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A hyperdynamic heart is defined as a left ventricular (LV) with an ejection fraction (EF) above the normal range. Is this favorable? We looked at the diastolic properties of subjects with a hyperdynamic heart and its impact on outcome. Consecutive echocardiography examinations during 5 years were evaluated by EF subgroups, including a hyperdynamic heart (EF70%). All examinations with significant LV hypertrophy or valve disease were excluded. The study included 16,994 subjects. A total of 720 subjects (4.2%) had a hyperdynamic heart. Subjects with a hyperdynamic heart were older, more likely to be women, and more likely to have hypertension, diabetes, and obesity. A total of 20% of patients had a diagnosis of heart failure. This group had a higher heart rate, smaller ventricular size, and the highest relative wall thickness. All indexes of diastolic dysfunction were significantly more prevalent in the hyperdynamic group. This included a higher LV mass, larger left atrial volume, reduced relaxation (smaller mitral e'), longer deceleration time, and higher LV end-diastolic pressures (high mitral E/e' ratio) and peak tricuspid regurgitation gradient. Diastolic dysfunction, defined by an abnormal functional or structural parameter, was present in 78% of the subjects. Survival was significantly lower in the group with a hyperdynamic heart. The Cox regression analysis after adjustment demonstrated reduced survival during a median 9-year follow-up in the hyperdynamic group compared with those with a normal EF (hazard ratio 1.56, 95% confidence interval 1.38 to 1.76, p0.001). In conclusion, subjects with a hyperdynamic systolic function have increased prevalence of diastolic dysfunction and reduced survival. A hyperdynamic heart is not a normally functioning heart.

Objectives This study evaluated effects of protease-activated receptor-1 antagonist vorapaxar (Merck, Whitehouse Station, New Jersey) versus placebo among the TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) study patients with non–ST-segment elevation acute coronary syndromes undergoing coronary artery bypass grafting (CABG). Background Platelet activation may play a key role in graft occlusion, and antiplatelet therapies may reduce ischemic events, but perioperative bleeding risk remains a major concern. Although the TRACER study did not meet the primary quintuple composite outcome in the overall population with increased bleeding, an efficacy signal with vorapaxar was noted on major ischemic outcomes, and preliminary data suggest an acceptable surgical bleeding profile. We aimed to assess efficacy and safety of vorapaxar among CABG patients. Methods Associations between treatment and ischemic and bleeding outcomes were assessed using time-to-event analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the Cox hazards model. Event rates were estimated using the Kaplan-Meier method. Results Among 12,944 patients, 1,312 (10.1%) underwent CABG during index hospitalization, with 78% on the study drug at the time of surgery. Compared with placebo CABG patients, vorapaxar-treated patients had a 45% lower rate of the primary endpoint (i.e., a composite of death, myocardial infarction, stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization during index hospitalization) (HR: 0.55; 95% CI: 0.36 to 0.83; p = 0.005), with a significant interaction (p = 0.012). The CABG-related Thrombolysis In Myocardial Infarction major bleeding was numerically higher with vorapaxar, but not significantly different between vorapaxar and placebo (9.7% vs. 7.3%; HR: 1.36; 95% CI: 0.92 to 2.02; p = 0.12), with no excess in fatal bleeding (0% vs. 0.3%) or need for reoperation (4.7% vs. 4.6%). Conclusions In non–ST-segment elevation acute coronary syndrome patients undergoing CABG, vorapaxar was associated with a significant reduction in ischemic events and no significant increase in major CABG-related bleeding. These data show promise for protease-activated receptor 1 antagonism in patients undergoing CABG and warrant confirmatory evidence in randomized trials. (Trial to Assess the Effects of SCH 530348 in Preventing Heart Attack and Stroke in Patients With Acute Coronary Syndrome [TRA·CER] [Study P04736AM3]; NCT00527943 )

Although degenerative aortic valve disease is common with increasing age, limited data exist regarding prevalence and prognosis of aortic valve disease among the oldest old. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed at home in 498 randomly selected subjects. Subjects were divided into 3 groups; normal subjects, subjects with valve calcium but without stenosis (AVC), and subjects with aortic stenosis (AS). Survival status at 5-year follow-up was assessed via the centralized population registry. AVC was noted in 55% of the study subjects and AS was seen in 8.2%. There were no significant differences between the 3 groups in any of the clinical parameters examined including risk factors for atherosclerotic heart disease. Of the 498 subjects, 107 (21%) had died at the time of 5-year follow-up. Five-year mortality was similar among the normal (17%) and AVC (20%) subjects but was significantly higher among the subjects with AS (46%; p0.0001). AS was associated with a nearly fourfold increased likelihood of mortality (hazard ratio 3.7, 95% confidence interval 1.4 to 9.3). In conclusion, among subjects ≥85 years of age, the prevalence of AS is higher than previously reported and not associated with traditional vascular risk factors. AS but not AVC alone was independently predictive of 5-year mortality.

Individuals aged85 years are the world's most rapidly growing age group and have a high incidence of cardiovascular mortality. The objective of this study was to prospectively determine the prognosis of abnormal cardiac structure and function in an age-homogenous, community-dwelling population of subjects born in 1920 and 1921. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed with a portable echocardiograph at the subjects' places of residence. Standard echocardiographic assessment of cardiac structure and function was performed. Five-year mortality was assessed through a centralized government database. Five hundred two subjects (235 men, 267 women) were enrolled in the study, of whom 107 (21%) had died at the time of 5-year follow-up. Subjects who died had significantly higher left atrial volume indexes (42.3 ± 16.5 vs 36.6 ± 12.5 ml/m2, p0.01) and left ventricular mass indexes (133.1 ± 47.6 vs 119.8 ± 30.6 g/m2, p0.05). Ejection fractions were significantly lower in subjects who died (52.5 ± 11.5% vs 56.4 ± 9.4%, p0.003), but indexes of left ventricular diastolic function were not significantly different between the 2 groups (E/e' ratio 13.0 ± 5.3 vs 12.2 ± 4.9, p = 0.18). In conclusion, elevated left atrial volume index and left ventricular mass index and decreased LV systolic function predicted 5-year mortality in a community-dwelling population of subjects aged 85 years, even after correction for possible confounders. Left ventricular diastolic dysfunction did not predict 5-year mortality in this cohort.

Objectives The aims of this study were to perform an individual patient data meta-analysis of studies using B-type natriuretic peptides (BNPs) to predict the primary composite endpoint of cardiac death and nonfatal myocardial infarction (MI) within 30 days of vascular surgery and to determine: 1) the cut points for a natriuretic peptide (NP) diagnostic, optimal, and screening test; and 2) if pre-operative NPs improve the predictive accuracy of the revised cardiac risk index (RCRI). Background NPs are independent predictors of cardiovascular events in noncardiac and vascular surgery. Their addition to clinical risk indexes may improve pre-operative risk stratification. Methods Studies reporting the association of pre-operative NP concentrations and the primary study endpoint, post-operative major adverse cardiovascular events (defined as cardiovascular death and nonfatal MI) in vascular surgery, were identified by electronic database search. Secondary study endpoints included all-cause mortality, cardiac death, and nonfatal MI. Results Six data sets were obtained, 5 for BNP (n 632) and 1 for N-terminal pro-BNP (n 218). An NP level higher than the optimal cut point was an independent predictor for the primary composite endpoint (odds ratio: 7.9; 95% confidence interval: 4.7 to 13.3). BNP cut points were 30 pg/ml for screening (95% sensitivity, 44% specificity), 116 pg/ml for optimal (highest accuracy point; 66% sensitivity, 82% specificity), and 372 pg/ml for diagnostic (32% sensitivity, 95% specificity). Subsequent to revised cardiac risk index stratification, reclassification using the optimal cut point significantly improved risk prediction in all groups (net reclassification improvement 58%, p 0.000001), particularly in the intermediate-risk group (net reclassification improvement 84%, p 0.001). Conclusions Pre-operative NP levels can be used to independently predict cardiovascular events in the first 30 days after vascular surgery and to significantly improve the predictive performance of the revised cardiac risk index. (J Am Coll Cardiol 2011;58:522‐9) © 2011 by the American College of Cardiology Foundation

Echocardiography is a well-accepted tool for the diagnosis and quantification of pericardial effusion (PEff). Given the increasing use of computed tomographic (CT) scanning, more PEffs are being initially diagnosed by computed tomography. No study has compared quantification of PEff by computed tomography and echocardiography. The objective of this study was to assess the accuracy of quantification of PEff by 2-dimensional echocardiography and computed tomography compared to the amount of pericardial fluid drained at pericardiocentesis. We retrospectively reviewed an institutional database to identify patients who underwent chest computed tomography and echocardiography before percutaneous pericardiocentesis with documentation of the amount of fluid withdrawn. Digital 2-dimensional echocardiographic and CT images were retrieved and quantification of PEff volume was performed by applying the formula for the volume of a prolate ellipse, π × 4/3 × maximal long-axis dimension/2 × maximal transverse dimension/2 × maximal anteroposterior dimension/2, to the pericardial sac and to the heart. Nineteen patients meeting study qualifications were entered into the study. The amount of PEff drained was 200 to 1,700 ml (mean 674 ± 340). Echocardiographically calculated pericardial effusion volume correlated relatively well with PEff volume (r = 0.73, p0.001, mean difference -41 ± 225 ml). There was only moderate correlation between CT volume quantification and actual volume drained (r = 0.4, p = 0.004, mean difference 158 ± 379 ml). In conclusion, echocardiography appears a more accurate imaging technique than computed tomography in quantitative assessment of nonloculated PEffs and should continue to be the primary imaging in these patients.

Elevated levels of troponin T have been demonstrated in number of studies to be a strong, independent prognostic indicator in patients with acute coronary syndromes [1–7]. In acute and chronic heart failure increased serum levels of troponin I and troponin Twere also found to correlate with a poorer prognosis [8–12]. A recent report has documented an overall poor prognosis in patients with acute pulmonary edema and elevated troponin T levels [13]. While pulmonary edema may often be secondary to acute ischemia, other causes such as hypertensive crisis and volume overload may precipitate decompensated heart failure and pulmonary edema [1]. Distinguishing ischemia-induced pulmonary edema from pulmonary edema due to other causes is a difficult clinical challenge with important implications for clinical management [14–17]. In the clinical setting of pulmonary edema, echocardiography is an important diagnostic tool to assess prognosis and treatment. The role of echocardiography in determining prognosis and treatment is well established in patients with chronic heart failure; however, little is known about its role in patients with acute pulmonary edema. In addition, the relationship between left ventricular function as assessed by echo and elevated troponin T as predictors of adverse prognosis remains unclear. The objective of this study was to determine the individual and additive prognostic value of assessment of left ventricular function by echocardiography and serum troponin T levels in patients presenting with acute pulmonary edema.

Objectives: The objectives of the study were to assess pulmonary artery systolic pressure, its association with clinical and echocardiographic variables and its impact on 5-year mortality in a community-dwelling population of the oldest old. Methods: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed at home, with standard measurements being taken including tricuspid regurgitation (TR) velocity (n = 300). Survival status at 5-year follow-up was assessed via the centralized population registry. Results: The mean TR gradient in the study population as a whole was 30.5 ± 9.4 mm Hg. A significant relationship was noted between right-ventricular systolic pressure (RVSP) and left-atrial (LA) volume (r = 0.27, p < 0.0001), left-ventricular (LV) mass index (r = 0.26, p < 0.0001) and the ratio E/e (r = 0.19, p < 0.03). At the 5-year follow-up, 71 of the 300 subjects (23.7%) had died. TR gradient was significantly associated with mortality in both the unadjusted (HR 1.036, 95% CI 1.015-1.058; p < 0.007) and adjusted (HR 1.036, 95% CI 1.012-1.061; p < 0.0029) models. Conclusions: We demonstrate that RVSP is elevated and related to LV mass, LA volume and reduced diastolic function in the oldest old. An elevated RVSP is significantly associated with mortality in this population.

The diagnosis and treatment of acute pulmonary thromboembolism (PE) remains a complex clinical challenge. Many studies have used both transthoracic and transesophageal echocardiography as a diagnostic and/or prognostic tool in this common disorder. In patients with central, hemodynamically significant PE, echocardiography can directly visualize thrombus or demonstrate the hemodynamic consequences of PE, whereas in the majority of patients, the sensitivity of echocardiography appears limited. Echocardiography may be useful in assessing the prognosis of patients with PE as well as their response to therapy. Further studies are needed in larger populations of patients to clarify the role of echocardiography in the assessment of patients with clinically suspected PE. (J Am Soc Echocardiogr 2001;14:921-6.)

Background Combined therapy with aspirin and clopidogrel is currently the standard treatment for patients undergoing coronary artery stenting. Some stented patients do not tolerate aspirin and are treated by clopidogrel only, the risk of major adverse clinical events (MACE) in such patients is unclear. Objective To assess the risk of MACE in stented patients treated by clopidogrel only. Methods We reviewed records of consecutive patients who underwent bare metal coronary stenting between 1999 and 2004, looking for patients that were treated by clopidogrel without aspirin. Our search revealed 43 such patients with adequate clinical follow-up for at least 1 year following the procedure. We collected information regarding stent thrombosis, acute MI, death or repeat PCI. Results Two patients (4.7%) were admitted due to acute MI within 30 days of stenting. Stent thrombosis was documented by coronary angiography and target vessel revascularization was performed. Conclusions Clopidogrel as a sole anti-platelet treatment after coronary stenting resulted in a relatively high percentage of subacute stent thrombosis. Even higher percentages may be expected when using drug eluting stents. More aggressive anti-platelet therapy may be needed in patients who cannot tolerate aspirin. PTCA alone may be preferable to stenting in such patients.

Background Myocardial infarction (MI) may be classified as ST elevation MI (STEMI) or non ST elevation MI (NSTEMI). We used the term recurrent MI (RMI's) to denote repeated MI episodes, in a particular patient, in which a different coronary site is responsible for each episode. Recently we reported that most patients with recurrent MI episodes will have either STEMI's or NSTEMI's but not both. A history of smoking was associated with recurrent STEMI's. Objective To determine whether smoking cessation will alter the type of RMI in patients with an index MI of STE type. Methods The analysis included 128 patients who underwent at least 2 MI episodes. We attempted to include only MI's of native vessels, without the presence of extra cardiac conditions that intensify myocardial ischemia. All 128 patients were active smokers who presented with an index MI of the STE type. Of these patients 94 had recurrent STEMI and 34 had recurrent NSTEMI (STE/NSTE group). Results We identified all patients who were no longer active smokers at the time of the recurrent MI: there were 31 (33%) such patients in the STEMI group and 13 (38%) in the STE/NSTE group ( p =NS). Conclusion Smoking cessation did not influence the type of recurrent MI in these patients.

Background/objectives Patients presenting with acute pulmonary embolism associated with hemodynamic compromise exhibit right ventricular enlargement and dysfunction on transthoracic echocardiogram. However, the degree of echocardiographic abnormalities among hemodynamically stable patients without preexisting cardiopulmonary disease during the acute stage of pulmonary embolism, and following treatment, is unknown. Therefore, this study was designed to assess the extent of right ventricular abnormalities detected on transthoracic echocardiogram in patients following acute pulmonary embolism and during treatment with anticoagulation or vena caval interruption. The extent of pulmonary vascular obstruction and complication rate on follow-up were also assessed. Design/interventions Sixty-four consecutive hemodynamically stable patients without preexisting known cardiopulmonary disorder presenting with acute pulmonary embolism and undergoing treatment with anticoagulation or inferior vena caval interruption were studied. All subjects underwent a two-dimensional transthoracic echocardiogram within 24 h of diagnosis. The degree of perfusion abnormality on lung scan was quantified. Twenty-six patients underwent follow-up echocardiogram and lung scan at 6 weeks. The echocardiographic findings were compared with those obtained from a group of normal control subjects matched for gender and age. Results Although the mean right ventricular end-diastolic areas did not differ (21.9±5.2 cm 2 vs 20.1±2.9 cm 2 for control subjects; p=not significant), the right ventricular end-systolic area was larger in comparison to our series of control subjects (14.6±5.1 cm 2 vs 11.7±2.0 cm 2 ; p=0.025). Fractional right ventricular area change was reduced in the patient group compared with the control subjects (34.3±9.0% vs 41.3±7.0%; p=0.003). The extent of right ventricular end-systolic area enlargement and decrease in fractional area change did not correlate with the degree of pulmonary vascular obstruction. Patients who were restudied at 6 weeks showed minimal improvement in echocardiographic findings, despite almost complete resolution of perfusion defects on lung scan. Conclusions The extent of right ventricular dysfunction in hemodynamically stable, previously normal patients with acute pulmonary embolism does not reflect the extent of the perfusion abnormalities. Further, right ventricular enlargement and systolic dysfunction are present and persistent despite treatment with heparin and warfarin therapy or vena caval interruption.

Frailty is a biological syndrome reflecting a state of decreased physiologic reserve and vulnerability to stressors of increasing importance in cardiovascular disease given the aging of the population. The relationship between frailty and indices of cardiac structure and function remain unclear

Objectives . This study attempted to document the incidence of pulmonary vein complications and their potential relation to clinical outcome in patients after lung transplantation. Background . Several case reports have documented the presence of pulmonary venous thrombosis causing graft failure in patients after lung transplantation. Because the presentation of these complications mimics that of other postoperative problems, the true incidence of pulmonary vein abnormalities remains unclear. Transesophageal echocardiography is ideally suited to examine the pulmonary veins in the postoperative setting. Methods . Twenty-one consecutive patients undergoing lung transplantation at our institution underwent transesophageal echocardiography within 32 days of transplantation (mean [± SD] 6.5 ± 7.8 days). Special attention was placed on visualizing the pulmonary veins. Results . Six (29%) of the 21 patients were noted to have abnormalities of the pulmonary veins in the vicinity of the anastomotic site. After follow-up of 30 days, 4 of these patients (67%) had significant cardiovascular morbidity, and 2 died, compared with 1 (7%) of 15 patients with normal pulmonary veins (p = 0.03). The degree of obstruction of the pulmonary vein appeared to correlate with short-term outcome. Conclusions . Abnormalities of the pulmonary veins are common after lung transplantation and are easily identified by transesophageal echocardiography. Occlusive thrombi appear to be detrimental to short-term outcome.

Background . Left ventricular hypertrophy (LVH) is more frequent in women and increases with age; however, it is unclear whether this fi nding is true in the very elderly. The objective of this study was to examine gender differences in the prevalence of LVH in a very elderly cohort. Methods . Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Three hundred and thirty-nine of the subjects from the most recent set of data collection in 2005–2006 underwent echocardiography in addition to structured interviews and physical examination. Results . The overall prevalence of LVH was high and signifi cantly higher among women (60% vs 43%, p 0.0023). Systolic blood pressure (SBP) was signifi cantly higher in women with LVH compared with women without LVH ( p 0.01) and both groups of men ( p 0.005). Women with LVH were three times more likely than women without LVH and 6.5 times more likely than men with LVH to believe that a BP of 160/100 mmHg represents their BP goal ( p 0.05). Conclusions . This study demonstrates a high prevalence of LVH in a very elderly population, a fi nding signifi cantly more pronounced in women and related to SBP.

We describe a case of primary cardiac lymphoma diagnosed by transvenous biopsy under fluoroscopic and transthoracic echocardiographic guidance. A 38-year-old man was admitted because of exertional dyspnea. ECG revealed complete atrioventricular block. Transthoracic echocardiography revealed a large mass attached to the interventricular septum and protruding into the right atrium. The patient underwent a right heart catheterization and a biopsy was taken from the mass using fluoroscopic and transthoracic echocardiographic guidance. Diagnosis of malignant lymphoma was established by the biopsy specimen. The use of transthoracic echo in conjunction with fluoroscopy may be useful for the diagnosis of intracardiac mass transvenously.

In a study recently published in JACC , Scognamiglio et al. ([1][1]) suggest that patients with type 2 diabetes mellitus with ≤1 other risk factor should undergo routine stress imaging to diagnose asymptomatic coronary artery disease (CAD), a strategy the investigators believe will lead to early

Transient ST-segment elevation may occur following direct-current cardioversion [1]. The significance of this electrocardiographic (ECG) alteration is unclear [2,3]. In this report, we describe two patients with post cardioversion ST-segment elevation, in whom significant myocardial ischemia or damage were effectively ruled out by simultaneous echocardiography. Case 1: A 25-year-old male was brought unconscious after a 220-V alternate-current electrical injury. An ECG showed ventricular fibrillation (VF). The patient stabilized after multiple defibrillations, epinephrine and amiodarone infusions. Fifteen minutes later an ECG revealed sinus rhythm, accompanied by marked ST-segment elevations in the anterolateral leads (Fig. 1). Echocardiography performed during the period of ST-segment elevation demonstrated a normal heart. A day later an ECG was normal. Case 2: Three weeks post-partum, a 28-year-old woman underwent laparotomy due to perforated appendicitis. During readmission for acute renal failure and headaches the patient collapsed. VF was noted on the monitor. Cardiopulmonary resuscitation including treatment with epinephrine, atropine, magnesium, lidocaine and amiodarone restored circulation. An ECG (Fig. 2) revealed sinus tachycardia and anterolateral ST-segment elevation. Echocardiography performed simultaneously showed borderline left ventricular systolic function, with

The study by Dokainish et al. ([1][1]) addresses an interesting subgroup of patients with acute coronary syndromes (ACS), namely those with elevated troponin but without significant coronary artery disease (CAD) on angiography. The investigators conclude that a 6.3% incidence of death, reinfarction

Objectives The study determines whether treatment of coronary disease by percutaneous coronary intervention (PCI) in the presence of severe aortic stenosis (AS) is feasible and defines which patients might benefit most. Background Severe symptomatic AS is considered a class I indication for aortic valve replacement (AVR). Many patients with AS have concomitant coronary artery disease (CAD), and the true reason for symptoms is often unclear. It is common practice to combine AVR with coronary artery bypass grafting. However, in some cases PCI alone might improve symptoms and allow surgery to be deferred. Methods We analyzed 38 consecutive patients who underwent PCI for CAD in the presence of significant AS between 1989 and 2004. Data included demographic factors, clinical features, angiographic, and echocardiographic information. Events during follow-up included PCI complications, improvement post-PCI, AVR, and death. Statistical analysis was used to assess the impact of PCI on outcome and survival. Results The mean age of the study group was 71 ± 9.3 years, and the mean aortic valve area was 0.84 ± 0.28 (0.4–1.2) cm 2 . Reasons for choosing PCI over surgery were patients' preference, high surgical risk, and cardiologist recommendation. Thirty-five patients (92.1%) reported symptomatic improvement after PCI, and no major PCI-related complications were recorded. Significant predictors for long-term event-free survival were good functional class ( P = .006) and single-vessel coronary disease ( P = .017). Conclusion PCI in patients with severe AS and significant CAD is safe, offers relief of symptoms in most cases, and has good long-term outcome in a subset of patients who have mild CAD and good functional class. This therapeutic approach should be considered in such patients and in those with high surgical risk.

The frequency of right-to-left shunt through a patent foramen ovale is increased in hemodynamically stable patients without preexisting cardiopulmonary disease with acute pulmonary embolism. This is associated with a greater degree of perfusion abnormalities as quantified by perfusion scan and the presence of tricuspid regurgitation.

We have analyzed human cellular DNA for its delta--and beta-globin gene sequence content by separation of restriction enzyme fragments by agarose gel electrophoresis; transfer of the DNA fragments to nitrocellulose filters; hybridization of filters with 32P--beta-globin cDNA; and analysis by autoradiography. A short cDNA has been used to identify specifically the 3' end of the genes and to orient the fragments. A comparison of the globin gene fragments generated by normal and Lepore DNA has been used to distinguish fragments representing DNA sequences between the delta and beta genes and those containing sequences flanking either 5' to the delta gene or 3' to the beta gene. The results indicate that unique restriction fragments are presented in normal DNA and absent in Lepore DNA, and allow preliminary ordering of these fragments on a restriction enzyme map. In addition, the Lepore, delta--and beta-globin genes have been found to contain at least one inserted nucleotide sequence of about 1000 bases which is not represented in mature globin mRNA.