Development and appropriateness of a scoring method for International Classification of Functioning, Disabilities, and Health assessment in older patients with heart failure: a Delphi survey of expert panel in Japan.

OBJECTIVE: The number of older patients with heart failure (HF) is increasing in Japan and has become a social problem. There is an urgent need to develop a comprehensive assessment methodology based on the common language of healthcare; the International Classification of Functioning, Disability and Health (ICF). The purpose of this study was to develop and confirm the appropriateness of a scoring methodology for 43 ICF categories in older people with HF. DESIGN: Cross-sectional survey. We applied the RAND/University of California at Los Angeles (UCLA) Appropriateness Method with a modified Delphi method. SETTING AND PARTICIPANTS: We included a panel of 26 multidisciplinary experts on HF care consisting of home physicians, cardiovascular physicians, care managers, nurses, physical therapists, a pharmacist, occupational therapist, nutritionist and a social worker. MEASURES: We conducted a literature review of ICF linking rules and developed a questionnaire on scoring methods linked to ICF categories in older people with HF. In the Delphi rounds, we sent the expert panel a questionnaire consisting of three questions for each of the 43 ICF categories. The expert panel responded to the questionnaire items on a 1 (very inappropriate) - 9 (very appropriate) Likert scale and repeated rounds until a consensus of 'Appropriate' and 'Agreement' was reached on all items. RESULTS: A total of 21 panel members responded to all the Delphi rounds. In the first Delphi round, six question items in four ICF categories did not reach a consensus of 'Agreement', but the result of our modifications based on panel members' suggestions reached to a consensus of 'Appropriate' and 'Agreement' on all questions in the second Delphi round. CONCLUSION: The ICF-based scoring method for older people with HF developed in this study was found to be appropriate. Future work is needed to clarify whether comprehensive assessment and information sharing based on ICF contributes to preventing readmissions.

Selection of Comprehensive Assessment Categories Based on the International Classification of Functioning, Disability, and Health for Elderly Patients with Heart Failure: A Delphi Survey among Registered Instructors of Cardiac Rehabilitation.

The development of a comprehensive assessment tool based on the International Classification of Functioning, Disability, and Health (ICF) for elderly patients with heart failure is urgently required. In this study, we classified the ICF categories relevant to heart failure in the elderly through a Delphi survey (3-step questionnaire survey) of 108 Registered Instructors of Cardiac Rehabilitation in the Hiroshima Prefecture. Questionnaires were conducted using postal mail or a web-based platform. The survey was conducted three times, and the survey results were provided as feedback to the participants in the second and third rounds. More than 80% of the respondents selected categories according to the ICF core set methodology. Data were collected from December 2018 to March 2019, with 67, 54, and 46 participants in the first, second, and third rounds, respectively. A total of 58 ICF items were adopted based on the results: 27 body function items, 4 body structure items, 20 activity and participation items, and 7 environmental factor items. This study is characterised by the inclusion of a large number of ICF items for mental function. This result seems to be influenced by the increasing interest in cognitive dysfunction in elderly patients with heart failure. The ICF categories selected for this study allow for a comprehensive assessment of clients for occupational therapy. The findings of this study are expected to provide a basis for an outcome measure to determine the effectiveness of occupational therapy for these patients.

Aortic valve calcium is associated with left ventricular diastolic function in patients without evidence of ischaemic heart disease: assessment by gated single-photon emission computed tomography.

BACKGROUND: Several studies have shown that aortic valve calcium (AVC) is associated with cardiovascular events. Furthermore, the extent of AVC is associated with adverse prognosis even in patients without significant aortic stenosis. We investigated the relationship between AVC and left ventricular (LV) diastolic parameters determined by gated single-photon emission computed tomography (SPECT) in patients with no evidence of ischaemic heart disease. METHODS: This study included 157 patients with no evidence of ischaemic heart disease who underwent both coronary computed tomography and gated SPECT. The AVC scores were calculated by the Agatston method, and peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were determined as LV diastolic parameters. RESULTS: There were 93 (59%) and 64 (41%) patients with and without AVC, respectively, and the AVC scores ranged from 0 to 1251. There was no significant difference in LV end-diastolic volume (EDV) (60 ± 18 vs 62 ± 25 mL, p = 0.52) or LV ejection fraction (67% ± 10% vs 66% ± 8%, p = 0.60) between the two groups. Patients with AVC had lower PFR (2.2 ± 0.5 vs 2.4 ± 0.5 EDV/s, p = 0.002) and 1/3 MFR (1.3 ± 0.3 vs 1.5 ± 0.4 EDV/s, p = 0.003) than those without AVC. Multivariate linear regression analysis showed that ln(AVC score + 1) was significantly associated with PFR and 1/3 MFR. CONCLUSION: In patients without evidence of ischaemic heart disease, the extent of AVC was inversely correlated with gated SPECT-derived parameters of LV diastolic function.

Current Medical and Social Issues for Hospitalized Heart Failure Patients in Japan and Factors for Improving Their Outcomes　- Insights From the REAL-HF Registry.

Background: We investigated the current medical and social conditions and outcomes of heart failure (HF) patients in Hiroshima Prefecture, a local district in Japan. Methods and Results: From March 2017 to February 2018 we enrolled all adult patients with hospitalized HF in 8 regional core hospitals that provided an interprofessional team approach for HF patients. We collected patients' clinical characteristics and information regarding living circumstances, cognitive function, quality of life, and interprofessional team approach. For patients discharged home, we followed up the primary endpoint (all-cause death and all-cause unscheduled readmission), conditions of outpatient cardiac rehabilitation, and home nursing-care services over a 1-year period after discharge. Of the registered patients (n=1,218), 39.2% were super-elderly (≥85 years old); more than half of these patients had preserved ejection fraction (≥50%). In the follow-up cohort (n=632), 140 patients (22.2%) were readmitted with HF exacerbation as the primary endpoint, and almost half (n=295, 46.7%) experienced any primary endpoint. The multivariate analysis adjusted for medical and social factors showed that completion of outpatient cardiac rehabilitation (5-month program) remained a strong negative predictor of the primary endpoint (hazard ratio: 0.15; 95% confidence interval: 0.05-0.48; P=0.0013). Conclusions: Our cohort study highlighted the super-aging of current HF patients in Japan. Cardiac rehabilitation through continuous team approach appears to be associated with favorable overall outcomes in this population.

New assessment of endothelial function measured by short time flow-mediated vasodilation: Comparison with conventional flow-mediated vasodilation measurement.

BACKGROUND: Measurement of flow-mediated vasodilation (FMD) is an established method for assessing endothelial function. Measurement of FMD is useful for showing the relationship between atherosclerosis and endothelial function, mechanisms of endothelial dysfunction, and clinical implications including effects of interventions and cardiovascular events. To shorten and simplify the measurement of FMD, we have developed a novel technique named short time FMD (stFMD). We investigated the validity of stFMD for assessment of endothelial function compared with conventional FMD. METHODS AND RESULTS: We evaluated stFMD and conventional FMD in 82 subjects including patients with atherosclerotic risk factors and cardiovascular disease (66 men and 16 women, 57 ±â€¯16 years). Both stFMD and conventional FMD were significantly correlated with age, systolic blood pressure, diastolic blood pressure and baseline brachial artery diameter. In addition, stFMD was significantly correlated with conventional FMD (r = 0.76, P < 0.001). Bland-Altman plot analysis showed good agreement b etween stFMD and conventional FMD. Moreover, stFMD in the at risk group and that in the cardiovascular disease group were significantly lower than that in the no risk group (4.6 ±â€¯2.3% and 4.4 ±â€¯2.2% vs. 7.3 ±â€¯1.9%, P < 0.001, respectively). Optimal cutoff value of stFMD for diagnosing atherosclerosis was 7.0% (sensitivity of 71.0% and specificity of 85.0%). CONCLUSIONS: These findings suggest that measurement of stFMD, a novel and simple method, is useful for assessing endothelial function. Measurement of stFMD may be suitable for screening of atherosclerosis when repeated measurements of vascular function are required and when performing a clinical trial using a large population. CLINICAL TRIAL REGISTRATION INFORMATION: URL for Clinical Trial: http://UMIN; Registration Number for Clinical Trial: UMIN000025458.

Assessment of endothelium-independent vasodilation: from methodology to clinical perspectives.

: Vascular response to exogenously administered nitroglycerine, an index of endothelium-independent vasodilation, has been used as a control test for the assessment of endothelium-dependent vasodilation (endothelial function) in humans. However, evidence has been accumulating that not only endothelium-dependent vasodilation but also endothelium-independent vasodilation per se is impaired in individuals with cardiovascular risk factors and cardiovascular disease. Impaired endothelium-independent vasodilation is associated with structural vascular alterations and alterations in vascular smooth muscle cells. Several methods, including assessment of vascular responses to vasoactive agents using angiography in a coronary artery and vascular responses to vasoactive agents using venous occlusion plethysmography and ultrasonography in a peripheral artery, are used to assess endothelium-independent vasodilation in humans. Measurement of endothelium-independent vasodilation is also useful for assessment of atherosclerosis and may be a predictor of future cardiovascular events. In this review, we focus on assessment of endothelium-independent vasodilation from methodology aspects to clinical perspectives.

Reactive hyperemia-peripheral arterial tonometry is useful for assessment of not only endothelial function but also stenosis of the digital artery.

BACKGROUND: Although reactive hyperemia-peripheral arterial tonometry (RH-PAT) is widely used for assessment of endothelial function, RH index (RHI) cannot be measured in some cases when pulse wave amplitude (PWA) is very low. Decrease in PWA is mainly caused by proper palmar digital artery (PPDA) stenosis. The purpose of this study was to evaluate the relationship between PWA measured by RH-PAT and stenosis of the PPDA measured by digital subtraction angiography and to evaluate the limitation of assessment of endothelial function measured by RHI in patients with PPDA stenosis. METHODS: We measured baseline PWA in 51 fingers including the first to third fingers of both hands in 10 patients who had PPDA stenosis and in 66 fingers that were the first fingers of both hands in 33 subjects who had no PPDA stenosis. Severe stenosis was defined as over 75% by lower percent diameter stenosis between two PPDAs in a finger. RESULTS: PWA was significantly correlated with stenosis of the digital artery (r=-0.55; P<0.0001). A PWV value of 300mV was the optimal cut-off value for severe stenosis (sensitivity, 84.0%; specificity, 88.5%). Log RHI was significantly lower in patients with PPDA stenosis than in subjects without PPDA stenosis (0.33±0.27 versus 0.73±0.27, P=0.007). CONCLUSIONS: RH-PAT may be useful for assessment of not only endothelial function but also PPDA stenosis. RHI may be underestimated in patients with PPDA stenosis. We should pay attention to low baseline PWA when measuring RHI. CLINICAL TRIAL REGISTRATION INFORMATION: URL for clinical trial: http://UMIN; registration number for clinical trial: UMIN000003409.

Hospitalization and medical cost of patients with elevated serum N-terminal pro-brain natriuretic peptide levels.

BACKGROUND: Patients with heart failure (HF) are reportedly at high risk for 'all-cause' re-hospitalization. A biomarker for HF, N-terminal pro-brain natriuretic peptide (NT-proBNP), enables to simply detect patients with possible HF (pHF). We examined the hospitalization and medical cost of Japanese patients detected by an elevated serum NT-proBNP, and also evaluated the effects of institutional team approaches for HF on their all-cause hospitalizations. METHODS: We retrospectively extracted all adult patients with serum NT-proBNP ≥400 pg/ml measured between January and March 2012 in Hiroshima University Hospital as pHF-positive patients. We studied their all-cause hospitalization records during the past 3-year period. We also extracted all pHF-negative patients with NT-proBNP <400 pg/ml and studied as well. In the pHF-positive patients followed for 3 years after starting interprofessional team approaches to prevent the onset and exacerbation of HF in the hospital, we compared the hospitalization and medical cost between the 3-year periods before and after the start of the team approaches. RESULTS: We enrolled 432 pHF-positive and 485 pHF-negative patients with one or more hospitalization records. Compared to the pHF-negative patients, the pHF-positive patients had longer total hospitalization days (median [interquartile range], 30 [13-58] versus. 18 [8-39], p <0.0001) and higher total medical cost for hospitalizations (2.42 [1.07-5.08] versus. 1.80 [0.79-3.65] million yen, p <0.0001). A subset of 303 pHF-positive patients was followed for 3 years after starting the team approaches, and we found that both total hospitalization days (30 [13-57] to 8 [0-31]) and medical cost for hospitalizations (2.59 [1.37-5.05] to 0.76 [0-2.38] million yen) showed marked reduction in them. CONCLUSIONS: Patients with an elevated serum NT-proBNP have longer hospitalizations and higher costs for all-cause hospitalizations than those without. Institutional team approaches for HF may reduce them.

Brachial artery diameter as a marker for cardiovascular risk assessment: FMD-J study.

BACKGROUND AND AIMS: Baseline brachial artery (BBA) diameter has been reported to be a potential confounding factor of flow-mediated vasodilation (FMD). The purpose of this study was to evaluate the relationships between BBA diameter and cardiovascular risk factors and compare the diagnostic accuracy of BBA diameter in subjects without cardiovascular risk factors and patients with cardiovascular disease (CVD) with that of FMD. METHODS: We measured BBA diameter and FMD in 5695 male subjects. In addition, we retrospectively investigated the incidence of cardiovascular events using another population sample consisting of 440 male subjects, to compare the accuracy of BBA diameter with that of FMD in predicting cardiovascular events. RESULTS: BBA diameter and FMD significantly correlated with age, body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, high-density lipoprotein cholesterol, and glucose as well as Framingham risk score. The prevalence of cardiovascular risk factors and CVD increased with the increase in BBA diameter and FMD. Area under the curve (AUC) value of the receiver operating characteristic (ROC) curve for BBA diameter to diagnose subjects without cardiovascular risk factors (0.59 vs. 0.62, p = 0.001) or patients with CVD (0.58 vs. 0.64, p < 0.001) was significantly lower than that for FMD. In the retrospective study, the AUC value of the ROC curve for BBA diameter to predict first major cardiovascular events was significantly lower than that of FMD (0.50 vs. 0.62, p = 0.03). CONCLUSIONS: In men, BBA diameter was inferior to FMD for assessment of cardiovascular risk.

Endothelial Function Is Impaired in Patients Receiving Antihypertensive Drug Treatment Regardless of Blood Pressure Level: FMD-J Study (Flow-Mediated Dilation Japan).

Hypertension is associated with endothelial dysfunction. Blood pressure significantly correlates with endothelial function in antihypertensive drug-naive subjects. The purpose of this study was to determine whether treatment status affects the relationship between blood pressure and endothelial function. We measured flow-mediated vasodilation (FMD) in 2297 subjects, including 1822 antihypertensive drug-naive subjects and 475 treated hypertensive patients. FMD significantly decreased in relation to increase in systolic blood pressure (8.2±3.1% in subjects with systolic blood pressure of <120 mm Hg, 7.5±2.8% for 120-129 mm Hg, 7.1±2.8% for 130-139 mm Hg, and 6.7±2.6% for ≥140 mm Hg; P<0.001). Systolic blood pressure was independently associated with FMD in untreated subjects. In contrast, there was no significant relationship between systolic blood pressure and FMD in treated hypertensive patients (4.6±3.1% in treated hypertensives with systolic blood pressure of <120 mm Hg, 4.8±2.7% for 120-129 mm Hg, 4.9±2.8% for 130-139 mm Hg, and 4.5±2.3% for ≥140 mm Hg; P=0.77). Propensity score matching analysis revealed that the prevalence of endothelial dysfunction defined as FMD of less than the division point for the lowest tertile, and the middle tertile of FMD was significantly higher in treated hypertensive patients than in untreated subjects in all systolic blood pressure categories. Endothelial function assessed by FMD was impaired regardless of the level of blood pressure achieved by antihypertensive drug treatment in hypertensive patients.

A novel noninvasive and simple method for assessment of endothelial function: enclosed zone flow-mediated vasodilation (ezFMD) using an oscillation amplitude measurement.

BACKGROUND: It is clinically important to estimate the degree of endothelial dysfunction. Several methods have been used to assess endothelial function in humans. Recently, we developed a new noninvasive method for measurement of vascular response to reactive hyperemia in the brachial artery, named enclosed zone flow-mediated vasodilation (ezFMD). The purpose of this study was to determine the validity of ezFMD for assessment of endothelial function. METHODS AND RESULTS: We measured ezFMD by a new device using an oscillometric method and conventional FMD using ultrasonography in 306 subjects, including patients with hypertension, dyslipidemia, and diabetes mellitus (218 men and 88 women, 30 ± 16 yr). Univariate regression analysis revealed that ezFMD significantly correlated with age (r = -0.42, P < 0.0001), body mass index (r = -0.13, P = 0.028), systolic blood pressure (r = -0.15, P = 0.009), diastolic blood pressure (r = -0.14, P = 0.011), fasting glucose level (r = -0.27, P = 0.006), smoking (r = -0.21, P = 0.007) and baseline pulse wave amplitude (r = -0.51, P < 0.0001). ezFMD significantly correlated with conventional FMD (r = 0.34, P < 0.0001). Multiple regression analysis revealed that age (P = 0.002), body mass index (P = 0.013), systolic blood pressure (P = 0.009), smoking (P = 0.004) and baseline pulse wave amplitude (P < 0.001) were independent predictors of ezFMD. CONCLUSIONS: These findings suggest that measurement of ezFMD, a novel noninvasive and simple method, may be useful for determination of vascular diameter response to reactive hyperemia. Since ezFMD is automatically measured by a device with an oscillometric method, measurement of ezFMD is easier and less biased than that of conventional FMD.

Nitroglycerine-induced vasodilation for assessment of vascular function: a comparison with flow-mediated vasodilation.

OBJECTIVE: Nitroglycerine-induced vasodilation has been used as a control test for flow-mediated vasodilation (FMD) to differentiate endothelium-dependent from endothelium-independent response when evaluating endothelial function in humans. Recently, nitroglycerine-induced vasodilation has also been reported to be impaired in patients with atherosclerosis. The purpose of this study was to determine the relationships between nitroglycerine-induced vasodilation and cardiovascular risk factors. APPROACH AND RESULTS: We measured nitroglycerine-induced vasodilation and FMD in 436 subjects who underwent health examinations (mean age, 53 ± 19 years; age range, 19-86 years), including patients with cardiovascular diseases. There was a significant relationship between nitroglycerine-induced vasodilation and FMD (r=0.42; P<0.001). Univariate regression analysis revealed that nitroglycerine-induced vasodilation correlated with age (r=-0.34; P<0.001), systolic blood pressure (r=-0.32; P<0.001), diastolic blood pressure (r=-0.24; P<0.001), heart rate (r=-0.21; P<0.001), glucose (r=-0.23; P<0.001), and smoking pack-year (r=-0.12; P=0.01), as well as Framingham risk score (r=-0.30; P<0.001). Nitroglycerine-induced vasodilation was significantly smaller in patients with cardiovascular disease than in both subjects with and without cardiovascular risk factors (10.5 ± 5.6% versus 13.7 ± 5.4% and 15.3 ± 4.3%; P<0.001, respectively), whereas there was no significant difference in nitroglycerine-induced vasodilation between subjects with and without cardiovascular risk factors. Multivariate analysis revealed that male sex, body mass index, hypertension, diabetes mellitus, baseline brachial artery diameter, and FMD were independent predictors of nitroglycerine-induced vasodilation. CONCLUSIONS: These findings suggest that nitroglycerine-induced vasodilation may be a marker of the grade of atherosclerosis. FMD should be interpreted as an index of vascular function reflecting both endothelium-dependent vasodilation and endothelium-independent vasodilation in subjects with impaired nitroglycerine-induced vasodilation.

Novel assessment of temporal variation in fractionated electrograms using histogram analysis of local fractionation interval in patients with persistent atrial fibrillation.

BACKGROUND: The characteristics of atrial electrograms associated with atrial fibrillation (AF) termination are controversial. We investigated the electrogram characteristics that indicate procedural AF termination during continuous complex fractionated electrogram ablation. METHODS AND RESULTS: Fifty-two consecutive patients with persistent AF (47 men; aged 54 ± 9 years), who underwent electrogram-based catheter ablation in the left atrium and coronary sinus after pulmonary vein isolation, were enrolled. The intracardiac bipolar atrial electrogram recordings were characterized by (1) fractionation interval (FI) analysis (>6 seconds), (2) kurtosis (shape of the FI histogram), and (3) skewness (asymmetry of the FI histogram). Sites showing complex, fractionated electrograms (mean FI ≤ 60 ms) were targeted, and AF was terminated in 20 patients (38%) after the pulmonary vein isolation. The conventional complex fractionated electrogram sites (mean ≤ 120 ms) in patients with AF termination exhibited higher median kurtosis (2.69 [interquartile range, 2.03-3.46] versus 2.35 [interquartile range, 1.79-2.48]; P=0.024) and higher complex fractionated electrogram-mean interval (102.7 ± 19.8 versus 87.7 ± 15.0; P=0.008) than patients without AF termination. Furthermore, AF termination sites had higher median kurtosis than targeted sites without AF termination (5.13 [interquartile range, 3.51-6.47] versus 4.18 [interquartile range, 2.91-5.34]; P<0.01) in patients with procedural termination. In addition, patients with AF termination had a higher sinus rhythm maintenance rate after a single procedure than patients without AF termination (log-rank test, P=0.007). CONCLUSIONS: A kurtosis analysis using the FI histogram may be a useful tool in identifying the critical substrate for persistent AF and potential responders to catheter ablation.

Transthoracic Doppler echocardiographic assessment of left anterior descending coronary artery and intramyocardial artery predicts left ventricular remodeling and wall-motion recovery after acute myocardial infarction.

BACKGROUND: Previous studies reported that a coronary flow velocity (FV) pattern with a rapid diastolic deceleration time (DDT) immediately after percutaneous coronary intervention implies advanced microvascular damage in patients who have experienced an acute myocardial infarction (AMI). METHODS: Using transthoracic echocardiography, we recorded the coronary FV in the left anterior descending coronary artery (LAD) and the FV in the intramyocardial artery 2 days after successful percutaneous coronary intervention in 24 patients who had experienced an anterior AMI. We measured the DDT of the LAD and the intramyocardial artery. DDT of the LAD and the intramyocardial artery was detected in the anteroseptal lesion, the wall motion of which revealed severe hypokinesis or akinesis. We performed echocardiography during both the acute phase and 6 months after the AMI. RESULTS: Patients were divided into two groups (group A: DDT of the LAD < or = 600 milliseconds [n = 10], group B: DDT of the LAD > or = 600 milliseconds [n = 14]). DDT of the LAD and the intramyocardial artery was significantly shorter for group A than group B (373 +/- 223 vs 786 +/- 105 milliseconds, P < .0001). In the acute phase, there were no significant differences in left ventricular (LV) wall-motion score index (WMSI), LV end-diastolic volume (EDV), or ejection fraction (WMSI: 2.38 +/- 0.24 vs 2.08 +/- 0.58, P = .20; LV EDV: 160 +/- 41 vs 154 +/- 34 mL; ejection fraction: 45 +/- 11 vs 46 +/- 5%). However, WMSI and LV EDV in group A were significantly greater than in group B (WMSI: 2.47 +/- 0.16 vs 1.84 +/- 0.57, P = .01; LV EDV: 198 +/- 28 vs 132 +/- 37 mL, P = .0004) and the ejection fraction in group A was significantly lower than in group B (38 +/- 9 vs 55 +/- 10%, P = .001) during the chronic phase. CONCLUSIONS: In patients who had experienced an anterior AMI, we could predict wall-motion recovery of the infarcted area by using the coronary FV of the LAD and FV of the intramyocardial artery.

[Left ventricular volume and ejection fraction by the axius auto ejection fraction method: comparison with manual trace method and visual assessment of ejection fraction].

OBJECTIVES: Visual assessment of the ejection fraction (EF) is often used in clinical practice, but is subjective and requires training and experience. The auto EF method has been newly developed for automated detection of the left ventricular (LV) endocardial border throughout the cardiac cycle. The clinical feasibility was assessed of the auto EF method for measuring LV volumes and EF in patients. Manually traced EF measured by the biplane modified Simpson's rule was used as the reference standard. METHODS: The study population consisted of 30 consecutive patients with normal sinus rhythm. All patients underwent two-dimensional echocardiography. The auto EF method incorporated pattern and shape recognition to automatically locate the LV, track the endocardium, and calculate EF from routine digital images. LV end-diastolic and end-systolic volumes and EF measured by the auto EF method were compared those by the manually traced method. LVEF by the Auto EF method was also compared with visual EF determined by nonattending physicians. RESULTS: Auto EF was more reproducible than visual EF by the expert reader. LVEF by the auto EF method had excellent correlation and close limits of agreement with manually traced EF compared with visual EF(4-chamber view: y = 1.10 x - 4.28, r = 0.94, bias = 1.6%, 2-chamber view: y = 0.88 x + 7.25, r = 0.90, bias = 0.4%). LV volumes by the auto EF method underestimated those by manually traced EF (end-diastolic volume by 4-chamber view: y = 0.72 x + 8.92, r = 0.93, bias = - 16.7 ml, end-systolic volume by 4-chamber view: y = 0.82 x - 0.97, r = 0.98, bias = - 8.5 ml, end-diastolic volume by 2-chamber view: y = 0.73 x + 12.4, r = 0.82, bias = - 12.3 ml, end-systolic volume by 2-chamber view: y = 0.65 x + 6.94, r = 0.90, bias = - 6.8 ml). CONCLUSIONS: The auto EF method is a clinically useful tool for the measurement of LV volumes and EF.

Quantitative assessment of harmonic power doppler myocardial perfusion imaging with intravenous Levovist in patients with myocardial infarction: comparison with myocardial viability evaluated by coronary flow reserve and coronary flow pattern of infarct-related artery.

BACKGROUND: Myocardial contrast echocardiography and coronary flow velocity pattern with a rapid diastolic deceleration time after percutaneous coronary intervention has been reported to be useful in assessing microvascular damage in patients with acute myocardial infarction. AIM: To evaluate myocardial contrast echocardiography with harmonic power Doppler imaging, coronary flow velocity reserve and coronary artery flow pattern in predicting functional recovery by using transthoracic echocardiography. METHODS: Thirty patients with anterior acute myocardial infarction underwent myocardial contrast echocardiography at rest and during hyperemia and were quantitatively analyzed by the peak color pixel intensity ratio of the risk area to the control area (PIR). Coronary flow pattern was measured using transthoracic echocardiography in the distal portion of left anterior descending artery within 24 hours after recanalization and we assessed deceleration time of diastolic flow velocity. Coronary flow velocity reserve was calculated two weeks after acute myocardial infarction. Left ventricular end-diastolic volumes and ejection fraction by angiography were computed. RESULTS: Pts were divided into 2 groups according to the deceleration time of coronary artery flow pattern (Group A; 20 pts with deceleration time > or = 600 msec, Group B; 10 pts with deceleration time < 600 msec). In acute phase, there were no significant differences in left ventricular end-diastolic volume and ejection fraction (Left ventricular end-diastolic volume 112 +/- 33 vs. 146 +/- 38 ml, ejection fraction 50 +/- 7 vs. 45 +/- 9 %; group A vs. B). However, left ventricular end-diastolic volume in Group B was significantly larger than that in Group A (192 +/- 39 vs. 114 +/- 30 ml, p < 0.01), and ejection fraction in Group B was significantly lower than that in Group A (39 +/- 9 vs. 52 +/- 7%, p < 0.01) at 6 months. PIR and coronary flow velocity reserve of Group A were higher than Group B (PIR, at rest: 0.668 +/- 0.178 vs. 0.248 +/- 0.015, p < 0.0001: during hyperemia 0.725 +/- 0.194 vs. 0.295 +/- 0.107, p < 0.0001; coronary flow velocity reserve, 2.60 +/- 0.80 vs. 1.31 +/- 0.29, p = 0.0002, respectively). CONCLUSION: The preserved microvasculature detecting by myocardial contrast echocardiography and coronary flow velocity reserve is related to functional recovery after acute myocardial infarction.