Androgen status in non-diabetic elderly men with heart failure.

PURPOSE: We aimed at evaluating androgen status (serum testosterone [TT] and estimated free testosterone [eFT]) and its determinants in non-diabetic elderly men with heart failure (HF). Additionally, we investigated its associations with body composition and long-term survival. METHODS: Seventy three non-diabetic men with HF and 20 healthy men aged over 55 years were studied. Echocardiography, 6-min walk test, grip strength, body composition measurement by DEXA method were performed. TT, sex hormone binding globulin, NT-proBNP, and adipokines (adiponectin and leptin) were measured. All-cause mortality was evaluated at six years of follow-up. RESULTS: Androgen status (TT, eFT) was similar in elderly men with HF compared to healthy controls (4.79 ± 1.65 vs. 4.45 ± 1.68 ng/ml and 0.409 ± 0.277 vs. 0.350 ± 0.204 nmol/l, respectively). In HF patients, TT was positively associated with NT-proBNP (r= 0.371, p = 0.001) and adiponectin levels (r = 0.349, p = 0.002), while inverse association was noted with fat mass (r = -0.413, p < 0.001). TT and eFT were independently determined by age, total fat mass and adiponectin levels in elderly men with HF (p < 0.05 for all). Androgen status was not predictor for all-cause mortality at six years of follow-up. CONCLUSIONS: In non-diabetic men with HF, androgen status is not altered and is not predictive of long-term outcome.

Cobalt-chromium KAname™ coRonary stEnt system in the treatment of patients with coronary artery disease (KARE study).

OBJECTIVES: To evaluate the safety and effectiveness of the Kaname™ cobalt-chromium (Co-Cr), thin strut, bare metal stent (BMS) system for the treatment of coronary artery lesions. BACKGROUND: Despite widespread use of drug-eluting stents, a certain percentage of patients with coronary artery disease are still treated with BMS. Therefore, it is essential to evaluate their clinical performance. METHODS: Two hundred eighty-two patients were enrolled in this prospective, single-arm study including a predefined subset of 79 patients with small vessels. The primary end-point was freedom from target vessel failure (TVF) at 6 months. Key angiographic and intravascular ultrasound (IVUS) end-points were late loss, diameter stenosis, binary restenosis, and neointimal hyperplasia volume. RESULTS: Freedom from TVF at 6 months was 93.3% and at 1 year 90.8% in total population, and 92.4% and 87.3% in small vessels, respectively. Clinically driven target lesion revascularization (TLR) rates at 6 and 12 months were 4.3% and 6.4% in total population, and 3.8% and 7.6% in small vessels, respectively. At 6 months in-stent late loss was 0.75 ± 0.43 mm and binary restenosis rate was 16.9% in total population, and 0.64 ± 0.40 mm and 26.1% in small vessels, while IVUS assessed neointimal hyperplasia volume at 6 months was 128.9 ± 42.6 mm(3) for total population. There were no definite and probable stent thromboses up to 12 months. CONCLUSIONS: Results indicate good safety and effectiveness of the Kaname™ stent with clinically equivalent results in small and larger vessels, as such providing useful treatment option for patients with ischemic heart disease considered for BMS implantation.

Two-dimensional speckle tracking-derived strain to distinguish acute coronary syndrome from a marked early repolarization in a patient with chest pain: a fancy gadget or a useful tool?

BACKGROUND: With a potential of detecting subtle myocardial injury, two-dimensional (2D) speckle tracking-derived strain could help to distinguish between ischemic and nonischemic ST-segment elevation. Little is known if limitations of strain imaging could prevent its applicability in acute cardiac care settings. CASE PRESENTATION: We present a 56-year-old male with persistent ST-segment elevation in the inferolateral leads and suspected hypokinesia of the inferior wall. Semiautomated 2D speckle tracking strain analysis showed normal longitudinal peak systolic strain (LPSS) in all segments of the inferior wall, ruling out wall-motion abnormalities in this region. Stationary reverberations and spuriously low values of LPSS in the posterolateral wall required operator's expertise to distinguish pathological myocardial deformation from artifacts. Additional workup revealed that early repolarization pattern was mistaken for the inferior wall acute myocardial infarction in our patient. CONCLUSIONS: Semiautomated quantification of regional left ventricular function by 2D speckle tracking echocardiography could facilitate decision making even in the emergency settings. Due to intrinsic limitations of this novel method, its actual clinical value in acute cardiac care settings may depend on the expertise of the operator and is yet to be determined.

Establishing the diagnosis of inverted stress cardiomyopathy in a patient with cardiac arrest during general anesthesia: a potential role of myocardial strain?

In cardiac arrest survivors, postresuscitation myocardial stunning usually presents as either global left ventricular dysfunction or regional dyssynergy including the various forms of stress cardiomyopathy, in which rare variants may be difficult to diagnose. We present a patient with cardiac arrest during general anesthesia, in whom speckle tracking-derived myocardial strain helped to distinguish between the inverted variant of stress cardiomyopathy and global postresuscitation myocardial stunning.

Aborted myocardial infarction in a patient with rapid progression of Wellens syndrome.

BACKGROUND: Wellens syndrome refers to a distinct electrocardiographic pattern of deeply inverted or biphasic T waves in the anterior precordial leads, in the presence of critical proximal stenosis of the left anterior descending coronary artery (LAD). The natural history of the syndrome is an extensive myocardial infarction within weeks of hospital admission. CASE REPORT: This report describes a 63-year-old man in whom typical electrocardiographic signs of Wellens syndrome advanced to persistent ST-segment elevation within 7min of presentation. Extensive anterior myocardial infarction (AMI) was aborted by primary percutaneous coronary intervention of a sub-occluded proximal LAD. CONCLUSION: Given the large area of the left ventricle supplied by a sub-occluded LAD, devastating AMI could have been expected and may have resulted in serious ventricular dysfunction and death. Therefore, early recognition of Wellens syndrome is essential and can be lifesaving.

Pulmonary aspergilloma.

INTRODUCTION: Aspergillosis is a serious pathologic condition caused by Aspergillus organisms and is frequently seen in immunocompromised patients. Aspergillus species causes a variety of pulmonary diseases such as saphrophyticus (aspergilloma/mycetoma), hypersensitivity reaction (allergic bronhopulmonary), semi- invasive (chronic necrotizing) and angioinvasive aspergillosis. CASE REPORT: We report a case of pulmonary aspergilloma (PA) in 38 years old patient who was previously healthy with complaints of fever and hemoptysis. PA was diagnosed radiologically and confirmed by serology. CONCLUSION: Oral itraconazole was administered. The patient responded well to the treatment with improvement in his systemic symptoms and regression of the pulmonary lesions.

Relationship of reduced cerebral blood flow and heart failure severity in elderly males.

INTRODUCTION: Brain detrimental effects are under-recognised complication of chronic heart failure (CHF). One of the major causes may be cerebral hypoperfusion. This study was designed to investigate the relationship between cerebral blood flow (CBF) and severity of CHF as well as to evaluate its determinants among different parameters of cardiac dysfunction. METHODS: Seventy-one CHF males with NYHA class II and III and 20 control subjects age ≥ 55 years were recruited. CBF was evaluated by colour duplex sonography of extracranial arteries. Echocardiography, 6-min walk test, quality of life and endothelial function were also assessed. Serum NT-pro-BNP and adipokines levels (adiponectin and leptin) were measured. RESULTS: CBF was significantly reduced in elderly patients with CHF compared to healthy controls (677 +/- 170 vs 783 +/- 128 ml/min, p=0.011). Reduced CBF was associated with reduced left ventricular ejection fraction (LVEF) (r=0.271, p=0.022), lower 6-min walk distance (r=0.339, p=0.004), deteriorated quality of life (r= -0.327, p=0.005), increased serum adiponectin (r= -0.359, p=0.002), and NT-pro-BNP levels (r= -0.375, p=0.001). In multivariate regression analysis, LVEF and adiponectin were independently associated with reduced CBF in CHF patients (R(2)=0.289). CONCLUSION: CBF was reduced in elderly males with mild-to-moderate CHF, and was associated with factors that represent the severity of CHF including high serum adiponectin and NT-pro-BNP levels, decreased LVEF, impaired physical performance, and deteriorated quality of life.

The absence of the ST-segment elevation in acute coronary artery thrombosis: what does not fit, the patient or the explanation?

In a few patients with acute proximal thrombotic occlusion of the left anterior descending coronary artery (LAD), tall ischemic T waves never evolve into ST-segment elevation. This was recently inaccurately reported as a "novel sign" of proximal LAD occlusion. It has been speculated that the absence of ST-segment elevation could be attributed to the large area of transmural ischemia, the anatomic variant of Purkinje fibers, or to lack of activation of sarcolemal adenosine triphosphate-potassium channels. This electrocardiographic picture was recently explained by changes in the subendocardial but not in the epicardial action potential, suggesting subendocardial ischemia as the underlying mechanism. We present a patient with thrombotic lesion of proximal LAD, static precordial ST-segment depression, and tall T waves who underwent primary percutaneous intervention and stent placement. Surprisingly, total thrombotic stent occlusion on the following day was associated with ST-segment elevation in precordial leads, indeed supporting the concept of the regional subendocardial ischemia that was first described more than a decade ago.

Prognostic significance of contractile reserve assessed by dobutamine-induced changes of Tei index in patients with idiopathic dilated cardiomyopathy.

AIMS: To determine prognostic significance of global left ventricular (LV) contractile reserve, defined by dobutamine-induced changes of Tei index (Delta Tei), in patients with dilated cardiomyopathy (DCM). METHODS AND RESULTS: Thirty-eight patients with idiopathic DCM underwent high-dose (up to 40 microg/kg/min) dobutamine stress echocardiography. Prognostic value of different indices of LV contractile reserve, including Delta Tei, as well as changes of ejection fraction (Delta EF) and wall motion score index (Delta WMSi), was analysed. Patients were followed up for 5 years for cardiac mortality. Patients with preserved contractile reserve, defined by Delta Tei > -0.35, had significantly lower cardiac mortality when compared with those without it (38 vs. 77%, P = 0.02). Also, the Kaplan-Meier survival analysis revealed that patients with contractile reserve had better 5-year survival when compared with those without contractile reserve (log-rank = 6.01, P = 0.014). However, of all examined indices of contractile reserve, Cox's regression analysis identified Delta WMSi as the only independent predictor of 5-year mortality. CONCLUSION: Our data indicate that the presence of contractile reserve assessed by Delta Tei may identify patients with favourable long-term prognosis. Prognostic value of Delta Tei appears to be similar to Delta EF, but less powerful than Delta WMSi.

Primary PCI for acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura. A case report and review of the literature.

BACKGROUND AND PURPOSE: The occurrence of acute myocardial infarction (AMI) in patients with idiopathic thrombocytopenic purpura (ITP) is rare, especially when the platelet count is low. Since only few case reports have been published, there are no recommendations for the management of thrombocytopenic patients with AMI. The aim of the present study is to discuss different aspects of this challenging issue and to review limited data available in the literature. CASE STUDY: An 80-year-old patient with ITP (platelet count 5 . 10(9)/l) is presented who developed an AMI (ST segment elevation myocardial infarction) and was successfully treated by primary percutaneous coronary intervention (PCI). CONCLUSION: Considering the high bleeding risk in patients with ITP and AMI, careful balance between usual anticoagulation and antiplatelet therapy on the one hand, and efforts to raise platelet count on the other hand are needed.

Hypothetical mechanism of sodium pump regulation by estradiol under primary hypertension.

Causal relationship between sodium and hypertension has been proposed and various changes in Na+,K+-ATPase (sodium pump) activity have been described in established primary hypertension. A number of direct vascular effects of estradiol have been reported, including its impact on the regulation of sodium pump activity and vasomotor tone. The effects of estradiol involve the activation of multiple signaling cascades, including phosphatydil inositol-3 kinase (PI3K) and p42/44 mitogen-activated protein kinase (p42/44(MAPK)). In addition, some of the effects of estradiol have been linked to activity of cytosolic phospholipase A(2) (cPLA(2)). One possible cardioprotective mechanism of estradiol involves of the interaction between estradiol and the rennin-angiotensin system (RAS). Elevated circulating and tissue levels of angiotensin II (Ang II) have been implicated in the development of hypertension and heart failure. The aim of our investigation was to elucidate the signaling mechanisms employed by estradiol and Ang II in mediating sodium pump, in vascular smooth muscle cells (VSMC). The aim of our investigation was to elucidate the signaling mechanisms employed by estradiol and Ang II in mediating sodium pump activity/expression in VSMC, with particular emphasis on PI3K/cPLA(2)/p42/44(MAPK) signaling pathways. Our primary hypothesis is that estradiol stimulates sodium pump activity/expression in VSMC via PI3K/cPLA(2)/p42/44(MAPK) dependent mechanism and, that impaired estradiol-stimulated sodium pump activity/expression in hypertensive rodent models (i.e. SHR), Ang II-mediated vascular impairment of estradiol is related to a decrease ability of estradiol to stimulate the PI3K/cPLA(2)/p42/44(MAPK) signaling pathways. An important corollary to this hypothesis is that in hypertensive state (i.e. SHR rats) the decreasing in ACE enzyme activity and/or AT1 receptor expression caused by administration of estradiol is accompanying with abrogated ability of Ang II to decrease IRS-1/PI3K association, and consequent PI3K/cPLA(2)/p42/44(MAPK) activity and associated sodium pump activity/expression. A clear characterization of how Ang II attenuates estradiol signaling may lead to a better understanding of the molecular mechanism(s) underlying pathophysiological conditions such as hypertension and to understanding how certain pathophysiological situations affect sodium pump activity/expression in VSMC.

Mechanical dispersion is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks.

OBJECTIVES: Bundle branch blocks (BBB)-related mechanical dyssynchrony and dispersion may improve patient selection for device therapy, but their effect on the natural history of this patient population is unknown. METHODS: A total of 155 patients with LVEF ≤ 35% and BBB, not treated with device therapy, were included. Mechanical dyssynchrony was defined as the presence of either septal flash or apical rocking. Contraction duration was assessed as time interval from the electrocardiographic R-(Q-)wave to peak longitudinal strain in each of 17 left ventricular segments. Mechanical dispersion was defined as either the standard deviation of all time intervals (dispersionSD) or as the difference between the longest and shortest time intervals (dispersiondelta). Patients were followed for cardiac mortality during a median period of 33 months. RESULTS: Mechanical dyssynchrony was not associated with survival. More pronounced mechanical dispersiondelta was found in patients with dyssynchrony than in those without. In the multivariate regression analysis, patients' functional class, diabetes mellitus and dispersiondelta were independently associated with mortality. CONCLUSIONS: Mechanical dispersion, but not dyssynchrony, was independently associated with mortality and it may be useful for risk stratification of patients with heart failure (HF) and BBB. Key Messages Mechanical dispersion, measured by strain echocardiography, is associated with poor outcome in heart failure with a severely depressed left ventricular function and bundle branch blocks. Mechanical dispersion may be useful for risk stratification of patients with heart failure and bundle branch blocks.

The ß-blocker uptitration in elderly with heart failure regarding biomarker levels: CIBIS-ELD substudy.

AIM: We investigated if the baseline value of mid-regional pro-atrial natriuretic peptide (NP), N-terminal pro-B-type NP and copeptin may be helpful in optimizing ß-blocker uptitration in elderly patients with heart failure. PATIENTS & METHODS: According to the biomarkers' levels, 457 patients were divided into three subgroups and compared with each other at baseline and 3 months after. RESULTS: All mid-regional pro-atrial NP and N-terminal pro-B-type NP subgroups had significant amelioration of left ventricle ejection fraction and New York Heart Association (NYHA) class after 3 months of ß-blocker uptitration (p < 0.001). More prominent improvement of left ventricle ejection fraction and New York Heart Association class was observed in subgroups with lower versus higher NPs levels. CONCLUSION: NPs levels, unlike copeptin levels, might be useful tool for objective selection of elderly heart failure patients who could have the greatest benefit of forced uptitration.

Regulation of the inducible nitric oxide synthase and sodium pump in type 1 diabetes.

Insulin-like growth factor-1 (IGF-1) is a hormone and growth factor closely related to insulin. The autocrine/paracrine actions of IGF-1 involve activation of inducible nitric oxide synthase (iNOS) and the Na(+), K(+)-ATPase sodium pump in cardiovascular tissues. Data from literature indicate that iNOS is expressed in vascular smooth muscle cells (VSMC) and that IGF-1-induced release of NO is both rapid and delayed. We hypothesize that impaired IGF-1-induced sodium pump activity/expression in rats with type 1 diabetes is related to activation of phosphatidylinositol 3 kinase (PI3K)/cytosolic phospholipase 2 (cPLA(2))/protein kinase B (Akt) signaling, and that IGF-1 prevents acute and chronic dysfunction of iNOS and sodium pump activity in a chemically induced model of type 1 diabetes, the streptozotocin-treated rat heart (STZ). Understanding how iNOS and sodium pump activity are regulated by IGF-1 activation of the PI3K/cPLA(2)/Akt cascade should provide novel and fundamental knowledge regarding the regulatory actions of IGF-1 in promoting vasodilation. Since insulin resistance is currently a major focus of research, the use of IGF-1 to improve insulin resistance and glucose metabolism has opened a new arena for treatment of comorbid conditions. Future investigations should now focus on mechanisms of action of IGF-1 and its clinical applicability.

T-wave changes in patients with Wellens syndrome are associated with increased myocardial mechanical and electrical dispersion.

Some patients with unstable angina and critical stenosis of the left anterior descending coronary artery (LAD) present with Wellens syndrome (WS), i.e., inverted or biphasic T-waves in the anterior precordial leads. We assessed clinical, angiographic, electro- and echocardiographic characteristic of patients with WS. In this retrospective study, clinical, angiographic, electro- and echocardiographic characteristic of 35 patients with WS were compared to 57 patients with critical LAD stenosis and normal resting electrocardiogram (ECG), and 45 subjects with normal coronary angiogram. QTc dispersion was measured from the 12-lead ECG as the difference between longest and shortest QTc intervals. Mechanical dispersion was defined as the time difference between the longest and shortest contraction durations which were measured as the time from the first deflection of the QRS complex to maximum myocardial shortening of each 18 segmental longitudinal strain curves derived by speckle tracking echocardiography. There were no significant differences in the complexity and location of the LAD lesion, anterograde and collateral flow in LAD and coronary artery dominance between patients with WS and normal ECG (P > 0.05, for all). Patients with WS had lower global longitudinal strain (GLS) and more pronounced both QTc and myocardial mechanical dispersion than patients with critical LAD stenosis and normal ECG, and control subjects (P < 0.05). T-wave changes in patients with WS are associated with more profound regional myocardial dysfunction and increased QTc and myocardial mechanical dispersion. Similar angiographic characteristics of the LAD lesion were seen in patients with WS and normal ECG.

Prognostic implications of heart failure with preserved ejection fraction in patients with an exacerbation of chronic obstructive pulmonary disease.

Diagnosing heart failure with preserved ejection fraction (HFpEF) in patients with chronic obstructive pulmonary disease (COPD) is difficult due to overlapping pathophysiological pathways, risk factors and clinical presentations. We investigated the prevalence and prognostic implications of coexisting HFpEF in patients hospitalized for acute exacerbation of COPD. A total of 116 consecutive patients with an acute exacerbation of COPD were evaluated for HFpEF and followed for an average period of 22 ± 9 months for the occurrence of death from any cause. HFpEF was diagnosed in 22 (19 %) patients with COPD, who were older, and also had higher LV mass, left atrial size, and mitral E/Ea ratio than those without HFpEF (p < 0.05 for all comparisons). HFpEF was not independently associated with all-cause mortality [hazard ratio (HR) 1.07, 95 % confidence interval (CI) 0.44-2.62]. Global initiative for chronic Obstructive Lung Disease (GOLD) stage (IV vs. I-III, HR 2.37, CI 1.23-4.59) and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels (HR 2.79, CI 1.12-6.98) were independent predictors of long-term survival. HFpEF is present in one-fifth of patients with exacerbated COPD. Non-invasively diagnosed HFpEF may not be an independent predictor of all-cause mortality. Elevated NT-proBNP levels and very severe COPD were independently associated with unfavorable overall survival.

Favorable outcomes in octogenarians treated with bioresorbable polymer drug-eluting stent.

AIM: As a result of a higher prevalence of comorbidities, elderly adults are often underrepresented in clinical trials, and more often experience complications during percutaneous coronary intervention. Our aim was to evaluate clinical outcomes of patients older than 80 years, compared with their younger counterparts, when bioresorbable polymer biolimus A9 drug-eluting stent is used for their treatment. METHODS: The prospective, observational e-Nobori registry was created to validate the safety and efficacy of bioresorbable polymer drug-eluting stent in unselected patients. The primary end-point of the study was freedom from target lesion failure defined as a composite of cardiac death, target vessel-related myocardial infarction and clinically-driven target lesion revascularization at 1 year. RESULTS: There were 781 (7.8%) octogenarians, they were less frequently male (62% vs 77%; P < 0.0001) and more often presented as acute coronary syndrome (44% vs 39%; P = 0.0182). The index percutaneous coronary intervention success was lower in the elderly patients (98% vs 99%; P = 0.0398). One-year follow up was completed for 97% of the elderly patients and 99% of the younger patients. The difference in target lesion failure (3.33% vs 2.83%; log-rank P = 0.0114) was mainly driven by increased mortality in octogenarians (3.73% vs 1.47%; P < 0.0001). Elderly patients had more bleeding and vascular complications (2.67% vs 1.05%; P = 0.0001). CONCLUSIONS: Despite advanced age, multiple comorbidities and complexity of treated lesions, clinical outcomes are favorable in octogenarians treated by bioresorbable polymer biolimus A9 drug-eluting stent. Geriatr Gerontol Int 2016; 16: 1246-1253.

Influence of manual thrombus aspiration on left ventricular diastolic function in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

INTRODUCTION: Data on effects of thrombus aspiration on left ventricular diastolic function in ST-elevation myocardial infarction (STEMI) population are scarce. OBJECTIVE: We sought to compare echocardiographic indices of the diastolic function and outcomes in STEMI patients treated with and without manual thrombus aspiration, in an academic, high-volume percutaneous coronary intervention (PCI) center. METHODS: A total of 433 consecutive patients who underwent primary PCI in 2011-2012 were enrolled in the study. Patients were not eligible for the study if they already suffered a myocardial infarction, had been previously revascularized, received thrombolytics, presented with cardiogenic shock, had significant valvular disease, atrial fibrillation or had previously implanted pacemaker. Comprehensive echocardiogram was performed within 48 hours. During follow-up patients'status was assessed by an office visit or telephone interview. RESULTS: Patients treated with thrombus aspiration (TA+, n=216) had similar baseline characteristics as those without thrombus aspiration (TA-, n = 217). Groups had similar total ischemic time (319 ± 276 vs. 333 ± 372 min; p = 0.665), but TA+ group had higher maximum values of troponin I (39.5 ± 30.5 vs. 27.6 ± 26.9 ng/ml; p < 0.001). The echocardiography revealed similar left ventricular volumes and systolic function, but TA+ group had significantly higher incidence of E/e' > 15, as a marker of severe diastolic dysfunction' (TA+ 23.1% vs. TA- 15.2%; p = 0.050). During average follow-up of 14 ± 5 months, major adverse cardiac/cerebral events occurred at the similar rate (log rank p = 0.867). CONCLUSION: Thrombus aspiration is associated with a greater incidence of severe diastolic dysfunction in unselected STEMI patients treated with primary PCI, but it doesn't influence the incidence of major adverse cardiovascular events.

Hand-held Echo is Not So Handy in Everyone's Hands: Misdiagnosing Congenital Septal Defects in Patients with Heart Murmurs.

INTRODUCTION: Echocardiography is a highly operator-dependant technique which requires adequate training and skills that are frequently not present, considering the widespread use of cardiovascular ultrasound. This could particularly be true for hand-held echo devices which made echocardiography more accessible but are frequently used by non-cardiologists and non-experts. OUTLINE OF CASES: We present a 45-year-old female and a 37-year-old male with heart murmurs due to atrial and ventricular septal defect, respectively. Congenital septal defects were undiagnosed in both patients during several outpatient examinations due to challenging image acquisition. C reful re-evaluation revealed that, depending on the scanning technique, it was possible to detect or overlook the real cause of the murmur using either hand-held or high-end echo device. CONCLUSION: Our report underlines the need of adequate knowledge and training of medical professionals performing pocket-size hand-held echocardiography, since potential misdiagnoses may not be related to limited imaging capabilities of pocket-sized echo devices only, but also to inability of insufficiently trained users to obtain good quality images and interpret them adequately.

Visual assessment vs. strain imaging for the detection of critical stenosis of the left anterior descending coronary artery in patients without a history of myocardial infarction.

AIMS: We sought to determine the prevalence of overt and subclinical LV dysfunction in patients with critical left anterior descending coronary artery (LAD) stenosis but without a history of myocardial infarction and to compare diagnostic value of routine echocardiographic parameters with myocardial strain analysis for detection of critical LAD stenosis. METHODS AND RESULTS: We retrospectively studied 269 patients with suspected coronary artery disease (CAD)-209 consecutive patients with critical LAD stenosis and 60 consecutive patients with atypical chest pain and without CAD. Conventional visual assessment of LV asynergy in the LAD territory was compared with global, regional, and segmental peak systolic longitudinal strain (PSLS) parameters derived by two-dimensional speckle tracking echocardiography (2D STE). Wall motion abnormalities in the LAD territory were found in 41% of patients with critical LAD stenosis, whereas, depending on the cut-off value, global longitudinal strain (GLS) was impaired in 42-69% of patients. GLS with an area under the receiver operating characteristic curve (AUC) of 0.85 showed better discriminative power for detecting critical LAD stenosis than conventional wall motion score index (AUC 0.73, P < 0.05, for the difference between the AUCs). PSLS values were significantly lower in basal and midventricular segments supplied by critically narrowed LAD, particularly if they also appeared dysfunctional on visual assessment. CONCLUSIONS: Detection of subclinical LV dysfunction by 2D STE might improve identification of patients with critical LAD stenosis, although visually apparent regional LV dysfunction in the LAD territory is not uncommon finding in this subset of patients.