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Background: Meta-analysis has demonstrated an exponential relationship between 2-hr postchallenge hyperglycemia and coronary artery disease (CAD). Pulsatile hyperglycemia can acutely increase proinflammatory cytokines by oxidative stress. We hypothesized that postchallenge proinflammatory and nitrosative responses after 75 g oral glucose tolerance tests (75 g-OGTT) might be associated with CAD in patients without previously recognized type 2 diabetes mellitus (T2DM)., Methods: Serial changes of plasma glucose (PG), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and nitrotyrosine levels were analyzed during 75 g-OGTT in 120 patients (81 male; age 62 ± 11 years) before coronary angiography. Patients were classified as normal (NGT; 42%), impaired (IGT; 34%) and diabetic (T2DM; 24%) glucose tolerance by 75 g-OGTT., Results: Postchallenge hyperglycemia elicited TNF-α, IL-6 and nitrotyrosine levels time-dependently, and 2-hr median levels of TNF-α (7.1 versus 6.4 pg/ml; P < 0.05) and nitrotyrosine (1.01 versus 0.83 μmol/l; P < 0.05), but not IL-6 or PG, were significantly higher in patients with CAD in either IGT or T2DM groups. After adjusting risk factors and glucose tolerance status, 2-hr nitrotyrosine in highest quartiles (OR: 3.1, P < 0.05) remained an independent predictor of CAD by logistic regression analysis., Conclusions: These results highlight postchallenge proinflammatory and nitrosative responses by 75 g-OGTT, rather than hyperglycemia per se, are associated with CAD in patients without previous recognized diabetes.

Previous studies which included patients with preserved left ventricular (LV) systolic function demonstrated that arterial stiffness progressively increased as LV diastolic function decreased. However, it was unknown whether this correlation was still present in a heterogeneous study population involving patients with a wide range of LV systolic function. Seventy-five patients with depressed LV systolic function were consecutively included and 192 patients with preserved LV systolic function were randomly selected from subjects arranged for echocardiography examination. Brachial-ankle pulse wave velocity (baPWV) was measured using an ABI-form device. Of the 267 subjects (mean age 58 ± 14 years) included in the study, 105 had normal diastolic function, 74 had impaired relaxation, and 60 had pseudonormal and 28 restrictive diastolic dysfunction. BaPWV was only lower in patients with normal diastolic function than in those with abnormal diastolic function (p ≤ 0.001). It did not gradually rise as diastolic dysfunction grade increased. Multivariate analysis showed that increased age and systolic blood pressure and decreased LV ejection fraction, transmitral A velocity, and left atrial volume index (p ≤ 0.039) were correlated with increased baPWV. Our study showed that there were no positive correlation between echocardiographic LV diastolic parameters and baPWV. BaPWV did not progressively rise with increasing LV diastolic dysfunction grade. Therefore, patients with advanced LV diastolic dysfunction may not have increased arterial stiffness.

Background: Vascular endothelial growth factor (VEGF) is important in atherosclerotic development. We examined two VEGF polymorphisms, including +405 C/G (rs2010963) and -2578C/A (rs699947), to assess their relation to the extent of coronary atherosclerosis., Methods: We recruited 398 patients with advanced coronary artery disease (CAD). Angiographic "clinical vessel score" (CVS, 1-3 vessels) and "diffuse score" (DS, 0-11.5) were used to evaluate the extent of coronary atherosclerosis. CVS are further categorized into single- (SVD) and multi-vessel disease (MVD: 2 and 3 vessels). Genotyping was performed by TaqMan assay., Results: The frequency of +405 C/G genotype was correlated with CVS and DS (P = 0.016 and 0.016, respectively). The +405C allele frequency was significantly increased in patients with MVD (P = 0.020). The odds ratio (OR) for the CC to the GG genotype was 2.92 (95% confidence interval (CI): 1.31-6.55, P = 0.007). Univariate and logistic regression analysis showed a significant independent association of +405 C/G genotype with SVD/MVD (P = 0.010 and 0.015, respectively) in the recessive model. Furthermore, there is a synergistic effect of CC genotype and diabetes on the occurrence of MVD (P = 0.001 for interaction). There is also a significant independent association of +405 C/G genotype in the recessive model with DS in the uni- and multivariate regression analysis (P = 0.013 and 0.005, respectively). No association was found between VEGF -2578C/A polymorphism and both atherosclerotic parameters., Conclusions: The VEGF +405C/G polymorphism is a novel genetic factor to influence the extent of coronary atherosclerosis in the Chinese CAD population.

Background: Right brachial pre-ejection period (rbPEP), brachial-ankle pulse wave velocity (baPWV), and right brachial ejection time (rbET) can be automatically determined from an ABI-form device. The aims of this study are to test the applicability of baPWV-derived myocardial performance index (MPI) (defined as the ratio of rbPEP divided by its own s.d. + baPWV divided by its own s.d. to rbET divided by its own s.d.) as an indicator of combined left ventricular (LV) systolic and diastolic functions., Methods: A sum of 215 patients were consecutively included. The rbPEP, baPWV, and rbET were measured using an ABI-form device and LV function was determined by echocardiography., Results: After a multivariate analysis, diastolic blood pressure (beta = 0.220, P < 0.001), LV ejection fraction (LVEF) (beta = -0.291, P < 0.001), transmitral E wave velocity (E) (beta = -0.106, P = 0.032), early diastolic mitral annular velocity (Ea) (beta = -0.142, P = 0.009), and ET obtained by tissue Doppler echocardiography (beta = -0.397, P < 0.001) were the major determinants of baPWV-derived MPI. The area under the curve for rbPEP, baPWV, rbET, rbPEP/rbET, and baPWV-derived MPI in prediction of Ea <8 cm/s, E/Ea >10, or LVEF <50% were 0.69, 0.76, 0.67, 0.73, and 0.83, respectively., Conclusions: BaPWV-derived MPI had a significant correlation with echocardiographic LV diastolic and systolic function. It may be a novel and feasible indicator in assessment of global LV function.

Objectives: To test the association between angiotensin-converting enzyme (ACE) insertion or deletion (I/D) polymorphism and decline of renal function in people aged 60 and older., Design: Population-based prospective study with 4-year follow-up., Setting: Department of Internal Medicine and Family Medicine, Kaohsiung Medical University (KMU) Hospital and Graduate Institute of Medicine and Public Health, KMU., Participants: Of 1,500 people screened, 193 subjects were enrolled, and 144 completed 4 years of follow-up, 112 non-diabetic normotensive elderly people were analyzed., Measurements: Subjects received biochemistry examination at baseline and at 2- and 4-year follow-ups. Serum creatinine and calculated renal parameters, including the Cockroft-Gault (CG) formula, the Jelliffe formula, and the Modification of Diet in Renal Disease (MDRD) Study equation, were used. Genetic polymorphism was analyzed according to the polymerase chain reaction., Results: The mean age+/-standard deviation of the subjects was 71.9+/-3.7 (range 60-81). Serum creatinine, CG creatinine clearance (CrCl), Jelliffe CrCl, and MDRD glomerular filtration rate (GFR) were significantly lower at the 2- and 4-year follow-ups (all P < or = .001). At the 4-year follow-up, the magnitude of declines of the above four renal parameters was significantly higher in subjects with the ACE D allele than in the non-D-allele carriers (P = .01, .01, .04, and .01 for creatinine, CG CrCl, Jelliffe CrCl, and MDRD GFR, respectively). This association was still significant in multivariate analyses (P < or = .02 for all parameters)., Conclusion: This longitudinal study showed the ACE I/D gene polymorphism might modulate renal function decline in elderly Chinese. This provides further knowledge essential in the assessment of renal disease and determination of renal function in older Chinese.

Atrial electrical remodeling (ER) after spontaneous or pacing-induced atrial fibrillation has been previously described in humans. We investigated atrial ER induced by a 5-minute period of rapid atrial pacing and the pharmacologic effects of verapamil and procainamide on this atrial ER phenomenon. The atrial effective refractory periods (ERPs) at drive cycle lengths of 400 (ERP 400 ) and 600 (ERP 600 ) ms, at five representative atrial sites (high right atrium [HRA]; proximal, middle and distal coronary sinus; interatrial septum), were determined in 20 patients at baseline and immediately after cessation of a 5-minute period of rapid pacing from the HRA at a rate of 150 bpm. The degrees of atrial ERP 400 and ERP 600 shortening after pacing were calculated as acute atrial ER. The same protocol was repeated in another 15 patients after intravenous administration of verapamil (0.15 mg/kg) and in another 15 patients after intravenous administration of procainamide (15 mg/kg). The results demonstrated that, in the control state acute atrial ER can be significantly demonstrated at each atrial representative site ( p < 0.001). The mean ERP 400 and ERP 600 shortenings were 9 +/- 4% and 8 +/- 4%, respectively. After procainamide infusion, but not after verapamil, baseline ERP 400 and ERP 600 values were significantly prolonged at the five representative atrial sites ( p < 0.01). Acute atrial ER could still be demonstrated at each atrial site after procainamide or verapamil infusion ( p < 0.001). In conclusion, acute atrial ER can be demonstrated after only a 5-minute period of rapid atrial pacing in humans. Intravenous verapamil or procainamide does not abolish this ER process.

Background: Cross-sectional studies investigated the impact of renin-angiotensin system (RAS) gene polymorphism on left ventricular mass index (LVMI) with conflicting results. We conducted a longitudinal study to investigate the influence of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) and angiotensinogen (AGT) M235T and angiotensin II type 1 receptor (AT1R) A1166C gene polymorphisms on the LVMI and geometry., Methods: Of 1500 people screened, 110 nondiabetic normotensive elderly Chinese persons were recruited and received echocardiography at baseline and at the 2nd and 4th year follow-up. No participants had a history of organic heart disease or chronic medication. The gene polymorphisms were analyzed by using polymerase chain reaction., Results: Participant age was 71.9 +/- 3.9 years (range 60-81 years). The prevalence of concentric remodeling, eccentric hypertrophy, and concentric hypertrophy was significantly increased as well as LVMI after 4 years (all p <.05). These changes and the magnitude of LVMI increase were significantly higher in participants carrying the ACE D allele than non-D-allele carriers (all p <.05). This association was still significant in multivariate analyses (p

This study evaluated the effects of heart rate (HR) on brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI). Thirty-two patients without significant organic heart disease underwent elective cardiac catheterization or electrophysiologic study, and were then enrolled in right atrial pacing (RAP; 11 men, 9 women; aged 48 -/+ 15 years) or right ventricular pacing (RVP; 6 men, 6 women, aged 45 -/+ 13 years) studies. Three different HR levels (90, 100, and 110 beats per minute) were paced in random order. By stepwise, multiple linear regression analysis, age, systolic blood pressure (SBP), and pulse pressure (PP) correlated positively with baseline baPWV. In the RAP group, as HR increased, baPWV and left brachial diastolic blood pressure increased significantly (p < or = 0.015), while ABI, left ankle SBP, left brachial PP, and left ankle PP decreased significantly (p < or = 0.013). In the RVP group, as HR increased, baPWV also increased significantly (p = 0.001), while ABI, left ankle SBP, and PP decreased significantly (p < or = 0.034). Values of baPWV and ABI may be influenced by HR in young and middle-aged patients without significant organic heart disease. When these values are used to evaluate and follow up cardiovascular risk in patients, HR changes should be considered.

To evaluate whether isovolumic relaxation flow propagation velocity (IRFPV) is independent of preload alterations, 41 healthy subjects (35 +/- 7 years) were included for Doppler examinations at three different positions, i.e., supine, Trendelenburg, and reverse Trendelenburg. A positional difference was detected in the peak velocity of the transmitral early diastolic flow wave (P = 0.012) and the peak velocities of both early (P = 0.004) and late (P = 0.007) diastolic mitral annular velocity waves. In contrast, there was no positional difference in the early diastolic inflow propagation velocity or IRFPV. In conclusion, IRFPV is a preload-independent Doppler parameter.

Background: Tei index obtained from tissue Doppler echocardiography (TDE-Tei index) has an inherent advantage of recording its systolic and diastolic components simultaneously on the same cardiac cycle. The aims of this study are to evaluate whether TDE-Tei index also exerts a correlation with left ventricular (LV) systolic and diastolic function and filling pressure and to see whether it can effectively identify the pseudonormal/restrictive mitral filling pattern., Methods: Echocardiographic examination was performed in 243 consecutive patients. These patients were classified into three groups as normal, abnormal relaxation, and pseudonormal/restrictive groups according to the transmitral E/A-wave velocity (E/A), early diastolic velocity of lateral mitral annulus (Ea) and E/Ea., Results: Standard Doppler indices of LV filling such as E, A, E/A, and E-wave deceleration time had a bimodal distribution, but Ea decreased and E/Ea and TDE-Tei index increased progressively with worsening of LV diastolic function. The sensitivity and specificity of TDE-Tei index>0.51 in the discrimination of pseudonormal/restrictive filling pattern were 85% and 96%, respectively. After stepwise multiple linear regression analysis, TDE-Tei index had a significant negative correlation with Ea (beta=-0.296, P<0.001) and ejection fraction (beta=-0.293, P<0.001) and positive correlation with E/Ea (beta=0.235, P=0.001)., Conclusions: TDE-Tei index increased with worsening of LV diastolic function and can effectively identify the pseudonormal/restrictive mitral inflow pattern. It also correlated with the echocardiographic parameters of LV systolic and diastolic function and filling pressure. It suggests that TDE-Tei index is a simple and feasible marker in assessing global LV function.

We sought to evaluate whether the combination of phantom E wave peak velocity (Ep) to phantom A wave peak velocity (Ap) ratio at the apex (Ep/Ap) and pulsed wave Doppler left ventricular (LV) inflow propagation velocity (LVIPVpw) or the combination of Ep/Ap and Ep/LVIPVpw obtained from the same heartbeat can effectively differentiate LV filling patterns. The study population included 132 patients. They were classified into normal, abnormal relaxation, and pseudonormal/restrictive groups according to the ratio of early to late transmittal filling wave peak velocity (E/A), color M-mode Doppler LV inflow propagation velocity, and E/color M-mode Doppler LV inflow propagation velocity. Standard Doppler parameters of LV filling such as E, A, E/A, and E-wave deceleration time had a bimodal distribution, but LVIPVpw decreased and Ep/LVIPVpw increased progressively with worsening of LV diastolic function (both P < .001). The sensitivity and specificity of combination of Ep/Ap 1 or greater and LVIPVpw less than 77 cm/s or of Ep/Ap 1 or greater and Ep/LVIPVpw greater than 0.87 from the same heartbeat in identifying the pseudonormal/restrictive LV filling pattern were 81% and 95% or 81% and 93%, respectively. In conclusion, with application of range ambiguity phenomenon, it is simple and feasible to differentiate LV filling patterns on the same cardiac cycle by pulsed wave Doppler echocardiography.

Statin therapy can reduce the biosynthesis of both cholesterol and coenzyme Q10 by blocking the common upstream mevalonate pathway. Coenzyme Q10 depletion has been speculated to play a potential role in statin-related adverse events, and withdrawal of statin is the choice in patients developing myotoxicity or liver toxicity. However, the effect of statin withdrawal on circulating levels of coenzyme Q10 remains unknown. Twenty-six patients with hypercholesterolemia received atorvastatin at 10 mg/day for 3 months. Serum lipid profiles and coenzyme Q10 were assessed before and immediately after 3 months and were also measured 2 and 3 days after the last day on the statin. After 3 months' atorvastatin therapy, serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and coenzyme Q10 (0.43 +/- 0.23 to 0.16 +/- 0.10 microg/mL) were all significantly reduced (all p<0.001). On day 2 after the last atorvastatin, the coenzyme Q10 level was significantly elevated (0.37 +/- 0.16 microg/mL) and maintained the same levels on day 3 (0.39 +/- 0.18 microg/mL) compared with those on month 3 (both p< 0.001), while TC and LDL-C did not significantly change within the same 3 days. These results suggest that statin inhibition of coenzyme Q10 synthesis is less strict than inhibition of cholesterol biosynthesis.

Aneurysm of the sinus of Valsalva (ASV), frequently associated with ventricular septal defect (VSD), is a rare cardiac disease that may be acquired or congenital. Rupture of an ASV, rare in the noncoronary cusp, usually produces serious hemodynamic change and carries poor prognosis if not treated surgically. We present the case of a 55-year-old female who came to us complaining of exertional dyspnea. Transthoracic echocardiography and aortography showed a noncoronary cusp ASV with rupture into the right atrium but without VSD. Because of high left to right shunt flow, she underwent successful surgical intervention with aneurysm repair approached from both the aorta and right atrium with a knitted Dacron patch. This was a rare case of noncoronary cusp involvement in ASV that ruptured into the right atrium without VSD.

Background: It is still unknown whether a correlation exists between left ventricular Tei index obtained by tissue Doppler imaging and that determined by flow Doppler waveforms. This study was conducted to evaluate their relationship and to assess the positional effect on them., Methods: Twenty-six healthy subjects and 25 patients with essential hypertension were included. On the tissue Doppler images, the time interval from the end to the onset of the mitral annular velocity pattern during diastole and the duration of the S-wave were used to calculate tissue Doppler Tei index., Results: The tissue Doppler Tei index correlated with the flow Doppler Tei index at sitting position (r = 0.406, P = 0.003), but not at left lateral decubitus position. The limits of agreement for the Tei index measured by both methods were -0.26 to 0.62 at left lateral decubitus position and -0.09 to 0.55 at sitting position. Preload reduction associated with sitting position with dangling feet raised the Tei index both in the healthy controls [0.54 (0.14) vs 0.42 (0.12), P < 0.001] and in the hypertensives [0.53 (0.15) vs 0.46 (0.12), P = 0.005]. There was a similar positional effect on the tissue Doppler Tei index in the control subjects [0.75 (0.12) vs 0.53 (0.10), P < 0.001]., Conclusions: Tissue Doppler Tei index does not seem to be a suitable substitute for flow Doppler Tei index. Flow Doppler Tei index is preload dependent and the loading status should be taken into consideration at the application of Tei index to the evaluation of myocardial performance.

Vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-beta1) play an important role in angiogenesis. We wanted to determine if concentrations of growth factors in the coronary sinus (CS) and right atrium (RA) are higher in coronary artery disease patients with total occlusions than in those with partial occlusions. Fifty-one patients scheduled for coronary artery angiography were evaluated for possible recruitment. A 6F Goodale-Lubin catheter was used to collect blood from the CS and RA. Data for all but four patients were gathered successfully, leaving 47 study patients. The reviewer was blinded to growth factor data when interpreting coronary angiographic findings. Of the 47 enrolled patients, 32 had at least one diseased vessel, seven of whom had at least one major total epicardial coronary occlusion. In all 32 patients, the concentrations of VEGF in the CS were higher than those in the RA (31.5 +/- 2.7 vs 27.1 +/- 1.8 pg/mL; p = 0.005). Patients with total occlusions had higher VEGF concentrations in the CS than those with non-total occlusions (38.9 +/- 8.0 vs 29.5 +/- 2.6 pg/mL; p = 0.037). The differences in TGF-beta1 in the two groups were not statistically significant. The higher CS VEGF concentrations in patients with total occlusion indicate that VEGF may play a part in the development of angiogenesis.

To predict pulmonary capillary wedge pressure (PCWP) noninvasively, several Doppler combination indices have been developed. Recently, a fair correlation has been found between the time constant of isovolumic left ventricular (LV) relaxation (tau) and pulsed wave Doppler LV inflow propagation velocity (LVIPVpw) derived through the application of range ambiguity phenomenon. In the measurement of LVIPVpw, we can simultaneously measure the peak phantom E-wave velocity (Ep) from the same heartbeat. Hence, it is hypothesized that Ep/LVIPVpw is a useful index in predicting PCWP. In all, 29 patients who underwent elective cardiac catheterization for suggested coronary artery disease were included. Mean PCWP (mPCWP) obtained from right heart catheterization was compared with echocardiographic data before and 5 minutes after sublingual application of nitroglycerin (0.6 mg). Nitroglycerin caused a significant decrease in Ep and mPCWP, but not in LVIPVpw (P < .001, P < .001, and P = .687, respectively). By stepwise multiple linear regression analysis, only the Ep/LVIPVpw (beta = 0.832, P < .001) was the independent predictor of mPCWP. After nitroglycerin intake, the change in mPCWP was significantly correlated with the change in Ep/LVIPVpw (r = 0.455, P = .015). The sensitivity and specificity of Ep/LVIPVpw > 0.74 in predicting mPCWP > 15 mm Hg were 78% and 90%, respectively (area under curve 0.86). In conclusion, Ep/LVIPVpw derived from the same heartbeat provides a good estimate of mPCWP and can be used to rapidly track the change in mPCWP.

Objective: The ratio of early transmitral pulsed Doppler velocity (E) to colour M-mode Doppler flow propagation velocity (Vp) has been reported to be a good predictor of pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure (LVEDP). It is unknown whether E/Vp can be used to reflect the instantaneous haemodynamic change after drug intervention., Methods and Results: The study population was composed of 19 patients who underwent elective cardiac catheterization for suspected coronary artery disease. Mean PCWP (mPCWP) obtained from right heart catheterization and LVEDP from a micromanometer-tipped catheter were compared with echocardiographic data before and 5 minutes after sublingual application of nitroglycerin (NTG) 0.6 mg. By stepwise multiple linear regression analysis, we found a positive correlation between mPCWP and E/Vp (beta, = 0.687, p = 0.001) and LVEDP and E/Vp (beta, = 0.718, p = 0.001). After NTG intake, the change in ENp was significantly correlated with the changes in mPCWP and LVEDP (r = 0.574, p = 0.010; r = 0.627, p = 0.004, respectively)., Conclusions: In addition to being a useful predictor of mPCWP and LVEDP, the index, E/Vp, can be used to track the instantaneous changes in mPCWP and LVEDRP.

Patients with moderate to severe hypertension may need more than two antihypertensive drugs in combination to achieve ideal blood pressure (BP) control. The purpose of this study was to compare the efficacy and safety of administering the antihypertensive agents either all together in the morning or separately with two agents in the morning and one calcium channel blocker (CCB) in the evening. Twenty-four-hour ambulatory BP monitoring (ABPM) was performed among 15 patients (mean, 59 years) with moderate to severe essential hypertension. All patients received at least 3 antihypertensive drugs for ideal BP control. Two treatment regimens were given to each patient: Regimen 1: All antihypertensive agents were given once a day in the morning; Regimen 2: All antihypertensive agents were given in the morning, except the CCB which was given at 4:00 pm. After receiving regimen 1 for 4 weeks, each patient underwent 24-hour ABPM to analyze the BP control. After the first ABPM, each patient was switched to regimen 2. After 4 weeks of treatment with regimen 2, each patient underwent the second ABPM measurement. The pretreatment mean systolic and diastolic BP were 179.6 +/- 21.7 and 107.4 +/- 19.9 mmHg, respectively. Between the two regimens, there was no significant difference in the mean 24-hour BP (126.1 +/- 5.8/73.3 +/- 3.8 versus 130.2 +/- 6.2/75.1 +/- 4.7 mmHg), daytime BP (128.2 +/- 6.5/75.3 +/- 3.8 versus 132.4 +/- 5.8/77.2 +/- 4.4 mmHg), nighttime BP (125.2 +/- 4.9/72.4 +/- 3.3 versus 130.9 +/- 6.2/73.8 +/- 4.1 mmHg), and 24-hour heart rate (65.1 +/- 3.8 versus 64.2 +/- 3.4 bpm). The circadian BP and heart rate profiles were almost identical between regimen 1 and regimen 2. We conclude that in patients with moderate to severe hypertension treated with at least 3 antihypertensive agents, administering a CCB simultaneously with other antihypertensive agents in the morning or separately in the evening did not affect the 24-hour BP control.

To test whether left ventricular inflow propagation velocity at the pulsed wave Doppler analysis (IPVpw) is a useful noninvasive index of relaxation, 21 patients under coronary angiography for chest pain were included for simultaneous catheter-based and Doppler studies. IPVpw was derived through the application of range ambiguity, and the time constant of isovolumic left ventricular pressure decline (tau) was acquired by a previously described method. At baseline status, IPVpw correlated significantly with the peak negative dP/dt and tau ( r = -0.609, P = .003), but not with the peak velocity of transmitral early flow (E) wave. Sublingual application of nitroglycerin increased heart rate, decreased the transmitral E velocity and transmitral E-to-A velocity ratio, and prolonged the deceleration time of the transmitral E wave. However, there was no significant impact on IPVpw, peak negative dP/dt, or tau. IPVpw correlated with tau ( r = -0.533, P < .001) at the combined analysis of the data before and after nitroglycerin application. In conclusion, IPVpw is a preload-independent, noninvasive index of left ventricular relaxation.

Heparin, a commonly used anticoagulant agent, is frequently used in patients undergoing hemodialysis. As with most medications, heparin has a significant side effect profile. Two of its most important side effects, major bleeding and hyperkalemia, may be devastating without immediate diagnosis and treatment. Major bleeding such as gastrointestinal, genitourinary or intracranial bleeding is occasionally encountered and rarely neglected. However, heparin-induced cardiac tamponade is rarely encountered and may be easily overlooked. Another side effect, heparin-induced hyperkalemia, an unusual but well-described side effect, is frequently forgotten until life-threatening arrhythmia has occurred. We report a case involving a 40-year-old male patient with uremia, who had received heparin for 10 days for deep vein thrombosis in the left lower extremity. Hemopericardium with cardiac tamponade and life-threatening hyperkalemia were both noted in this patient.

To evaluate the propagation velocity of isovolumic relaxation flow within the left ventricle (IRFPV) associated with impaired ventricular relaxation, 49 patients with diseases known to impair ventricular relaxation (disease group) and 38 age-matched control subjects (control group) were studied. IRFPV was measured as the slope of the first aliasing velocity line segment of the isovolumic relaxation flow wave front in the color M-mode Doppler echocardiogram. Compared with the control group, the disease group had thicker interventricular septum and left ventricular posterior wall, more left ventricular mass, and lower early diastolic mitral annular velocity (8 +/- 3 vs 11 +/- 4 cm/s, P < .001), early (E) wave propagation velocity (47 +/- 16 vs 70 +/- 41 cm/s, P = .002), and IRFPV (193 +/- 149 vs 395 +/- 220 cm/s, P < .001). No matter in subgroup or whole population analysis, either the early diastolic mitral annular velocity or the E wave propagation velocity was selected as one of the determinants of IRFPV. In conclusion, diseases impairing ventricular relaxation may retard IRFPV.

Acute respiratory distress syndrome (ARDS) is characterized by acute-onset dyspnea, diffuse bilateral pulmonary infiltration, low pulmonary capillary wedge pressure (PCWP), and an arterial oxygen tension/inspired oxygen fraction (PaO2/FiO2) ratio of less than 200 mmHg. Acute myocardial infarction (AMI), whether complicated by circulatory arrest, cardiogenic shock, and hypotension or not, was reported as an etiologic factor in the development of ARDS in the prethrombolytic era. In the thrombolytic era, two cases of AMI complicated with ARDS have been reported. ARDS in these two patients resulted from anaphylactic reaction to the thrombolytic agent and not from the hemodynamic consequences of AMI. Development of ARDS during the AMI period has not been reported after early successful primary percutaneous coronary intervention (PCI). Herein, we report a 61-year-old male patient with persistent chest pain who was diagnosed with Killip II anterior ST-segment elevation AMI. He was treated successfully with primary PCI 2.5 hours after the onset of chest pain. Unfortunately, on the third hospital day, acute-onset dyspnea (respiratory rate, 33 beats/min), fever (38.5 degrees C), leukocytosis (white blood cell count, 18,360/microL), and diffuse bilateral pulmonary infiltration were noted. ARDS was diagnosed from the low PCWP (8 mmHg) and a PaO2/FiO2 of less than 200 mmHg (160 mmHg). No usual causes of ARDS such as infection, aspiration, trauma, shock, or drug reactions were noted. We assumed that, in this particular patient, the systemic inflammatory response syndrome frequently induced by AMI might have caused this episode of ARDS. This may imply that AMI itself is a possible etiology of ARDS.

Hyperthyroidism is associated with an increase in myocardial oxygen consumption that, due to an imbalance of oxygen demand and supply, can cause angina. However, subclinical hyperthyroidism rarely presents as chest pain in the resting state. Herein, we present a case of subclinical hyperthyroidism involving a 58-year-old male who complained of frequent chest tightness and typical electrocardiographic changes while in a resting state. Coronary angiography showed no significant lesion. Laboratory data showed that the patient suffered from hyperthyroidism, for which he was successfully treated with anti-thyroid agents. We are reminded that typical chest pain might be the first symptom of hyperthyroidism.

Background: Inhomogenous left ventricular activation-inactivation has been suggested to play a role in the genesis of segmental early relaxation and in turn of isovolumic relaxation flow (IRF). The spatial distribution of conduction system in the left ventricle leads to heterogenous activation sequence even in healthy subjects. This study was conducted to evaluate our hypothesis that IRF should be ubiquitous in healthy subjects., Methods: This prospective study included 126 healthy subjects (aged 15-81 years) free of acute or chronic illness by history and physical examination. No significant abnormality appeared in the resting 12-lead electrocardiogram or transthoracic echocardiogram. With the pulsed-wave Doppler echocardiography, the sample volume was placed at the mid-ventricle to detect the IRF., Results: An apically directed IRF, with the velocity 17-101 cm/sec and the duration 57-145 ms, could be detected in all the study subjects. There was no inter-sex difference in such characteristics of IRF. However, its duration and velocity got longer and higher with aging. The fractional shortening of the left ventricle and the interventricular septal thickness were stepwisely selected as the determinants of the IRF velocity, and the transmitral E-to-A wave velocity ratio, the left ventricular inflow propagation velocity, and the interventricular septal thickness as the determinants of the IRF duration., Conclusions: IRF is ubiquitous in healthy subjects. Both the duration and the velocity of IRF present an aging trend and may be mainly related to left ventricular diastolic and systolic performance, respectively.

Electrocardiographic changes in neurovascular disease are not rare. Patients with subarachnoid hemorrhage have electrocardiographic (ECG) abnormalities that may mimic ischemic heart disease and acute myocardial infarction. Outflow of catecholamines in the early stage of subarachnoid hemorrhage contributes to elevated blood pressure in most patients. Hypotension is a rare presentation in subarachnoid hemorrhage. We report a case of subarachnoid hemorrhage with transient ST elevation and intractable shock simulating acute myocardial infarction, and review the mechanism of ECG changes in subarachnoid hemorrhage.

Coronary artery aneurysms are not uncommon. They are usually arteriosclerotic in origin, and may be congenital or secondary to injury, dissection, infection, inflammation, or Kawasaki disease (KD). Herein, we report a case involving a 25-year-old male smoker with acute myocardial infarction (AMI). Coronary angiography showed triple-vessel disease, coronary artery aneurysms, and diffuse ectasia. Coronary artery bypass grafting was performed without complications. Based on his history, serologic examinations, and angiographic findings, we suspected that his coronary artery aneurysms and ectasia were the adult sequelae of KD. This case is a good reminder that KD victims may suffer from young-onset AMI.

The transit time of mitral late flow (A wave) to the outflow tract (A-Ar interval) has been demonstrated to be shorter in the presence of increased ventricular stiffness. However, the A-Ar interval is just a measure of time duration and the data of intraventricular A-wave propagation velocity are still unavailable. In this study we presented the aging trend in various intracardiac Doppler signals, including the mitral A-wave propagation velocity toward the apex (APV(apex)). It was measured as the slope of the first aliasing velocity line segment of the mitral A wavefront at color M-mode Doppler analysis. Age correlated significantly with peak velocity of mitral early flow (E wave), peak A velocity, velocity ratio of E to A wave, deceleration time of E wave, and mitral E-wave propagation velocity toward the apex, but not with the A-Ar interval (r = -0.262, P =.066) or the APV(apex) (r = -0.047, P =.748). Neither the A-Ar interval nor the APV(apex) was different between the young and the elderly groups. Furthermore, there was no significant correlation between the APV(apex) and the A-Ar interval (r = -0.135, P =.348). In conclusion, aging has a major adverse impact on myocardial relaxation associated with a minor one on the noninvasive indices of ventricular compliance. The APV(apex) is age-independent and, moreover, there is no significant correlation between the APV(apex) and the A-Ar interval.

To evaluate if pericardium is a suitable calibration reference in the integrated backscatter (IBS) analysis, the grossly normal pericardial specimens from 23 patients without a history of pericarditis were mounted on a steel platform and immersed in a 0.9% saline bath. The 2-D IBS images acquired at the uniform time gain compensation settings of 50 and 70 dB were analyzed. For the pericardial IBS, the limits of agreement for intraobserver and interobserver measurements were -1.2 to 1.4 dB and -1.6 to 2.2 dB, respectively. However, the calibrated IBS intensity of the pericardium presented a rather wide range of variation and was -13 +/- 5 (-5 to -29) and -10 +/- 4 (-4 to -22) dB at the overall gain settings of 50 and 70 dB, respectively. Conclusively, pericardium may not be an ideal IBS calibration reference in a population study of cardiac tissue characterization.

Ankle-brachial pressure index (ABI) measured using a conventional Doppler method is an independent predictor of the number of coronary vessels affected in coronary artery disease (CAD). Recently, a new clinical device has been developed to measure ABI using an oscillometric method. It is unclear whether ABI measured using this device is a significant predictor of the severity of coronary atherosclerosis. We retrospectively included 87 patients from our outpatient clinic who had ever undergone coronary angiography. ABI was determined in all subjects using the new ABI-form device. The lower value of ABI in either limb was used for analysis. We divided our subjects into two groups, with either ABI less than 0.9 or at least 0.9, and compared basal characteristics between groups. We analyzed the relationship between ABI and the severity of CAD. In addition, we calculated the sensitivity, specificity, and positive and negative predictive values of ABI less than 0.9 in predicting multivessel (two-vessel + three-vessel) involvement in our patients. There were 15 patients with ABI less than 0.9 and 72 with ABI at least 0.9. Patients with ABI less than 0.9 were older and had higher plasma levels of uric acid. The prevalence of diabetes mellitus, hypertension, smoking, and diuretic use was significantly higher in patients with ABI less than 0.9. In addition, the group with ABI less than 0.9 had a lower prevalence of one-vessel CAD and higher prevalence of three-vessel or multivessel CAD. The sensitivity, specificity, and positive and negative predictive values of ABI less than 0.9 in predicting multivessel CAD were 22%, 96%, 93%, and 34%, respectively. In conclusion, ABI measured using the automated oscillometric method can be used to predict the severity of coronary atherosclerosis in patients with CAD.

Ventricular septal defect (VSD) is a severe complication of acute myocardial infarction and has a high mortality rate. This complication appears to have declined in the reperfusion era. It has mostly been reported in elderly or female patients who suffer from anterior wall infarction, patients with multivessel coronary artery disease (CAD) or occluded infarct-related artery (IRA) without collateral circulation, or patients who have had delayed reperfusion therapy. Here, we report the case of a 60-year-old male patient who presented with persistent chest pain and Killip I ST-segment-elevation myocardial infarction. Thrombolytic therapy was started 3 hours after the onset of chest pain. Based on the subsidence of chest pain, resolution of the elevated ST segment, and early peak of cardiac enzymes, reperfusion was thought to be successful. However, on the third day of admission, the patient complained of dyspnea after defecation and was found to have new-onset grade 3 pansystolic murmur over the left sternal border. Cardiac echography showed an apical VSD. A Swan-Ganz catheter was inserted into the right side of the heart; analysis of blood oxygen saturation revealed a 6% step-up of oxygen in the right ventricle. Coronary angiography showed only one-vessel CAD and TIMI 3 flow in the IRA. The patient received intensive medical management and underwent VSD repair and internal mammary artery bypass grafting to the left anterior descending artery. His recovery was uneventful. This case illustrates that VSD can be found in patients receiving early successful reperfusion therapy, with one-vessel CAD, and TIMI 3 flow in the IRA.

Background: The actual relationship between the interval change of myocardial thallium 201 (Tl-201) radioactivity in the infarct area and the pattern of Q-wave regression is still unknown. This study was conducted to evaluate their relationship after acute myocardial infarction (AMI)., Methods and Results: A total of 30 patients who had a first Q-wave AMI (11 without Q-wave regression and 19 with Q-wave regression) were retrospectively included. Two sets of 12-lead surface electrocardiograms and Tl-201 myocardial perfusion images were obtained 0 to 2 months and 14 to 84 months after the AMI event, respectively. The acute/subacute redistribution Tl-201 radioactivity was similar between the patients with and those without Q-wave regression. However, the patients with Q-wave regression had higher chronic redistribution Tl-201 radioactivity than those without Q-wave regression. Moreover, the patients with Q-wave regression presented a higher gradient in the redistribution Tl-201 radioactivity between the chronic and acute/subacute images than those without Q-wave regression., Conclusions: This study supports the role of functional recovery of stunning and/or hibernating myocardium in the disappearance of Q waves after AMI.

Sixty-six participants (age 58 +/- 16 years) were included for evaluation of the relationship between color M-mode and pulsed wave Doppler left ventricular inflow propagation velocity (LVIPVcmm and LVIPVpw, respectively). LVIPVpw was measured through the application of the range ambiguity phenomenon, and LVIPVcmm was obtained by manually tracing the first aliasing velocity during the early filling. The variability for LVIPVpw measurements was significantly less than that for LVIPVcmm measurements. There was a significant correlation (r = 0.678, P <.001) between LVIPVcmm and LVIPVpw for all study participants. However, LVIPVpw was greater than LVIPVcmm, especially when the inflow propagation time was relatively short. Age was the only determinant of both LVIPVcmm and LVIPVpw in the control group. As for the patients with diseases retarding inflow propagation, age remained its determinant. However, its impact decreased and the end-systolic dimension and fractional shortening of the left ventricle, instead, turned out to be its major determinant. In conclusion, LVIPVpw measurements are more reproducible than LVIPVcmm measurements. LVIPVpw correlates with LVIPVcmm and their difference significantly correlates with left ventricular inflow propagation time.

Several epidemiological studies have shown a positive correlation between chronic gastric infection with Helicobacter pylori (HP) and coronary artery disease. A number of reports also claimed that there are strong relationships between HP infection and coronary risk factors. However, clinical studies concerning the changes of coronary risk factors after eradication of HP infection are few and contradictory. We conducted a prospective study aiming to compare sugar, lipid and fibrinolytic profiles before HP eradication with those after HP eradication. HP infection was confirmed by endoscope-based examinations and eradicated by a standard OAC (omeperazole-amoxicillin-clarithromycin) regimen. We measured and compared pre- and post-eradication blood sugar, lipid profiles (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride) and fibrinolytic profiles (tissue-plasminogen activator, plasminogen activator inhibitor-1, fibrinogen, and D-dimer levels). Forty-eight patients (male:female, 25:23; mean age, 50.8 +/- 11.3 years) with gastric HP infection were enrolled in this study. Although HP infection was confirmed to have been successfully eradicated, no significant changes of blood fasting sugar, lipids or fibrinolytic profiles were found in patients after treatment. Coronary risk factors including fasting sugar, lipid and fibrinolytic profiles were not changed after successful HP eradication treatment. The relationship between HP infection and coronary artery disease needs to be clarified.

Thirty-one healthy subjects, aged 35 +/- 6 (21 to 48) years, were included in the study to evaluate the effect of ice water immersion on QT dispersion. There was no difference in the age between females (n = 11) and males (n = 20). Baseline, stress (at the end of ice water immersion, 4 degrees C, for 3 minutes) and recovery 12-lead electrocardiograms (ECGs) were recorded on each subject. During the test, a significant variability developed in both the QT dispersion (52 +/- 17, 68 +/- 25 and 59 +/- 21 ms; p = 0.015) and the corrected QT dispersion (56 +/- 17, 76 +/- 27 and 64 +/- 23 ms; p = 0.005), but not in the heart rate (74 +/- 11, 76 +/- 9, and 74 +/- 9 bpm, respectively; p = 0.447). There was no inter-sex difference in the baseline heart rate or QT dispersion, or in their response to ice water immersion. Age significantly correlated with the variation of QT dispersion to ice water immersion (r = 0.380, p = 0.035). With 37 years of age as a separation point, the variation of QT dispersion to ice water immersion was more obvious in the older group (28 +/- 22 vs. 10 +/- 19 ms, p = 0.023). In conclusion, cold may increase QT dispersion in healthy subjects, with a more obvious effect in the older ones.

Adenosine has a potent negative dromotropic effect. However, comparative effects of adenosine on the three pathways of atrioventricular (AV) nodal reentry remain unclear. In this study, we sought to determine the effects of adenosine on the antegrade fast, antegrade slow, and retrograde fast pathway conduction in patients with AV nodal reentrant tachycardia (AVNRT). Twenty patients with common slow-fast AVNRT (mean cycle length 360 +/- 49 ms) were studied. The effects of adenosine on the antegrade slow pathway and on the retrograde fast pathway conduction were determined during sustained AVNRT and constant right ventricular pacing at identical cycle lengths (mean 360 +/- 49 ms), respectively. Incremental doses of adenosine were rapidly administered: initial dose of 0.5 mg, followed by stepwise increases of 0.5 or 1.0 mg given at 5-min intervals until termination of AVNRT or second-degree ventriculoatrial block occurred. After the antegrade slow pathway conduction was selectively and completely ablated by radiofrequency catheter ablation, the effect of adenosine on the antegrade fast pathway conduction was evaluated. The dose-response curve of adenosine and the dose of adenosine required to produce AV or ventriculoatrial block among the representative three conduction pathways were compared. The dose-response curve for the effect of adenosine on the antegrade fast pathway lies to the left and upward to that of the effect of adenosine on the antegrade slow pathway which in turn lies to the left and upward to that of the retrograde fast pathway. The mean dose of adenosine required to produce conduction block at antegrade fast, antegrade slow, and retrograde fast pathways were 1.4 +/- 0.5, 4.2 +/- 1.6, and 8.5 +/- 2.6 mg, respectively (p < 0.01). Adenosine has a differential potency to depress antegrade fast, antegrade slow, and retrograde fast pathway conduction in patients with AVNRT. The depressant effect of adenosine on the antegrade fast pathway is more potent than that on the antegrade slow pathway which in turn is more potent than that on the retrograde fast pathway conduction., (Copyright 2002 S. Karger AG, Basel)

With application of the range ambiguity, a delay between the flow onset at both the mitral valve and the apex has been shown to be present in patients with a severely dilated and poorly contracting left ventricle and those with acute myocardial infarction with abnormal apical wall motion, but the delay has been absent in normal subjects. Nevertheless, whether there is a delay between the flow onset at both regions in the presence of impaired left ventricular relaxation remains unknown. This study was undertaken to evaluate the left ventricular inflow wave propagation in control subjects and patients with impaired left ventricular relaxation. Eighteen patients with normal systolic function and Doppler characteristics of impaired relaxation of the left ventricle and 17 age- and sex-matched healthy control subjects were included. Range ambiguity was used to simultaneously record the phantom Doppler signals from the mitral valve region and the true ones from the apex. The inflow wave propagation velocity was derived from the inflow wave propagation distance divided by the time between the mitral valve and the apex. There was always some delay between the flow onset at both the mitral valve and the apex in both the controls and the patients (47 +/- 13 msec vs 85 +/- 19 msec, P < 0.001). The inflow wave propagation velocity was 160 +/- 50 cm/sec and 90 +/- 20 cm/sec in the control subjects and the patients, respectively (P < 0.001). Multiple linear regression analyses of the significantly correlated variables stepwisely selected the deceleration time of the E wave (R(2) = 0.53, P < 0.001) and age (R(2) = 0.06, P = 0.039) as the significant determinants of the left ventricular inflow wave propagation velocity. In conclusion, the application of the range ambiguity offers a new method of determining the left ventricular inflow wave propagation velocity, and Doppler characteristics of impaired left ventricular relaxation are associated with a slower inflow wave propagation from the mitral valve to the apex.

PURPOSE: The purpose of this study was to test the hypothesis that with the range gate fixed, random adjustment of the pulse repetition frequency will offer a rapid and accurate way to avoid misinterpretation of range ambiguity. BACKGROUND: Traditionally, to avoid the misdiagnosis of Doppler artifacts caused by range ambiguity, time must be spent on checking the flow patterns in the calculated phantom range gates. METHODS: Twenty-four patients (mean age 64 +/- 15 years, 15 men and nine women) with mitral regurgitation were included in the study. Pulsed Doppler evaluation was performed with sample volume initially at the shallow left ventricle and then, along the direction of ultrasonic beam, at the calculated range gate distal to the mitral valve to search for the high velocity Doppler signal. The highest velocity scale was initially selected. After detection of high velocity signal, the velocity scale was lowered to achieve the lower pulse repetition frequency. RESULTS: For all patients, a high velocity regurgitant Doppler signal could be recorded both distal to the mitral valve and at the shallow left ventricle. Such signal persisted at the range gate distal to the mitral valve but disappeared at the range gate at the shallow left ventricle after manual adjustment of the velocity scale. The sensitivity, specificity, and accuracy of disappearance of the high velocity Doppler signal after adjustment of the pulse repetition frequency for confirmation of a phantom phenomenon are 100%, 100%, and 100%, respectively. CONCLUSIONS: Without the necessity of exact information about the pulse repetition frequency used, random adjustment of the pulse repetition frequency for the selected gate range is a rapid and exact method for initial differentiation of in situ from phantom signal in pulsed Doppler echocardiography.

The measurements of the left ventricular inflow parameters do not necessarily reflect the measurements of the respective outflow ones. The A wave transit time from the mitral valve to the left ventricular outflow tract has been demonstrated to have a fair correlation with measures of the left ventricular late diastolic stiffness. We performed this study to obtain the normal patterns of the diastolic left ventricular outflow as well as inflow waveforms and to evaluate the roles of aging and other physiological parameters in their evolution. The study population consisted of 60 healthy subjects (aged 22-66 years). They were divided into three groups: group 1 (aged 20-34 years), group 2 (aged 35-49 years), and group 3 (aged 50-70 years). Pulse-wave Doppler echocardiography was performed to get the patterns of diastolic left ventricular inflow and outflow waveforms. With aging, the peak velocity and velocity-time integral of the transmitted transmitral E wave decreased, and those of the transmitted transmitral A wave increased with a progressive decrease in their ratio of transmitted transmitral E to A wave. The diastolic left ventricular inflows followed a similar aging course. There was no obvious aging trend in the A wave transit time from the mitral valve to the left ventricular outflow tract. Multiple linear regression analyses selected age as the most important determinant in the differences in most left ventricular inflow and outflow indices among normal subjects. Besides, heart rate had modest influences on some Doppler indices. This study confirms the age related changes in the left ventricular inflow waveforms and further establishes the concept that the diastolic left ventricular outflow waveforms are also significantly influenced by age and heart rate. Hence, both factors should be taken into account in interpreting the diastolic left ventricular outflow as well as inflow indices.

To investigate the characters of the transmitted transmitral A wave associated with a fourth heart sound, left ventricular inflow, and outflow Doppler echocardiography and phonocardiography were recorded in 13 patients with a fourth heart sound and 9 age-matched control subjects. The Doppler echocardiographic data were compared between both groups and the peak velocity and acceleration rate of the transmitted transmitral A wave were correlated with other parameters. The peak velocity and acceleration rate of the transmitted transmitral A wave were significantly greater, but the A wave transit time from the mitral valve to the left ventricular outflow tract (A-Ar interval) was significantly shorter in patients with a fourth heart sound. There was a significant correlation between the A-Ar interval and the peak velocity (r = -0.54, P = 0.01) or acceleration rate (r = -0.63, P = 0.002) of the transmitted transmitral A wave. The A-Ar interval was shown to be the independent determinant of both the peak velocity and acceleration rate of the transmitted transmitral A wave by stepwise multiple linear regression. In conclusion, the presence of a fourth heart sound was associated with a higher peak velocity and acceleration rate of the transmitted transmitral A wave, to which increased ventricular stiffness may make some contributions.