The impact of clinical practice on the outcome of central venous access devices in children with haemophilia.

INTRODUCTION: Central venous access devices facilitate home treatment in boys with haemophilia. These are usually fully implanted lines, referred to as ports. Caregivers are taught to manage the port using sterile techniques and maintaining patency by flushing with saline or heparin solution. National and international guidelines for the home care of ports are lacking. AIM: To evaluate if infection or occlusion rates differ between home care regimens used for ports in children with haemophilia. METHODS: Children with ports were identified from the PedNet registry. Data on the homecare policy were acquired from each centre. To ensure a complete data set for each port, only ports that had been removed were included in the study. Three care groups were defined: 'aseptic non touch technique', 'sterile technique' and 'fully sterile technique'. Outcomes within and between the groups were analysed. RESULTS: A total of 240 children with 352 ports were studied. Insertion occurred at a median age of 1.32 years. The median port duration was 2.94 years with a total of 215 688 port days in children without and 183 852 in children with inhibitors. Infection was the most common cause of port removal (34%); there was no significant difference with infection as reason for removal between the different care groups. Occlusion was not more frequent in centres that did not use heparin. CONCLUSION: Use of sterile gloves and gowns did not reduce the risk of port infection. Using less stringent sterile techniques for accessing ports is easier for caregivers and in addition may have health economic benefits.

Quality of life in adult patients with haemophilia--a single centre experience from Sweden.

Increased or maintained health and quality of life (HRQoL) are essential goals in health care among patients with a chronic disease. To gain an understanding of HRQoL in patients with haemophilia at the Haemophilia Treatment Centre in Malmö, Sweden, patients seen from 2004-2008 were asked to complete the Short form Health Survey, SF-36, also answering to what extent haemophilia, physically and mentally, interferes with their daily life at their annual check-up. Data were extracted from the UMAS Haemophilia Database. Interference of haemophilia in daily life was estimated using a Visual Analogue Scale. A total of 105/144 haemophilia patients were included in the study (73%); 28 mildly, 21 moderately and 56 severely affected. The median age of patients at study entry was 44.0 years (range 18-84 years). The comparison of SF-36 data of Swedish haemophilia patients with the general Swedish male population yielded no significant differences in age groups 15-24, 25-34 and 65-74 years. Patients in age groups 35-44 years, 45-54 years and 55-64 years were significantly impaired in some of their HRQoL domains. For severely affected patients who filled in SF-36 over a period of 5 years no statistical differences in HRQoL were found. For patients undergoing orthopaedic surgery HRQoL increased in most SF-36 domains. Patients reported in general on the VAS that they feel 'somehow' interfered in their daily life due to haemophilia. The results indicate a need for continuous monitoring of HRQoL to identify an increased need of care in the ageing haemophilia population.

Daily dosing prophylaxis for haemophilia: a randomized crossover pilot study evaluating feasibility and efficacy.

Regular replacement therapy (prophylaxis) for haemophilia has been shown to prevent development of disabling arthropathy and to provide a better quality of life compared to treatment on demand; however, at a substantially higher cost. Calculations based on pharmacokinetic principles have shown that shortening dose intervals may reduce cost. The aim of this prospective, randomized, crossover pilot study was to address whether daily dosing is feasible, if it reduces concentrate consumption and is as effective in preventing bleeding as the standard prophylactic dosing regimen. In a 12+12 month crossover study, 13 patients were randomized to start either their own previously prescribed standard dose, or daily dosing adjusted to maintain at least the same trough levels as obtained with the standard dose. Ten patients completed the study. A 30% reduction in cost of factor concentrates was achieved with daily prophylaxis. However, the number of bleeding events increased in some patients in the daily dosing arm and patients reported decreased quality of life during daily prophylaxis. Daily treatment had a greater impact on daily life, and the patients found it more stressful.Prophylaxis with daily dosing may be feasible and efficacious in some patients. A substantial reduction of factor consumption and costs can be realized, but larger studies are needed before the introduction of daily prophylaxis into clinical routine can be recommended.

The Swedish version of the Haemophilia Activity List.

There has been increasing interest in the patient's perspective on outcome of treatment. The Haemophilia Activity List (HAL) has been developed as a disease-specific questionnaire for haemophilia patients and is a validated self-report measure of function developed according to WHO's International Classification of Functioning, Disability and Health. To validate HAL in Sweden. The Dutch and English versions of HAL were translated into Swedish using 'the forward-backward translation' method and merged into a final Swedish version. Validation was performed against the Swedish version of the questionnaires Arthritis Impact Measurement 2 (AIMS 2) and Impact on Participation and Autonomy (IPA). Two hundred and twenty-five patients with severe and moderate forms of haemophilia A and B from three centres were invited to participate in the study. Spearman's rank correlation test was used for validation, and internal consistency of the HAL was calculated with Cronbach's alpha. Eighty-four patients (39%) (18-80 years old) filled out the questionnaires. The internal consistency of the Swedish version of HAL was high, with Cronbach's alpha being 0.98-0.71. Function of the legs had the highest consistency and transportation had the lowest. The correlation was excellent between the HAL sum score and AIMS 2 physical (r = 0.84, P < 0.01), IPA autonomy indoors (r = 0.83, P < 0.01) and autonomy outdoors (r = 0.89, P < 0.01). The Swedish version of HAL has both internal consistency and convergent validity and may complement other functional tests to gather information on the patient's self-perceived ability.

Knowledge of disease and adherence in adult patients with haemophilia.

Patients with moderate and severe haemophilia are evaluated on a regular basis at their haemophilia centres but patients with mild haemophilia are seen less often because of fewer problems related to their disease. The needs of patients with milder forms of haemophilia, however, are often underestimated, both by the patient and staff at healthcare facilities. This study evaluated the knowledge of disease and adherence to treatment among patients with severe, moderate and mild haemophilia. This was a prospective multicentre study performed in Haemophilia Centres in Scandinavia. A total of 413 (67%) of 612 patients aged >25 years with mild, moderate and severe haemophilia completed a self-administered questionnaire. The mean age of the respondents was 49.7 years (range 25-87 years). Of the 413 respondents, 150 had a mild, 86 had a moderate and 177 had a severe form of haemophilia. A total of 22 (5%) patients did not know the severity of their disease, and 230 (56%) patients knew the effect of factor concentrate in the blood. Of the 413 respondents, 53 (13%) of the cohort never treated a haemorrhage. Patients with mild haemophilia, P

Accuracy and feasibility of contrast echocardiography for detection of perfusion defects in routine practice: comparison with wall motion and technetium-99m sestamibi single-photon emission computed tomography. The Nycomed NC100100 Investigators.

OBJECTIVES: We sought to assess the feasibility and accuracy of myocardial contrast echocardiography (MCE) using standard imaging approaches for the detection of perfusion defects in patients who had a myocardial infarction (MI). BACKGROUND: Myocardial contrast echocardiography may be more versatile than perfusion scintigraphy for identifying the presence and extent of perfusion defects after MI. However, its reliability in routine practice is unclear. METHODS: Fundamental or harmonic MCE was performed with continuous or triggered imaging in 203 patients with a previous MI using bolus doses of a perfluorocarbon-filled contrast agent (NC100100). All patients underwent single-photon emission computed tomography (SPECT) after the injection of technetium-99m (Tc-99m) sestamibi at rest. Quantitative and semiquantitative SPECT, wall motion and digitized echocardiographic data were interpreted independently. The accuracy of MCE was assessed for detection of segments and patients with moderate and severe sestamibi-SPECT defects, as well as for detection of patients with extensive perfusion defects (>12% of left ventricle). RESULTS: In segments with diagnostic MCE, the segmental sensitivity ranged from 14% to 65%, and the specificity varied from 78% to 95%, depending on the dose of contrast agent. Using both segment- and patient-based analysis, the greatest accuracy and proportion of interpretable images were obtained using harmonic imaging in the triggered mode. For the detection of extensive defects, the sensitivity varied from 13% to 48%, with specificity from 63% to 100%. Harmonic imaging remained the most accurate approach. Time since MI and SPECT defect location and intensity were all determinants of the MCE response. The extent of defects on MCE was less than the extent of either abnormal wall motion or SPECT abnormalities. The combination of wall motion and MCE assessment gave the best balance of sensitivity (46% to 55%) and specificity (82% to 83%). CONCLUSIONS: Although MCE is specific, it has limited sensitivity for detection of moderate or severe perfusion defects, and it underestimates the extent of SPECT defects. The best results are obtained by integration with wall motion. More sophisticated methods of acquisition and interpretation are needed to enhance the feasibility of this technique in routine practice.

Stress-induced laboratory blood pressure in relation to ambulatory blood pressure and left ventricular mass among borderline hypertensive and normotensive individuals.

Our primary aim in the present study was to investigate the association between blood pressure measured in the laboratory and in the ambulatory state in a group of middle-aged borderline hypertensive men and age-matched normotensive control subjects. In addition, we examined the relation between stress-induced blood pressure measurements and left ventricular mass. Blood pressure and heart rate were measured noninvasively during a standardized laboratory stress protocol and four times per hour throughout 24 hours. Borderline hypertensive subjects had significantly higher systolic and diastolic pressures than normotensive subjects during both the daytime (systolic pressure, 141.1 +/- 9.7 versus 130.9 +/- 8.6 mm Hg; diastolic pressure, 88.8 +/- 7.0 versus 79.4 +/- 6.2 mm Hg, P < .001) and nighttime (systolic pressure, 114.0 +/- 9.9 versus 107.1 +/- 8.3 mm Hg; diastolic pressure, 71.5 +/- 7.5 versus 64.6 +/- 7.2 mm Hg, P < .001). The borderline hypertensive group also displayed increased systolic pressure reactivity in the laboratory compared with the normotensive group. The groups did not differ significantly in left ventricular mass (index). In both borderline hypertensive and normotensive individuals, blood pressure levels during stress testing were closely related to ambulatory blood pressure levels (r = .51 to .82). Furthermore, stress-induced blood pressure levels were significantly correlated to left ventricular mass in borderline hypertensive (r = .33 to .40) but not normotensive subjects. Since stress-induced blood pressure levels were significantly associated with both ambulatory blood pressure levels and left ventricular mass in borderline hypertensive subjects, the addition of standardized stress testing to casual blood pressure measurements may improve risk estimation.

Differences in the subjective well-being and symptoms of normotensives, borderline hypertensives and hypertensives.

In this study, previously untreated subjects were randomly recruited from a blood pressure screening programme. After repeated measurement of blood pressure levels, the subjects were divided into three major groups: normotensives (n = 95), borderline hypertensives (n = 69) and hypertensives (n = 30). Three self-administered standardized questionnaires were used to measure different aspects of subjective well-being and symptoms: the Nottingham Health Profile (NHP), the Subjective Symptoms Assessment Profile (SSAP) and the Minor Symptoms Evaluation Profile (MSEP). The results indicate gradual differences between the three groups, the most pronounced symptoms being seen among the hypertensives. Statistically significant differences were found for cardiac and gastrointestinal symptoms as well as for emotional reactions, home life, social life, sex life and sleep. The differences in well-being and subjective symptoms noted between the groups are important in the evaluation of new antihypertensive agents. Self-administered questionnaires of the type used in this study could also be valuable in identifying symptoms and disturbances in subjective well-being related to the antihypertensive medication per se.

Assessment and significance of ST-segment changes detected by ambulatory electrocardiography after acute myocardial infarction.

This study assessed the prognostic value of ST-segment changes detected by ambulatory electrocardiographic monitoring during the early in-hospital period after acute myocardial infarction. New methods for defining the ST-segment reference level and for measuring ST-segment elevation were used. ST-segment depression was defined as a change in ST level by > or = 0.1 mV 80 ms after the J point, elapsing > or = 1 minute. ST-segment elevation was defined as a deviation by > or = 0.15 mV, elapsing > or = 1 minute, and measured at the J point. An interval of > or = 2 minutes was required before another discrete episode was counted. Four ST-segment reference levels were automatically calculated: (1) "isoelectric," (2) "nearest to normal," (3) "24-hour median," and (4) "first-hour median." During a mean follow-up period of 3 years (mean 36 +/- 15 months), 47 cardiac events occurred in 38 patients: 18 deaths, 9 nonfatal reinfarctions, and 20 revascularization procedures. More deaths occurred in patients with than without ST elevation-24-hour median (22% vs 5%, p = 0.03), and in patients with than without ST depression-isoelectric (61% vs 32%, p = 0.02), and in patients with than without ST-depression-24-hour median (61% vs 23%, p = 0.003). "All cardiac events" (deaths, infarctions, or revascularization procedures) occurred more often in patients with than without ST depression-isoelectric (55% vs 22%, p = 0.003), and in patients with than without ST-depression-24-hour median (47% vs 17%, p = 0.004). Sensitivity, specificity, and accuracy of ST depression/elevation-24-hour median to assess mortality were 78%, 71%, and 73%, respectively.

Prevalence and significance of transient--predominantly asymptomatic--myocardial ischemia on Holter monitoring in unstable angina pectoris, and correlation with exercise test and thallium-201 myocardial perfusion imaging.

The prevalence and clinical significance of transient myocardial ischemia was evaluated prospectively in 43 patients with a clinical diagnosis of unstable angina. Continuous 2-channel Holter electrocardiographic monitoring was begun < 24 hours after admission. In 3,558 hours of recordings (mean 83 +/- 20 hours/patient), there were 1,671 episodes of transient ischemia; > 90% were asymptomatic. All patients but 1 had at least 1 episode of transient ischemia. Twenty-two patients (group 1) had a total ischemic duration of > or = 30 minutes/day, whereas 21 patients (group 2) had a total ischemic duration of < 30 minutes/day. A predischarge symptom-limited exercise test was performed in 40 of these patients after medical stabilization and 39 patients underwent exercise thallium-201 imaging, an average of 3 days after the exercise test. During a follow-up period of 39.9 +/- 9 months (range 28 to 49), 4 patients developed myocardial infarction and 22 required revascularization because of medically refractory angina. There were significantly more patients with total cardiac events (myocardial infarction or a need for revascularization) in group 1 than in group 2 (p < 0.05). Among patients undergoing an exercise test and exercise thallium-201 imaging, a positive exercise electrocardiogram and the presence of a reversible thallium-201 perfusion defect were also significant predictors of subsequent cardiac events (p < 0.05 and p < 0.001, respectively). The results of the Holter recordings did not add significantly more prognostic information.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of predischarge exercise stress echocardiography after acute myocardial infarction.

A predischarge exercise test was performed by 70 patients 7 +/- 4 days (mean +/- SD) after acute myocardial infarction (AMI) to determine the short- and long-term prognostic value of predischarge exercise stress echocardiography (Ex-Echo) compared with exercise stress electrocardiography (Ex-ECG). Two-dimensional echocardiograms were obtained at rest and immediately after exercise; a wall motion score index was obtained both at rest and immediately after exercise. Results of the Ex-Echo were positive in 27 patients (39%), whereas those of Ex-ECG were positive in 34 (49%). The wall motion index after exercise was lower in patients who died during follow-up (85 vs 98, p = 0.01) and in those with cardiac events, defined as death, nonfatal reinfarction, or revascularization (88 vs 98, p = 0.005). More patients with a positive Ex-Echo result had short-term cardiac events (within 2 weeks) than patients with a negative Ex-Echo (6 [22%] vs 2 [5%], p = 0.04). The same was true for long-term mortality (12 [44%] vs 3 [7%], p = 0.0002), reinfarctions (10 [37%] vs 4 [9%], p = 0.01), revascularization procedures (11 [41%] vs 7 [16%], p = 0.023), and cardiac events (22 [81%] vs 12 [28%], p < 0.0001). Survival time was shorter in patients with positive compared with negative Ex-Echo results (34% difference between groups, 95% confidence interval [CI] 10% to 58%, p = 0.002). The same applied for cumulative survival free from cardiac events (43%, p = 0.001, 95% CI 9% to 77%.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of left ventricular wall motion in angina pectoris by two-dimensional echocardiography and myocardial perfusion by technetium-99m sestamibi tomography during adenosine-induced coronary vasodilation and comparison with coronary angiography.

Myocardial perfusion and regional wall motion during adenosine-induced coronary vasodilation were assessed in 40 patients with angina pectoris by technetium-99m sestamibi single-photon emission computed tomography (SPECT) and simultaneous 2-dimensional echocardiography. Adenosine was infused intravenously at a dose of 140 micrograms/kg body weight per minute for 6 minutes, and technetium-99m sestamibi was injected at 3 minutes. Adenosine caused a significant decrease in systolic and diastolic blood pressure and a significant increase in heart rate and the heart rate-blood pressure product. Adverse effects were mild and transient and no patient required aminophylline. Completely or partially reversible defects on SPECT were present in 28 patients, a fixed defect was seen in 4 patients, and no defect was seen in 8 patients. Two-dimensional echocardiography revealed a new or worsening wall motion abnormality in 21 patients, a fixed abnormality in 4 patients and no abnormality in 15. Transient perfusion defects were associated with transient wall motion abnormalities in 71% of cases. The overall sensitivity, specificity and predictive accuracy of adenosine echocardiography in detecting significant coronary artery disease (> 50% diameter stenosis) were 74, 100 and 78%, respectively, whereas those of adenosine SPECT were 94, 100 and 95%, respectively (p < 0.05, NS, and < 0.05, respectively). Thus adenosine technetium-99m sestamibi SPECT has a higher sensitivity and predictive accuracy than adenosine echocardiography, suggesting that adenosine-induced perfusion defects are not always associated with wall motion abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive ambulatory 24 h blood pressures and basal blood pressures predict development of sustained hypertension from a borderline state.

A sample of 143 male borderline hypertensives aged 35 to 45, screened from a population cohort, were subjected to psychological stress, static work, and ambulatory 24 h blood pressure (BP) monitoring to assess the predictive power of BP reactivity in the development of established hypertension. After 1 year, a follow-up showed that 21 subjects (14.7%) had developed established hypertension (causal diastolic (D) BP > or = 95 mm Hg), 25 subjects (15.7%) had become normotensive (causal DBP < 85 mm Hg), and 97 (67.8%) remained within the borderline range (causal DBP 85 to 94 mm Hg). Those who developed established hypertension had considerably higher initial basal resting blood pressures than those who remained borderline: systolic (S) BP 134.2 +/- 12.5 v 127.6 +/- 10.7 mm Hg, P < .05 and DBP 86.8 +/- 7.9 v 80.4 +/- 7.0 mm Hg, P < .01. They had also somewhat higher BP values during mental arithmetic exercises and hand-grip work (peak DBP 101.1 +/- 8.8 v 96.8 +/- 8.7 mm Hg, P < .05, and 131.4 +/- 14.8 v 123.5 +/- 12.9 mm Hg, P < .05, respectively). Those subjects who developed established hypertension had significantly higher 24 h mean blood pressures than those who remained borderline (24 h SBP 133.3 +/- 11.4 v 126.0 +/- 10.1 mm Hg, P < .01, and DBP 84.7 +/- 5.7 v 81.6 +/- 6.8 mm Hg, P < .05). This difference was attributed mainly to the differences found during daytime (07:00 to 19:00) hours but was also found to be nominally dependent upon those found during nighttime (01:00 to 07:00) hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of CNS-related subjective symptoms in hypertensive patients treated with either a new controlled release (CR/ZOK) formulation of metoprolol or atenolol.

The present study evaluated and compared subjective symptoms in hypertensive patients (N = 83) at therapeutically comparable dosages of a new controlled release (CR/ZOK) formulation of metoprolol (100 mg od) and atenolol (50 mg od). The trial was a 4-week randomized double-blind study preceded by a placebo run-in period. Blood pressure (BP) was recorded 24 hours after intake of last dose. In subpopulations, 24-hour ambulatory BP was recorded and exercise tests performed. Subjective symptoms were evaluated with a previously documented questionnaire (MSE-profile) which has been shown to be sensitive in detecting CNS-related symptoms caused by beta blockers. The MSE-profile includes three dimensions: Contentment, Vitality and Sleep. The results showed that there were no significant differences between the groups in BP reduction either at 24 hours or over the entire 24-hour dose interval. Furthermore, the degree of beta 1-blockade (reduction in exercise-induced tachycardia) 24 hours after last dose did not differ between the groups. There were no significant differences regarding subjective symptoms (Contentment, Vitality, Sleep) between the two treatment groups. An a posteriori power analysis showed that the power to detect a true difference was of an acceptable magnitude. In conclusion, there was no difference in CNS-related symptoms between metoprolol and atenolol at therapeutically comparable dosages indicating that the degree of lipophilicity may be of minor importance for the occurrence of such symptoms.

Changes in cardiac diastolic dimensions precede hypertrophy in early stages of hypertension.

BACKGROUND: Left ventricular hypertrophy (LVH) has been identified as a main target organ change resulting from hypertension, also being a long-term predictor of myocardial infarction, stroke and cardiovascular death. However, very few longitudinal studies exist following the development of LVH in the hypertensive process. METHODS: The present longitudinal study investigated a population based group of borderline hypertensive men (BHT, n = 66, diastolic blood pressure (BP) 85-94 mm Hg). M-mode echocardiography was performed at baseline and after 3 years, and anthropometrical data recorded. RESULTS: There was no increase in LVH indices over the 3-year period, while there was a statistically significant increase in aortic root dimension (P < 0.001), left atrial diameter in diastole (LADD, P < 0.001), left ventricular diameter in diastole (LVDD, P < 0.001) and peak systolic wall stress (PSWS, P < 0.01) and a significant decrease in left ventricular ejection time (LVET, P < 0.01). Baseline BP levels correlated to PSWS (P < 0.05) but not to LVH indices, whereas body mass index (BMI) correlated significantly to wall thickness (P < 0.05) and LV mass (P < 0.05). CONCLUSIONS: LVH indices did not increase over a 3-year period. However, there was a significant increase in aortic root dimension, LADD, LVDD and PSWS, and a significantly shortened LVET, suggesting that these changes precede any increase in LVH. Finally, BMI showed stronger correlation to LVH indices than did BP levels.

Effects of sympatho-adrenal activation on the finger microcirculation in mild hypertension.

Finger skin circulatory responses to three forms of sympatho-adrenal activation were investigated in 14 patients with mild hypertension and 14 matched normotensive controls. Finger nailfold skin capillary blood cell velocity was measured by video-photometric capillaroscopy and finger pulse volume by strain-gauge plethysmography (digital arterial pulse amplitude; DAPA). DAPA decreased more markedly in the normotensive as compared with the hypertensive group during mental arithmetic stress (38 vs. 19%; P less than 0.05) and a cold pressor test (55 vs. 32%; P less than 0.05). Intravenous infusions of adrenaline (0.1-0.8 nmol/kg/min) decreased DAPA in normotensives but not in hypertensives (P less than 0.05). Capillary blood cell velocity was similar in the two groups at rest and decreased promptly and to a similar extent in both groups following mental arithmetic, adrenaline infusion and the cold pressor test (by approximately 60, 60 and 35%, respectively). It is concluded that mental stress and the cold pressor test induce instantaneous and marked effects on the skin circulation via neurogenic activation. The less marked effect on DAPA in the hypertensive group may reflect an elevation of basal vascular tone and/or early structural vascular changes in mild hypertension. The discrepancy between total finger and capillary circulatory responses to adrenaline may be attributable to different adrenoceptor populations and/or sensitivity in arteriovenous shunts, as compared with precapillary vessels.

Determinants of left ventricular systolic function after acute myocardial infarction: the role of residual myocardial ischaemia.

BACKGROUND: Left ventricular systolic function (LVSF) is one of the major determinants of survival after acute myocardial infarction (AMI). Some factors such as the infarct size and localization, and the patency of the infarct-related artery are known determinants of LVSF. However, the long-term effect of myocardial ischaemia on LVSF has been poorly studied in clinical settings. OBJECTIVES: To assess the acute and long-term effects of myocardial ischaemia on LVSF in patients recovering from an AMI. METHODS: A cohort of 74 patients recovering from AMI was studied. Myocardial ischaemia was detected by means of ambulatory electrocardiogram (ECG) monitoring at recruitment (4+/-2 days after AMI), exercise ECG test and stress echocardiography at discharge (7+/-4 days after AMI). LVSF was studied by means of two-dimensional echocardiography at recruitment, at discharge, and at 1, 3, 6 and 12 months after AMI. RESULTS: Patients with myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had worse LVSF at recruitment than those without ischaemia. The presence of myocardial ischaemia on ambulatory ECG monitoring was an independent determinant of LVSF at recruitment together with infarct localization and size (assessed by creatine kinase MB isoenzyme (CK-MB) levels). Patients with signs of myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had a progressive left ventricular dysfunction compared with those without ischaemia. CONCLUSIONS: Residual ischaemia is an independent determinant of LVSF after AMI and its presence implied a progressive worsening of the LVSF. Because left ventricular systolic dysfunction is a major determinant of survival after AMI, its precursors, among them residual myocardial ischaemia, should be identified. Treatment of ischaemia is known to be associated with improved prognosis and improved LVSF.

Prognostic value of exercise stress testing versus ambulatory electrocardiography after acute myocardial infarction: a 3 year follow-up study.

BACKGROUND: The aim of this study was to evaluate the prognostic significance of myocardial ischemia detected by ambulatory ECG monitoring (AEM) and exercise stress testing (ExT) following acute myocardial infarction. METHODS: The prognostic value of AEM versus ExT was studied prospectively in 74 patients with a recent acute myocardial infarction. Myocardial ischemia was diagnosed by the presence of ST-segment depression occurring during AEM or ExT 4 +/- 2 and 7 +/- 4 days after hospital admission respectively. ST-segment depression during AEM was defined as a horizontal/downsloping depression of > or = 0.1 mV from the reference baseline, measured 80 ms after the J point, elapsing > or = 1 min. ST-segment depression at ExT was determined as > or = 1mm horizontal or downsloping ST-segment depression in at least two consecutive ECG leads. RESULTS: Twenty-two patients (30%) showed ST-segment depression during AEM and 34 (49%) on ExT. During a mean follow-up period of 3 years (36 +/- 15 months), 10 patients (45%) with ST-segment depression on AEM died compared with eight (15%) without; 12 patients (35%) with ST-segment depression on ExT died versus three (8%) without. Death or reinfarction occurred in 13 patients (59%) with ST-segment depression on AEM versus nine (17%) without, and in 13 patients (38%) with ST-segment depression on ExT compared with six (17%) without. Revascularization procedures were similar in patients with or without ST-segment depression during AEM and ExT. Cardiac events defined as death, nonfatal reinfarction or revascularization, occurred in 18 patients (82%) with ST-segment depression on AEM versus 20 (38%) without, and in 23 patients (68%) with ST-segment depression on ExT versus 11 (31%) without. Survival analysis using Kaplan-Meier curves showed that patients showing no ST-segment depression with either technique had longer survival times than did patients showing ST-segment depression on either AEM or ExT, or showing ST-segment depression with both techniques. This was also true when analyzing the cumulative survival rate until the occurrence of any endpoint. With multivariate regression analysis, ST-segment depression on AEM was the variable most strongly predictive of mortality, followed by ST-segment depression on ExT, hypertension, and diabetes. CONCLUSIONS: These findings illustrate the ability AEM and Ext independently to predict long-term cardiac mortality and morbidity rates in patients recovering from acute myocardial infarction. The combined use of these techniques is useful for detecting patients at high risk after acute myocardial infarction.

Markers of risk after acute myocardial infarction. A comparison of clinical variables, ambulatory and exercise electrocardiography, echocardiography, and stress echocardiography.

BACKGROUND: Short-term mortality after myocardial infarction has decreased continuously among members of selected populations. Nonetheless, the long-term prognosis among members of unselected populations remains bad. Further research in risk stratification is therefore needed. In the present study we tested the additive value of clinical variables, echocadiography, ambulatory electrocardiography, exercise testing, and stress echocardiography in assessing the long-term prognosis after acute myocardial infarction. METHODS: Two-dimensional echocardiography and ambulatory electrocardiography (analysis of ST-segment changes and of heart rate variability) were performed for 74 patients aged < 75 years who had had an acute myocardial infarction. Before their discharge from hospital, 70 patients were subjected to a combined exercise test and stress echocardiography. The time of follow-up was > or = 3 years. RESULTS: During follow-up 18 patients died, and 38 suffered cardiac events defined as death, nonfatal reinfarction and the need for revascularization. We first tested 31 covariates in a univariate regression analysis. A subsequent multivariate analysis was performed in two stages. During the first of these, clinical variables (a history of systemic hypertension, infarct localization, and diabetes mellitus) and variables derived from noninvasive tests (new-onset wall-motion abnormality during stress echocardiography, ST-segment depression and heart-rate variability during ambulatory electrocardiography, the ejection fraction by echocardiography at rest, and the double product during exercise tests) predicted mortality. After the second stage, however, the only remaining independent predictors of mortality were the presence of a new-onset wall-motion abnormality (P < 0.0001, relative risk 13.5, 95% confidence interval 3.6-51.3), ST-segment depression during ambulatory electrocardiography (P = 0.003, relative risk 5.0, 95% confidence interval 1.7-15.7) and a decreased heart rate variability (P = 0.007). CONCLUSIONS: The only variables that were of independent value in assessing the long-term mortality were those expressing residual myocardial ischemia and the cardiovascular sympatho-vagal balance. It is, therefore, recommended that one should monitor these variables for patients recovering from an acute myocardial infarction.

Prognostic significance of exercise thallium-201 myocardial perfusion imaging compared to stress echocardiography and clinical variables in patients with unstable angina who respond to medical treatment.

The prognostic value of thallium-201 imaging in patients with unstable angina is not well established. Forty consecutive patients with unstable angina who had responded to medical therapy underwent predischarge symptom-limited exercise testing and 39 of them underwent exercise thallium-201 imaging, on average 3 days after the exercise test. Exercise echocardiography was performed in 36 of these patients in conjunction with the predischarge exercise test. Patients with previous myocardial infarction, coronary revascularization, left bundle branch block and dilated cardiomyopathy were not included in the study. An echocardiographic wall-motion score index was derived by analyzing left ventricular regional wall motion. During a follow-up period of 30 +/- 6.4 months, 3 patients had a non-fatal myocardial infarction and 20 required revascularization because of a recurrence of severe medically refractory angina. Univariate predictors of cardiac events (non-fatal myocardial infarction or a need for revascularization) during follow-up included ST-depression during exercise, positive exercise echocardiography, a low exercise wall-motion score index, the presence of thallium-201 redistribution and the number of myocardial segments with thallium-201 redistribution. However, stepwise logistic regression analysis revealed that the presence of thallium-201 redistribution was the only significant non-invasive predictor (P < 0.005) of a cardiac event among patients who underwent predischarge exercise testing and exercise thallium-201 imaging. Among patients undergoing exercise echocardiography and exercise thallium-201 imaging, the number of segments with thallium-201 redistribution was the only significant predictor (P < 0.0005) of future cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)