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In this work, a functional supervised learning scheme is proposed for the classification of subjects into normotensive and hypertensive groups, using solely the 24-hour blood pressure data, relying on the concepts of Fréchet mean and Fréchet variance for appropriate deformable functional models for the blood pressure data. The schemes are trained on real clinical data, and their performance was assessed and found to be very satisfactory., (Copyright © 2017 John Wiley & Sons, Ltd.)

Bone metabolism has not been systematically studied in primary (AL) amyloidosis. Thus we prospectively evaluated bone remodeling indices in 102 patients with newly diagnosed AL amyloidosis, 35 healthy controls, 35 newly diagnosed myeloma and 40 monoclonal gammopathy of undetermined significance patients. Bone resorption markers (C-telopeptide of type-1 collagen, N-telopeptide of type-1 collagen) and osteoclast regulators (soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteoprotegerin (OPG)) were increased in AL patients compared with controls (P<0.01), but bone formation was unaffected. Myeloma patients had increased bone resorption and decreased bone formation compared with AL patients, while sRANKL/OPG ratio was markedly decreased in AL, due to elevated OPG in AL (P<0.001). OPG correlated with N-terminal pro-brain natriuretic peptide (P<0.001) and was higher in patients with cardiac involvement (P=0.028) and advanced Mayo stage (P=0.001). OPG levels above the upper value of healthy controls was associated with shorter survival (34 versus 91 months; P=0.026), while AL patients with OPG levels in the top quartile had very short survival (12 versus 58 months; P=0.024). In Mayo stage 1 disease, OPG identified patients with poor survival (12 versus >60 months; P=0.012). We conclude that increased OPG in AL is not only a compensation to osteoclast activation but may also reflect early cardiac damage and may identify patients at increased risk of death within those with earlier Mayo stage.

Bortezomib and lenalidomide are increasingly used in patients with AL amyloidosis, but long term data on their use as primary therapy in AL amyloidosis are lacking while early mortality remains significant. Thus, we analyzed the long term outcomes of 85 consecutive unselected patients, which received primary therapy with bortezomib or lenalidomide and we prospectively evaluated a risk adapted strategy based on bortezomib/dexamethasone to reduce early mortality. Twenty-six patients received full-dose bortezomib/dexamethasone, 36 patients lenalidomide with oral cyclophosphamide and low-dose dexamethasone and 23 patients received bortezomib/dexamethasone at a dose and schedule adjusted to the risk of early death. On intent to treat, 67% of patients achieved a hematologic response (24% hemCRs) and 34% an organ response; both were more frequent with bortezomib. An early death occurred in 20%: in 36% of those treated with full-dose bortezomib/dexamethasone, in 22% of lenalidomide-treated patients but only in 4.5% of patients treated with risk-adapted bortezomib/dexamethasone. Activity of full vs. adjusted dose bortezomib/dexamethasone was similar; twice weekly vs. weekly administration of bortezomib also had similar activity. After a median follow up of 57 months, median survival is 47 months and is similar for patients treated with bortezomib vs. lenalidomide-based regimens. However, risk adjusted-bortezomib/dexamethasone was associated with improved 1-year survival vs. full-dose bortezomib/dexamethasone or lenalidomide-based therapy (81% vs. 56% vs. 53%, respectively). In conclusion, risk-adapted bortezomib/dexamethasone may reduce early mortality and preserve activity while long term follow up indicates that remissions obtained with lenalidomide or bortezomib may be durable, even without consolidation with alkylators., (© 2015 Wiley Periodicals, Inc.)

Background: Left ventricular (LV) remodeling after acute myocardial infarction (AMI) is related to increased morbidity and mortality. The aim of the present study was to examine whether LV deformational and torsional parameters can predict LV remodeling in patients with AMI., Methods: Forty-two patients (age 57 ± 14 years) presenting with an anterior ST-elevation AMI and treated with primary percutaneous transluminal coronary angioplasty (PTCA) were included in the study. Four days post MI, LV ejection fraction (EF), LV torsion, longitudinal (4-, 3- & 2-chamber) and circumferential strain of the LV apex were evaluated by conventional and speckle-tracking echocardiography. The echocardiographic study was repeated at 3 months post-AMI and patients with LV remodeling, i.e. an increase >15% in LV end-systolic volume (LVESV), were identified., Results: The 13 patients with LV remodeling had significantly more impaired apical circumferential strain (-7.3 ± 2.2% vs. -18.9 ± 5.2%, p=0.001), EF (42 ± 7% vs. 48.9 ± 6%, p=0.005), LV apical rotation (6.8 ± 4.8° vs. 11.1 ± 4.0°, p=0.027), and LV global longitudinal strain (-9.7 ± 1.9% vs. -12.9 ± 2.9%, p=0.03) on the 4th day post-AMI, in comparison to those without LV remodeling. Apical circumferential strain on the 4th day post-AMI showed the strongest correlation with the LVESV 3 months post-AMI (r=0.76, p=0.001), compared to EF (r=-0.60, p=0.001), global longitudinal strain (r=0.56, p=0.001), and LV apical rotation (r=-0.53, p=0.001). Furthermore, apical circumferential strain demonstrated the highest diagnostic accuracy: area under the receiver operating characteristic (ROC) curve 0.98, with sensitivity 100% and specificity 96% for prediction of LV remodeling, using a cutoff value <-11.0%., Conclusion: In patients with anterior AMI, LV apical circumferential strain in the early post-MI period constitutes a significant prognostic factor for LV remodeling at 3 months. Assessment of this parameter may identify patients at high risk for heart failure development.

Objectives: Both brain edema and increased blood pressure (BP) variability are associated with poor outcome after stroke. The aim of the present study was to evaluate a possible association between edema formation and a relatively new index of BP variability defined as time rate (TR) of BP variation., Patients and Methods: A total of 128 first-ever acute stroke patients underwent 24-h ambulatory BP monitoring within 24 h from onset of stroke. All patients were imaged with computed tomography scan on admission and after 5 days to determine the presence of brain edema. The TR of BP variation was defined as the first derivative of the BP values against time. Known risk factors and neurological severity on admission were documented., Results: The 24-h TR of systolic BP variation was significantly higher (P<0.001) in stroke patients with brain edema (0.69±0.15 mmHg/min) compared with those without edema (0.57±0.12 mmHg/min). The multivariate logistic regression model showed that a 0.1 mmHg/min increase in the TR of 24-h systolic BP variation was associated with a 13.9% increased probability of the presence of brain edema (odds ratio=1.139, 95% confidence interval: 1.058-1.225, P<0.001), after adjusting for history of diabetes mellitus, hypercholesterolemia, type of stroke, neurological deficit, and 24-h systolic BP., Conclusion: Increased values of 24-h TR of systolic BP variation are associated independently with formation of edema in acute stroke patients.

Introduction: The aim of this study was to determine whether left ventricular (LV) apical rotation assessed by speckle tracking echocardiography (STE) can predict global LV systolic dysfunction after acute anterior myocardial infarction (AMI)., Methods: STE analysis was applied to LV short-axis images at the basal and apical levels in 21 open-chest pigs, before and after left anterior descending coronary artery ligation. LV radial and circumferential strain and strain rate, apical and basal rotation, and LV torsion were recorded., Results: LV apical rotation (3.68 ± 1.73° pre-AMI vs. 2.19 ± 1.64° post-AMI, p<0.009), peak systolic rotation rate, and radial and circumferential strain as well as strain rate decreased significantly 30 min postAMI. The LV global torsion decreased significantly. Strain and rotational changes of the LV apex were primarily correlated with ejection fraction (EF), but those of the LV base were not. EF had a significant correlation with the global LV twist (r=0.31, p<0.05). On multivariate linear regression analysis, fractional shortening of the long-axis (FSL) (b=0.58, p<0.001), rotation of the LV apex (b=0.32, p<0.006) and LV dp/dtmax (b=0.26, p<0.02) were independently related with EF. On analysis, of the receiver operating characteristic curve, the area under the curve for apical rotation was 0.765, p<0.006; the best cutoff value of 2.92° had sensitivity 80% and specificity 71% in predicting EF<40%., Conclusion: Apical rotation assessed by STE is a potential noninvasive early indicator of global LV systolic dysfunction in AMI and has a satisfactory association with LVEF. Its assessment could be valuable in clinical and research cardiology.

Acute myocardial infarction (AMI) causes left ventricular (LV) remodeling, which forms the substrate for its early and late complications. The purpose of this study was to compare the acute effect of dobutamine or intra-aortic balloon pumping (IABP), alone or in combination, on LV function in the early phase of an experimental AMI. In 18 pigs, AMI was induced by ligation of the left anterior descending artery (LAD). IABP or dobutamine infusion at a rate of 5 µg/kg/min, or a combination of the two, was applied immediately after ligation of the LAD. Echocardiographic measurements of the long and short LV axes were obtained before (baseline) and post LAD ligation and at the end of each intervention for 5, 15, and 30 min. The fractional shortening (FS) of both axes, as well as the ejection fraction (EF), was calculated. The combination of dobutamine with IABP increased the EF significantly after the AMI in comparison to dobutamine or IABP alone, and improved the stroke volume, cardiac output, and long axis FS in comparison to IABP alone. Dobutamine alone produced a significantly higher increase of EF in comparison to IABP alone. These results indicate that the combination of dobutamine with IABP may be useful during AMI., (© 2011, Copyright the Authors. Artificial Organs © 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Objective: This study investigated whether changes in thyroid hormone (TH) in plasma are associated with the recovery of cardiac function in patients with acute myocardial infarction (AMI). Previous experimental studies have provided evidence of potential implication of TH signaling in post-ischemic recovery of cardiac function., Methods: A total of 47 patients with AMI and early reperfusion therapy were included in this study. Myocardial injury was analyzed by peak creatinine kinase-MB (CKMB) and cardiac function was assessed by echocardiographic left ventricular ejection fraction (LVEF%). Recovery of function (ΔEF%) was estimated as the difference of LVEF% between 48  h and 6 months (6  mo) after AMI. Total triiodothyronine (T(3)), thyroxine (T(4)), and TSH were measured in plasma at different time points (24  h, 48  h, 5  d, and 6  mo)., Results: A significant correlation between LVEF% and T(3) (r=0.5, P=0.0004) was found early after AMI (48  h), whereas no correlation was observed between CKMB and T(3) (r=-0.04, P=0.81). A strong correlation was found between ΔEF% and total T(3) (r=0.64, P=10(-6)) at 6  mo after AMI. Furthermore, multivariate regression analysis revealed that T(3) at 6  mo (r=0.64, r(2)=0.41, P=10(-6)) was an independent determinant of ΔEF%., Conclusion: Changes in T(3) levels in plasma are closely correlated with the early and late recovery of cardiac function after AMI. T(3) levels at 6  mo appear to be an independent predictor of late functional recovery.

It has been suggested that control of GH and IGF excess can arrest the progression of cardiovascular abnormalities and normalize cardiac performance. The aim of the present study was to investigate the reversibility of acromegalic cardiomyopathy in patients with active and inactive disease and to evaluate the effect of the inactivity of the disease on left ventricular (LV) diastolic dysfunction, irrespective of the applied treatment. The patient population consisted of 55 patients who were studied in the active and/or inactive phase. A complete M-mode, two-dimensional and color-flow Doppler echocardiographic examination was performed. LV mass index and posterior wall index were significantly lower in patients with inactive acromegaly compared to those with active disease (P < 0.03 respectively). Diastolic dysfunction was improved in patients with inactive compared to those with active disease (E/A ratio P < 0.009). IGF was positively correlated with LV mass index (r = 0.28, P < 0.02). Multivariate linear regression analysis showed that in active patients the E/A ratio was independently related to age (β = -0.674, P < 0.001) and GH (β = 0.282, P < 0.03), whereas in inactive patients none of the parameters were related significantly with the E/A ratio. In a subgroup of 15 patients who were studied in both the active and inactive phase of the disease, the reduction in GH levels was correlated positively with the reduction in LV mass index (r = 0.89, P < 0.0001) and negatively with the improvement in E/A ratio (r = -0.74, P < 0.001). In conclusion, the results of the present study indicate an improvement of left ventricular diastolic function and a significant improvement of cardiac hypertrophy in patients with inactive acromegaly and normal systolic cardiac function compared to those with active disease.

Objective: The early appearance of ventricular fibrillation (VF) following acute myocardial infarction (MI) is associated with adrenergic effects and electrical interactions although some early "mechanical" changes may also occur. The aim of the present experimental study was to examine whether early changes in the functional geometry of left ventricular (LV) contraction may be associated with ventricular arrhythmias occurring during the first 120min of MI., Methods: In 11 swine left anterior descending (LAD) coronary artery ligation was performed. Aortic flow, LV end-diastolic pressure (LVEDP), LV long and short axis lengths were measured and their fractional shortening (FS) was calculated before and during the initial 120min period of MI., Results: LV long axis FS and aortic flow decreased (p<0.001) whereas LVEDP increased (p<0.01) in all 11 animals within 30min following LAD ligation. LV long and short axis lengths and LV short axis FS did not change significantly. VF occurred in 5 of the 11 animals within this 30min period. LV short axis FS decreased (p<0.05) in all 5 animals prior to VF and increased (p<0.05) in all 6 animals without VF. In 3 of the 6 animals that had no VF during the initial 30min VF occurred later. Similarly, LV short axis FS decreased prior to VF in all those 3 animals. LV short axis FS did not decrease in any of the remaining 3 swine without VF during the same period of time., Conclusion: Early changes in the functional geometry of LV contraction, in the form of a reduction of LV short axis FS, are associated with a greater incidence of VF in experimental acute MI., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: The aim of this study was to examine the effects on left ventricular (LV) function of LV apical or/and lateral wall pacing during an experimental acute myocardial infarction., Methods: In 12 anesthetized pigs, epicardial LV pacing at the apex or lateral wall, or at both sites simultaneously, was performed before and after left anterior descending (LAD) ligation. Data concerning LV function were obtained by two-dimensional echo during spontaneous sinus rhythm (SR) and during pacing before and 15, 45, 60, and 90 minutes after LAD ligation., Results: Before ligation of the LAD, pacing at the lateral wall (48.04 ± 6.25%) or both sites (45.71 ± 6.31%) reduced the LV ejection fraction (EF) significantly (P < 0.01) in comparison to SR (55.44 ± 4.10%). However, during pacing at the apex (50.19 ± 6.50%), the reduction was not significant. After LAD ligation, the EF during lateral pacing (43.02 ± 7.71%) was significantly higher than during apical pacing (38.78 ± 8.26%, P < 0.04) but was not significantly different from that during dual-site pacing (41.65 ± 8.69%)., Conclusions: Pacing within the ischemic LV apical zone after LAD ligation impairs left ventricular ejection fraction, as compared with pacing the nonischemic LV lateral wall, and should therefore be avoided in clinical settings where the LV pacing site may be chosen., (©2010, The Authors. Journal compilation ©2010 Wiley Periodicals, Inc.)

Background: Patients on long-term maintenance hemodialysis (HD) are at high risk of developing cardiovascular disease and suffering various cardiovascular complications during HD., Hypothesis: The purpose of this study was to evaluate the influence of changing loading conditions on the myocardial performance index (MPI) in patients on long-term HD and to specify an optimal level of fluid loss during HD that would maintain stable global cardiac function., Methods: The study consisted of 52 patients with end-stage renal failure (ESRF), mean age 56±11.7 y, range: 25-80 y, on regular HD. For each patient a complete echocardiographic-Doppler examination was performed before and after HD. Systolic and diastolic parameters of left ventricular function were measured, and the myocardial performance index (MPI) was calculated., Results: The MPI was significantly prolonged after HD (0.47±0.15 before HD versus 0.59±0.16 after HD, p < 0.001). Mean change in body weight during HD was 2.1±0.86 kg. The MPI did not change significantly in patients with intradialytic weight loss up to 1.75 kg., Conclusions: The MPI value seems to be independent of acute preload changes only when fluid loss is less than 1.75 kg. A 1.75-kg fluid loss during HD seems to be the optimal goal. In ESRF patients on HD, the MPI seems to be a good indicator of global left ventricular function and potentially a valuable aid in the effort to maintain optimal fluid balance., (Copyright © 2010 Wiley Periodicals, Inc.)

Introduction: Transesophageal atrial pacing stress echocardiography (TEAPSE) has been proposed as an alternative stress echo test in selected patients with known or suspected coronary artery disease. The purpose of this study was to determine: (1) whether TEAPSE could serve as a suitable provocative stress test in patients with stroke and (2) to investigate whether the pseudohypertrophy during TEAPSE that has been observed in experimental studies is also seen in the clinical setting., Methods: TEAPSE at increasing heart rates was performed in 29 patients with stroke. The end-diastolic and end-systolic left ventricular (LV) wall/cavity circumferential area was traced and the ratio was calculated at each pacing stage, as well as the percent systolic thickening., Results: A progressive increase in LV wall thickness was noted at high TEAPSE rates (from 1.31 +/- 0.21 mm at baseline to 1.47 +/- 0.27 mm at +50 beats/min of TEAPSE, p<0.05). The ratio wall/cavity area increased significantly at end diastole (from 1.65 +/- 0.36 at baseline to 2.12 +/- 0.49 at +50 beats/min, p<0.05). Percent systolic thickening was inversely correlated with the increase in wall thickness (r=-0.30, p<0.004) and the ratio wall/cavity area in diastole (r=-0.41, p<0.001). Feasibility of TEAPSE was 52% (15 of the 29 patients)., Conclusions: The occurrence of pseudohypertrophy during TEAPSE in conjunction with the low feasibility rate makes the performance and the interpretation of the test problematic. Therefore, other modalities of stress echocardiography should be considered for routine clinical use and TEAPSE could be applied in specific circumstances when other modalities are either contraindicated or unavailable.

Introduction: The contribution of the collateral network to myocardial oxygenation under normal circumstances is not clear. However, it is possible that in diseased myocardium this network may be activated and contributes significantly to cardiac blood supply. The purpose of this study was to examine the coronary sinus flow after acute, synchronous, complete occlusion of all epicardial coronary arteries and to investigate methods to increase the flow in the setting of ischaemia., Methods: In 8 pigs, the coronary sinus flow was measured after complete ligation of all coronary arteries. In two of the 8 experiments adrenaline and dobutamine were infused into the left ventricular cavity, while clamping of the ascending aorta was performed in another three animals in an effort to increase left ventricular systolic pressure., Results: The mean coronary sinus flow decreased from 36.06 +/- 11.01 ml/min to 5.61 +/- 6.96 ml/min (p < 0.001) after ligation of the coronary arteries. A 67% mean reduction of coronary sinus flow at the first minute after ligation was observed and a progressive decrease of coronary sinus outflow to almost zero within 60 minutes was seen in some experiments. Neither infusion of adrenaline and dobutamine nor ascending aorta clamping increased the coronary sinus flow., Conclusions: The preservation of coronary sinus flow after the complete occlusion of all coronary arteries indicates that retrograde flow through the collateral network from cardiac chambers may exist. Methods that increase the blood flow through the collateral network may contribute to the improvement of myocardial perfusion in severe coronary insufficiency.

Pulse pressure has been recognized as a marker of cardiovascular disease in normotensives. Moreover, internal carotid artery intima-media thickness (IMT) has been proposed to reflect coronary artery lesions. The aim of the present study was to evaluate the predictive value of other parameters derived from ambulatory blood pressure monitoring (ABPM), myocardial ultrasound, and carotid ultrasound to predict the location and the severity of coronary artery disease in normotensives. One hundred and thirteen patients with suspected coronary artery disease underwent coronary angiography, 24-h ABPM and myocardial/carotid ultrasound. Multivariate analysis was applied and equations were extrapolated based on independent variables derived from ABPM and ultrasound. The Gensini score was independently correlated with male gender, pulse pressure, average heart rate for both 24-h (p=0.001) and night (p=0.006) values, as well as percentage of high systolic blood pressure (BP), average diastolic BP, average mean BP, and heart rate concerning daily mesurements (p=0.001). Moreover, the Gensini score was independently correlated with end-systolic volume, posterior wall thickness during systole and intraventricular septum thickness during diastole, along with male gender and age (p=0.001), as well as mean internal and right common carotid artery IMT (p=0.002). Similar mathematical formulas have been calculated separately for the coronary arteries and their main branches. In conclusion, the location and the severity of coronary disease can be effectively evaluated by ABPM and myocardial/carotid ultrasound in normotensives. This approach could be useful for determining atypical patients at risk and/or for treating patients with suspected coronary disease who refuse coronary angiography.

Introduction: Acute myocardial infarction causes left ventricular (LV) remodelling, which forms the substrate for its early and late complications. The aim of this experimental study was to evaluate the acute changes in LV functional geometry after acute myocardial infarction using echocardiography and to investigate the effect of continuous intravenous dobutamine administration on those changes., Methods: In 22 pigs acute myocardial infarction was induced by ligation of the anterior descending branch of the left coronary artery. In 11 animals dobutamine was administered at a rate of 5 microg/kg/min (Group B), while the remainder (Group A) served as controls. Before infarction and 5, 15, 45 and 75 minutes after, the fractional shortening of the long (FSL) and short (FSS) axes of the LV were measured echocardiographically and the ejection fraction (EF) was calculated., Results: In Group A FSL and EF reduced significantly after infarction (p < 0.0001), while FSS increased significantly (p < 0.05). In Group B FSL and EF reduced significantly 5 minutes after infarction and then returned progressively to normal values after 15 min (EF) and 45 min (FSL). FSS did not change significantly during 75 minutes after infarction., Conclusions: Dobutamine, administered at a rate of 5 microg/kg/min during acute experimental anterior myocardial infarction, before the appearance of early complications, may prevent the acute, unfavourable remodelling of the LV, as manifested by a decrease in FSL and EF and a compensatory increase in FSS.

Objective: The aim of the present study was to evaluate 24 hours blood pressure (BP) and heart rate changes as well as 24-hour circadian BP rhythm of cardiac transplant recipients., Methods: Twenty-five transplant recipients and twenty-five healthy volunteers underwent 24-hour ambulatory BP monitoring. Parameters of 24-hour ambulatory BP monitoring (24-h/daytime/nightime systolic, diastolic BP, pulse pressure, and heart rate) were determined in all patients., Results: Clinic systolic/diastolic BP, mean 24-h systolic/diastolic BP, mean daytime systolic/diastolic BP, mean nighttime systolic/diastolic BP, and mean 24-h/daytime/nighttime heart rate were significantly higher in transplant recipients than in control group subjects. Standard deviations of 24-h/daytime/nighttime heart rates were significantly lower in transplant recipients. Dippers were 48% of the control and only 12% of the transplantation group., Conclusions: Cardiac transplant recipients had increased ambulatory BP. They also had increased 24-h/daytime/nighttime heart rate and decreased heart rate variability. Also, diminished nocturnal decrease of BP was found in transplant recipients.

The purpose of the present study was to examine whether intima-media thickness (IMT) predicts the presence of the coronary artery lesions independent of other risk factors including clinic blood pressure (BP), parameters of 24-h ambulatory BP monitoring, body mass index, serum cholesterol, and glucose levels. The study population consisted of 390 consecutive subjects who had recently undergone coronary arteriography; 51 subjects with no measurable lesions in their coronary arteries (control group) and 339 subjects with coronary artery lesions (coronary artery disease [CAD] group). Mean IMT of the common carotid artery (MCCA) and internal carotid artery (MICA) were significantly higher in subjects with CAD compare control subjects (P < .0001). Carotid IMT could predict the presence of coronary artery lesions independently of clinic or ambulatory BP values, BMI, serum cholesterol, and glucose levels (P < .01). Carotid IMT predicted the presence of significant coronary artery lesions with cutoff values 0.85 and 0.80 for MICA and MCCA, respectively. The IMT could be a clinical useful test for the presence of significant coronary artery lesions.

Background: Early diagnosis of heart transplant rejection is mandatory, since even mild rejection can rapidly progress to more severe rejection. Noninvasive diagnosis of heart transplant rejection still remains a challenge., Hypothesis: The purpose of the study was to determine a possible association between myocardial performance index (MPI) and biopsy score of the heart transplant., Methods: This is a retrospective cohort analysis of 99 complete Doppler echocardiographic studies from 24 consecutive patients (23 men) performed within 24 h of endomyocardial biopsy. Mean age of the cohort was 50 +/- 9 years and mean time from transplantation was 19 +/- 21 months (1-81). All patients were in sinus rhythm. Myocardial performance index was calculated as the ratio of isovolumic contraction time plus isovolumic relaxation time divided by ejection time. Left ventricular dimensions, left ventricular mass, ejection fraction, and a number of Doppler indices (E-point velocity, A-point velocity, deceleration time, and deceleration slope) were also measured. The International Society for Heart and Lung Transplantation (ISHLT) grading system was used for the classification of endomyocardial biopsies., Results: Myocardial performance index was significantly prolonged (0.60 +/- 0.13, 0.68 +/- 0.08, 0.75 +/- 0.20, in biopsy scores 0, IA, and IB, respectively; p<0.001). Isovolumic contraction time was significantly prolonged; isovolumic relaxation time was not significantly changed. Ejection time and deceleration time were significantly shortened. Multivariate stepwise regression analysis revealed that MPI and deceleration time were the only independent predictors of biopsy score (r=0.48, F=10.53, p<0.0001)., Conclusion: Myocardial performance index seems to be a useful adjunct in the follow-up of cardiac transplant patients. These preliminary data suggest that a larger study may be indicated to clarify the relevance of myocardial performance index.

Background: Impaired left ventricular diastolic function is a common finding in essential hypertension., Methods: In order to investigate possible relationships between flow velocity through the mitral valve (E/A; index of left ventricular diastolic function) and 24-hour blood pressure and heart rate variations, 198 patients with mild to moderate essential hypertension were studied by Doppler echocardiography and ambulatory blood pressure monitoring. They were divided according to age into group 1 (n = 88, age 40-54 years) and group 2 (n = 110, age 55-79 years). Each group was divided into subgroups with (1a, 2a) or without (1b, 2b) left ventricular hypertrophy according to the end-diastolic posterior wall thickness and/or the interventricular septum thickness., Results: In a multivariate stepwise regression analysis, age (beta = -0.25, p < 0.0001), posterior wall thickness (beta = -0.31, p < 0.0057) and mean heart rate during the day (beta = -0.34, p < 0.0284) were the independent predictors of E/A in the pooled population. In group 1a (young subjects with left ventricular hypertrophy), mean systolic blood pressure during the night (beta = -0.33, p < 0.041) was the only independent predictor of E/A. In the elderly group without left ventricular hypertrophy (group 2b), the mean heart rate during the day (beta = -0.44, p < 0.0000) and mean pulse pressure during the night (beta = -0.60, p < 0.0007) were the independent predictors of E/A., Conclusions: The new finding provided by this study is that in elderly hypertensive patients without left ventricular hypertrophy, a large pulse pressure at night may serve as an independent predictor of abnormal left ventricular diastolic filling., (Copyright 2004 S. Karger AG, Basel)

Objectives: The difference between clinic and daytime ambulatory blood pressure is referred to as the white-coat effect. In this study, we investigated (i) the magnitude of the white-coat effect in subjects with different daytime ambulatory blood pressure levels, and (ii) the association of the white-coat effect with left ventricular mass., Methods: A total of 1581 subjects underwent clinic blood pressure readings, 24-h ambulatory blood pressure monitoring and left ventricular echocardiographic assessment. Their mean daytime systolic blood pressure varied from 88.0 to 208.9 mmHg and their mean daytime diastolic blood pressure from 40.3 to 133.0 mmHg., Results: A negative correlation was found between the systolic or diastolic white-coat effect and the systolic or diastolic daytime ambulatory blood pressure (r = -0.22, P < 0.000 and r = -0.50, P < 0.000, respectively). Left ventricular mass significantly correlated with ambulatory blood pressure (P < 0.001), but there was no association between left ventricular mass and clinic blood pressure or white-coat effect. Furthermore, the white-coat effect was reversed at the highest level of systolic or diastolic daytime ambulatory blood pressure (systolic over 170 mmHg or diastolic over 100 mmHg) when systolic or diastolic daytime ambulatory blood pressure was higher than systolic or diastolic clinic blood pressure (ambulatory blood pressure hypertension)., Conclusions: The white-coat effect shows an inverse association with daytime ambulatory blood pressure level (systolic or diastolic), being significantly more prominent for levels below 140/80 mmHg for systolic/diastolic daytime ambulatory blood pressure and reversed with daytime ambulatory blood pressure levels above 170/100 mmHg.

The purpose of the present study was to evaluate the relation of the systemic arterial pulse pressure and other parameters derived from the 24-h arterial blood pressure (BP) monitoring to the severity of coronary artery disease, carotid lesions, and left ventricular (LV) mass index in patients without arterial hypertension. One hundred ten patients with known coronary artery disease underwent coronary arteriography, 24-h arterial BP monitoring, and ultrasound imaging of the carotid arteries and the myocardium. Measurements of 24-h arterial BP monitoring (systolic, diastolic, and average BP, pulse pressure, abnormal values of systolic and diastolic BP, and heart rate), the severity of coronary heart disease (Gensini score), intima-media thickness (IMT) of the common carotid artery and LV mass index were determined in all patients. By univariate analysis, only 24-h pulse pressure was significantly related to the severity of coronary artery disease (P < .01), carotid IMT(P < .01), and LV mass index (P < .01). In a multivariate analysis, 24-h pulse pressure was also the best predictor of the severity of coronary lesions (P = .009), carotid IMT (P = .003), and LV mass index (P = .009). Gensini score was related (P < .01) to LV mass index and not to carotid IMT. In conclusion, systemic arterial pulse pressure derived from 24-h arterial BP monitoring is related to coronary artery disease, carotid IMT, and LV mass index independently of age or any other derivative of 24-h arterial BP monitoring, indicating that this parameter could be a marker of global cardiovascular risk.

This study examined the prognostic value and the evolution of the heart-to-lung ratio of monoclonal antimyosin antibody (MAA) uptake in patients with a diagnosis of idiopathic dilated cardiomyopathy (IDC). Uptake of indium-111-labeled MAA occurs when the myocytes become irreversibly damaged. The study included 29 men with IDC followed up for 3 years. The diagnosis was verified by endomyocardial biopsy in all patients. Patients who survived beyond 1 year were restudied. Baseline heart-to-lung ratio of MAA was 1.74+/-0.22. Multivariate Cox regression analysis revealed that MAA and New York Heart Association class were independent predictors of late mortality, with a hazard ratio of 4.4 (95% confidence interval 1.1 to 17.9, p = 0.036) and 7.5 (95% confidence interval 2.0 to 28.4, p = 0.003), respectively, when heart-to-lung ratio of MAA uptake was > 1.74 and New York Heart Association class was >11. When these patients were divided into those with chronic IDC (group I [n = 19]) and those with subacute IDC (group II [n = 10]), baseline heart-to-lung ratio was 1.7+/-0.2 and 1.86+/-0.25, respectively (p = NS). In the surviving patients, on restudy, the heart-to-lung ratio of MAA uptake was unchanged in group I (1.64+/-0.20, p = NS), but had decreased to the level of group I (1.66+/-0.21 [p = 0.008]) in group II. Thus, men with IDC and a high heart-to-lung ratio of MAA uptake have a worse long-term prognosis than patients with a lower ratio. The heart-to-lung ratio of MAA decreases comparably over time in subacute IDC and remains stable in chronic IDC.

Objective: A new derivative of 24 h ambulatory blood pressure monitoring (ABPM) is introduced and its association with left ventricular mass index (LVMI) in essential hypertension is examined., Patient: population One hundred and fifty-three previously untreated essential hypertension patients., Methods: Patients underwent casual blood pressure (BP) readings, 24 h ABPM and left ventricular echocardiographic assessment The following 24 h awake and sleep ABP variables were calculated: mean systolic and diastolic BP, systolic and diastolic BP loads (percentage of systolic readings > 140/120 mmHg (day/ night) and diastolic readings > 90/80 mmHg (day/night)), standard deviation of systolic and diastolic ABP and nocturnal fall of systolic BP, as well as the integrated areas under the ABP curve. The area under the BP curve divided in horizontal slices was accurately modelled by a sigmoid curve. The parameters controlling the shape of the curve and in particular that regarding its 'slope' is hereafter called the 'pressure-time index'., Results: 'Systolic pressure-time index 24 h' (SPTI24) is related to left ventricular mass index (multivariate analysis, P= 0.008). Using either partial correlation coefficients or a multivariate analysis, SPTI24 is related to left ventricular mass index, independently of age, casual blood pressure, mean systolic and diastolic ABP, systolic and diastolic BP loads, BP variability (standard deviation (SD), nocturnal fall of systolic BP) and integrated area under the curve (multivariate analysis, P= 0.004)., Conclusions: In essential hypertension, the SPTI24 is related to LVMI independently of age, casual blood pressure, integrated area under the curve or any other derivative of 24 h ABPM, and might be used to assess the extent of hypertensive load.

To evaluate the accuracy of exercise echocardiography for the recognition of coronary artery disease in the presence of left ventricular hypertrophy 70 patients were studied. Significant coronary artery disease was present in 25 patients and left ventricular hypertrophy had 29 patients. All patients underwent an exercise ECG and echocardiographic test during which cine-loop digitized echocardiography was obtained. Wall motion was analyzed and a regional wall motion score index was calculated. The overall sensitivities of exercise ECG and echocardiography for detecting coronary artery disease were 60% and 64%, respectively, and the specificities were 49% and 78%, respectively. In patients with left ventricular hypertrophy the specificity of exercise echocardiography was higher (71%) compared to exercise ECG (21%) while in patients without hypertrophy the sensitivity was higher (70% vs. 40%, respectively). Of the 19 patients with a non-diagnostic stress ECG, echocardiography correctly identified 100% of those with coronary artery disease but only 53% of those without disease. It is concluded that exercise digital echocardiography represents a good diagnostic alternative to the exercise ECG for identifying coronary artery disease in the presence of left ventricular hypertrophy and should be useful in patients with a non-diagnostic exercise ECG.

A possible profibrillatory effect on the atria of an elevated atrial pressure and the site of atrial stimulation was examined. In 15 anesthetized dogs, right or left atrial or biatrial pacing was applied at a high rate (300-600/min) for 5 seconds at double threshold intensity under a wide range of atrial pressures achieved by venous or arterial transfusion or bleeding. Induction of atrial fibrillation in 236 of 1,971 pacing runs was associated with a significantly higher (P < 0.001) atrial pressure (21.6 +/- 12.2 mmHg, mean +/- SD) than maintenance of sinus rhythm (16.8 +/- 11.1 mmHg in 1,735 of 1,971 pacing runs). Stimulation of the right atrium resulted in atrial fibrillation more frequently than left atrial or biatrial stimulation, with biatrial stimulation less frequent than right or left atrial stimulation. The induction of atrial fibrillation was related to the atrial pressure and to the site of stimulation but not to the pacing rate or the prepacing heart rate. The prepacing heart rate, associated with failure to induce sustained atrial fibrillation, was higher than that associated with atrial fibrillation in 12 of 15 experiments (significantly in 6) and not significantly lower in 3 of 15. Atrial fibrillation lasting 1 minute or more was more frequently associated with simultaneous stimulation of both atria than of either atrium alone. Thus, an elevated atrial pressure may facilitate the induction of atrial fibrillation. The site of stimulation also plays an important role for both the induction and maintenance of atrial fibrillation in this model.

The purpose of this study is to evaluate the early morphological and functional abnormalities of the heart in patients with collagen disease. The study population was free of risk factors for coronary artery disease and without any clinically evident cardiac manifestations. In 62 patients with collagen disease (25 with progressive systemic sclerosis, 19 with systemic lupus erythematosus, 15 with rheumatoid arthritis, three with dermatomyositis) and in 40 healthy subjects an echocardiographic study was performed. Echocardiographic examination from the apical four-chamber view was performed at rest and during the end of a 3 min isometric exercise with handgrip. Global and regional ejection fraction of the left ventricle were calculated. In the group with progressive systemic sclerosis the left ventricular mass index was significantly higher than in the control group (110.78 +/- 48.61 vs 82.18 +/- 28.46 g.m-2) and the ejection fraction (53.61 +/- 7.95%) was the lowest of all groups (control: 61.47 +/- 8.52%, systemic lupus erythematosus: 59.04 +/- 8.58%, rheumatoid arthritis: 62.38 +/- 6.88%). Regional ejection fraction analysis revealed a major dysfunction of the proximal segment of the interventricular septum, in all groups. During isometric exercise, the global and regional ejection fraction did not change significantly, although differences between groups disappeared. In rheumatoid arthritis, mitral and aortic valve leaflet separation appeared to be reduced. In the group with systemic lupus erythematosus, mild abnormalities were noticed, although the mean age and duration of the disease were the smallest compared with the other groups. In conclusion, patients with progressive systemic sclerosis mainly present left ventricular hypertrophy with a reduced ejection fraction while rheumatoid arthritis patients show a predominant valve dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)