David P. Lipkin

Use of limb movement sensors as indicators of the level of everyday physical activity in chronic congestive heart failure

The level of everyday physical activity of patients with chronic congestive heart failure (CHF) may be an important reflection of their quality of life. Everyday physical activity is difficult to measure objectively, and may not relate to exercise capacity determined by laboratory exercise testing. A light-weight sensor worn on the wrist or ankle, which provides a cumulative record of limb movement, was evaluated. The sensor counted reliably when tested in a laboratory rig and during treadmill exercise. In 20 young normal subjects, hourly movement scores showed the expected diurnal rhythm. Twenty-four-hour movement scores in 30 patients with stable CHF were lower than in 20 age-matched control subjects (p less than 0.005). Movement scores in CHF correlated with a standard questionnaire scale assessing everyday physical activity (R = +0.72, p less than 0.001). Consecutive daily scores varied widely, but wrist and ankle scores were correlated (R greater than +0.7, p less than 0.05 in each subject), suggesting true day-to-day differences in activity rather than variability in the recording method. Recording for 5 to 6 consecutive days provides a reliable estimate of mean 24-hour movement score for a subject, and mean 24-hour scores were reproducible when subjects were retested after 8 weeks. There was a weak correlation between movement scores and exercise capacity as measured by peak oxygen consumption during maximal treadmill exercise (R = +0.42, p = 0.01). Quality-of-life score correlated with movement scores (R = +0.53, p less than 0.002) but not with peak oxygen consumption (R = +0.36; p = not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced pulmonary microvascular permeability in severe chronic left heart failure

Pulmonary edema is a serious complication of heart failure, but often patients with chronic heart failure resist pulmonary edema despite elevated pulmonary venous pressures. This protection might be a result of decreased pulmonary microvascular permeability. Double-isotope scintigraphy with 113mindium-labeled transferrin and 99mtechnetium-labeled erythrocytes allows noninvasive estimation of pulmonary microvascular permeability; an index of transferrin accumulation is calculated that reflects microvascular permeability. Fourteen patients with severe chronic left ventricular dysfunction were compared with a control group of 15 patients with mild coronary artery disease. In the control group the transferrin accumulation index was 0.35 (range -0.3 to 1.0) x 10(-3)/min, and in patients with heart failure the index was 0.0 (range -1.0 to 0.7) x 10(-3)/min, which was significantly lower (p less than 0.01). The reduction in the transferrin accumulation index correlated weakly with the duration of heart failure (R = -0.5, p less than 0.02). These data indicate reduced protein efflux consistent with a decrease in pulmonary microvascular permeability in patients with severe chronic heart failure. Similar changes have been observed in severe mitral stenosis and may reflect a generalized adaptation to chronic pulmonary venous hypertension.

Prognostic value of negative dobutamine stress echo in women with intermediate probability of coronary artery disease

Women with an intermediate pretest probability of coronary artery disease represent a significant proportion of patients referred for the investigation of chest pain. Dobutamine stress echocardiography can be used to restratify these patients into a low-risk group without resorting to cardiac catheterization.

Radiation dose of CT coronary angiography in clinical practice: Objective evaluation of strategies for dose optimization

BACKGROUND CT coronary angiography (CTCA) is an evolving modality for the diagnosis of coronary artery disease. Radiation burden associated with CTCA has been a major concern in the wider application of this technique. It is important to reduce the radiation dose without compromising the image quality. OBJECTIVES To estimate the radiation dose of CTCA in clinical practice and evaluate the effect of dose-saving algorithms on radiation dose and image quality. METHODS Effective radiation dose was measured from the dose-length product in 616 consecutive patients (mean age 58 ± 12 years; 70% males) who underwent clinically indicated CTCA at our institution over 1 year. Image quality was assessed subjectively using a 4-point scale and objectively by measuring the signal- and contrast-to-noise ratios in the coronary arteries. Multivariate linear regression analysis was used to identify factors independently associated with radiation dose. RESULTS Mean effective radiation dose of CTCA was 6.6 ± 3.3 mSv. Radiation dose was significantly reduced by dose saving algorithms such as 100 kV imaging (-47%; 95% CI, -44% to -50%), prospective gating (-35%; 95% CI, -29% to -40%) and ECG controlled tube current modulation (-23%; 95% CI, -9% to -34%). None of the dose saving algorithms were associated with a significant reduction in mean image quality or the frequency of diagnostic scans (P = non-significant for all comparisons). CONCLUSION Careful application of radiation-dose saving algorithms in appropriately selected patients can reduce the radiation burden of CTCA significantly, without compromising the image quality.

Exercise physiology and the role of the periphery in cardiac failure.

Cardiopulmonary exercise testing remains the standard method of functional assessment in chronic heart failure, and both peak oxygen consumption achieved on progressive maximal exercise testing and anaerobic threshold are widely used endpoints in clinical trials. Peak oxygen consumption achieved on progressive maximal exercise testing may be used in clinical practice to estimate prognosis and aid the prioritization of patients for cardiac transplantation. Anaerobic threshold is a valuable index of submaximal exercise performance, but there are many different criteria used to define anaerobic threshold and careful attention to the methodology is essential. The mechanisms of limitation of exercise capacity and the importance of the peripheral abnormalities in chronic heart failure are still not elucidated. The skeletal muscles are reduced in size, weak, and easily fatigued; in addition, nuclear magnetic resonance spectroscopic studies have shown that high-energy phosphates are depleted and acidosis develops more rapidly during exercise in patients with chronic heart failure than in normal subjects. However, the relationship of these abnormalities to the mechanical performance of the muscles, the differences between treated and untreated heart failure, and the effects of physical training have yet to be clarified.

Central cyanosis following coronary artery bypass graft surgery

A case of central cyanosis occurring after coronary artery bypass graft surgery is described. This was due to the development of a right ventricular infarction which facilitated shunting from right to left through a previously undiagnosed patent foramen ovale or small atrial septal defect.

Pseudo preexcitation syndrome

During the course of investigation for palpitations, a 62-year-old man underwent exercise testing using a MARQUETTE CASE 12 computerized exercise testing system. By stage III of the modified Bruce protocol, the computer-generated electrocardiogram appeared to show the development of exercise-induced preexcitation. Closer examination of the raw unfiltered data showed this to be a computer-generated artifact rather than true preexcitation. This artifact arose due to inherent limitations common to all computerized exercise testing systems and emphasizes the need to always review raw data, even when a seemingly clear-cut abnormality is present on a computer-averaged electrocardiogram.

Exercise physiology and changes in the periphery

Dyspnea, fatigue, and reduced exercise capacity are cardinal features of patients with chronic heart failure. The mechanisms of limitation of exercise capacity are not known. Over the last 10 years there has been increasing use of cardiopulmonary exercise testing to study the pathophysiology of heart failure. Exercise testing in patients with heart failure has revealed little or no correlation between central hemodynamic measurements at rest or during exercise and either exercise capacity or symptoms. Interest has therefore been directed toward changes in the peripheral circulation and in the function of exercising skeletal muscle. Reduced vasodilatory capacity, altered muscle fiber types, and altered muscle biochemistry (studied from muscle biopsies or by 31P-NMR spectroscopy) have all been described.