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The correlation between Doppler deceleration time (DT) and brain natriuretic peptide (BNP) and their predictive value for detecting left ventricular (LV) remodeling in patients who are treated with primary percutaneous intervention for infarction and LV dysfunction are unknown. Fifty-six patients (64 +/- 12 years of age; 11 women) who had a first ST-segment elevation myocardial infarction and systolic dysfunction that was successfully treated with direct primary coronary intervention underwent 2-dimensional Doppler echocardiographic and plasma BNP evaluation at days 1 and 3 and 1 and 6 months after the index infarction. Repeat coronary angiograms were obtained at 1 and 6 months. Because of previous consistent evidence, 3 days after the index infarction was the time point of comparison between BNP and DT values. Echocardiographic LV remodeling was defined as an increase in end-diastolic volume index above baseline values of 2 x SD. Ventricular remodeling occurred in 20 patients (36%). Multivariate analyses that included BNP level, Doppler DT, echocardiographic measurements of systolic function, peak creatine kinase, and anterior infarct location showed Doppler DT to be the only predictor of LV remodeling (odds ratio 0.963, 95% confidence interval 0.936 to 0.990, p = 0.008). The optimal cutoff for DT in the prediction of 6-month LV remodeling was <136 ms (sensitivity 75%, specificity 97%, accuracy 81%, area under receiver-operating characteristic curve 0.90). Thus, in patients who have a first ST-segment elevation myocardial infarction and LV systolic dysfunction that is successfully treated with primary percutaneous coronary intervention, Doppler-derived DT 3 days after index infarction is more effective than BNP level in detecting patients who are at higher risk for 6-month LV remodeling. [ABSTRACT FROM AUTHOR]

Background: The relationship among plasma brain natriuretic peptide (BNP), markers of extracellular matrix (ECM) remodeling, and left ventricular (LV) dilation after reperfused acute myocardial infarction is poorly known., Methods and Results: Echocardiogram, plasma BNP, and ECM degradation markers (serum amino-terminal telopeptide of type I procollagen and type III procollagen and carboxy-terminal telopeptide of type I procollagen [ICTP]) were evaluated in 34 patients at days 1, 3, and 30 after first reperfused acute myocardial infarction. At 1 month, infarct size and severity and LV volume were measured by sestamibi gated single photon emission computed tomography. Patients were stratified according to day 3 BNP levels into 2 groups: group 1 (n = 17) had BNP values over the median value, and group 2 (n = 17) had BNP values under the median value. Infarct size and severity were similar in the 2 groups. LV volumes increased in group 1 but decreased in group 2 (P < .01). BNP values, LV volume/mass index, and infarct size were independent predictors of 1-month LV dilation (beta = .58 [P = .001], beta = .41 [P = .01], and beta = .32 [P = .03], respectively). Levels of serum amino-terminal propeptide of type I procollagen and type III procollagen were similar in both groups. The level of ICTP increased significantly in group 1 only, and after 3 days, it was higher (P < .01) than in group 2. In group 1 ICTP significantly interacted with the relationship between BNP release and serial changes in LV volumes (F = 4.87, P = .03)., Conclusions: ICTP is related to elevated BNP level independently of infarct size and severity and interacts with the relationship between BNP and LV dilation. BNP levels could play a role in LV remodeling by favoring ECM degradation.

The aim of the study is to investigate the relation between plasma brain natriuretic peptide (BNP), collagen type I turnover, and left ventricular (LV) remodeling after primary angioplasty. Echo-Doppler, BNP, carboxy-terminal telopeptide of procollagen type I (ICTP), C-terminal propeptide of procollagen type I (PICP), and their ratio PICP/ICTP (as an index of coupling between the synthesis and degradation of collagen type I) were evaluated at days 1 and 3 and months 1 and 6 after primary angioplasty in 56 consecutive patients with a first large acute myocardial infarction (AMI). During the 6 months after AMI, a direct relation was shown between BNP and ICTP (day 1, r = 0.54, p = 0.000; day 3, r = 0.64, p = 0.000; month 1, r = 0.64, p = 0.000; month 6, r = 0.41, p = 0.005) and BNP and PICP/ICTP (day 1, r = -0.54, p = 0.003; day 3, r = -0.58, p = 0.000; month 1, r = -0.50, p = 0.000; month 6, r = -0.30, p = 0.043), but not between BNP and PICP. Using analysis of covariance, relations between BNP and ICTP and PICP/ICTP were independent from infarct size. Patients with LV remodeling had significantly higher plasma ICTP and BNP levels and lower PICP/ICTP than patients without LV remodeling. Day-1 ICTP independently predicted 6-month remodeling (exp beta = 2.14, 95% confidence interval 1,120 to 3,550, p = 0.01). In conclusion, a relation exists between plasma BNP collagen type I turnover and LV remodeling after reperfused AMI.

Objectives: We sought to assess the relative prognostic role of a restrictive left ventricular (LV) filling pattern after a first anterior acute myocardial infarction (AMI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA)., Background: In thrombolized patients, a short Doppler-derived mitral deceleration time (DT) of early filling is a powerful independent predictor of heart failure and death. However, it is still unknown whether the outcome of patients with AMI with a short DT may be improved by a more aggressive treatment., Methods: In 104 patients, two-dimensional and Doppler echocardiograms were obtained three days after the index AMI. Coronary angiography was performed in all patients one and six months after PTCA. The patients were classified into two groups according to the DT duration: group 1 (n = 34) with DT < or = 130 ms and group 2 (n = 70) with DT >130 ms. All patients were followed-up for a mean (+/- SD) period of 32 +/- 10 months., Results: During the follow-up period, 14 patients (13%) were admitted to the hospital for congestive heart failure, and 9 patients (9%) died. All cardiac deaths (n = 7) occurred in group 1. The survival rate at mean follow-up was 79% in group 1 and 97.2% in group 2 (p = 0.003). Multivariate Cox analysis showed that only age and restrictive filling were independent predictors of event-free survival. Furthermore, when survival with no cardiovascular events was analyzed, a short DT still emerged as the most powerful independent predictor., Conclusions: Patients with a restrictive LV filling pattern early after anterior AMI have a poor clinical outcome, even if treated with primary PTCA.

Objectives: This study was designed to prospectively assess the ability of the 12-lead electrocardiogram (ECG) and optimal ECG criteria to predict late functional recovery in patients with acute myocardial infarction (AMI) treated with primary coronary angioplasty (PTCA) BACKGROUND: A simple clinical method to predict clinical outcome in patients with reperfused AMI is highly desirable from a clinical point of view., Methods: Seventy-five patients with AMI treated with successful PTCA (TIMI flow grade 3 and residual stenosis < 30%) underwent serial 12-lead ECG before PTCA and every hour for the first 6 hours and then at 9, 12, and 18 hours after PTCA. All patients underwent two-dimensional echocardiography before PTCA and 1 and 6 months later for the evaluation of regional wall motion. The ST segment level in the lead exhibiting the maximal ST elevation (ST increase max) and the sum of the ST segment elevation (sigma ST increases) were calculated on initial ECG and a cut-off values of > or = 50% reduction of ST increases max sigma ST increases elevation and sampling intervals were correlated with late functional recovery. A wall motion score index (WMSI: 1 = normal to 4 = dyskinesia) and 16-segment model were used. Reversible dysfunction was defined as a decrease of > or = 0.22 in WMSI., Results: At univariate analysis a > or = 50% reduction of both ST increases max and sigma ST increases was related to late functional recovery. Multiple logistic regression analysis revealed that reduction of sigma ST increases was the most powerful predictor of late functional recovery (p = 0.008). A > or = 50% reduction of sigma ST increase within 4 hours of PTCA provided the optimal criterion for predicting late functional recovery., Conclusions: Rapid reduction of sigma ST increases elevation is an accurate predictor of left ventricular functional recovery in patients with AMI treated with primary PTCA. Optimal criteria include a reduction in sigma ST increases elevation > or = 50% within 4 hours of PTCA.

Progressive left ventricular dysfunction in acute myocardial infarction patients is associated with a poor prognosis. It has been shown that some therapeutic measures which have the potential for limiting the infarct size and preserving ventricular function, are also able to reduce the incidence of congestive heart and improve survival. The aim of this protocol was to assess the effects of transdermal nitroglycerin administered within 72 hours after the onset of acute myocardial infarction and for the following 6 months, on left ventricular function. A total of 98 consecutive acute myocardial infarction patients were randomly allocated, within 72 hours of onset of symptoms, to a double-blind 6-month-therapy with either 10 mg/24 hour transdermal nitroglycerin or placebo. Patients underwent two-dimensional echocardiography at entry, after 2 weeks, 3 months and 6 months. In the nitroglycerin group, end-diastolic volume increased during the follow-up (+6.7%, p < 0.05) while end-systolic volume remained nearly unchanged; ejection fraction and stroke volume increased progressively (+6.3%, p < 0.05, +14.2%, p < 0.05, respectively) and a important reduction of percent of dyssynergic segments was present (-19.2%, p < 0.005). In the placebo group end-diastolic volume and end-systolic volume slightly increased during the follow-up (+2% and +4.9% respectively); ejection fraction and stroke volume remained nearly unchanged during the study; percent of dyssynergic segments showed an important decrease after 2 weeks and 6 months (-21.3%, p < 0.005). A clinically relevant increase (> 20%) in ejection fraction was present more frequently in the nitroglycerin than in the placebo group (p < 0.001). In conclusion, the early (within 72 hours) and prolonged (6 months) administration of transdermal nitroglycerin in acute myocardial infarction improves ejection fraction and stroke volume but does not modify ventricular remodeling.

The acute effects on exercise tolerance and electrocardiographic ischaemia of felodipine and diltiazem, alone or in combination, were investigated in 12 patients with documented stable effort-induced angina pectoris. After being withdrawn from their previous antianginal treatments, patients received a single oral dose of felodipine 10 mg, diltiazem 60 mg, their combination or placebo on four different days, according to a double-blind, 4 x 4 latin-square design. Exercise time to ischaemic threshold (ST-segment depression = 1 mm) and to peak exercise was significantly prolonged by the felodipine-diltiazem combination (492 and 504 s, respectively) against placebo (301 and 370 s, both P less than 0.01), felodipine alone (381 and 428 s, both P less than 0.01) and diltiazem alone (367 and 422 s, both P less than 0.01). The effects on total work followed a similar pattern. In comparison with placebo, the administration of felodipine and diltiazem alone significantly increased exercise duration as well as total work to ischaemic threshold and to peak exercise, with no differences between the two drugs. Systolic blood pressure during exercise was not affected by any of the treatments. However, in comparison with both placebo and diltiazem, the combination induced an increase (P less than 0.01) in heart rate during exercise. One patient suffered from symptomatic hypotension with the combination, and another had sinus tachycardia after felodipine. In conclusion, the acute concomitant administration of felodipine and diltiazem in patients with stable effort angina induces a marked improvement in exercise tolerance in comparison with placebo, felodipine alone and diltiazem alone. However, the benefit/risk profile of such a combination requires further, long-term investigation.

A study was undertaken in order to compare the effects of Diltiazem, Nifedipine and Verapamil on 11 male adults (aged 44 to 70 yrs: mean age 60 yrs) affected by effort angina with a stable exercise threshold. The study was carried out according to a 4 week double-blind randomized protocol. Diltiazem (300 mg/die), Nifedipine (50 mg/die), Verapamil (400 mg/die) and placebo were administered each for 7 day periods. An ergometric test was performed on the last of each therapeutic cycle in order to evaluate the effects of the treatments. The three active drugs globally provoked an increased tolerance to physical effort with respect to placebo (p less than 0.01); no significant differences, as regards physical performance, could be detected among the three drugs. Treatment with Nifedipine significantly increased heart rate at rest (p less than 0.05), under submaximal (p less than 0.05) and maximal load (p less than 0.05), with respect to treatment with Diltiazem and Verapamil. Systolic and diastolic arterial blood pressure did not vary significantly with any of the three drugs. Rate pressure product under submaximal load (p less than 0.05) and at the end of the exercise (p less than 0.05) was higher with Nifedipine than with the other two drugs. These results show that patient response to Nifedipine is different from that to Verapamil and Diltiazem and suggest that the three drugs exert their anti ischemic effect through different mechanisms. The evaluation of individual response revealed that only one patient showed no increased tolerance to physical effort with any of the drugs.(ABSTRACT TRUNCATED AT 250 WORDS)