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Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.

STEMI patients admitted urgently to the hospital but experience early complete resolution of both ischemic symptoms and ST-elevations on the electrocardiogram are diagnosed as transient STEMI (TSTEMI). Current evidence indicates that primary intervention is plausible but in certain circumstances intervention can be delayed. We sought to examine whether there is a time limit to such a delay that may affect long-term outcome. Study population included prospectively admitted TSTEMI patients whose demographics, pertinent medical history, and clinical and angiographic features were recorded. Study patients were divided by the median time interval from admission to intervention and their characteristics and long-term survival were compared. Study population comprised 260 consecutive patients (age: 57±10 years, men: 84%) diagnosed as TSTEMI who were included from January 2000 to June 2019, which represent 6% of all STEMI patients. Coronary angiography was performed in 254 patients. The median time interval from admission to angiography was 17 hours (IQR: 7.2 to 38.7 hours). Early (17 hours from admission) and late (17 hours from admission) study groups were comparable. One patient died during admission and 41 throughout the long follow-up period of 8.5 ± 5.2 years (median: 8.2 years, IQR: 3.4 to 13.1). Mortality of early-treated TSTEMI patients (11.2%) was significantly lower than of the late-treated patients (21.6%, p0.04). The Kaplan-Meier curve demonstrated a clear tendency toward improved survival in early-treated TSTEMI patients (p0.09). In conclusion, the present data suggest that TSTEMI patients should be treated, if not by primary coronary intervention, then at least within 17 hours from admission to achieve better long-term outcome.

Aims We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. Methods Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). Results Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). Conclusions Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

Few data exist regarding the effect of image quality on measurements of two-dimensional longitudinal strain (2DLS). In the 2DLS for Diagnosing Chest Pain in the Emergency Room (2DSPER) multicenter study, 2DLS was not useful for ruling out acute coronary syndromes (ACS) in the emergency department (ED). The aim of this substudy was to determine the effect of 2D image quality on the diagnostic accuracy of 2DLS for ACS. We reviewed apical views used for 2DLS analysis in all 605 patients included in the 2DSPER study. Studies with the best image quality (HighQ, n = 177), were compared to the lower quality group (LowQ, n = 428). Abnormal 2DLS was defined as PSS20% > − 17% (PSS20% being the peak left ventricular systolic strain value identifying the 20% worst strain values). Global longitudinal strain (GLS) and PSS20% were significantly worse in LowQ compared to HighQ patients. LowQ independently predicted abnormal 2DLS (OR 1.9, 95% CI 1.3–2.9, P = 0.003). The sensitivity of PSS20% > − 17% for ACS was 85% for LowQ vs. 73% for HighQ (P = 0.2), specificity 22% vs. 38% (P

Funding Acknowledgements Type of funding sources: None. Background Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) was a prospective multicenter study designed to determine whether 2D longitudinal strain (2DLS) can assist in triage of patients with chest pain in the emergency department (ED). In that study 2DLS was not useful to rule out acute coronary syndromes (ACS) in the ED, partly because many patients without ACS had abnormal 2DLS. The prognostic significance of 2DLS in these patients is unclear. The aim of the current study was to determine whether global longitudinal strain (GLS), measured using 2D echocardiography in the ED, can predict long-term outcome. Methods Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure or atrial fibrillation) was available in 525 of 605 patients (87%) enrolled in the 2DSPER study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. Global longitudinal strain (GLS) was computed from echocardiograms performed within 24 hours of chest pain using a dedicated 2DLS software (EchoPAC SW; GE Vingmed Ultrasound AS). MACE of patients with worse GLS (>median) was compared to those with better GLS (≤median). Results Median GLS was -18.8%. MACE occurred in 43/249 (17.3%) of patients with worse GLS (-16.8 ± 1.5) as compared with 49/276 (17.8%) with better GLS (-20.8 ± 1.6), HR 0.98 (95%CI 0.65-1.4, p = 0.9) (Figure). Similarly, there was no significant difference in total mortality (6% vs. 4.7%, p = 0.5), cardiac death (0.4% vs. 0.7%, p = 0.6), ACS (8% vs. 8.3%, p = 1), revascularization (10% vs. 10.9%, p = 0.8), hospitalization for heart failure (0.8% vs. 2.2%, p = 0.2) or atrial fibrillation (3.6% vs. 4.3%, p = 0.7) between groups. Predictors of MACE were male gender (HR 2.5, 1.4-4.3, p = 0.02), history of coronary artery disease (HR 3.3, 2-5.4, p Conclusions GLS did not predict long term outcome in patients presenting to the ED with chest pain. Long-term outcome was favorable in the group of patients with worse GLS, similar to better GLS. Abstract Figure.

AIMS Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions. METHODS AND RESULTS The present study is based on pre-defined secondary analysis of the IMPEDANCE-HF extended trial comprising 266 HF patients at New York Heart Association Class II-IV and left ventricular ejection fraction ≤ 35% randomized to LI-guided or conventional therapy during long-term follow-up. Lung impedance-guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P

Shortening door-to-balloon time intervals in ST-elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PPCI) is necessary in order to limit myocardial damage. Direct admission to the cardiac care unit (CCU) facilitates this goal. We compared characteristics and short- and long-term mortality of PPCI-treated STEMI patients admitted directly to the CCU with those admitted via the emergency department (ED).To compare 303 patients admitted directly to the CCU (42%) with 427 admitted via the ED (58%) included in the current registry comprising 730 consecutive PPCI-treated STEMI patients.Groups were similar regarding demographics, medical history and risk factors. Pain-to-CCU time was 151±164 minutes (median-94) for patients admitted directly and 242±226 minutes (160) for those admitted via the ED, while door-to-balloon intervals were 69±42 minutes (61) and 133±102 minutes (111), respectively. LVEF evaluated during admission (48.3±13% [47.5%] vs. 47.7±13.7% [47.5%]) and mean CK level (893±1157 [527] vs. 891±1255 [507], p=0.45) were similar between groups. Mortality was 4.2% vs. 10.3% at 30-days (p0.002), 7.6% and 14.3% at one-year (p0.01), reaching 12.2% and 21.9% at 3.9±2.3 years (median-3.5, p0.004) among directly-admitted patients vs. those admitted via the ED, respectively. Long-term mortality was 4.1%, 9.4%, 21.4%, and 16% for pain-to-balloon quartiles of140 min, 141-207 min, 208-330 min, and330 mins, respectively (p=0.026).Direct admission of STEMI patients to the CCU for PPCI facilitated the attainment of guidelines-dictated door-to-balloon time intervals and yielded improved short- and long-term mortality. Longer pain-to-balloon time was associated with higher long-term mortality.

Multiline acquisition (MLA) is a well-established method for a high-frame-rate cardiac ultrasound imaging, which is commonly used in conjunction with delay-and-sum (DAS) beamforming. The block-like artifacts that occur secondary to the use of MLA can be reduced using interpolation of the data acquired from adjacent transmitted beams—a method called synthetic transmit beamforming (STB). A recently proposed filtered delay-multiply-and-sum (F-DMAS) is a novel beamforming method, based on modified autocorrelation of the aperture data, which provides superior contrast resolution compared to the DAS beamforming. In this study, we demonstrate that a combination of the F-DMAS with the STB compensated MLA results in superior contrast as compared to both DAS beamformed STB and DAS beamformed single-line acquisition. Moreover, we propose a novel formulation for adaptive-lag F-DMAS that outperforms both DAS and F-DMAS in terms of contrast and lateral resolutions. The results are demonstrated in tissue-mimicking phantom and in human cardiac data.

OBJECTIVES We present our experience with a novel method for real time co-registration of intravascular ultrasound (IVUS) and coronary angiography. BACKGROUND A major limitation of the current practice of concomitant use of coronary angiography and IVUS is that the locations of the acquired IVUS images are not correlated with their exact locations on the vessel roadmap obtained by coronary angiography. METHODS Phantoms simulating the coronary tree were used to test the accuracy and potential of co-registration. Subsequently we examined patients who underwent IVUS during cardiac catheterization. Analysis and feasibility were performed in 42 arteries of 36 patients. RESULTS The statistical validation in phantoms resulted in a co-registration accuracy of 1.12 mm. The length measurement on an angiogram resulted in an accuracy of 0.38 mm. Co-registration in patients was successful in all cases and four categories were assisted by 1(bad) to 5 (good) grading. Accuracy (the co-registration precision in pointing at the exact corresponding location): 4.8±0.41; Ease of use and workflow: 4.74±0.44; Stent landing zone detection and evaluation: 4.58±0.5; Stent landing zone length and diameter measurement: 4.94±0.23. The co-registration error was estimated as no more than 1 mm. CONCLUSION In this pilot study, we found that the novel IVUS and coronary angiography co-registration method is accurate, easy to use, fast and user-friendly. This method precludes the need to use motorized automated pull back device.

Since the introduction of the electrocardiogram (ECG) in 1902, the fundamentals of ECG data acquisition, display, and interpretation in the clinical arena have not changed much.To present a new method to enhance and improve acquisition, analysis, and display of the standard ECG.We performed ECG enhancement by superimposition and summation of multiple standard ECG cycles of each lead, by temporal alignment to peak R wave and voltage alignment to an improved baseline, at the T-P segment.We enhanced ECG recordings of 504 patients who underwent coronary angiograms for routine indications. Several new ECG features were noted on the enhanced recordings. Examination of a subgroup of 152 patients with a normal rest 12-lead ECG led to the discovery of a new observation, which may help to distinguish between patients with and without coronary artery disease (CAD): namely, a spontaneous cycle-to-cycle voltage spread (VS) at the S-T interval, normalized to VS at the T-P interval. The mean normalized VS was significantly greater in those with CAD (n=61, 40%) than without (n=91, 60%), 5.61 ± 3.79 vs. 4.01 ± 2.1 (P0.05).Our novel method of multiple ECG-cycle superimposition enhances the ECG display and improves detection of subtle electrical abnormalities, thus facilitating the standard rest ECG diagnostic power. We describe, for the first time, voltage spread at the S-T interval, an observed phenomenon that can help detect CAD among individuals with normal rest 12-lead ECG.

Aims Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions. Methods and results The present study is based on pre‐defined secondary analysis of the IMPEDANCE‐HF extended trial comprising 266 HF patients at New York Heart Association Class II–IV and left ventricular ejection fraction ≤ 35% randomized to LI‐guided or conventional therapy during long‐term follow‐up. Lung impedance‐guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P

Cardiac ultrasound imaging requires a high frame rate in order to capture rapid motion. This can be achieved by multi-line acquisition (MLA), where several narrow-focused received lines are obtained from each wide-focused transmitted line. This shortens the acquisition time at the expense of introducing block artifacts. In this paper, we propose a data-driven learning-based approach to improve the MLA image quality. We train an end-to-end convolutional neural network on pairs of real ultrasound cardiac data, acquired through MLA and the corresponding single-line acquisition (SLA). The network achieves a significant improvement in image quality for both 5- and 7-line MLA resulting in a decorrelation measure similar to that of SLA while having the frame rate of MLA.

Patients with acute myocardial infarctions (AMIs) present as persistent ST-elevation myocardial infarction (STEMI) or as non-ST-segment elevation myocardial infarction (NSTEMI). In some patients with STEMI, ST elevations are transient and resolve before coronary intervention (transient ST-elevation myocardial infarction [TSTEMI]). We analyzed our registry comprising all consecutive patients with AMI admitted during 2009 to 2014, and compared the characteristics, management, and outcome of patients with TSTEMI with those of patients with STEMI and NSTEMI. Of 1,847 patients with AMI included in the registry, 1,073 patients sustained a STEMI (58%), 649 had a NSTEMI (35%), and 126 presented with TSTEMI (6.9%). Patients with TSTEMI were younger than patients with NSTEMI and STEMI (56.5 vs 62.8, p

Background Shortness of breath (SOB) is common among healthy women with normal pregnancies. However, when no overt cardiac or extra cardiac etiology is found, a subtle cardiac source must be excluded. Hypothesis Pregnancy may induce or unmask myocardial dysfunction that may cause SOB. Methods Healthy pregnant women with significant SOB were recruited for this study. We performed a comprehensive echocardiographic assessment including tissue Doppler imaging (TDI) and 2- dimensional strain imaging (2DS). The echocardiographic data obtained were compared with that of a control group of pregnant women without SOB. Results Thirty pregnant women with SOB were enrolled in the study (age, 31.8 ± 4.9 years, and gestation, 38.2 ± 2.8 weeks) for whom no overt etiology for SOB was detected. Patients with SOB compared with controls had thicker hearts (septum: 10.1 ± 1.1 vs 8.9 ± 0.9 mm; P

Trials have shown superiority of primary percutaneous intervention (PPCI) over in-hospital thrombolysis in ST-elevation myocardial infarction (STEMI) patients treated within 6-12 hours from symptom onset. These studies also included high-risk patients not all of whom underwent a therapeutic intervention.To compare the outcome of early-arriving stable STEMI patients treated by thrombolysis with or without coronary angiography to the outcome of PPCI-treated STEMI patients.Based on six biannual Acute Coronary Syndrome Israeli Surveys comprising 5474 STEMI patients, we analyzed the outcome of 1464 hemodynamically stable STEMI patients treated within 3 hours of onset. Of these, 899 patients underwent PPCI, 383 received in-hospital thrombolysis followed by angiography (TFA), and 182 were treated by thrombolysis only.Median time intervals from symptom onset to admission were similar while door-to-reperfusion intervals were 63, 45 and 52.5 minutes for PPCI, TFA and thrombolysis only, respectively (P0.001). The 30-day composite endpoint of death, post-infarction angina and myocardial infarction occurred in 77 patients of the PPCI group (8.6%), 64 patients treated by TFA (16.7%), and 36 patients of the thrombolysis only group (19.8%, P0.001), with differences mostly due to post-infarction angina. One-year mortality rate was 27 (3%), 13 (3.4%) and 11 (6.1%) for PPCI, TFA and thrombolysis only, respectively (P = 0.12).PPCI was superior to thrombolysis in early-arriving stable STEMI patients with regard to 30-day composite endpoint driven by a decreased incidence of post-infarction angina. No 1 year survival benefit for PPCI over thrombolysis was observed in early-arriving stable STEMI patients.

The instantaneous lung impedance (ILI) is one of the methods to assess pulmonary congestion or edema (PCE) in chronic heart failure (CHF) patients. Due to usually existing PCE in CHF patients when evaluated, baseline lung impedance (BLI) is unknown. Therefore, the relation of ILI to BLI is unknown. Our aim was to evaluate methods to calculate and appraise BLI or its derivative as reflecting the clinical status of CHF patients. ILI and New York Heart Association (NYHA) class were assessed in 222 patients (67 ± 11 years, LVEF

It is frequently difficult to differentiate between perimyocarditis and acute myocardial infarction (AMI). Diagnosis is usually established by excluding obstructive coronary disease. The primary process in perimyocarditis is inflammation, associated with high C-reactive protein (CRP) and low

This case report describes a 37-year-old female who was admitted to our Emergency Department because of shortness of breath. On physical examination, she had dyspnea and tachycardia and blood pressure was 80/50 mmHg with a pulsus paradoxus of 22 mmHg. Neck veins were distended, heart sounds were distant, and dullness was found on both lung bases. Her chest X-ray revealed bilateral pleural effusion and cardiomegaly. On both computed tomography and echocardiography the heart was of normal size and a large pericardial effusion was noted. The echocardiogram showed signs of impending tamponade, so the patient underwent an emergent pericardiocentesis. No infectious etiology was found and she was assumed to have viral pericarditis and was treated accordingly. However, when the pericardial effusion recurred and empirical therapy for tuberculosis failed, a pericardial window was performed. A typical staining pattern for mesothelioma was found on her pericardial biopsy specimen. Since no other mesodermal tissue was affected, a diagnosis of primary malignant pericardial mesothelioma was made. Chemotherapy was not effective and she passed away a year after the diagnosis was made. This case highlights the difficulties in diagnosing this uncommon disease in patients that present with the common finding of pericardial effusion.

Aims Left ventricular (LV) two-dimensional longitudinal strain (2DLS) analysis by echocardiography has been suggested as a useful tool for the detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DLS analysis could assist in triage of patients with chest pain (CP) in the emergency department (ED). Methods and results We prospectively enrolled patients presenting to the ED with CP and suspected ACS but without a diagnostic ECG or elevated troponin. An echocardiogram was performed within 24 h of CP. For each patient, a histogram of LV myocardial peak systolic strain (PSS) was generated and the value identifying the 20% worst strain values (PSS20%) was determined. A predefined value of greater than −17% was considered abnormal. 2DLS analysis was available for 605 patients (mean age 58 ± 9 years, 70% males), of which 74 (12.2%) had ACS. During a 6-month follow-up, MACE occurred in 4 (5.8%) patients with and in 3 (0.6%) without ACS. An abnormal PSS20% was present in 60/74 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 391/531 patients without ACS (specificity 26%, positive predictive value 13%). Similar results were found for global longitudinal strain (GLS). Receiver-operating characteristic curves showed an area under curve of 0.59 for PSS20% and 0.6 for GLS ( P = 0.3). Independent predictors of abnormal 2DLS were male gender, body mass index, heart rate, and mean tissue Doppler e ′, but not ACS. Conclusion In this large multicentre prospective study, 2DLS was not a useful tool to rule out ACS in the ED. Clinical trial registration . Unique identifier NCT01163019.

We present our experience with a novel method for real time co-registration of intravascular ultrasound (IVUS) and coronary angiography.A major limitation of the current practice of concomitant use of coronary angiography and IVUS is that the locations of the acquired IVUS images are not correlated with their exact locations on the vessel roadmap obtained by coronary angiography.Phantoms simulating the coronary tree were used to test the accuracy and potential of co-registration. Subsequently we examined patients who underwent IVUS during cardiac catheterization. Analysis and feasibility were performed in 42 arteries of 36 patients.The statistical validation in phantoms resulted in a co-registration accuracy of 1.12 mm. The length measurement on an angiogram resulted in an accuracy of 0.38 mm. Co-registration in patients was successful in all cases and four categories were assisted by 1(bad) to 5 (good) grading. Accuracy (the co-registration precision in pointing at the exact corresponding location): 4.8±0.41; Ease of use and workflow: 4.74±0.44; Stent landing zone detection and evaluation: 4.58±0.5; Stent landing zone length and diameter measurement: 4.94±0.23. The co-registration error was estimated as no more than 1 mm.In this pilot study, we found that the novel IVUS and coronary angiography co-registration method is accurate, easy to use, fast and user-friendly. This method precludes the need to use motorized automated pull back device.

Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) level is useful to diagnose or exclude acutely decompensated heart failure (ADHF) in dyspnoeic patients presenting to the emergency department (ED).To evaluate the impact of ED NT-proBNP testing on admission, length of stay (LOS), discharge diagnosis and long-term outcome.Dyspnoeic patients were randomized in the ED to NT-proBNP testing. Admission and discharge diagnoses, and outcomes were examined.During 17 months, 470 patients were enrolled and followed for 2.0±1.3 years. ADHF likelihood, determined at study conclusion by validated criteria, established ADHF diagnosis as unlikely in 86 (17%), possible in 120 (24%), and likely in 293 (59%) patients. The respective admission rates in these subgroups were 80, 91, and 96%, regardless of blinding, and 61.9% of blinded vs. 74.5% of unblinded ADHF-likely patients were correctly diagnosed at discharge (p=0.029), with similar LOS. 2-year mortality within subgroups was unaffected by test, but was lower in ADHF-likely patients with NT-proBNP levels below median (5000 pg/ml) compared with those above median (p=0.002). Incidence of recurrent cardiac events tracked NT-proBNP levels.ED NT-proBNP testing did not affect admission, LOS, 2-year survival, or recurrent cardiac events among study patients but improved diagnosis at discharge, and allowed risk stratification even within the ADHF-likely group. (ClinicalTrials.gov#NCT00271128).

Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223).The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality.There were 67 vs 158 AHF hospitalizations during the first year (P .001) and 211 vs 386 AHF hospitalizations (P .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar.Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality.

Aims Assessing the quality of wall motion (WM) on echocardiograms remains a challenge. Previously, we validated an automated application used by experienced echocardiographers for WM classification based on longitudinal two-dimensional (2D) strain. The aim of this study was to show that the use of this automatic application was independent of the user's experience. Methods and results We compared the WM classifications obtained by the application when used by 12 highly experienced readers (Exp-R) vs. 11 inexperienced readers (InExp-R). Both classifications were compared with expert consensus classifications using the standard visual method. Digitized clips of cardiac cycles from three apical views in 105 patients were used for these analyses. Reproducibility of both groups was high (overall intra-class correlation coefficient: InExp-R = 0.89, Exp-R = 0.83); the lowest was noted for hypokinetic segments (InExp-R = 0.79, Exp-R = 0.72). InExp-R scores were concordant with Exp-R mode scores in 88.8% of segments; they were overestimated in 5.8% and underestimated in 3.2%. The sensitivity, specificity, and accuracy of InExp-R vs. Exp-R for classifying segments as normal/abnormal were identical (87, 85, and 86%, respectively). Conclusion Classification of WM from apical views with an automatic application based on longitudinal 2D strain by InExp-R vs. Exp-R was similar to visual classification by Exp-R. This application may be useful for inexperienced echocardiographers/technicians and may serve as an automated ‘second opinion’ for experienced echocardiographers.

Background: Monitoring of lung fluid content (LFC) in order to predict acute heart failure (AHF) during acute myocardial infarction (AMI) is an unmet challenge.Aim: To evaluate in AMI patients the ability of proposed radiological score (RS), which is the sum of selected radiological signs of congestion, to reflect correctly LFC, as assessed with repeat physical examinations and lung impedance (LI) measurements.Methods: Chest X-rays were taken at baseline, when rales were detected, whenever indicated, and at conclusion of monitoring. RS grading for LFC assessment was: RS = 0–1 for normal X-ray, RS = 2–4 for interstitial congestion, and RS values of 5–6, 7–8 and 9–10 signified mild, moderate and severe alveolar edema, respectively.Results: 624 AMI patients without AHF at baseline were monitored (94 ± 42 h). 476 patients (76%) with baseline RS of 0.3 ± 0.5 did not develop AHF. Overt AHF developed in 148 patients (24%) during monitoring; baseline RS (0.6 ± 0.8) reached 5.4 ± 0.7, 7.0 ± 0.8, and 9.8 ± 0.5 at t...

The validity of angiographic collateral grade according to the Rentrop classification during acute myocardial infarction (AMI) and its relation to flow in occluded coronary arteries before angioplasty have never been evaluated.We assessed the validity of the angiographic collateral grade according to Rentrop classification in relation to collateral pressure and flow beyond occluded coronary arteries during AMI. Pressure distal to coronary artery occlusions before balloon dilatation was measured in 111 patients undergoing angioplasty for AMI. We calculated the collateral flow index (CFI) and compared it to observed Rentrop grade and measured creatine kinase sum.The values of pressure distal to coronary artery occlusions with respect to collateral grades 0 to 3 were 33 +/- 12, 37 +/- 13, 42 +/- 10, and 60 +/- 14 mm Hg (P.0001). Overall CFI was 0.35 +/- 0.13 (median 0.33), with CFI values of 0.3 +/- 0.13, 0.33 +/- 0.13, 0.39 +/- 0.1, and 0.57 +/- 0.2 for collateral grades 0 to 3, respectively (P.0001). Larger creatine kinase elevation (P.016) and higher white blood cell count (P.022) were recorded in the lowest tertile CFI compared with highest tertile CFI group; but no difference in the global, regional, or infarct-related regional left ventricular contraction was found.These observations demonstrate that the Rentrop classification is valid in AMI patients with occluded coronary arteries and that collaterals are recruited acutely. These collaterals, whose pressure-derived CFI during AMI was shown for the first time to be higher than its value reported in chronic conditions, may limit the immediate myocardial damage or the systemic inflammatory response. No impact on global or regional cardiac contraction was detected in a population where most patients were treated early.

BACKGROUND: Shortness of breath (SOB) is common among healthy women with normal pregnancies. However, when no overt cardiac or extra cardiac etiology is found, a subtle cardiac source must be excluded. HYPOTHESIS: Pregnancy may induce or unmask myocardial dysfunction that may cause SOB. METHODS: Healthy pregnant women with significant SOB were recruited for this study. We performed a comprehensive echocardiographic assessment including tissue Doppler imaging (TDI) and 2‐ dimensional strain imaging (2DS). The echocardiographic data obtained were compared with that of a control group of pregnant women without SOB. RESULTS: Thirty pregnant women with SOB were enrolled in the study (age, 31.8 ± 4.9 years, and gestation, 38.2 ± 2.8 weeks) for whom no overt etiology for SOB was detected. Patients with SOB compared with controls had thicker hearts (septum: 10.1 ± 1.1 vs 8.9 ± 0.9 mm; P

Stent thrombosis is a clinically significant event occurring days to weeks or, infrequently, months or years after percutaneous coronary intervention (PCI). Current therapeutic approach is immediate PCI aimed to recanalize the occluded artery in order to restore flow and diminish irreversible myocardial damage.We evaluated the coronary patency, TIMI flow and TIMI myocardial perfusion grade (TMPG) in 6 patients presenting with STEMI due to stent thrombosis treated by thrombolysis followed by immediate PCI. These were compared with control patients treated conventionally by primary PCI.Immediate or early coronary angiography in the treatment group showed good coronary flow in 5 of 6 implicated arteries, whereas immediate angiography in the control group demonstrated 8 completely occluded coronary arteries of 9 with stent thrombosis. The pre-intervention TIMI flow in the control study group was 0.2±0.5 (median-0), and TMPG was 0.1±0.3 (median-0) compared with 2.1±1.1 (median-2.3, p0.001) and 1.8±1.0 (median-2, p0.001) in the treatment group, respectively. This striking difference in the rate of coronary patency, pre-procedural TIMI flow and TMPG, however, did not translate into better cardiac function in the treatment group.These findings suggest that thrombolysis-facilitated PCI may confer benefit and need not be considered contraindicated when treating stent thrombosis. This therapeutic approach should be evaluated as a viable therapeutic approach to stent thrombosis.

Objective Clinical follow-up of aortic dimensions is performed interchangeably by multi-detector computed tomography (MDCT) and by cardiac echocardiography (ECHO). This study assesses the relationship between measurements of the aortic diameter by MDCT and ECHO at various predetermined locations using several methods. Methods The aortic diameter was measured at 6 locations between the aortic annulus and the aortic arch in 49 patients who underwent both MDCT and ECHO. Measurements were performed by three methods: internal-to-internal edge (INT), external-to-internal edge (MIX), and external-to-external edge (EXT). Measurements by MDCT and ECHO were made by an experienced radiologist and cardiologist, respectively, both blinded to results and images from the other modality. Results The average aortic diameter at all locations was significantly different between the MDCT and ECHO by all three methods (INT: 30.0 ± 5.8 mm vs. 27.8 ± 5.9 mm; MIX: 31.5 ± 5.8 mm vs. 30.8 ± 5.8 mm; EXT: 32.9 ± 6.6 mm vs. 33.8 ± 6.5 mm, p

One hundred thirty-nine patients who underwent transesophageal echocardiographic studies were grouped by their maximal left atrial (LA) volumes, and their stroke volumes, emptying fractions, and fractional shortening were calculated. In large atria, an inverse relation was found between further increases in LA volume and LA function, determined by emptying fractions and fractional shortening.

Background In advanced heart failure, the compensatory responses to reduced cardiac output, in spite of fluid retention, lead to maladaptive consequences. Methods We performed a Medline survey for fluid overload and heart failure as well as reviewing textbook chapters. Results The increased sympathetic nervous system, renin-angiotensin-aldosterone system, and antidiuretic hormone stimulation and release lead to a vicious cycle--augmenting pre-load, contractility and after-load, as well as increased fluid overload. The elevated work load on an already failed cardio-circulatory system results in further deterioration. Plasma volume is usually increased in untreated patients with increased extracellular fluid. However, it may range from reduced to increased in treated patients. Currently, diuretics remain the initial first line of therapy. In refractory cases, restoring plasma volume and osmolality, by adding albumin or hypertonic saline solutions, neurohormonal antagonists such as vasopressin receptors antagonists, aldosterone antagonists, or administration of nesiritide, may help in overcoming fluid overload. Conclusion Exact measurement of plasma volume in various forms of heart failure and adjusting the treatment accordingly, establishing favourable and detrimental effects of various therapies, and introducing additional and new therapeutic options require further investigation.

Aims: Midazolam is often used for conscious sedation before transesophageal echo (TEE) studies. It is not clear to what extent midazolam administration or the insertion of the TEE probe itself is responsible for the respiratory and hemodynamic depression during TEE examinations. We compared the performance of TEE with versus without midazolam to elucidate the effects of each. Methods: Patients were given the choice of having midazolam prior to their TEE. Thirty-one patients preferred to have sedation (Sed+) and 31 others declined sedation (Sed−). Both groups had SaO2 and blood pressure measured before the study, following sedation (in Sed+) and at the end of the TEE study. Results: Increase in HR was greater in Sed+ than in Sed− (12 ± 19% vs 6 ± 11%, both P < 0.05). There was a greater decrease in saturation of O2 in Sed+ than in Sed− (3 ± 3% vs 2 ± 3%, both P < 0.05). Systolic blood pressure (SBP) increased in Sed− by 6 ± 11% (P< 0.05) but dropped in Sed+ immediately after sedation (16 ± 8%, P < 0.000001). Diastolic blood pressure decreased in Sed+ after sedation by 11 ± 9% (P < 0.05). Conclusions: Midazolam sedation before TEE examinations causes more prominent tachycardia and depression of SaO2than insertion of the TEE probe alone. It also causes a substantial drop in SBP. Midazolam should be offered only to hemodynamically stable patients without preceding respiratory depression. (ECHOCARDIOGRAPHY, Volume 21, April 2004)

This study addresses the impact of availability of on-site catheterization laboratories on the 1-year survival of patients with post-acute myocardial infarction ischemia (P-AMI-I), a high-risk subgroup of AMI patients.A prospective 5 month national survey was conducted in 1996 in all operating intensive care units (ICCUs) in Israel (N=26) and included 2377 patients. Four hundred and three (17%) had P-AMI-I, 317 of them were admitted to 18 ICCUs with on-site catheterization laboratories (CATH+) and 86 patients to 8 ICCUs without such facilities (CATH-). A retrospective analysis was performed comparing the in-hospital course and 7 day, 1 month and 1 year mortality data of CATH+ vs. CATH- patients.Patient characteristics in both groups were similar with regard to age, gender AMI location, risk factors, hemodynamic parameters on admission and rate of thrombolytic therapy. Of patients in CATH+, 79% were catheterized before hospital discharge vs. 42% in CATH- (P0.0001), 45 vs. 15% had PTCA (P0.0001) and 19 vs. 9% had CABG (P0.05). At 30 days, patients in CATH+ still had significantly more revascularization procedures (71 vs. 48%, P0.001). Patients hospitalized in ICCUs with CATH+ and CATH- facilities had similar cardiac mortality rates at 7 days (2.0 vs. 2.3%), 30 days (5.7 vs. 4.7%) and at 1 year (7.6 vs. 7.0%).Despite a more invasive strategy used during the index hospitalization of patients with P-AMI-I hospitalized in CATH+ ICCUs, their survival was similar to CATH- patients at 7 days, 30 days and at 1 year follow-up.

Functional status in chronic heart failure is evaluated in general by subjective means, such as the New York Heart Association class, or by invasive techniques difficult to use routinely. The aim of this study was to evaluate noninvasively the contractile reserve in cases of heart failure as a means to define the functional status of the patients. Cardiac peak power, a new noninvasively obtained afterload-independent index of contractility, was calculated from online Doppler and central arterial blood pressure estimated noninvasively in 35 patients with heart failure and 10 healthy subjects during dobutamine infusion. Cardiac output increased in all patients to the same extent, without differentiation among the functional classes. Contractile reserve, as assessed by peak power, was found to be a good marker of functional class: it was significantly higher in functional class 1 than in functional classes 2 through 4. A correlation of r = 0.99 and probability of p0.001 was found with the functional status. This new, noninvasive contractility index, peak power, allows an objective evaluation of the severity of heart failure.

Collaterals to occluded coronary arteries have been observed early after the onset of acute myocardial infarction (AMI). The pressure distal to the occluded segment of the culprit coronary artery (P(d)) is generated by collateral flow from the feeding coronary artery supplied by the systemic circulation. The aim of the study was to assess the relation between systemic blood pressure (BP) and P(d). Systemic BP and P(d) were measured simultaneously during intervention of totally occluded coronary arteries in 152 patients admitted for AMI. Patients were divided into groups by time from symptom onset to P(d) measurement. There was a significant positive correlation between P(d) and the systolic, diastolic, and mean BPs measured during the first 3 hours from symptom onset (n = 60; p0.05, p0.006, and p0.005, respectively), from 3 to 12 hours (n = 56; p0.02 for all), and12 hours after symptom onset (n = 36; p0.003 for all). The collateral flow, represented by calculated collateral flow index (mean 0.37 ± 0.14, median 0.36), was correlated with mean BP (p = 0.05) but not with diastolic or systolic BP (p = NS) in the overall study population. A direct relation was established during AMI between systemic BP and P(d) at all time intervals from symptom onset. Collateral flow index correlated with mean BP and was strongly associated with P(d) at all time intervals. In conclusion, the relation between P(d) and systemic BP suggests caution when administering therapy that may lower systemic BP during AMI before restoring flow in the occluded culprit artery, as it may compromise collateral pressure and exacerbate myocardial ischemia.

Patients sustaining an ST-segment elevation myocardial infarction (STEMI) frequently develop pulmonary congestion or pulmonary edema (PED). We previously showed that lung impedance (LI) threshold decrease of 12% to 14% from baseline during admission for STEMI marks the onset of the transition zone from interstitial to alveolar edema and predicts evolution to PED with 98% probability. The aim of this study was to prove that pre-emptive LI-guided treatment may prevent PED and improve clinical outcomes. Five hundred sixty patients with STEMI and no signs of heart failure underwent LI monitoring for 84 ± 36 hours. Maximal LI decrease throughout monitoring did not exceed 12% in 347 patients who did not develop PED (group 1). In 213 patients LI reached the threshold level and, although still asymptomatic (Killip class I), these patients were then randomized to conventional (group 2, n = 142) or LI-guided (group 3, n = 71) pre-emptive therapy. In group 3, treatment was initiated at randomization (LI = -13.8 ± 0.6%). In contrast, conventionally treated patients (group 2) were treated only at onset of dyspnea occurring 4.1 ± 3.1 hours after randomization (LI = -25.8 ± 4.3%, p0.001). All patients in group 2 but only 8 patients in group 3 (11%) developed Killip class II to IV PED (p0.001). Unadjusted hospital mortality, length of stay, 1-year readmission rate, 6-year mortality, and new-onset heart failure occurred less in group 3 (p0.001). Multivariate analysis adjusted for age, left ventricular ejection fraction, risk factors, peak creatine kinase, and admission creatinine and hemoglobin levels showed improved clinical outcome in group 3 (p0.001). In conclusion, LI-guided pre-emptive therapy in patients with STEMI decreases the incidence of in-hospital PED and results in better short- and long-term outcomes.

BACKGROUND The effect of collaterals to occluded coronary arteries during ST-elevation myocardial infarction (STEMI) is unclear. The conventional CVP-based formula to calculate collateral flow index during STEMI yields values higher than in elective patients, which prompted derivation of a modified formula, pertinent in STEMI when left ventricular mean diastolic pressure (LVMDP) is the extravascular pressure limiting collateral flow. We aimed to evaluate this new LVMDP-based acute collateral flow index (ACFI). METHODS AND RESULTS The pressure distal to coronary artery occlusion (P(d)) was measured during intervention in 111 consecutive STEMI patients, 67 (61%) of whom underwent primary intervention, followed for 58 months. ACFI (0.18 ± 0.17, median 0.15) correlated with both P(d) and collateral grade (P

Monitoring of lung fluid content (LFC) in order to predict acute heart failure (AHF) during acute myocardial infarction (AMI) is an unmet challenge.To evaluate in AMI patients the ability of proposed radiological score (RS), which is the sum of selected radiological signs of congestion, to reflect correctly LFC, as assessed with repeat physical examinations and lung impedance (LI) measurements.Chest X-rays were taken at baseline, when rales were detected, whenever indicated, and at conclusion of monitoring. RS grading for LFC assessment was: RS = 0-1 for normal X-ray, RS = 2-4 for interstitial congestion, and RS values of 5-6, 7-8 and 9-10 signified mild, moderate and severe alveolar edema, respectively.624 AMI patients without AHF at baseline were monitored (94 ± 42 h). 476 patients (76%) with baseline RS of 0.3 ± 0.5 did not develop AHF. Overt AHF developed in 148 patients (24%) during monitoring; baseline RS (0.6 ± 0.8) reached 5.4 ± 0.7, 7.0 ± 0.8, and 9.8 ± 0.5 at the stages of mild, moderate, and severe alveolar edema, respectively. AHF resolved with treatment. RS decreased to 1.5 ± 1.3 (P0.01) and correlated with physical examination (r = 0.6, P0.01) and LI (r = -0.9, P0.01).RS correlated well with findings on physical examination during AHF and closely correlated with LI.

Patients with recurrent acute myocardial infarction (AMI), who represent ≤35% of hospitalized patients with AMI, are at an increased risk of complications and death. Our study purpose was to compare the treatment and outcome of patients hospitalized with recurrent acute ST-segment elevation myocardial infarction (STEMI) from 1998 to 2006 with those of patients with a first STEMI. We performed 5 biennial nationwide 2-month surveys during 1998 to 2006, collecting data prospectively from all patients hospitalized for AMI or acute coronary syndrome in all 25 coronary care units in Israel. The present cohort included 4,543 patients with STEMI, 3,679 (76%) with first and 864 (24%) with recurrent STEMI. The patients with recurrent STEMI were older (66 ± 13 vs 62 ± 13 years), had greater rates of diabetes, hypertension, and previous angina, had a worse Killip class on admission, and experienced more in-hospital complications. The all-cause hospital crude mortality rate was 8.1% in patients with recurrent STEMI versus 5.5% in those with a first STEMI (adjusted odds ratio 1.71 95% confidence interval 1.19 to 2.44), and the 1-year mortality rate was 18.9% versus 10.9%, respectively (hazard ratio 1.85, 95% confidence interval 1.41 to 2.43). From 1998 to 2006, an insignificant trend toward a 1-year mortality reduction among patients with recurrent STEMI was seen and those with a first STEMI had a significant mortality decrease. In conclusion, patients admitted for recurrent STEMI have worse in-hospital and 1-year outcomes that did not improve during the study period. An improved therapeutic approach is needed for these high-risk patients.

Familial occurrence of idopathic dilatation of the right atrium is extremely rare. This is the first description of a family in which 2 siblings had a syndrome of idiopathic dilatation of the right atrium associated with complete atrio-ventricular block. The family workup did not show other family members to be affected, and the question we raise is whether or not this might be a new syndrome.

Background— Identification and quantification of segmental left ventricular wall motion abnormalities on echocardiograms is of paramount clinical importance but is still performed by a subjective visual method. We constructed an automatic tool for assessment of wall motion based on longitudinal strain. Methods and Results— Echocardiograms of 105 patients (3 apical views) were blindly analyzed by 12 experienced readers. Visual segmental scores (VSS) and peak systolic longitudinal strain were assigned to each of 18 segments per patient. Ranges of peak systolic longitudinal strain that best fit VSS (by receiver operating characteristic analysis) were used to generate automatic segmental scores (ASS). Comparisons of ASS and VSS were performed on 1952 analyzable segments. There was agreement of wall motion scores between both methods in 89.6% of normal, 39.5% of hypokinetic, and 69.4% of akinetic segments. Correlation between methods was r =0.63 ( P Conclusions— Automatic quantification of wall motion on echocardiograms by this tool performs as well as visual analysis by experienced echocardiographers, with a greater reliability and similar agreement to angiographic findings.

Mitral annular calcification is known to be associated with conduction abnormalities, embolic phenomena, endocarditis, mitral regurgitation, and thromboembolic cerebrovascular events in the younger population. The size of our elderly population is growing dramatically with the fastest growth in those aged greater than 85 years. The incidence of mitral annular calcification increases sharply in these “very elderly group of patients.” To determine if mitral annular calcification in the elderly patients has the same implications as in the younger population, electrocardiographic and echocardiography (M-mode, two-dimensional, Doppler) data from 553 octogenarian patients who were referred for a variety of clinical indications were analyzed. Patients with mitral annular calcification were quantified into mild, moderate, and severe, and the association of each was determined with various cardiac abnormalities. Mitral annular calcification was found in 59% of the octogenarian patients. Out of these, mild mitral annular calcification was present in 38%, moderate in 40%, and severe mitral annular calcification in 22% of the patients. Mild mitral annular calcification was not associated with an increased incidence of any cardiac abnormalities. Moderate mitral annular calcification was also not associated with any increased incidence of significant aortic stenosis, conduction abnormalities, and enlarged left ventricular size. However, severe mitral annular calcification was associated with all these findings. Moderate and severe mitral annular calcification were associated with significant mitral regurgitation and left ventricular hypertrophy. Thus, in the majority of elderly patients with mild and moderate mitral annular calcification (78%), its presence merely represents an aging process and an innocent bystander as compared to elderly patients without mitral annular calcification. However, only severe mitral annular calcification is strongly associated with cardiac abnormalities. Therefore, quantification of mitral annular calcification in the elderly is important before associating it with various cardiac abnormalities. (ECHOCARDIOGRAPHY, Volume 8, May 1991)

Patients presenting with ST-elevation myocardial infarction (STEMI), whose symptoms and electrocardiographic changes completely resolve upon admission and before the administration of reperfusion therapy, pose a therapeutic dilemma. The optimal management of this syndrome, termed here as transient STEMI (TSTEMI), has not yet been fully determined. We describe 69 prospectively recorded patients with TSTEMI, of which 63 patients (56.7 +/- 11 years, 48 men) were available for long-term follow-up out of 1244 consecutive patients with acute myocardial infarction (5%). Patients with TSTEMI treated with intravenous isosorbide dinitrate, aspirin, and clopidogrel, and/or with glycoprotein IIb/IIIa inhibitors were compared with a control group of matched patients with STEMI without resolution, who were treated conventionally. The time interval from symptom onset to presentation at the emergency department of patients with TSTEMI was 1.7 +/- 1.3 hours, and to first recording of ST elevations, 1.5 +/- 1.4 hours. Symptoms and electrocardiographic changes fully resolved 1.2 +/- 0.8 hours later, 1 hour after aspirin and nitrate administration. Coronary angiography, performed 36 +/- 39 hours (median, 24 hours) from admission, demonstrated no obstructive lesion or single-vessel obstructive disease in 43 patients (70%). Primary coronary intervention was performed in 48 patients (77%), and 8 patients (13%) were referred to surgery. Left ventricular ejection fraction was within normal limits, and peak creatine kinase was mildly elevated. Patients with TSTEMI had less extensive coronary artery disease (P.038), better thrombolysis in myocardial infarction flow on angiography (P.01), lower peak creatine kinase level (P.001), higher left ventricular ejection fraction (P.0001), and lower likelihood to sustain a second additional coronary event after index admission (P = .024) than patients with STEMI. Transient STEMI was associated with less myocardial damage, less extensive coronary artery disease, higher thrombolysis in myocardial infarction flow grade in culprit artery, and better cardiac function. These data suggest that immediate intense medical therapy with an early invasive approach is an appropriate therapy in patients with TSTEMI.

The adjustment of medications and dosages to the needs of individual patients with heart failure is mostly intuitive, but even when their effect on global myocardial function is measured by classic indexes, their effect on segmental function is overlooked. This study was conducted to assess the feasibility of using echocardiographic myocardial strain imaging to evaluate the effect of medication on global and segmental function in 21 ambulatory patients with heart failure (mean age 65+/-11 years) who had echocardiographic studies performed before and 2 hours after ingesting their regular morning medications. The ejection fraction, global and regional strain, and time to regional peak strain were compared between the 2 examinations. Medication induced no significant changes in mean ejection fraction (28.6+/-7.8% to 27.5+/-9.9%) and mean global strain (-9.5+/-3.6% to -9.8+/-3.2%). Changes in segmental strain depended on baseline function: normal segments (peak strain more negative than -12%) deteriorated (-15.5+/-2.7% to -13.7+/-4.6%, p0.0001), but dysfunctional segments (peak strain less negative than -8%) improved (-5.3+/-2.0% to -7.4+/-4.3%, p0.0001). Medication also improved segmental synchronization: average time to peak strain of segments in which peak strain was attained before aortic valve closure increased (325+/-69 to 375+/-100 ms, p0.0001), but that of segments with postsystolic shortening at baseline decreased (451+/-93 to 435+/-93 ms, p0.006). Thus, the time interval between time to peak strain of segments with systolic and post-systolic shortening at baseline was halved after medication. In conclusion, medications for heart failure induced an increase in the echocardiographically determined peak strain of myocardial segments with impaired function at baseline but decreased the peak strain of normally contracting segments. Medications also improved the synchronization of myocardial contraction. Neither the global ejection fraction nor global strain reflected these changes. Thus, medication tended to improve the homogeneity of left ventricular contraction.