[The hypertensive emergency situation : Recommendations for initial drug therapy management]. / Der hypertensive Notfall : Empfehlungen zum initialen medikamentösen Therapiemanagement.

The hypertensive emergency situation is characterized by an acute-mostly life-threatening-blood pressure derailment with the risk of acute end organ damage. It is an acute manifestation of arterial hypertension, which manifests in a variety of symptoms. The etiology is in most cases long-term (chronic) hypertension as a result of low compliance or inadequate antihypertensive therapy. It can also occur as a first manifestation of arterial hypertension. It requires timely antihypertensive drug therapy, which should be initiated in an intensive or intermediate care unit. The choice of antihypertensive therapy regimen should be based on the underlying end organ damage. Fast-acting, easily controllable and intravenously administered substances should be preferred. The most commonly used substances (groups) are urapidil, nitroglycerin, beta blockers and short-acting calcium channel blockers. With a few exceptions, a deliberate, rapid reduction in blood pressure of no more than 20-25% of the initial value is sufficient for extracerebral causes. A subsequent systolic blood pressure target of 160/100 mm Hg should be aimed for within the next 2-6 h. An overly rapid drop in blood pressure can lead to reduced blood flow to the central nervous system due to changes in autoregulation. Exceptions to this rule are acute aortic dissection and flash pulmonary edema-in these cases, prompt blood pressure normalization should be achieved. The initial acute therapy should be followed by a more detailed investigation of the cause and a long-term therapy setting based on this.

[Music, pulse, heart and sport]. / Musik, Puls, Herz und der Sport.

Music, with its various elements, such as rhythm, sound and melody had the unique ability even in prehistoric, ancient and medieval times to have a special fascination for humans. Nowadays, it is impossible to eliminate music from our daily lives. We are accompanied by music in shopping arcades, on the radio, during sport or leisure time activities and in wellness therapy. Ritualized drumming was used in the medical sense to drive away evil spirits or to undergo holy enlightenment. Today we experience the varied effects of music on all sensory organs and we utilize its impact on cardiovascular and neurological rehabilitation, during invasive cardiovascular procedures or during physical activities, such as training or work. The results of recent studies showed positive effects of music on heart rate and in therapeutic treatment (e. g. music therapy). This article pursues the impact of music on the body and the heart and takes sports medical aspects from the past and the present into consideration; however, not all forms of music and not all types of musical activity are equally suitable and are dependent on the type of intervention, the sports activity or form of movement and also on the underlying disease. This article discusses the influence of music on the body, pulse, on the heart and soul in the past and the present day.

[Stress echocardiography and its central role in cardiac diagnostics]. / Stressechokardiographie und ihre zentrale Rolle in der kardiologischen Diagnostik.

Stress echocardiography (SE) has an established central role as a diagnostic tool in cardiology. It is not only an established method for the diagnostic and prognostic stratification of patients with coronary artery disease but also shows an emerging value for assessment of cardiac function beyond coronary artery disease. The enormous conceptual technological development of ultrasound technology (Doppler, digitizing, tissue Doppler imaging, strain technology, 3­D-echo and new ultrasound contrast agents) has led to applications of SE in almost all diagnostic fields of cardiology. The use of SE provides not only the possibility to identify coronary stenosis but also to evaluate the function of the microvasculature and heart valves, to detect possible pulmonary hypertension and also to test the systolic/diastolic reaction/mechanics of the right/left ventricle (LV/RV) and left atrium (LA) in response to load. Further developments of ultrasound technology enable better temporal resolution and contemporary analyses of cardiac mechanics of the LV/RV and LA. Pharmacological stress echocardiography extends the diagnostic field to patients who are not able to endure physical stress. SE represents an environmentally friendly, patient-friendly, cost-efficient and radiation-free examination method; however, SE requires extensive basic training as well as continuous training of the examiner to ensure that all possible advantages of the method can be utilized to the benefit of patients.

Physical activity, cardiorespiratory fitness and carotid intima thickness: sedentary occupation as risk factor for atherosclerosis and obesity.

OBJECTIVE: The influence of occupational physical activity on markers of atherosclerosis, prevalence of metabolic syndrome and physical performance has been understudied in current literature. Main aim of this study was to examine the association between physical work environment and physiological performance measures, physical activity, metabolic parameters and carotid atherosclerosis among German career firefighters and sedentary clerks. PATIENTS AND METHODS: We prospectively examined and recruited 143 male German civil servants (97 firefighters [FFs], and 46 sedentary clerks [SCs]). Correlation for each parameter for the groups were compared using a linear regression model adjusted for age. RESULTS: 97 firefighters (FFs) showed higher maximal aerobic power (VO2max) of 3.17 ± 0.44 L/min compared to 46 sedentary clerks (SCs) 2.85 ± 0.52 L/min (-0.21 CI -0.39-0.04, p = 0.018). Physical activity (PA, in METS/week) in FFs was 3953 ± 2688 and in SC 2212 ± 2293 (-1791.86 CI -2650--934, p = 0.000). Body fat was 17.7 ± 6.2% in FFs and in SCs 20.8 ± 6.5% (1.98 CI -0.28-4.25, p = 0.086). Waist circumference was 89.8 ± 10.0 cm in FFs and in SCs 97.3 ± 11.7 (-4.89 CI 1.24-8.55, p = 0.009). Carotid intima media thickness (IMT) showed significant difference for the left carotid artery 0.69 ± 0.19 mm in FFs vs. SCs 0.81 ± 0.20 (0.07 CI 0.01-0.14, p = 0.030). Metabolic syndrome was found in 12 out of 98 FFs (13.4%), and in 14 out of 46 SCs (30.43%). CONCLUSIONS: FFs showed significantly higher physical activity levels compared with the SCs. SCs had higher cardiovascular risk profile, higher prevalence of metabolic syndrome, higher waist circumference and significantly higher IMT than FFs. In conclusion, sedentary occupations have higher cardiovascular risk secondary to accelerated atherosclerosis.

Ugly duckling or Nosferatu? Cardiac injury in endurance sport - screening recommendations.

In the beginning sporting activity may be exhausting, but over time, physical activity turns out to have beneficial effects to the body and even extended cycling or running is an emotional and healthy enrichment in life. On the other hand, spectacular sudden deaths during marathon, football and, just recently, in the trend discipline triathlon seem to support the dark side of the sporting activity. Since years there are constantly appearing reports about a potential myocardial injury induced by intensive sporting activities. Cardiac hypertrophy is the heart's response to arterial hypertension and to physical activity, but can be associated with an unfavorable outcome - in worst case for example with sudden death. The question of the right dose of sporting activity, the question how to prevent cardiac death induced by physical activity and the question how to screen the athletes for the possible risk of sudden death or other cardiac complications during sporting activity are those that will be answered by this review article. In this review we summarize recent insights into the problem of endurance sport and possible negative cardiac remodeling as well as the question how to screen the athletes.

Intraobserver and interobserver reproducibility for radial, circumferential and longitudinal strain echocardiography.

OBJECTIVES: Strain echocardiography (StE) promises to be a new tool for quantitative assessment of cardiac function. Analysis of intra- and interobserver reliability is an important aspect in the process of developing these novel techniques from theory to the implementation into daily routine diagnostics.The purpose of the study was to estimate reliability of the segmental StE. METHODS: Left ventricular strain analysis for radial strain (RS), circumferential strain (CS) and longitudinal strain (LS) was performed in 21 healthy volunteers. RS and CS values were obtained in the parasternal short axis at the level of the papillary muscles. LS values were determined in the apical 2-, 3- and 4-chamber views. Cine-loops were recorded and quantitative analyses were conducted on an off-line workstation. RESULTS: Intraobserver reproducibility was highest using LS in the 4-chamber view (9 ± 13.6 % mean deviation, rho = 0.624, p = 0.003), followed by CS (13.3 ± 8.3 %, rho = 0.406, p = 0.068) and lowest in RS (26.3 ± 30.1 %, rho = 0.391, p = 0.080). Interobserver analyses of LS derived from 3-chamber view showed lowest deviation (11.9 ± 9.5 %, rho = 0.513, p = 0.017), followed by CS (15.2 ± 12.0 %, 0.263, p = 0.249) and the least consistent measurements in RS (35.9 ± 46.3 %, rho 0.382, p = 0.088). CONCLUSION: This study shows that the clinical utility of StE depends on the regional differences of LV wall motion and image quality. LS-values showed promising intra- and interobserver reproducibility values. For quantitative follow-up studies LS should be preferred.

[Cardiovascular screening for recreational, leisure, vigorous and competitive sport activities over 35 years]. / Kardiovaskuläre Vorsorge im Breitensport, ambitionierten Freizeitsport und Wettkampfsport über das 35. Lebensjahr hinaus.

Particularly among over 30 years old ambitious hobby- and competitive athletes arrhythmias and even sudden cardiac deaths occur again and again. The spectacular sudden deaths during marathon, football and, just recently, in the trend discipline triathlon seem to support that view. Reports about the "athlete`s heart" and complications in the elderly causes uncertainty among athletes, fitness fans and sports physicians. The question arises, how to avoid complications caused by ambitious sporting activity in the elderly and how to screen hobby- and ambitious athletes between the age of 35 and 75 years. For athletes > 35 years old besides medical history and physical examination basic examinations including resting ECG, echocardiography and exercise ECG/stress echocardiography are mandatory. Further examinations, if clinically necessary, should be spiroergometry, Holter ECG or magnetic resonance tomography and Carotis-Duplex or Cardio-CT for the purpose of arteriosclerosis screening. In suspicious inflammation a further extended laboratory testing may become necessary (incl. viral/bacterial antibodies) or even a multidisciplinary approach (immunological, neurological, dental or orthodontic examination).

Reproducibility of stress echocardiography using intravenous injection of ultrasound contrast agent (BY 963).

UNLABELLED: Despite the widespread use of stress echocardiography, its reproducibility is still limited by high interobserver variability. Therefore, the purpose of the present study was to improve the reproducibility of a stress (exercise) echocardiography using a new transpulmonary ultrasound agent (BY 963). Stress echocardiography was performed in 12 healthy volunteers with suboptimal endocardial border delineation during exercise echocardiography. A special 45 degrees lateral tilted bike stress echocardiography table was used for exercise testing. Echocardiographic images were recorded on-line at rest and during exercise on a video tape and additionally digitized on-line on a stress echo computer. End-diastolic (EDVml), end-systolic (ESVml) volume and ejection fraction (EF%) were estimated in the 4-chamber view. The measurements were performed before and after injection of 2.5 ml and 5 ml BY963 at rest and in maximal exercise. A new contrast agent (BY 963) leads to a sufficient contrast effect for the left ventricular cavity after intravenous administration and permits a good delineation of left the endocardial border. The interobserver variability was determined using blinded investigation by two observers. The correlation of EDV and ESV determination at rest was r = 0.68/0.33, after 2.5 ml BY 963 r = 0.97/0.93 and after 5 ml BY 963 r = 0.90/0.93. The correlation for EDV and ESV during exercise was r = 0.52/0.33, after 2.5 ml BY 963 r = 0.88/0.80 and after 5 ml BY 963 r = 0.95/0.92. At rest mean EF without contrast was 61 +/- 6%/67 +/- 7% (r = 0. 130), after 2.5 ml BY 963 i.v. 69 +/- 8%/72 +/- 7% (r = 0.82) and after 5 ml BY 963 i.v. 73 +/- 8%/73 +/- 8% (r = 0.98%) respectively. In exercise, mean EF without contrast was 68 +/- 8%/70 +/- 6 (r = 0.013), after 2.5 ml BY 963 83 +/- 6%/81 +/- 5 and after 5 ml 83 +/- 4%/82 +/- 3 (r = 0.86). SUMMARY: The estimation of the end-systolic volume in exercise will be improved significantly and the estimated EF values will be higher compared to EF values obtained without contrast application. Transpulmonary contrast echocardiography for analysis of left ventricular volumes and ejection fraction can be routinely used in stress echocardiography. Intravenous administration of BY 963 improves the reproducibility of quantitative analysis of left ventricular function in healthy volunteers. Further studies in patients with cardiac diseases are required to corroborate this observation.

Stress echocardiography: new techniques.

Stress echocardiography is frequently used to evaluate coronary artery disease, and also in quantitative assessment of right and left ventricular function or cardiac valve integrity in patients with cardiomyopathy or during chemotherapy. Various new ultrasound techniques in stress echocardiography are now playing a significant role in this important area of cardiological diagnostics. New methods of echocardiographic signal processing have been developed to provide more quantitative and reproducible information on cardiac function during stress. The most important are: (1) raw data analysis techniques for endocardial border detection (acoustic quantification, CK = colour kinesis), (2) tissue Doppler imaging for myocardial velocity analysis and (3) transpulmonary contrast agents (Albunex, Laevovist, BY 963) for improving endocardial border delineation and for future analysis of myocardial perfusion. Like all new techniques, they must first be subjected to comprehensive scientific assessment, and appropriate training should be given, taking into account physical and physiological limits. These limits will constantly be redefined as echocardiographic techniques continue to change presenting new challenges for the further development of ultrasound technology. In this review, the improved new techniques will be discussed in detail.

[Treatment of a large intracoronary thrombus with urokinase and a chimeric monoclonal platelet aggregation inhibitor]. / Behandlung eines grossen intrakoronaren Thrombus mit Urokinase und einem chimären monoklonalen Thrombozytenaggregationshemmer.

HISTORY AND CLINICAL FINDINGS: 7 days after an operation for intervertebral disc prolapse a 43-year-old man was referred with the clinical and ECG signs of an acute posterior wall myocardial infarction. INVESTIGATIONS: Creatine kinase (CK) activity was raised to 204 U/I (myocardial-specific isoenzyme CKMB of 23.6 U/I, 11.6% of total) and glutamic-oxalate transferase (GOT) activity to 37 U/I. Emergency cardiac catheterisation, performed 4 hours after renewed onset of precordial pain showed no abnormal findings in the right coronary artery, despite the ECG signs, but a definite filling defect in the anterior interventricular branch, which on intravascular ultrasound was an echo-dense noncalcified structure. TREATMENT AND COURSE: After percutaneous transluminal coronary angioplasty in the area of the obstructing structure a free-floating mass was identified in the proximal part of the anterior interventricular branch, most likely a thrombus. Intercoronary thrombolysis was therefore undertaken with urokinase (bolus of 1 mill. IU) together with the chimeric monoclonal antibody c7E3, which inhibits platelet aggregation by blocking the platelet glycoprotein surface receptor IIb/IIIa. Coronary angiography 12 hours later revealed almost complete dissolution of the previously obstructing mass. CONCLUSION: Combining the platelet aggregation inhibitor c7E3 with a thrombolytic agent is an alternative treatment to the current management of intracoronary thrombi. Intravascular ultrasound is a suitable method for demonstrating angiographically inconspicuous or unclear but pathogenetically significant vessel changes.

Contrast echocardiography for assessment of myocardial perfusion.

It has been suggested that the myocardial perfusion can be qualitatively and quantitatively assessed by different ultrasound contrast techniques. It has been reported that the intracoronary or intraaortic administration of the ultrasound contrast agents can be used to visualize perfusion defects or to analyze the coronary flow reserve. The perfusion analysis after intracoronary injection of ultrasound contrast agents seems to be established, but there are a lot of open questions. A topographic (qualitative) perfusion analysis with visualization of perfusion defects and perfusion areas or analysis of collaterals has been demonstrated. A quantitative analysis of myocardial blood flow has been described but the existing studies are inconsistent. It is not known which parameters of the contrast wash-out curves should be used for perfusion analysis and if the Stewart-Hamilton curve analysis can be transferred to all ultrasound contrast agents as a model for quantitative myocardial blood flow assessment. The development of the transpulmonary contrast agents for echocardiographic evaluation of left ventricular cavity has the impact for myocardial perfusion imaging. The increase of myocardial intensity does not mean that a qualitative or quantitative perfusion analysis can be clinically used. In this field we have to differentiate between the possibilities of qualitative discrimination of perfusion defects and quantitative perfusion (myocardial blood flow) analysis. The different scanning conditions, the poor transthoracic ultrasound window and insufficient enhancement of the myocardial intensity make it problematic to quantify the myocardial perfusion. At the moment myocardial intensity will be increased after intravenous injection of transpulmonary contrast agents, but the value for perfusion analysis has not been shown. New ultrasound technologies such as second harmonic imaging, power-mode and raw data analysis have to show the clinical importance of these techniques for perfusion analysis in daily clinical routine. The open questions of the perfusion analysis by contrast echocardiography will be discussed in this review article.

[Detection of ventricular asynchrony using tissue Doppler echocardiography--a new method for assessing left ventricular wall motion]. / Aufdeckung ventrikulärer Asynchronie mittels Gewebe-Doppler-Echokardiographie (tissue Doppler echocardiography-TDE)--ein neues Verfahren zur linksventrikulären Wandbewegungsanalyse.

UNLABELLED: The asynchrony of the heart in patients with coronary artery disease can be detected by digitized cine- and radionuclidventriculography. Both methods require time-consuming offline analysis. The aim of the current study was the assessment of the clinical value of the recently developed tissue Doppler echocardiography (TDE) to detect myocardial asynchrony. In the current study, 21 healthy subjects (age 49 +/- 14 y) and 22 patients with known coronary artery disease (20 with > 70% luminal narrowing of the LAD, 4 with a history of CABG, age 58 +/- 12 y) were included. In the apical 4-chamber-view, midseptal and midlateral LV segments were analyzed by 2-D and M-Mode-TDE. Evaluation was possible in 20 healthy subjects (95%) and 20 CAD patients (91%). During isovolumic relaxation time (IVRT) healthy subjects showed slow synchronous outward motion of the septum and the free wall with homogenous color coding (blue/green) and low negative tissue velocities followed by rapid symmetrical outward motion during rapid filling (RF) and atrial contraction (AC) phase (high negative velocities). During diatasis (DI) almost no wall motion could be detected. In 17 (85%) of 20 CAD patients, myocardial asynchrony during IVRT was detected; while the septum was moving inward (red coding with low positive velocities), the free wall was moving outward (blue green coding with low negative/velocities). After opening of the mitral valve, all CAD patients showed rapid, symmetrical outward motion of both the septum and the free wall with homogenous color coding and high negative tissue velocities. CONCLUSION: Tissue Doppler echocardiography detects ventricular asynchrony online. In patients with significant LAD stenosis, a pathological septal movement is observed during isovolumic relaxation time. Determinants of the etiology could be chronic hypoperfusion or ischemia ("hibernating myocardium").

[Comparison of stress echocardiography and radionuclide ventriculography in the diagnosis of cardiomyopathy in patients receiving chemotherapy for malignant diseases]. / Vergleich von Belastungsechokardiographie und Radionuklidventrikulographie in der Diagnostik der Kardiomyopathie bei Patienten mit malignen Erkrankungen unter Chemotherapie.

BACKGROUND AND OBJECTIVE: Early evidence of drug-induced cardiomyopathy (CMP) is of great importance in haematological treatment, especially with anthracyclines. Stress echocardiography (SEC) has proved of value in determining left ventricular function at rest and under stress in patients with heart disease. The study was undertaken to assess the value of SEC in comparison with radionuclide ventriculography (RNV). PATIENTS AND METHODS: 63 unselected patients with malignant tumour (20 women, 43 men; mean age 49 +/- 15 years) underwent SEC and RNV. No chemotherapy had yet been started in 17 of them, 43 had received anthracyclines as main component of the chemotherapy (mean anthracycline dose 339 +/- 251 mg/m2). Left ventricular ejection fraction (LVEF) was measured by both SEC and RNV at rest and during standardized stress (recumbent ergometry). Both methods were applied and results measured independently by two examiners. RESULTS: The time interval between the two tests averaged 1 = 2 days. EC could be performed at rest in 62 of 63 and under stress in 59 of 63 patients (RNV: 63 of 63 and 54 of 63, respectively). Resting LVEF was 61 +/- 8% by SEC and 64 +/- 9% by RNV (P < 0.05). LVEF during stress, measured by SEC, was 71 +/- 11% and 73 +/- 10% by RNV (not significant). Mean LVEF increase between rest and stress was 9 +/- 10% by SEC and 9 +/- 8% by RNV (not significant). CONCLUSION: SEC is a satisfactory alternative to RNV in the assessment of ventricular function in patients receiving chemotherapy. It is less involved and more cost-effective than RNV, avoids radiation exposure and provides additional information on heart size and segmental contraction abnormalities.

Tomographic left ventricular volume determination in the presence of aneurysm by three-dimensional echocardiographic imaging. I: Asymmetric model hearts.

To improve the accuracy of measurements of left ventricular volume in the presence of an aneurysm, we used three-dimensional echocardiographic imaging to analyze the shape of left ventricles in 23 asymmetric model hearts with eccentric aneurysms of different sizes, shapes, and localizations. A standard 3.75 MHz ultrasound probe with a rotation motor device was used to obtain a three-dimensional data set. By rotating the probe stepwise 1 degree, 180 radial ultrasound pictures were digitized. On the basis of the three-dimensional data set, the following parameters were determined and compared with the dimensions of the model hearts obtained by direct measurement: total left ventricular volume (LVV), aneurysm volume, area of the aneurysm's base, the longest aneurysm long diameter, and the longest aneurysm cross diameter. In addition, quantification of LVV by three-dimensional echocardiography was compared with biplane two-dimensional echocardiographic measurement according to the disk method. Good agreements were found for LVV measured by both techniques, three-dimensional echocardiographic and direct measurement (mean of differences = 0.91 ml; SD of differences = +/- 6.23 ml; line of regression y = 1.07 x - 14.24 ml; r = 0.968; standard error of the estimate [SEE] = +/- 6.17 ml), aneurysm volume (mean of differences = 0.43 ml; SD of differences = +/- 2.14 ml; line of regression y = 1.05 x - 0.81 ml; r = 0.996; SEE = +/- 1.96 ml), area of the aneurysm's base (mean of differences = 0.24 cm2; SD of differences = +/- 1.72 cm2; line of regression y = 1.02 x - 0.02 cm2; r = 0.981; SEE = +/- 1.75 cm2), the longest aneurysm long diameter (mean of differences = -0.26 mm; SD of differences = +/- 1.60 mm; line of regression y = 0.97 x + 1.34 mm; r = 0.996; SEE = +/- 1.54 mm), and the longest aneurysm cross diameter (mean of differences = 1.35 mm; SD of differences = +/- 3.94 mm; line of regression y = 0.95 x + 3.17 mm; r = 0.941; SEE = +/- 3.99 mm). In contrast, in these extremely asymmetric-shaped model hearts, agreement between biplane two-dimensional echocardiographic and both direct LVV measurement (mean of differences = 7.8 ml; SD of differences = +/- 20.8 ml; line of regression y = 1.48 x - 92.45 ml; r = 0.874; SEE = +/- 18.36 ml) and three-dimensional echocardiographic measurements (mean of differences = -7.6 ml; SD of difference = +/- 18.1 ml; line of regression y = 0.59 x + 80.98 ml; r = 0.908; SEE = +/- 10.36 ml) was poor. Thus tomographic three-dimensional echocardiography allowed accurate volume determination of asymmetric model hearts in the shape of left ventricles with eccentric aneurysms.

[Intensive medical monitoring with transesophageal echocardiography in fulminant pulmonary embolism]. / Intensivmedizinisches Monitoring mit transösophagealer Echokardiographie bei fulminanter Lungenembolie.

HISTORY AND FINDINGS: A 60-year-old man underwent a continence-preserving anterior rectal resection for a high rectal carcinoma. After mobilisation on the 5th postoperative day dyspnoea and cyanosis suddenly developed requiring emergency intubation and mechanical ventilation. INVESTIGATIONS: His heart rate was 160/min, blood pressure 80/50 mmHg, mean pulmonary artery pressure by indwelling catheter was 70 mmHg. The electrocardiogram had the classical signs of acute right-heart overload. Transoesophageal echocardiography (TOE) demonstrated marked right-heart and pulmonary artery dilatation. TREATMENT AND COURSE: Despite thrombolytic treatment (bolus of 50 mg r-TPA; one day later bolus of 1 million IU urokinase followed by 100,000 IU/h) a new thromboembolus was seen by TOE to straddle the pulmonary artery bifurcation. After the urokinase dosage had been raised to 200,000 IU/h TOE on the 6th day no longer showed the embolus and documented a reduction in right-heart dilatation associated with improved haemodynamics. CONCLUSION: TOE is an ideal method for the rapid diagnosis and for monitoring the response to treatment of fulminant pulmonary arterial embolism. As it can also diagnose thromboembolism without significant haemodynamic consequences it is possible to adjust fibrinolytic treatment accordingly.

Comparison of a new intravenous echo contrast agent (BY 963) with Albunex for opacification of left ventricular cavity.

Transpulmonary echo contrast agents improve the evaluation of left ventricular function by two-dimensional echocardiography due to a better endocardial border delineation. To compare the contrast effect in the right and left ventricular cavities, a new transpulmonary echocontrast agent, BY 963 and Albunex were intravenously administered to five non-anaesthetized dogs. The right and left ventricular echocardiographic image intensities were quantitatively measured at 60 cardiac cycles using a commercially available ultrasound system. BY 963 and Albunex were intravenously administered at three doses: 0.01 ml/Kg, 0.05 ml/Kg and 0.1 ml/Kg. The area under the curve (AUC, intensity units x heart cycles) and peak intensity (Peak I, intensity units) were estimated for the right (RV) and left ventricular (LV) cavities at the mid ventricular level using acoustic intensitometry. BY 963 injection produced the following values: At the dose of 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 702 +/- 449, 877 +/- 470 and 890 +/- 320 intensity units x heart cycles in RV and to 542 +/- 406, 806 +/- 557 and 721 +/- 392 in LV (LV/RV ratios: 77%, 92% and 81%). Peak I was at the doses 0.01, 0.05 and 0.1 ml/Kg 29 +/- 4.7, 33 +/- 5.2 and 35 +/- 3.2 intensity units in RV and 18 +/- 5.9, 21 +/- 6.2 and 20 +/- 3.3 in LV (LV/RV ratios: 62%, 64% and 57%). Albunex also produced right and left heart opacification values: at the doses 0.01, 0.05 and 0.1 ml/Kg the AUC amounted to 416 +/- 231, 493 +/- 231 and 674 +/- 390 in RV and to 71 +/- 71, 158 +/- 102 and 277 +/- 120 in LV (LV/RV ratios: 17%, 34% and 41%). Peak I was at the doses of 0.01, 0.05 and 0.1 ml/Kg 19 +/- 5.2, 23 +/- 5.4 and 29 +/- 4.1 in RV and 8 +/- 4.8, 13 +/- 4.7 and 17 +/- 3.2 in LV (LV/RV ratios: 42%, 57% and 59%). Intravenous injection of BY 963 leads to complete opacification of the left ventricular cavity and to high AUC values and peak intensity values at all three dosages. The loss of contrast effect from the right to the left ventricular cavity was very low: the LV/RV ratio of BY 963 was higher than that of Albunex. The new transpulmonary echo contrast agent BY 963 promises to be an excellent echo contrast agent for the noninvasive assessment of left ventricular function.

Intravascular ultrasound: a guide for management of complications during intervention?

Within a few years, intravascular ultrasound (IVUS) has emerged from a research tool into an intrinsic part of modern invasive cardiology, mainly because histology can be obtained 'in-vivo'. For the first time in invasive cardiology it is possible to base decisions not only on lumenograms but also on vessel wall assessment. IVUS can be used as both a diagnostic tool and for intervention purposes. Its diagnostic strength lies in its ability to monitor compensatory coronary artery enlargement as a response to arteriosclerosis, to reveal occult left main stem disease, and angiographically 'silent' arteriosclerosis. As regards intervention, IVUS aids in optimal device selection, i.e. whether to use rotablators in calcified lesions or atherectomy devices in large plaques. The effects of PTCA on vessel wall morphology can be studied in great detail and the effect on luminal gain assessed almost on-line. Several groups have shown that the residual plaque area, even after angiographically successful PTCA, is about 60%. A significant reduction in this percentage may influence long-term outcome after PTCA. Luminal areas that are minimal after PTCA seem to indicate restenosis, while morphological appearance on its own seems to be less predictive. One answer to the shortcomings of standard PTCA are coronary artery stents. Intravascular monitoring of stent expansion led to the deployment of high-pressure stents with a significant increase in post-procedural luminal diameters, and finally the ability to withhold anticoagulation in patients with optimal stent deployment. Furthermore, integrated devices, such as balloons on IVUS catheters, steerable catheters, integrated flow measurements, pressure transducers, and, hopefully, tissue characterization, will further enhance the usefulness of IVUS.

[Stress echocardiography--a new test for evaluating the anti-ischemic effect of medication]. / Belastungsechokardiographie--ein neuer Test zur Erfassung einer antiischämischen Medikamentenwirkung.

Exercise echocardiography and exercise electrocardiography were performed to test the anti-ischemic effects of isosorbide dinitrates (2 x 40 mg) und nisoldipine (2 x 10 mg) using a randomized, double-blind, placebo-controlled crossover trial. A total of 24 patients with symptomatic coronary artery disease and exercise-induced ST segment depression underwent 144 investigations (6 in each patient) at the first placebo treatment, 1st and 8th day during treatment with the first drug and the second placebo treatment 1st and 8th day during treatment with the second drug. A wall motion score (sum of 14 segments; wall motion grading: normal = 1, hypokinetic = 2, akinetic = 3, dyskinetic = 4) and ST depression at the exercise were used to assess the anti-ischemic effects. Both drugs reduced the number of exercise-induced wall motion abnormalities on the maximal comparable exercise level in comparison to placebo treatment. The wall motion score on the maximal comparable exercise level during placebo treatment was 25.5 +/- 6.9, during isosorbide dinitrate treatment (1 day) 23.5 +/- 7.2 and 23 +/- 6.7 (8th day; for both treatment days, p < or = 0.001 vs. placebo treatment), and during nisoldipine treatment (1st day) 23.6 +/- 5.9 and 23 +/- 6.8 (8th day; p < or = 0.001). ST segment depression changed at exercise during first placebo treatment to 0.153 +/- 0.068 mV, during ISDN treatment to 0.102 +/- 0.055 (1st day, p < 0.001) and to 0.117 +/- 0.056 (8th day, p < 0.001). ST segment depression during nisoldipine treatment was 0.121 +/- 0.075 mV on the 1st day (p < or = 0.002) and 0.120 +/- 0.071 mV on the 8th day (p < 0.001). Exercise echocardiography can be used to test anti-ischemic drug effects. There were no differences in the reduction of exercise-induced ischemia between the two drugs.