Comparison of epicardial, abdominal and regional fat compartments in response to weight loss.

BACKGROUND AND AIMS: Echocardiographic measurement of epicardial fat (EF) seems to be a reliable and diagnostic marker of visceral adipose tissue (VAT). However, the weight loss-induced changes in EF have not been compared with those in VAT or the truncal depot. In this study, we aimed to compare the weight loss-induced changes in EF, VAT and other regional fat compartments in obese men. METHODS AND RESULTS: In this study, 27 moderately obese men (age 45.8+/-1.7 years; body mass index 30.5+/-0.7 kg/m(2)) followed a daily low-calorie diet as part of a clinical 12-week weight loss interventional study. We evaluated the EF thickness by transthoracic echocardiography, assessed the abdominal fat tissues by computed tomography scans, and examined the regional and whole body fat compartments by dual X-ray absorptiometry. An average decrease of 26.8% in the initial calorie intake corresponded to post-program reductions of 17.2%, 11.0%, 16.6%, and 29.8% in EF thickness (P<0.001), body mass, percentage fat mass, and abdominal fat compartments, respectively. The percentage change in VAT in response to weight loss was twice as high as the substantial change in EF tissue (P<0.001). CONCLUSION: The results of the study suggest that a low-calorie diet-induced weight loss decreases EF thickness. Moderate diet-induced weight loss alone may represent an effective nonpharmacological strategy for reducing EF, which is a unique, pathogenic fat depot and an emerging marker of VAT.

Effect of 12 weeks of moderate-intensity resistance training on arterial stiffness: a randomised controlled trial in women aged 32-59 years.

BACKGROUND: Resistance training has been increasingly incorporated into the overall exercise programme because of its effect on muscle strength, functional capacity and osteoporosis. High-intensity resistance training increases arterial stiffness. However, the effect of moderate-intensity resistance training on arterial stiffness is unknown. OBJECTIVE: To determine whether 12 weeks of moderate-intensity resistance training increases arterial stiffness in middle-aged women. METHODS: 35 middle-aged women (age range 32 to 59 years) volunteered to participate. The subjects were randomly assigned to one of three groups: resistance training (RT) group, aerobic exercise training (AET) group or control group. The RT and AET groups performed 12 weeks of moderate-intensity resistance training or aerobic exercise training (two days/week). RESULTS: In the RT group, one-repetition maximum strength significantly increased after the intervention. Interestingly, aortic (carotid-femoral) pulse wave velocity (PWV; an index of arterial stiffness), and peripheral (femoral-ankle) PWV did not change with moderate-intensity resistance training. In contrast, in the AET group, carotid-femoral PWV significantly decreased after the intervention. Resistance training and aerobic exercise training did not affect blood pressure. CONCLUSIONS: This study found that moderate-intensity resistance training did not increase arterial stiffness in middle-aged women, which may have great importance for health promotion with resistance training.

The regulation of adiponectin receptors expression by acute exercise in mice.

Adiponectin is an adipocyte-derived factor that plays a pivotal role in lipid and glucose metabolism. Recently, two types of adiponectin receptors (AdipoR1 and AdipoR2) were identified. While, although physical exercise is useful for improving insulin sensitivity, the effect of physical exercise on adiponectin and adiponectin receptors are still unclear. In present study, we investigated whether acute exercise affects the plasma adiponectin concentration and expression of adiponectin receptor in skeletal muscle and liver in healthy mice C57BL/6. Following an acute exercise, plasma glucose, insulin, FFA, and adiponectin were measured. The mRNA levels of AdipR1 and AdipoR2 were also analyzed. Although acute exercise did not significantly change plasma adiponectin concentration at 2 hours or 18 hours after the exercise compared with control group, the expression levels of AdipoR1 significantly increased in both skeletal muscle (2H: 1.2-fold, p=0.0423, 18H: 1.4-fold, p=0.0006) and liver (2H: 1.3-fold, p=0.0448) compared with control group. In contrast, the level of AdipoR2 mRNA was decreased in skeletal muscle (18H: 0.8-fold, p=0.027) and liver (2H: 0.9-fold, p=0.1551) compared with control group. Additionally, the transcription factor Foxo1 mRNA expression level was also significantly increased in skeletal muscle (2H: 10-fold, p=0.0001, 18H: 3-fold, p=0.0424) and liver (2H: 2-fold, p=0.002, 18H: 2-fold, p=0.0014) compared with control group by the acute exercise. These findings suggest that acute exercise affects the expression level of adiponectin receptors, and an increase of Foxo1 expression might be relative to regulate adiponectin receptors.

Effects of leg resistance training on arterial function in older men.

BACKGROUND: Little information is available on the effect of strength training on vascular function, particularly in older people. OBJECTIVE: To determine the effect of resistance training on arterial stiffness and endothelial function in older adults. METHOD: Eleven healthy men (mean (SEM) age 64 (1) years) performed 12 weeks of resistance training involving knee flexion and extension (three sets a day, two days a week). RESULTS: Resistance training increased maximal muscle power by 16% (p<0.0001). Arterial stiffness as assessed by aortic pulse wave velocity did not change with resistance training. Plasma concentration of nitric oxide (NO), measured as its stable end product (nitrite/nitrate), had increased (p<0.05) after resistance training (61.2 (10.4) v 39.6 (3.2) micromol/l). There was no change in plasma concentration of endothelin-1. CONCLUSION: The results suggest that short term resistance training may increase NO production without stiffening central arteries in healthy older men.

Alterations in left ventricular wall stress and coronary circulation in patients with isolated systolic hypertension.

OBJECTIVES: To study the alterations in cardiac function and coronary circulation in patients with isolated systolic hypertension (ISH). PATIENTS: Ten patients with a history of ISH were studied and findings were compared with those of seven normotensive subjects. All of the patients had angiographically normal coronary arteries. They underwent cardiac catheterization, and haemodynamic variables and coronary flow velocity were measured. All of the patients also underwent treadmill exercise testing. MAIN OUTCOME MEASURES: Left ventricular mass was evaluated by echocardiography. The coronary flow velocity data were obtained by using the intracoronary Doppler catheter technique. ST-segment depression was observed on the exercise electrocardiogram. RESULTS: Systemic vascular resistance did not differ, whereas total arterial compliance was decreased in the ISH patients versus the controls (P < 0.001). The left ventricular mass of the ISH patients was increased slightly, but their left ventricular systolic wall stress was greater than that of the controls (P < 0.01). The coronary flow reserve ratio and the ratio of diastolic to total coronary flow were decreased in the ISH patients versus the controls (P < 0.01). ST-segment depression on the exercise electrocardiogram was frequently observed in the hypertensive patients (80 versus 0% in control subjects, P < 0.01). CONCLUSIONS: Patients with ISH were characterized haemodynamically by a decrease in arterial compliance. They showed an increase in left ventricular systolic wall stress and also showed decreases in coronary flow reserve ratio and in the relative diastolic coronary flow. Such alterations observed in patients with ISH are detrimental to the heart and may contribute to a reduced exercise capacity and the induction of subendocardial ischaemia during exercise.

Resting asynchronous left ventricular contraction abnormality analyzed by a phase method in spastic angina pectoris.

UNLABELLED: Quantitative phase analysis of equilibrium ventriculography was performed to study the character of left ventricular (LV) wall motion abnormalities in patients with spastic angina pectoris, who may have clinically and electrocardiographically silent ischemia combined with myocardial stunning, during rest and hyperventilation stress testing. METHODS: Phase analysis of the left ventricle at rest was performed by equilibrium radionuclide ventriculography in 13 control subjects and 36 patients with spastic angina pectoris. First-pass methodology along with hyperventilation stress testing was performed to assess spasm occurrences. Phase analysis of equilibrium multigated blood-pool scintigrams was performed to evaluate LV asynchrony at rest. RESULTS: The mean s.d. of LV phase distribution in the patients with variant and vasospastic angina was greater than that in the healthy control subjects (11.28 +/- 1.79 and 10.02 +/- 1.57 degrees versus 6.16 +/- 1.07 degrees). In addition, the mean s.d. of LV phase distribution in the variant angina group was greater than that in the vasospastic angina group. Furthermore, a linear correlation was found between the s.d. of LV phase distribution at rest and the percent decrease in ejection fraction during hyperventilation stress. CONCLUSION: Asynchronous LV contraction without significant hypokinesis was detected at rest in spastic angina pectoris. The severity of this asynchronous contraction corresponded well with decreases in ejection fraction during hyperventilation stress testing. Thus, analysis of the s.d. of LV phase distribution at rest is expected to provide useful information regarding LV asynchrony in spastic angina pectoris.

Mechanisms of stress-induced ST elevation and negative T-wave normalization studied by serial cardiokymogram in patients with a previous myocardial infarction.

Seventeen patients with a previous myocardial infarction were studied during pacing to characterize the clinical correlates of ST elevation, to analyze the relation between ST elevation and negative T-wave normalization and to investigate the mechanism of these electrocardiographic changes. Myocardial ischemia was evaluated by measurement of blood lactate, and wall motion was analyzed using cardiokymographs concurrently and serially. Results show that ST elevation and negative T-wave normalization were most marked in leads containing abnormal Q waves, that ST elevation greater than or equal to 1 mm during pacing was associated with a significant increase in left ventricular end-diastolic pressure and deterioration of left ventricular wall motion and that the magnitude of ST elevation and negative T-wave normalization was significantly correlated, but the latter appeared earlier and more markedly. In addition, there was no significant correlation between the extent of either ST elevation or negative T-wave normalization and myocardial lactate production. Thus, ST elevation and negative T-wave normalization are caused by abnormal left ventricular wall motion rather than myocardial ischemia. Negative T-wave normalization is a more sensitive marker of abnormal wall motion than ST elevation in patients with a previous myocardial infarction.

Relation of a decrease in arterial compliance to ST segment depression on exercise electrocardiograms in patients with hypertension.

Decreased arterial compliance (ACo) and increased arterial resistance are the major alterations of arterial function in patients with hypertension. The influence of decreased ACo on the heart was investigated in patients with hypertension. Patients with a systolic blood pressure of > 140 mmHg, a diastolic blood pressure of > 90 mmHg, or both, who had normal coronary arteriograms were enrolled. These patients were divided into two groups according to the value of ACo: Group I, patients with ACo > or = 0.9 ml/mmHg (n = 15); and Group II, patients with ACo < 0.9 ml/mmHg (n = 13). There were no significant differences in arterial resistance, age, gender, and body surface area between the groups. Echocardiographic, hemodynamic, and exercise stress test variables were compared between the groups. There were no differences between the groups in left ventricular (LV) wall thickness and volume, cardiac output, LV end-diastolic pressure, and LV ejection fraction. However, pulse pressure was higher in Group II than in Group I. Ergometer exercise stress testing revealed that, although exercise duration and the peak rate-pressure product were similar in the two groups, ST segment depression of > or = 1.0 mm on the exercise electrocardiograms was induced more frequently in Group II than in Group I (92% vs. 27%, p < 0.001). Thus, the decrease in ACo in patients with hypertension may not significantly affect LV wall thickness, volume, or ejection fraction; however, it may increase pulse pressure and may adversely affect coronary circulation, as suggested by the ST segment depression on exercise electrocardiograms.

Variable neurohumoral and hemodynamic responses to exercise in patients with exertional angina: influence of the severity of coronary artery disease.

To assess neurohumoral and hemodynamic responses to exercise in patients with exertional angina, we measured plasma norepinephrine (NE) concentrations in 23 patients with exertional angina (with no heart failure) and compared the results with their coronary arteriographic findings. The 23 patients were divided into two groups: 14 cases with multiple vessel disease (MVD) and 9 cases with one-vessel disease. At resting state there were no significant differences between the two groups in levels of NE. At maximal exercise there were no significant differences between the groups in increases of heart rate, blood pressure, and rate-pressure product, but exercise-induced increase of plasma NE (%) was significantly larger in MVD (131.6 +/- 95.4%) (mean +/- SD) than in one-vessel disease (69.0 +/- 45.3%) (p less than 0.01). In conclusion, plasma NE responses to exercise differ between patients with multiple vessel disease and patients with one-vessel disease.

Difference in the response to isoproterenol between asymmetric septal hypertrophy and symmetric hypertrophy in patients with hypertrophic cardiomyopathy.

The response to isoproterenol was studied in 9 patients with hypertrophic cardiomyopathy (HCM) and asymmetric septal hypertrophy (ASH), 9 patients with HCM and symmetric hypertrophy (SH), and 9 normal controls (NC), using digitized M-mode echocardiography. There was no significant difference in fractional shortening (FS) between ASH and SH, nor between SH and NC before isoproterenol infusion. During isoproterenol infusion, however, FS was significantly greater in ASH (60 +/- 6%) than in SH (53 +/- 7%) and NC (49 +/- 5%) (p less than 0.05, p less than 0.01, respectively), and normalized peak rate of change of left ventricular dimension during systole (pVs) was greater in ASH (7.7 +/- 1.5/s) than in SH (5.2 +/- 0.8/s) and in NC (4.9 +/- 0.8/s) (p less than 0.001, p less than 0.001, respectively). This study shows that the response to isoproterenol of ASH differs from those of SH and of NC and suggests hypersensitivity of the beta-adrenergic receptor system in ASH and the possibility that ASH is a different clinical entity than SH.

Low-dose dobutamine radionuclide ventriculography for prediction of myocardial viability: quantitative analysis of regional left ventricular function.

BACKGROUND: It is important to distinguish viable myocardium from necrotic tissue in order to decide upon therapy in patients with ischemic heart disease. HYPOTHESIS: We verified the hypothesis that quantitative analysis of regional left ventricular function using low-dose dobutamine radionuclide ventriculography (RNV) can sensitively predict myocardial viability and compared its usefulness with thallium-201 (201Tl) single-photon emission computed tomography (201Tl-SPECT). METHODS: Radionuclide ventriculography at rest and during low-dose dobutamine infusion (5 micrograms/kg/min), 201Tl-SPECT, and coronary angiography were performed in 51 subjects with severe ischemia-related stenosis of coronary arteries and 3 subjects without coronary artery disease. 201Tl uptake was assessed as normal (control), low perfusion (LP), or defect. We compared the response of regional function to dobutamine with the regional 201Tl uptake. The accuracy of both methods for identifying viable myocardium was investigated in 17 patients who underwent successful coronary revascularization, with a resulting improvement in wall motion. RESULTS: The increase in regional ejection fraction (delta r-EF) in response to dobutamine was significantly greater in the control (12 +/- 6%) and LP (16 +/- 11%) regions than in the defect (5 +/- 10%) regions. The increase in one-third regional ejection fraction (delta r-1/3EF) was also significantly higher in the control (14 +/- 7%) and LP (10 +/- 8%) regions than in the defect regions (5 +/- 6%). We defined myocardial viability as a delta r-EF > 5% or a delta r-1/3EF > 2%. The sensitivity and specificity of the delta r-EF for identification of myocardial viability were 91.4 and 55.5%, respectively. The sensitivity and specificity of the delta r-1/3EF were 91.4 and 66.6%, respectively; the corresponding values for 201Tl SPECT were 74.2 and 77.8%. CONCLUSION: Low-dose dobutamine RNV with quantitative analysis of regional left ventricular function was more sensitive for identification of viable myocardium than 201Tl-SPECT.

Relationship between mitochondrial DNA polymorphism and the individual differences in aerobic performance.

This study focused on the mitochondrial DNA (mtDNA) as the genetic factor most likely to bring about the individual difference in endurance capacity or its trainability. Platelets contain mtDNA but no nuclear DNA, whereas rho(0)-HeLa cells have nuclear DNA but no mtDNA. The oxidative capacity of mitochondria in the cultured cells, which were fused rho(0)-HeLa cell with platelets obtained from individual subjects (the so-called "cybrids"), reflects the individual mtDNA polymorphism in the gene-coding region. The purpose of this study was to investigate the relationship between the oxidative capacity of cybrids and the individual difference in endurance capacity, or its trainability. Forty-one sedentary young males took part in an 8-week endurance training program. They were determined by using their VO(2 max) as an index of endurance capacity on an ergocycle before and after the endurance training program. The relations between VO(2 max) before endurance training or the change of it by endurance training and the oxidative capacity of cybrids were investigated. There was no relation between them, and two groups were drawn from all subjects, based on one standard division of their initial VO(2 max): the higher pre-VO(2 max) group (n = 6) and the lower pre-VO(2 max) group (n = 5) (51.8 +/- 3.5 ml/min/kg vs. 33.3 +/- 3.8 ml/min/kg, p < 0.01). No significant difference was found between the O(2) consumption of the cybrids in the higher initial VO(2 max) group and that in the lower initial VO(2 max) group (16.3 +/- 4.9 vs. 15.9 +/- 2.0 nmol O(2)/min/10(7) cells, NS). Furthermore, neither the cytochrome c oxidase (COX) activity nor the complex I + III activity of cybrids showed a significant difference between the two groups. The oxidative capacity of cybrids between the high trainability group (n = 6) (Delta VO(2 max) 12.1 +/- 1.6 ml/min/kg) and the low trainability group (n = 9) (Delta VO(2 max) 2.3 +/- 0.5 ml/min/kg) was also similar. Thus the mtDNA polymorphism is very unlikely to relate to the individual difference in endurance capacity or its trainability in young sedentary healthy subjects.

Perfusion and mechanical analysis with technetium-99m 2-methoxy-isobutyl-isonitrile in a case of dilated cardiomyopathy.

With technetium-99m 2-methoxy-isobutyl-isonitrile (99mTc-MIBI), regional wall thickening in a patient with dilated cardiomyopathy was analyzed by the first component Fourier method. The regional wall thickening was compared with thallium-201 and 99mTc-MIBI SPECT imaging. Thallium-201 SPECT images showed mildly reduced perfusion in the posterior wall and redistribution in the septum, whereas 99mTc-MIBI images showed heterogeneous accumulation around the left ventricular circumference. By means of phase analysis, diffusely decreased wall thickening and discontinuity of percent wall thickening in neighboring segments were observed throughout the left ventricle. Regional wall motion and wall thickening correlated roughly. However, discrepancies between the mechanical function and myocardial perfusion, and discrepancies in regional myocardial perfusion between thallium-201 and 99mTc-MIBI were observed.

Quantitative phase analysis of myocardial wall thickening by technetium-99m 2-methoxy-isobutyl-isonitrile SPECT.

Regional wall thickening was assessed by ECG-gated SPECT using technetium-99m 2-methoxy-isobutyl-isonitrile (99mTc-MIBI). For myocardial segments with an optimal short axis, regional count changes from end-diastole to end-systole were used to calculate the regional wall thickening. Functional images displaying amplitude, % wall thickening (% WT), and phase were generated by a fundamental Fourier analysis. In the control subjects, % WT analysis showed heterogeneous contraction among the left ventricular wall segments. The amplitude values showed a similar pattern to the %WT values. Phase images demonstrated that the timing of ventricular contraction was almost homogenous between the various wall segments. In the CAD patients, regional decreases in amplitude and %WT corresponding to zones of reduced perfusion were shown in the ischemic segments. Phase images also indicated asynchronous contraction in these segments. Phase analysis of regional wall thickening in 99mTc-MIBI scintigraphy seems to be useful for understanding regional myocardial function in combination with perfusion scanning.

A study of ventricular contraction sequence in complete right bundle branch block by phase analysis.

Twenty-four patients with complete right bundle branch block (CRBBB) combined with and without left axis deviation (LAD) on ECG, were compared with 17 normal subjects to evaluate the right ventricular contraction sequence and pattern in detail. Blood pool scintigrams were obtained in the left anterior oblique projection, and these images were analyzed by first component Fourier harmonics. In the normal subjects, the phase value distribution representing the pattern of ventricular contraction was almost homogeneous in both the right and left ventricles (RV & LV). In the CRBBB patients without LAD, the phase images showed apparent phase delay in the right ventricle. In the CRBBB patients with LAD, the phase images showed many different contraction patterns varying from normal to RV phase delay, owing to the effects of the hemi-block. Quantitative analysis of the absolute values, showed that the mean (RV-LV) value was 6.6 +/- 8.4 msec in the normal subjects. In the CRBBB patients without LAD, the duration of the QRS complex correlated with the mean (RV-LV) value, whereas no difference was observed between the duration of the QRS complex and the standard deviation of the right ventricle. Using phase analysis the degree of the RBBB can be determined from the phase images, and can be quantitatively analyzed as in electrical studies.

Phase changes caused by hyperventilation stress in spastic angina pectoris analyzed by first-pass radionuclide ventriculography.

To understand the effect of hyperventilation (HV) stress in patients with spastic angina, left ventricular (LV) contraction was analyzed by quantitative phase analysis. The study was performed on 36 patients with spastic angina pectoris, including vasospastic angina pectoris (VspAP: 16 patients) and variant angina pectoris (VAP: 20 patients). First-pass radionuclide ventriculography (first-pass RNV) was performed at rest and after HV stress, and standard deviation of the LV phase distribution (SD) was analyzed. The SD was lower in patients with VspAP than in VAP (12.8+/-1.4 degrees vs. 14.6+/-2.2 degrees, p < 0.005) at rest. After HV stress, the SD (HVSD) tended to increase in VspAP patients (62.5%), whereas the SD decreased in VAP patients (70%). Due to HV stress, the percentage change in SD (%SD) in VspAP patients was 8.9+/-23.7% whereas that in VAP patients was -9.1+/-17.3% (p < 0.01). Moreover, phase histograms were divided into HVSD increase and HVSD decrease groups. The HVSD increase group had a decrease of HVEF, but the HVSD decrease group tended to have more decreased HVEF than the HVSD increase group. These results indicate that spastic angina pectoris patients show various responses to HV stress. The HVSD increase group might have additional myocardial ischemia due to regional coronary spasm. In contrast, in the HVSD decrease group severe LV dysfunction or diffuse wall motion abnormality might have been generated, and this caused a reduction in the SD value. Phase analysis would therefore add new information regarding electrocardiographically silent myocardial ischemia due to coronary spasm, and HV stress might increase sensitivity for the detection of abnormalities in quantitative phase analysis, especially in VspAP patients.

Evaluation of myocardial perfusion abnormality by profile analysis for digital subtraction angiogram.

For quantitative estimation of ischemia, ECG-synchronized digital subtraction angiography was performed for selective coronary arteriography. The authors obtained sequential myocardial perfusion images at the arterial, capillary, and venous phases. Profile densitometry was performed along the cross section perpendicular to the long axis of the left ventricle to assess regional myocardial perfusion at the capillary phase quantitatively. By this densitometry, the volumes of vascular bed perfused by the left coronary artery could be estimated, and further, nontransmural myocardial infarction could be differentiated from transmural myocardial infarction through the profile of its density curve. This method appears to be useful for the analysis of myocardial perfusion of ischemic heart disease.

Sudden death in hypertrophic cardiomyopathy, a guideline to prevention in daily life.

To establish guidelines for individuals with hypertrophic cardiomyopathy (HCM) to follow in their daily lives and minimize the chance of sudden death (SD), circumstances of SD in 24 autopsied definite HCM cases were compared with those with 905 autopsied cases of other heart diseases. Circumstances of symptoms experienced in daily activities of 35 age-matched surviving HCM cases were also studied. In the autopsied HCM cases, SD occurred during exertion more frequently (79.2%) than in the other autopsied cardiac patients (22.7%). Sudden changes in pace or movement accompanied by mental excitement, such as hurrying to board a train, were more frequent causes of SD in HCM (47.4%) than in other cardiac patients (8.3%). In the surviving HCM cases, symptoms of distress occurred frequently during very hard work or with sudden rapid movement. Thus, one probable daily guideline for HCM sufferers would appear to be not only to eliminate very hard work but also to lead mentally and physically quiet and relaxed life.

Functional significance of coronary collateral vessels during exercise evaluated by radionuclide angiocardiography: the importance of supplying arteries.

To investigate the function of coronary collateral vessels, especially from view point of supplying arteries, radionuclide angiocardiography was performed before and during a symptom-limited ergometer exercise in 54 patients with effort angina. In single vessel disease, during exercise, left ventricular ejection fraction (EF) (%) increased in the cases with coronary collateral vessels (supplied from patent arteries) (72 +/- 7----77 +/- 8, p less than 0.025), but decreased in those without (66 +/- 10----61 +/- 10, P less than 0.001). In multivessel disease, EF decreased during exercise even in those with collaterals (supplied from stenosed arteries) (67 +/- 10----59 +/- 8, p less than 0.001). It is concluded that angiographic appearance of the coronary arteries supplying collateral vessels is a major predictive factor of the function of coronary collateral vessels and of left ventricle during exercise.

[New trends in diagnostic examinations in clinical cardiology].

There are various kinds of diagnostic examinations in the field of clinical cardiology. In this field, information concerning cardiac structure, dimensions (hypertrophy and dilatation) and cardiac functions are inevitably important. Noninvasive methods are desirable. Except for radiological examinations, electrocardiography and ultrasonic echocardiography are 2 main examinations in cardiology. Holter monitoring is one of the recent topics in clinical electro-cardiology. It is useful for the detection of rest angina or variant angina. Recently "silent myocardial ischemia" has been studied by using this method. This method is also useful for the study of arrhythmia, which is a major cause of sudden death. Quantitative analysis of arrhythmia in the studies of antiarrhythmic drugs can also be done by Holter monitoring. Late potential is also a topic in electro-cardiology. Ultrasonic echocardiography can detect the changes of cardiac structure and function. Doppler echocardiography, developed recently, has made it possible to estimate intracardiac pressure (especially pulmonary arterial pressure) noninvasively. With esophageal echocardiography findings in left atrium, such as thrombus or myxoma in left atrium can be obtained. The most appropriate tool must be selected from the many kinds of diagnostic examinations for efficient clinical diagnosis and therapy.