Armando Dagianti

Stress echocardiography: Comparison of exercise, dipyridamole and dobutamine in detecting and predicting the extent of coronary artery disease

OBJECTIVES This study was designed to compare exercise, dipyridamole and dobutamine echocardiography in the same patients and to evaluate, by measuring physiologic and echocardiographic variables, the mechanisms by which exercise and dobutamine induce ischemia. BACKGROUND The diagnostic value of stress echocardiography has been widely reported, but the specific effects of exercise, dipyridamole and dobutamine have not been directly compared. Furthermore, no echocardiography study has evaluated left ventricular volume changes at ischemic threshold during exercise and dobutamine administration. METHODS One hundred patients with suspected (Group A, n = 60) or known (Group B, n = 40) coronary artery disease underwent all three tests in random order. RESULTS In Group A, the sensitivities of exercise (mean 76%, 95% confidence interval [CI] 58% to 94%) and of dobutamine echocardiography (72%, 95% CI 53% to 91%) were higher than that of dipyridamole (52%, 95% CI 31% to 73%; p = 0.01 and p = 0.02, respectively). Specificity did not differ significantly among tests (94% for exercise [95% CI 86% to 100%] and 97% for dipyridamole and dobutamine [95% CI 91% to 100%]). Accuracy was identical for exercise and dobutamine (87%) and higher than that for dipyridamole (78%, p = 0.06). In Group B, the accuracy in predicting coronary disease extent was 71% for exercise, 33% for dipyridamole and 75% for dobutamine. At ischemic threshold, end-systolic volume index and the ratio of systolic blood pressure to end-systolic volume, a variable related to myocardial contractility, were significantly lower and higher, respectively, with dobutamine than during exercise (p < 0.05). CONCLUSIONS In a clinical setting, exercise echocardiography should represent the first diagnostic approach because it has high diagnostic efficacy and provides additional information on exercise capacity; pharmacologic stress, particularly that of dobutamine, provides a pivotal diagnostic tool when exercise is not feasible or its results are nondiagnostic. Our preliminary data on echocardiographic evaluation at ischemic threshold support the view that myocardial contractility is a major factor in inducing ischemia during dobutamine infusion.

Influence of residual perfusion within the infarct zone on the natural history of left ventricular dysfunction after acute myocardial infarction: A myocardial contrast echocardiographic study

OBJECTIVES This study used myocardial contrast echocardiography to investigate the extent of residual perfusion within the infarct zone in a select group of patients with recently reperfused myocardial infarction and evaluated its influence on the ultimate infarct size. BACKGROUND Limited information is available on the status of myocardial perfusion within postischemic dysfunctional segments at predischarge and on its influence on late regional and global functional recovery. METHODS Twenty patients with acute myocardial infarction were selected for the study. Patients met the following inclusion criteria: 1) single-vessel coronary artery disease; 2) patency of infarct-related artery with persistent postischemic dysfunctional segments at predischarge; 3) stable clinical condition up to 6 months after hospital discharge. All selected patients underwent coronary angiography and myocardial contrast echocardiography before hospital discharge and repeated the echocardiographic examination 6 months later. Patients were grouped according to the pattern of contrast enhancement in predischarge dysfunctional segments. RESULTS In nine patients (group I), the length of segments showing abnormal contraction coincided with that of the contrast defect segments. In the remaining 11 patients (group II), postischemic dysfunctional segments were partly or completely reperfused. There was no difference between the two groups in asynergic segment length at predischarge (7.3 +/- 2.5 vs. 7.2 +/- 4.3 cm, p = NS). At follow-up study, asynergic segment length was significantly reduced in group II patients, whereas no changes were observed in group I patients (from 7.2 +/- 4.3 to 4.7 +/- 3.7 cm, p < 0.005; and from 7.3 +/- 2.5 to 7.5 +/- 2.9 cm, p = NS, respectively). CONCLUSIONS Among patients with a predischarge patent infarct-related artery, further improvement in regional and global function may be expected during follow-up when residual perfusion in the infarct zone is present.

Transesophageal dipyridamole echocardiography for diagnosis of coronary artery disease

The value of transthoracic dipyridamole echocardiography has been extensively documented. However, in some patients, because of a poor acoustic window, the rest transthoracic examination is not always feasible and the transesophageal approach is more convenient. Therefore, transesophageal echocardiography with high dose dipyridamole (up to 0.84 mg/kg body weight over 10 min) was performed in 32 patients in whom the transthoracic dipyridamole test either was not feasible (n = 29) or yielded ambiguous results (n = 3). The transesophageal echocardiographic test results were considered abnormal when new dipyridamole-induced regional wall motion abnormalities were observed. All 32 patients underwent coronary angiography; significant coronary artery disease was defined as greater than or equal to 70% lumen diameter narrowing in at least one major vessel. All patients also performed a bicycle exercise test 1 day before transesophageal dipyridamole echocardiography. Transesophageal stress studies were completed in all patients, with a maximal imaging time (in tests with a negative result) of 20 min. No side effects or intolerance to drug or transducer was observed. The left ventricle was always visualized in the four-chamber and transgastric short-axis views. High quality two-dimensional echocardiographic images were obtained in all patients both at rest and at peak dipyridamole infusion and were digitally analyzed in a quad-screen format. Coronary angiography showed coronary artery obstruction in 24 patients: 6 had single-, 9 double- and 9 triple-vessel disease. The transesophageal dipyridamole test showed a specificity of 100% and an overall sensitivity of 92%. The sensitivity of this test for single-, double- and triple-vessel disease was 67%, 100% and 100%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Chlamydia pneumoniae infection and atherosclerotic coronary disease

BACKGROUND Previous works have suggested an association between Chlamydia pneumoniae infection and coronary heart disease. We evaluated the prevalence of C. pneumoniae infection in patients with acute myocardial infarction (AMI) and coronary heart disease (CHD). METHODS AND RESULTS Ninety-eight patients with AMI, 80 patients with CHD, and 50 control subjects matched for age and sex were investigated. Immunoglobulin (Ig)M, IgG, and IgA antibodies to C pneumoniae were measured by the microimmunofluorescence test. IgM antibodies were not found; IgG positivity was found in 58.2% of the AMI group, 60.0% of the CHD group, and 38% of the control group, whereas for IgA, positivity was found in 33.7%, 43.7%, and 22% of cases in AMI, CHD, and control groups, respectively. Titers indicating reinfection were found in AMI and CHD groups in 6.1% and 10%, respectively, whereas titers indicating chronic infection were found in 14% of the AMI group and 25% of the CHD group. A significant correlation was found between chronic C pneumoniae infection and dyslipidemias in the AMI and CHD groups (P =.003; P =. 0006). CONCLUSIONS The results suggest that chronic C pneumoniae infection may be associated with the development of atherosclerotic coronary disease. In our next step, we will test whether antichlamydial antibiotics may help to reduce the risk of atherosclerotic disease.

Tissue-Type Plasminogen Activator Therapy Versus Primary Coronary Angioplasty: Impact on Myocardial Tissue Perfusion and Regional Function 1 Month After Uncomplicated Myocardial Infarction

OBJECTIVES This study sought to compare the impact of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) on 1-month infarct size and microvascular perfusion. BACKGROUND The effect of the reperfusion strategies of primary coronary angioplasty and thrombolytic therapy on microvascular integrity still remains to be determined. METHODS Sixty-two consecutive patients with a first AMI, undergoing intravenous tissue-type plasminogen activator (t-PA) therapy (32 patients, Group I) or primary angioplasty (30 patients, Group II), were studied. Only patients with 1-month Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 were selected for the study. Patients in whom primary angioplasty was unsuccessful or those with clinical evidence of failed reperfusion were excluded. Microvascular perfusion was assessed at 1 month by intracoronary injection of sonicated microbubbles. Contrast score index (CSI) and wall motion score index (WMSI) were derived using qualitative methods. RESULTS At baseline there were no significant differences between groups for age, risk factors, time to hospital presentation, Killip class on admission, prevalence of multivessel disease or anterior infarct site, infarct area extension before reperfusion, peak creatine kinase levels and postinfarction treatment. Conversely, significant differences between groups were found at follow-up for percent residual infarct related-artery (IRA) stenosis (70 +/- 12 vs 36 +/- 14 [mean +/- SD], p = 0.0001), CSI (1.02 +/- 0.4 vs. 1.49 +/- 0.5, p = 0.0003) and WMSI (1.67 +/- 0.3 vs. 1.45 +/- 0.3, p = 0.015). In particular, in the subset of patients with TIMI grade 3 flow, a perfusion defect occurred in one or more segments subtended by the IRA in 72% of Group I versus 31% of Group II patients (p < 0.00001) and in 27% of Group I versus 8% of Group II segments (p < 0.00001). CONCLUSIONS The present study shows, in a highly selected cohort with successful IRA recanalization, that primary angioplasty is more effective than thrombolysis in preserving microvascular flow and preventing extension of myocardial damage at 1-month after AMI.

Assessment of severity of coronary narrowings by quantitative exercise echocardiography and comparison with quantitative arteriography

To determine the correlation of quantitative assessment of coronary narrowings with left ventricular functional impairment induced by exercise, 57 patients with 1-vessel coronary artery disease and without evidence of collateral flow were studied. A significant relation was observed between minimal cross-sectional area, percent area stenosis, minimal lumen diameter, percent diameter stenosis and the percentage of segmental area change from rest to peak exercise in a vascular distribution territory (r = 0.76, p less than 0.001; r = -0.55, p less than 0.001; r = 0.56, p less than 0.001; r = -0.75, p less than 0.001, respectively). For minimal cross-sectional area, the best cut-off value to separate significantly patients who had a decrease in contractility at peak exercise testing from those who had a normal response was 2 mm2 (p less than 0.001); for percent cross-sectional area stenosis, it was 75% (p less than 0.001); for minimal lumen diameter, it was 0.7 mm (p less than 0.001); and, for percent diameter stenosis, it was 85% (p less than 0.001). High cut-off values for angiographic variables are necessary to separate significantly patients who have a decrease in contractility at peak exercise testing from those who have a normal response. Several patients with mild coronary stenoses may have either normal or abnormal wall motion during exercise. Thus, exercise echocardiography is a useful tool in detecting the presence of fairly severe anatomic narrowing, whereas it is of limited clinical use in the assessment of intermediate coronary atherosclerotic lesions.

Identification of viable myocardium in patients with chronic coronary artery disease and left ventricular dysfunction: role of magnetic resonance imaging.

Nineteen patients (16 men and 3 women, mean age 51 years) with previous anterior myocardial infarction and severe stenosis (> or = 90%) of the left anterior descending coronary artery were studied by magnetic resonance imaging (MRI) without and with contrast media to verify the capability of MRI in identifying viable myocardium in areas of severe systolic dysfunction. In corresponding left ventricular segments, a comparison was made between regional signal intensities (SI) determined on MRI images before and 4, 8, 12, and 30 minutes after administration of paramagnetic contrast media (gadolinium diethylenetriaminepentaacetic acid, 0.4 mmol/kg intravenously) and metabolic parameters determined by iodine 123 phenylpentadecanoic acid (IPPA) scintigraphy. The SI and the time of maximum postcontrast enhancement were analyzed by dividing the left ventricle into 11 segments. Each segment was classified as normal (group 1, n = 116), hibernating (group 2, n = 50), or necrotic (group 3, n = 43) on the basis of the IPPA washout rate (> 30%, 10% to 30%, and < 10%, respectively). Regional SI demonstrated significant differences in absolute values at 12 minutes (group 3: 1.62 +/- 0.58 vs group 1: 1.32 +/- 0.52, p < 0.01, and vs group 2: 1.34 +/- 0.48, p < 0.05) and at 30 minutes (group 3: 1.71 +/- 0.47 vs group 1: 1.21 +/- 0.55, p < 0.01, and vs group 2: 1.49 +/- 0.57, p < 0.05) and in temporal distribution. These results suggest that MRI has a potential role in differentiating viable from necrotic myocardium in patients with chronic severe systolic dysfunction.

Clinical and Prognostic Usefulness of Supine Bicycle Exercise Echocardiography in the Functional Evaluation of Patients Undergoing Elective Percutaneous Transluminal Coronary Angioplasty

BACKGROUND Supine bicycle exercise echocardiography (SBEE) has never been used before and early after percutaneous transluminal coronary angioplasty (PTCA) for assessing the functional outcome of the procedure and predicting late restenosis. METHODS AND RESULTS We selected 76 subjects with stable angina, normal wall motion at rest, and exercise-induced wall-motion abnormalities before PTCA. SBEE with peak exercise imaging and the use of a 16-segment, four-grade score model was performed 54 +/- 15 hours after PTCA. No exercise-related adverse events occurred. Patients were grouped according to SBEE results: group 1 (n = 35, 46%) with negative exercise ECG and echo; group 2 (n = 19, 25%) with a positive exercise ECG but normal echo; and group 3 (n = 22, 29%) with a positive exercise echo with either a positive (n = 7, 32%) or negative (n = 15, 68%) ECG. Exercise performance significantly improved in all groups. In group 3, peak wall-motion score index decreased from 1.27 +/- 0.11 before to 1.15 +/- 0.06 after PTCA (P < .05), and duration of wall-motion abnormalities went from 81 +/- 24 to 47 +/- 19 seconds (P < .05). The rate of clinical restenosis (ie, angina recurrence or positive 6-month SBEE in asymptomatic patients, both associated with angiographic restenosis > 50%) was 37%. By multiple logistic regression analysis, clinical restenosis was associated with a positive post-PTCA exercise echo (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.66 to 5.72; P = .0004) and with increasing values of pre-PTCA wall-motion score index (OR 2.86, 95% CI 1.92 to 4.27; P = .005) and duration of wall-motion abnormalities (OR 2.12, 95% CI 1.07 to 4.20; P = .04). CONCLUSIONS SBEE is a safe and reliable tool to demonstrate changes in exercise-induced wall-motion abnormalities after PTCA and provides prognostic information in the risk assessment of clinical restenosis.

Assessment of regional left ventricular function during exercise test with pulsed tissue Doppler imaging.

To investigate whether mitral annular velocity, measured by tissue Doppler imaging (TDI), is able to get a feasible quantitative evaluation of global and regional left-ventricular function during exercise test, 29 patients with previous uncomplicated myocardial infarction were studied by exercise echocardiography. All patients underwent coronary arteriography within 10 days of stress echocardiography. All of them were in sinus rhythm and had no right or left bundle branch block or significant mitral regurgitation as observed by left ventriculography. A total of 12 patients had anteroseptal and/or posteroseptal wall asynergies and left anterior descending involvement; 9 patients had lateral and/or posteroinferior asynergies and left circumflex coronary artery involvement; 8 patients had inferior and posteroseptal wall asynergies and right coronary artery involvement. Twelve subjects of same age and sex with normal cardiovascular findings were selected as a control group. TDI sample volumes were set on the mitral annuli corresponding to anteroseptal, posterior, posteroseptal, lateral, anterior, and inferior wall in 4-chamber, 2-chamber, and long-axis views. There was a significant correlation between the left-ventricular ejection fraction (0.41 +/- 0.8) and the means of the systolic (S) values (6.1 +/- 0.9 cm/sec, r = 0.83, p < 0.01). The mean S at the sites corresponding to the infarct regions (5.5 +/- 0.4 cm/sec) was significantly lower than the control group (11 +/- 0.8 cm/sec, p < 0.001). After stress, in patients with multivessel disease, S values corresponding to remote regions were significantly lower (p < 0.01) compared with control subjects. Thus, the parameters obtained from mitral annular velocities with pulsed TDI in patients with previous myocardial infarction reflect left ventricular asynergy corresponding to the infarct regions and reversible regional dysfunction after exercise.

The complex relation between myocardial viability and functional recovery in chronic left ventricular dysfunction

Preserved myocardial viability and recurrent symptomatic ischemia are the most widely accepted criteria indicating that coronary revascularization should take place in patients with postischemic left ventricular dysfunction. However, the presence of viable myocardium within the infarct zone does not necessarily imply recovery of function after coronary revascularization. The complex relation between the extent of transmural necrosis and the degree of residual perfusion within the infarct area plays an important role. However, independently of functional recovery, cell viability may have important clinical implications, since it may improve long-term prognosis by attenuating left ventricular remodeling processes. Several different methods are used to detect hibernating myocardium. Mounting evidence suggests that thallium-201 scintigraphy is most sensitive in identifying tissue viability, whereas dobutamine echocardiography is most specific in predicting functional recovery after revascularization. In between, myocardial contrast echocardiography is the only technique able to evaluate the microvascular integrity that is a condition sine qua non for both cell viability and later functional recovery. Combined information derived from these 3 different approaches might be considered as the best way to understand how the combination of contractile, viable but noncontractile, and dead tissue affect resultant function and prognosis.