prevention of these perioperative cardiovascular complications. Perioperative statin therapy was associated with an improvement in postoperative cardiovascular outcome and a reduction in serum lipid levels and levels of inflammation markers.

Objective:to compare the additional prognostic value of Dobutamine Stress Echocardiography (DSE), Dipyridamole Stress Echocardiography (DiSE) and Perfusion Scintigraphy (DTS) on clinical risk factors in patients undergoing major vascular surgery.

The assessment of myocardial viability has become an important aspect of the diagnostic and prognostic work-up of patients with ischemic cardiomyopathy. Although revascularization may be considered in patients with extensive viable myocardium, patients with predominantly scar tissue should be treated medically or evaluated for heart transplantation. Among the many viability tests, noninvasive assessment of cardiac glucose use (as a marker of viable tissue) with F18-fluorodeoxyglucose (FDG) is considered the most accurate technique to detect viable myocardium. Cardiac FDG uptake has traditionally been imaged with positron emission tomography (PET). Clinical studies have shown that FDG-PET can accurately identify patients with viable myocardium that are likely to benefit from revascularization procedures, in terms of improvement of left ventricular (LV) function, alleviation of heart failure symptoms, and improvement of long-term prognosis. However, the restricted availability of PET equipment cannot meet the increasing demand for viability studies. As a consequence, much effort has been invested over the past years in the development of 511-keV collimators, enabling FDG imaging with single-photon emission computed tomography (SPECT). Because SPECT cameras are widely available, this approach may allow a more widespread use of FDG for the assessment of myocardial viability. Initial studies have directly compared FDG-SPECT with FDG-PET and consistently reported a good agreement for the assessment of myocardial viability between these 2 techniques. Additional studies have shown that FDG-SPECT can also predict improvement of LV function and heart failure symptoms after revascularization. Finally, recent developments, including coincidence imaging and attenuation correction, may further optimize cardiac FDG imaging (for the assessment of viability) without PET systems.

AimTo evaluate the angiographic, myocardial perfusion, and wall motion abnormalities in patients with severe compared with mild worsening of regional function during dobutamine stress echocardiography (DSE) for evaluation of myocardial ischaemia. Methods147 patients with significant coronary artery disease and new or worsening wall motion abnormalities during DSE were enrolled. Left ventricular function was evaluated using a 16 segment/4 grade score model where 1 = normal and 4 = dyskinesis. Simultaneous sestamibi SPECT myocardial perfusion imaging was performed in all patients. ResultsSevere worsening of regional function (an increase in wall motion score of two grades or more in ≥ 1 segment) was detected in 37 patients, while 110 patients had mild worsening (an increase in wall motion score of no more than one grade in ≥ 1 segment). Patients with severe worsening of regional function had more stenotic coronary arteries (2.31 (0.8) v 1.97 (0.8) (mean (SD)) (p <0.05), a higher prevalence of left anterior descending coronary artery disease (95% v 73%) (p < 0.05), a higher resting wall motion score index (1.71 (0.42) v 1.51 (0.40) (p = 0.01), and more stress perfusion defects (3.8 (1.5) v 2.8 (1.5) (p < 0.001) compared with patients with mild worsening. Multivariate analysis identified the number of stress perfusion defects (p < 0.005, χ² = 8.8) and the number of ischaemic segments on echocardiography (p < 0.05, χ² = 4.3) as independent variables associated with severe worsening of regional function. ConclusionsThe grade of worsening of regional function during DSE predicts the underlying extent of myocardial perfusion abnormalities. The occurrence of severe worsening of regional function is associated with variables known to predict worse prognosis in patients with coronary artery disease.

Assessment of myocardial viability has become an important issue in patients presenting with either acute myocardial infarction or presenting with chronic ischemic left ventricular dysfunction. In patients with viable myocardium recovery of left ventricular function can be anticipatedm, spontaneously in patients with acute myocardial infarction or following revascularization in patients with ischemic cardiomyopathy. In contrast, patients without viable tissue are not likely to improve in left ventricular function. Currently, nuclear imaging techniques and dobutamine stress echocardiography are used for assessment of viability; recent studies with magnetic resonance imaging (MRI) have however demonstrated the potential usefulness of this technique for the assessment of viability. Various parameters, derived from resting MRI, can be used as markers of myocardial viability, including the end‐diastolic wall thickness, systolic wall thickening and signal intensity without contrast‐enhancement. Other studies have combined the information from resting MRI with the assessment of contractile reserve during dobutamine stimulation. Finally, recent studies have evaluated the use of contrast‐enhanced MRI to detect viable myocardium. All of these parameters are potentially useful and MRI provide an alternative approach for the assessment of viable myocardium. J. Magn. Reson. Imaging 1999;10:418–422. © 1999 Wiley‐Liss, Inc.

Objective To investigate the functional significance of chronotropic incompetence during dobutamine stress echocardiography. Patients and methods The functional significance of chronotropic incompetence was evaluated during dobutamine stress echocardiography in 512 patients without β blocker treatment who underwent dobutamine stress echocardiography (up to 40 μg/kg/min) and completed the protocol or reached the target heart rate. Mean (SD) age was 60 (12) years (313 men, 199 women). Chronotropic incompetence was defined as failure to achieve 85% of the maximum exercise heart rate predicted for age and sex (220 - age in men; 200 - age in women) at maximum dobutamine dose. Results Chronotropic incompetence occurred in 196 patients (38%). Affected patients were significantly younger, more likely to be men (both p << 0.001) and smokers (p < 0.05), had a higher prevalence of previous myocardial infarction (p < 0.005) and resting wall motion abnormalities (p < 0.05), and had a lower resting heart rate (p << 0.001) and systolic blood pressure (p << 0.001) than patients without chronotropic incompetence, but there was no difference in the overall prevalence of ischaemia and significant coronary artery disease. By multivariate analysis, independent predictors of chronotropic incompetence were a lower resting heart rate (p << 0.001), younger age (p << 0.001), and male sex (p << 0.001). Conclusions The relations among sex, age, and chronotropic incompetence show the need to titrate the dobutamine dose using specific data based on age and sex related heart rate responses to dobutamine rather than to an exercise stress test. Obtaining specific heart rate criteria is necessary to determine whether chronotropic incompetence represents a real failure to achieve a normal response or is the result of applying an inappropriate gold standard.

ObjectiveTo assess the relation between ST segment elevation during the dobutamine stress test and late improvement of function after acute Q wave myocardial infarction.Patients and design70 patients were studied a mean (SD) 8 (3) days after acute myocardial infarction with high dose dobutamine-atropine stress echocardiography and a follow up echocardiogram at 85 (10) days. A score model based on 16 segments and four grades was used to assess left ventricular function. Functional improvement was defined as a reduction of wall motion score ≥ 1 in ≥ 1 segments at follow up.InterventionMyocardial revascularisation was performed in 23 patients (33%) before follow up studies.ResultsST segment elevation occurred in 40 patients (57%). Late functional improvement occurred in 35 patients (50%). Functional improvement was more common in patients with ST segment elevation (68% v 30%, P < 0·005) and they had a higher mean (SD) number of improved segments at follow up (1·9 (2·2) v 0·5 (1·1), P < 0·005). The wall motion score index decreased between baseline and follow up in patients with ST segment elevation (1·54 (0·50) v 1·48 (0·43), P < 0·05) but not in patients without ST segment elevation (1·39 (0·60) v 1·45 (0·47)). The accuracy of ST segment elevation for the prediction of functional improvement was similar to that of low dose dobutamine echocardiography in patients with anterior infarction (80% v 83%) and in patients who underwent revascularisation (78% v 83% respectively).ConclusionIn patients with a recent Q wave myocardial infarction, dobutamine-induced ST segment elevation is a valuable marker of myocardial viability particularly when the test is performed without or with suboptimal echocardiographic imaging.

Dobutamine-induced hypotension has been disregarded as a marker of more severe functional abnormalities in patients with suspected coronary artery disease. However, its functional significance in patients with myocardial infarction has not been studied. The aim of this study was to define the predictors of systolic blood pressure (SBP) response to dobutamine in patients with previous myocardial infarction. Dobutamine stress (up to 40 @mg/kg per minute) echocardiography was performed in 326 patients with prior myocardial infarction referred for evaluation of myocardial ischemia. A 16-segment, four-grade score model was used to assess left ventricular function. Wall motion score index was derived by summation of wall motion score divided by 16. SBP and heart rate increased from rest to peak dobutamine stress (127 +/- 22 vs 134 +/- 27 mm Hg and 72 +/- 14 vs 122 +/- 24 bpm, p < 0.00001 in both). An increase of SBP >=30 mm Hg occurred in 50 patients (15%). By multivariate analysis, independent predictors of failure of SBP increase were higher peak wall motion score index (p < 0.001), higher resting SBP (p < 0.01), and medication with calcium channel blockers (p < 0.05). SBP drop >=20 mm Hg occurred in 54 patients (17%). Independent predictors of SBP drop were higher resting wall motion score index (p < 0.001), higher resting SBP (p < 0.0001), and older age (p < 0.05). In patients with myocardial infarction, left ventricular function and baseline systolic blood pressure are powerful predictors of SBP response to dobutamine stress testing. (J Am Soc Echocardiogr 1998;11:436-41.)

This study shows the usefulness of a small, portable hand-held echo ultrasound device for the screening for abdominal aortic aneurysms.

There is growing interest in the assessment of myocardial viability in patients with ischaemic left ventricular dysfunction, in an attempt to identify those patients most likely to show functional improvement post-revascularization. Various techniques, focusing on different ‘viability characteristics’, are currently available. Of these, myocardial perfusion imaging (MPI) and dobutamine stress echocardiography are used most often; however, nuclear imaging techniques are more sensitive for the assessment of viable tissue. Revascularization of patients with viable tissue has been shown to improve function, reduce heart failure symptoms, improve exercise capacity and improve survival compared with patients with viable myocardium treated medically. Thus, assessment of viability using MPI may guide optimal management of patients with ischaemic left ventricular dysfunction.