Left Ventricular Myocardial Performance in Normotensive Offspring of Hypertensive Parents.

INTRODUCTION: Early alterations in the cardiovascular system have been described in offspring of hypertensive parents, but with conflicting results. AIM: To evaluate the influence of genetic predisposition to hypertension on left ventricular (LV) geometry and function, 30 normotensive male offspring of hypertensive parents (EH+) and 30 matched offspring of normotensive families (EH-), were studied. METHODS: All subjects underwent office and 24-h ambulatory blood pressure monitoring (ABPM), conventional and Tissue Doppler Echocardiography (TDE), including assessment of myocardial performance index (MPI). RESULTS: EH+ showed an increase in office BP with statistical significance in diastolic BP (84 ± 7 vs 73 ± 6 mmHg; p < 0.05). Relative wall thickness (RWT) was greater in EH+ (0.37 ± 0.05 vs 0.31 ± 0.03; p < 0.05) and significantly related to the EH+ condition at the univariate analysis (p < 0.003), whilst the LV mass index was unchanged (84.3 ± 14 vs 80 ± 17 g/m2; p = NS), suggesting a trend towards concentric remodeling. Systolic and diastolic function, in both ventricles, were superimposable in the two groups. The MPI was higher in EH+ (0.49 ± 0.10 vs 0.45 ± 0.08; p = NS) and significantly correlated to RWT (r = 0.47, p < 0.01). However, at the stepwise multiple regression analysis, only the condition of EH + was independently associated with RWT (p <0.006). RWT, according to ROC curves analysis, predicted the condition of EH+ (cutoff 0.359, specificity 89%, sensitivity 82%). CONCLUSION: Current results provide information about LV myocardial performance in EH+ subjects, related to a LV concentric remodeling and to endothelial dysfunction.

Hemodynamic and ECG responses to stress test in early adolescent athletes explain ethnicity-related cardiac differences.

BACKGROUND: Ethnicity is an important determinant of athletes' cardiovascular adaptation. Black adolescent and adult athletes exhibit a left ventricular (LV) hypertrophy with a concentric remodelling higher than their Caucasian counterparts. Scant data, however, are available on race-related differences in hemodynamic response of adolescent athletes to exercise and its relation with heart remodelling. We evaluated if race-specific, sport-related structural and electrical remodelling in adolescent athletes of Caucasian and African ethnicity exclusively depends on race itself rather than on different cardiovascular responses to physical exercise. METHODS: We examined 90 adolescent athletes, 60 Caucasian (WA) and 30 Black (BA). All participants underwent thorough clinical, echocardiographic and stress test evaluations. RESULTS: BA had greater indexed LV mass (LVM/BSA) with increased relative wall thickness (RWT) implying a concentric remodelling. BA showed higher systolic blood pressure (SBP) compared to WA during the whole exercise test. ECG data showed that BA vs WA had a significant shorter QRS duration in each step considered with a significant greater QT dispersion. BA reached a higher relative pressure peak as compared to WA. RWT was strongly influenced by ethnicity and less by SBP at peak of exercise (PE), although LVM/BSA was significantly related to SBP at PE and just marginally to age and not significantly to race. CONCLUSIONS: Black adolescent athletes showed higher SBP during all steps of exercise associated to a different trend. Ethnicity was the main determinant of RWT, suggesting that LV geometry is principally race-related rather than influenced by a different hemodynamic profile to physical activity.

Sex-related differences in left ventricular structure in early adolescent non-professional athletes.

BACKGROUND: Professional athletes exhibit lower left ventricular wall thicknesses, diameters and mass (in females), with less frequent training-related electrocardiogram (ECG) changes, as compared with controls. METHODS: We studied the association of sex with left ventricular structure in trained early adolescents. Two hundred and six adolescent Caucasian athletes (mean age 13.8 ± 1.6, range 11.8-16.9 years, 158 males and 48 females), with similar degree of training underwent ECG and echocardiographic measurements of left ventricular diameters, thicknesses and mass, with relative wall thickness as the remodelling index. RESULTS: As compared with females, males exhibited greater maximal wall thickness (males = 8.7 ± 1.2 vs. females = 7.9 ± 0.8) and indexed left ventricular mass (100 ± 18 g/m(2) vs. 79 ± 12, p < 0.001), without differences in relative wall thickness (males = 0.35 ± 0.04 vs. females = 0.34 ± 0.04) and with higher prevalence of ECG-based left ventricular hypertrophy, sinus bradycardia and ST-elevation. An analysis of covariance, using age, body surface area, systolic blood pressure, heart rate and sex as the covariates, reported that sex is a strong predictor of left ventricular mass, maximal wall thickness, left ventricular diastolic diameter and ECG-based left ventricular hypertrophy. In a binary logistic regression model analysis sex, like left ventricular mass, predicted ST-trait elevation. CONCLUSIONS: Our results suggest that, in early adolescence, female athletes have lower left ventricular mass and thicknesses compared with males, without geometrical differences. Therefore, sex, independent of age, is a strong determinant of structural parameters also in early adolescent athletes. These data indicate that sex-specific parameters are needed in the pre-participation cardiovascular screening of adolescent athletes.

Cardiac iron removal and functional cardiac improvement by different iron chelation regimens in thalassemia major patients.

Heart failure due to myocardial iron overload remains the leading cause of morbidity and mortality in adult thalassemia major (TM) patients. We evaluated the removal of cardiac iron and the changes of cardiac function by different iron chelation in TM patients by T2* cardiac magnetic resonance (CMR). Sixty-seven TM patients (27 males/40 females; mean age, 35 ± 6 years) on different chelation regimens underwent T2* CMR at baseline (t (0)), after 6-14 months (t (1)) and after 32 ± 7 months (t (2)). Patients were divided in four groups according to chelation treatment: group A (deferasirox), group B (deferoxamine), group C (combined treatment, deferoxamine plus deferiprone) and group D (deferiprone alone). Myocardial T2* at t (0) was <10 ms in 8 patients, between 10 and 20 ms in 22 patients and ≥ 20 ms in 37 patients. Progressive changes in T2* were observed at t (1) and t (2). Ten patients (10/36, 27.8 %) in group A, three patients (3/15, 20 %) in group B and three patients (3/12, 25 %) in group C moved from an abnormal T2* to normal values. We observed an improvement of left ventricular ejection fraction and a reduction of end-systolic and end-diastolic left ventricular volumes only in patients in group A with baseline cardiac T2* between 10 and 20 ms. Rigorous compliance to any chelation therapy at proper doses significantly improve myocardial T2*. Treatment with deferasirox significantly improves left ventricular function. Combination therapy seems to ameliorate cardiac T2* in a shorter period of time in severe siderosis.

Usefulness of myocardial performance index in multiple sclerosis mitoxantrone-induced cardiotoxicity.

AIMS: The authors sought to investigate the ability of the Doppler-derived myocardial performance index (MPI) to predict cardiotoxicity in multiple sclerosis (MS) patients under mitoxantrone therapy. METHODS AND RESULTS: The aauthors prospectively evaluated 28 MS patients (mean age 41±9 years, 12 males and 16 females) treated with low-dose mitoxantrone (basal mean cumulative dose 30±14 mg/m(2), end of follow-up mean dose 41±17 mg/m(2)). All patients underwent two-dimensional and Doppler-echocardiography at baseline and after a mean follow-up of 22±8 months. MPI was estimated using mitral inflow and left ventricular (LV) outflow pattern. Comparing data at baseline and at the end of follow-up, significant decrease in ejection fraction (EF) was observed (60±5 vs 56±4, p<0.03). The MPI was 0.52±0.1 at baseline and 0.60±0.1 at the end of follow-up (p<0.04). Such difference was mainly due to a isovolumic relaxation time prolongation (80±12 at baseline and 98±30 at the end of follow-up, p<0.05). The area under the receiver operating characteristic curve, analysed for an MPI cut-point value of 0.57, in identifying a significant reduction of LVEF ≤50% was of 0.94±0.065 with sensitivity and specificity of 97.5% and 90%, respectively. CONCLUSION: In conclusion, it can be speculated that a higher basal value of MPI could represent a subclinical LV cardiotoxicity, identifying a future decrease of EF and a progression to congestive heart failure in MS patients under mitoxantrone therapy.

Normotensive male offspring of essential hypertensive parents show early changes in left ventricular geometry independent of blood pressure.

For the purpose of detecting early left ventricle (LV) abnormalities in normotensive offspring of hypertensive parents (EH+), 23 normotensive sedentary male EH+ (age 25 ± 3 years) and 20 matched offspring of normotensive families (EH-), underwent: clinic bloop pressure (BP) measurement, 24-hour ambulatory BP monitoring (ABPM), frequency-domain parameters of autonomic heart rate control and conventional and Doppler tissue echocardiographic (DTE) study of both ventricles, including relative wall thickness (RWT) as an index of LV remodeling. EH+ subjects had slightly higher office systolic and diastolic (P < 0.05), average 24-hour systolic (P < 0.001), diastolic (P < 0.01), and mean BP (P < 0.05). No between-group differences were detected for heart rate variability, LV mass and systolic and diastolic function in both ventricles. RWT was greater in EH+ (0.38 ± 0.05 vs. 0.34 ± 0.03 SD; P < 0.01), which was significantly related, at the univariate analysis, to the condition of EH+ (P < 0.004) and to the clinic and ambulatory BP parameters as well (P = 0.06-0.01). However, at the stepwise multiple regression analysis, with RWT used as the dependent variable, only the condition of EH+ was independently associated with RWT (P < 0.008), whereas BP did not. RWT, according to receiver operating characteristic curves analysis, predicted the condition of EH+ (cutoff point 0.369, specificity 90%, sensitivity 65%). Our data suggest that an higher RWT, as an index towards LV concentric remodeling, is the earliest change in LV geometry in EH+ subjects, independent of any slight elevation in BP. Thus, RWT measurement may be a quite specific tool to detect early LV alterations due to the condition of EH+.

Oral iron chelators.

Deferoxamine (DFO) was the standard of care for transfusional iron overload for >40 years, requiring subcutaneous infusion for 8-12 h/day, 5-7 days/week. Oral iron chelators are an important development, offering the potential to improve compliance and patients' quality of life. The oral, three-times-daily agent deferiprone appeared to be a promising advance; however, its use has been limited owing to serious adverse events, such as neutropenia and agranulocytosis. Therapy combining deferiprone with DFO has proved effective in the management of severe cardiac siderosis. Deferasirox is a novel, orally active agent that provides 24-h chelation with a once-daily dose. An extensive clinical trial program has demonstrated that deferasirox at appropriate doses is effective in reducing or maintaining iron burden in adult and pediatric patients. The clinical program demonstrated that deferasirox has a safety profile that is clinically manageable with regular monitoring.

Long-term effects of perindopril on left ventricular structure and function in patients with stable coronary artery disease: a conventional and Doppler tissue echocardiographic pilot study.

OBJECTIVES: The aim of this study was to investigate the long-term effects of perindopril on left ventricular (LV) systolic and diastolic function in patients with stable coronary artery disease who had previously undergone coronary artery bypass graft. METHODS: Thirteen patients (12 male and one female patient) were treated with perindopril 8 mg/day and 13 (nine male and four female patients) with placebo, and both groups underwent conventional and Doppler tissue echocardiography (DTE) at baseline and after 12, 24, 36 and 47 months. DTE was sampled at the four sites of the mitral annulus and peak velocity (pv) and the time-velocity integral (tvi) of systolic (S) and diastolic (E and A) waves were calculated. RESULTS: During the 47 months of follow-up, ejection fraction significantly increased in the perindopril group from 58 +/- 10 to 69 +/- 6% (P < 0.01) without any significant change in LV volumes. LV shortening and relaxation, assessed by DTE, also significantly increased: Stvi from 1.57 +/- 0.18 to 1.95 +/- 0.19 cm (P < 0.01) and Etvi from 0.95 +/- 0.23 to 1.37 +/- 0.59 cm (P < 0.05). There were no changes in ejection fraction (64 +/- 6 vs. 65 +/- 8%; P = not significant) or S or E waves in the placebo group, but a significant increase in LV diastolic volume. Blood pressure remained unchanged in both groups. CONCLUSION: Our data suggest that perindopril improves both systolic and diastolic LV myocardial performance, a beneficial effect that may be due to the previously demonstrated biological, anti-ischemic and endothelium-dependent action of perindopril.

Assessment of mitoxantrone-induced cardiotoxicity in patients with multiple sclerosis: a tissue Doppler echocardiographic analysis.

AIM: Tissue Doppler echocardiography was investigated for its applicability in detecting subtle myocardial involvement in multiple sclerosis patients receiving a low dose of mitoxantrone. METHODS AND RESULTS: Twenty Caucasian patients with multiple sclerosis (mean age 43.9+/-9.3 years, 12 males and 8 females) treated with mitoxantrone (mean cumulative dose 35.4+/-21.6 mg/m(2)), were compared to 20 healthy subjects (mean age 45.4+/-15.3 years, 11 males and 9 females) matched for age and gender. All subjects underwent conventional and Tissue Doppler echocardiography. Patients with heart failure, life-threatening arrhythmias, and other prominent manifestations of heart disease were excluded. No differences were observed in blood pressure, heart rate, and conventional systolic and diastolic echocardiographic parameters. At Tissue Doppler echocardiography, patients with multiple sclerosis showed differences of the systolic mechanic expressed by a significant lower S-wave peak velocity at the lateral site of mitral annulus (11.4+/-2.5 cm/sec vs. 15.0+/-4.1 cm/sec, P < 0.02). Such S-wave peak velocity significantly correlated with a cumulative dose of mitoxantrone (r =-0.37, P < 0.05). CONCLUSION: Tissue Doppler echocardiography suggests an early involvement of the systolic myocardial function at the low dose of mitoxantrone. Therefore, Tissue Doppler echocardiography may be used as a noninvasive method for monitoring subclinical cardiotoxicity in multiple sclerosis patients receiving mitoxantrone.

[Echocardiography in internal medicine: usefulness of Doppler tissue analysis]. / Ecocardiografia in ambito internistico: contributo dell'analisi Doppler tissutale.

The Doppler echocardiographic examination is the most important and common method used for cardiac imaging due to its safety, its relatively low cost and the great amount of morphofunctional information it can provide. It also plays a relevant role in the assessment of cardiac involvement underlying systemic diseases, in most of which the complication rate is often subclinical and represents one of the main causes of mortality. Advances in technology have lead to an increase in diagnostic accuracy and the range of applications of echocardiography. Among the new techniques, tissue Doppler echocardiography has been shown to identify early ventricular changes in both diastolic and systolic phases and in the preclinical stage of systemic diseases such as amyloidosis, systemic lupus erythematosus, vasculitis, with possible cardiac involvement. The increased sensitivity derives from the possibility of assessing longitudinal mechanics, which seems affected earlier than the circumferential one by pathological processes. Tissue Doppler echocardiography analysis, associated with a complete clinical history, can make an early diagnosis or arise a diagnostic suspicion to the physician, allowing early detection and rapid implementation of diagnostic and therapeutic measures able to improve patient prognosis.

Myocardial involvement during the early course of type 2 diabetes mellitus: usefulness of myocardial performance index.

To evaluate whether myocardial performance index detects a subclinical impairment of left ventricular systolic and diastolic function in patients with early stage of type 2 diabetes, without coronary artery disease, with or without hypertension. Furthermore, to evaluate whether some echocardiographic parameters relate to the metabolic control. Fourty-five consecutive male patients (mean age 52.5 years) with type 2 diabetes mellitus of recent onset (23 hypertensives and 22 normotensives) and 22 age matched healthy controls males were analysed. All participants had normal exercise ECG. All subjects underwent standard and Doppler echocardiography for the assessment of the isovolumic Doppler time interval and Doppler-derived myocardial performance index. In all diabetic patients a glycated haemoglobin test was also performed. No differences were observed in blood pressure, heart rate, and conventional echocardiographic parameters comparing the 2 subgroups of diabetic patients and the controls. Myocardial performance index was significantly higher in diabetic patients independently of the hypertension occurrence, compared to the controls (0.49 and 0.49 diabetic normotensives and hypertensives respectively vs. 0.39, p < 0.01). Myocardial performance index correlated to glycated haemoglobin significantly (r = 0.37, p < 0.01) in both diabetic subgroups. Thus, an early involvement of left ventricular performance was shown by myocardial performance index in patients with type 2 diabetes of recent onset without coronary artery disease, independently of the hypertension presence. These abnormalities can provide a feasible approach to detect a pre-clinical diabetic cardiomyopathy and could be useful for an indirect assessment of the metabolic control.

Impact of myocardial geometry on left ventricular performance in healthy black and white young adults.

Racial differences in left ventricular (LV) structure are suggested by clinical and experimental studies. This study evaluates if racial differences in LV performance exist comparing black to white young males, by tissue Doppler echocardiography and myocardial performance index (MPI). We examined 40 healthy males, 20 blacks (mean age 27.6 +/- 4.4 years) and 20 whites (mean age 26.5 +/- 6.7 years). All subjects underwent conventional echocardiography, tissue Doppler echocardiography, and MPI assessment. No differences were found in LV diameters, volumes, mass, and hemodynamic measurements. Septal and posterior wall thicknesses were significantly increased in black subjects as well as the relative wall thickness. Systolic and diastolic functions estimated by conventional parameters were superimposable in the two groups. In black subjects, a significant increase of septal S-wave, peak velocity, and time-velocity integral were found. MPI was significantly higher in black compared to white subjects (0.46 +/- 0.05 vs 0.40 +/- 0.06, P < 0.002). A significant correlation between MPI and relative wall thickness (r = 0.54) was demonstrated. Besides, MPI correlated with S(pv) (r = 0.55) and S(tvi) (r = 0.38) at the septal site. In conclusion our data show a higher MPI in black subjects that seems to be geometry-dependent. Correlations between MPI and tissue Doppler echocardiography systolic indexes were found. Our findings suggest that racial differences in LV performance exist, especially, in the systolic function, even in the absence of other conventional echocardiographic changes.

Characterization of myocardial hypertrophy in prehypertensive spontaneously hypertensive rats: interaction between adrenergic and nitrosative pathways.

OBJECTIVE AND METHODS: Left ventricular hypertrophy in human and experimental hypertension is not always associated with pressure overload but seems to precede an increase in blood pressure. In this study, performed in male 5-week-old prehypertensive spontaneously hypertensive rats (SHR; n = 65) and age-matched Wistar-Kyoto rats (n = 56), the relationship between myocardial structure and activation of the adrenergic and nitric oxide systems was evaluated. RESULTS: Body weight, blood pressure and heart rate were similar in both groups. A higher left ventricle/body weight ratio was found in SHR, as a result of greater mononuclear (+47%) and binuclear (+43%) myocyte volumes, without changes in interstitial collagen. Both adrenergic and nitric oxide pathways were activated in SHR, as expressed by higher myocardial norepinephrine content, tyrosine hydroxylase activity, myocardial nitric oxide synthase 3 expression and protein nitration, indicating greater peroxynitrite (ONOO) generation from nitric oxide and superoxide. No difference was measured in nitric oxide synthase 1 expression, whereas nitric oxide synthase 2 was undetectable. A positive correlation between myocardial tyrosine hydroxylase activity and protein nitration was observed in SHR (r = 0.328; P < 0.01). Early treatment with a superoxide dismutase mimetic, 4-hydroxy-2,2,6,6-tetramethyl piperidinoxyl, from the third to the fifth week of age, reduced ONOO generation, protein nitration and sympathetic activation in SHR without changes in myocardial structure. CONCLUSION: In prehypertensive SHR, left ventricular hypertrophy is associated with adrenergic and nitrosative imbalance. Early superoxide dismutase mimetic treatment in SHR effectively reduces higher myocardial ONOO generation, sympathetic activation, and heart rate without affecting the development of myocardial hypertrophy.

Evaluation of the myocardial performance index for early detection of mitoxantrone-induced cardiotoxicity in patients with multiple sclerosis.

AIMS: Multiple sclerosis is the most common cause of neurological disability in young adults. Mitoxantrone is a synthetic anthracenedione, recently approved for the treatment of worsening multiple sclerosis, which is known to induce cardiotoxicity. This study was designed to evaluate the early alterations in left ventricular function in patients with multiple sclerosis receiving mitoxantrone, by the use of the myocardial performance index, a new parameter of global (systolic and diastolic) ventricular function. METHODS AND RESULTS: The study included 29 Caucasian patients with multiple sclerosis (mean age 41.8+/-9.3 years, 12 males and 17 females) treated with mitoxantrone (mean cumulative dose 30.8+/-18.2 mg/m(2)) who were compared with 28 healthy subjects (mean age 37.8+/-11.8 years, 13 males and 15 females). Both groups underwent a complete two-dimensional and Doppler echocardiography including assessment of the mitral inflow and left ventricular outflow patterns for estimation of the Doppler-derived myocardial performance index. This parameter is defined as the sum of isovolumic contraction time and isovolumic relaxation time, divided by ventricular ejection time. No differences were observed in blood pressure, heart rate, left ventricular diameters, mass and ejection fraction in multiple sclerosis patients compared to the controls. The mitral flow pattern showed a significant decrease of E wave calculated as peak velocity (E(pv)) (63.3+/-13.4 vs. 77.2+/-17.2, P<0.002) and time velocity integral (E(tvi)) (8.8+/-1.9 vs. 10.3+/-2.4, P<0.02), with a significant decrease of E(pv)/A(pv) ratio and a non-significant decrease of E(tvi)/A(tvi) ratio in the patients. In addition, E-wave deceleration time was significantly increased in multiple sclerosis patients compared to controls (178.2+/-30.2 vs. 137.9+/-14.7, P<0.0001). The mean value of myocardial performance index was 0.55+/-0.1 in patients compared to 0.37+/-0.06 in the controls (P<0.0001). A significant correlation between the given cumulative dose of mitoxantrone and myocardial performance index (r=0.67, P<0.001) and E-wave deceleration time (r=0.45, P<0.001) respectively were demonstrated. CONCLUSION: The myocardial performance index represents a parameter of combined systolic and diastolic myocardial performance strongly correlated with the given cumulative dose of mitoxantrone. The myocardial performance index may be an adjunctive parameter to conventional echocardiography for detecting sub-clinical cardiotoxicity of mitoxantrone in the clinical management of the multiple sclerosis patients.

Apical hypertrophic cardiomyopathy and atrial septal defect: part of a multi-organ syndrome?

AIM: We describe a case of non-obstructive apical hypertrophic cardiomyopathy with atrial septal defect, in a 48-year-old caucasian female patient with chronic renal failure, hypothyroidism and primary amenorrhea, referred to our hospital for syncope, palpitation and shortness of breath. METHODS AND RESULTS: Electrocardiogram, transthoracic echocardiogram and cardiac magnetic resonance showed classical features of apical hypertrophic cardiomyopathy. Apical hypertrophic cardiomyopathy is morphologically characterized by apical ventricular hypertrophy, and is reported to be a relatively benign prognosis compared with the other type of hypertrophic cardiomyopathy. CONCLUSION: Apical hypertrophic cardiomyopathy is very rare in the West, is occasionally encountered in Japanese persons, but there have been only a few reports of its coexistence with atrial septal defect. Our present report is the first case of apical hypertrophic cardiomyopathy with atrial septal defect associated with renal failure, hypothyroidism and primary amenorrhea that could represent a multi-organ syndrome. This hypothesis was supported by the finding of the same characteristics in a sister of the patient.

Junctional rhythm in hypertrophic cardiomyopathy: a case report.

We observed a case of a 47-year-old male patient with hypertrophic cardiomyopathy and family history of sudden death. During cardiac catheterization, the patient presented spontaneous intermittent atrioventricular junctional rhythm without significant changes related to sinus heart rate. The gradient was absent with sinus beats, but the junctional rhythm induced the appearance of a left ventricular-aorta gradient, with parallel reduction of aortic pressure from 156 to 120 mm Hg. Subsequently, a couple of pre-mature ventricular beats induced an important post-extrasystolic potentiation of the gradient, followed in the last beats by sinus rhythm with disappearance of the gradient. Our case suggests that the decrease of left ventricular volume, due to the absence of an effective atrial systole, leads to left ventricular increased gradient, not imputable to an increased inotropic effect or heart rate modifications but to the decrease of pre-load.

Cardiac involvement in the Churg-Strauss syndrome.

Churg-Strauss syndrome (CSS) is a rare systemic disease characterized by necrotizing vasculitis and peripheral eosinophilia. Cardiac involvement is considered common and is given a high rank among the causes of morbidity and mortality. The aim of this study was an update on the cardiac manifestations of this syndrome using a noninvasive approach. Sixteen patients with CSS were compared with a gender- and age-matched group of 20 healthy subjects. All patients but 1 were receiving treatment (steroids and/or immunosuppressive drugs). According to the Birmingham vasculitis activity score, 12 patients were in an active phase, and 4 were in drug-induced remission. All subjects underwent M-B-mode echocardiography and Doppler tissue echocardiography. Heart failure, life-threatening arrhythmias, and other prominent manifestations of heart disease were not observed. No differences were found in left ventricular diameter, volume, mass, or ejection fraction. The 2 groups did not differ in right ventricular diameter and pulmonary pressure. Few and nonspecific changes were detected by 2-dimensional echocardiography, including subclinical pericardial effusion and mitral regurgitation, in fewer than half the subjects. Subjects with CSS showed an impairment of ventricular relaxation. Changes were more prominent in the right ventricle. The peak velocity (PV) of early diastolic tricuspid inflow (E) was about 8% less than in controls, and the velocity of late diastolic inflow (A) was 35% greater. The E/A(PV) ratio was, on average, 33% less. In the left ventricle, E(PV) was 11% less and A(PV) 11% greater. The E/A ratio was decreased by 22%. Doppler analysis of tissue kinetics confirmed these indications. In the right ventricle, E(PV) was decreased by 10% and A(PV) was increased by 20% in the patient group. The E/A(PV) ratio was decreased by 29%. In the left ventricle, in which different sites were sampled, the average changes were -15%, +1%, and -23%, respectively. In the left ventricle, the velocity of systolic contraction was also decreased by 12%. Because of the small group size, only some of these differences were statistically significant. In conclusion, these moderate changes, devoid of clinical correlates, contrast with early reports emphasizing cardiac morbidity and poor prognosis in this syndrome.

Circadian blood pressure and heart rate changes in patients in a persistent vegetative state after traumatic brain injury.

Alteration of autonomic nervous system regulation is known to be present in the persistent vegetative state after traumatic brain injury, termed the dysautonomic syndrome. This study assessed the circadian blood pressure and heart rate pattern and variability in the persistent vegetative state through noninvasive 24-hour ambulatory blood pressure monitoring. The study was performed in 20 subjects: 10 patients (six men and four women; mean age, 29.5+/-9.9 years; range, 19-39 years) in a vegetative state (mean, 27.3+/-5.6 days after trauma) and 10 healthy subjects as controls (six men and four women; mean age, 28+/-5.7 years; range, 29-37 years). The patients showed a blood pressure nondipper pattern; 24-hour, daytime, and nighttime values of blood pressure and heart rate were significantly higher in patients than in controls. The day-night difference in heart rate and blood pressure was also significantly lower in patients. Finally, SD and variation coefficients were significantly lower in patients. The results show changes in the variability and circadian blood pressure and heart rate patterns in persistent vegetative state patients with dysautonomic syndrome, as an expression of the sympathetic-parasympathetic activity imbalance in the control of vasomotor tone.

Correlation between non-reversible thallium-201 myocardial perfusion defect and ECG criteria in the diagnosis of apical myocardial infarction.

BACKGROUND: ECG identification of apical myocardial infarction (MI) is controversial and lacks of accuracy. Our aim was to investigate the sensitivity of different proposed ECG criteria in the presence of apical perfusion defects assessed with SPECT analysis. METHODS: One hundred twenty-four (98 M, 26 F) out of 1500 patients with suspected coronary artery disease, showed apical perfusion defect not reversible at rest and after reinjection at tomographic SPECT analysis during thallium-201 scintigraphy. RESULTS: In the group of 29 patients presenting wide isolated apical perfusion defect (wAPD) Q waves in anterior segments with definition of antero-septal MI was prevalent (51.7%), while few patients (41.3%) presented the ECG criteria of apical MI as proposed in the literature. In 19 of the 25 patients with partial isolated apical perfusion defect (pAPD), the absence of Q wave was clearly prevalent. Fifty patients had a wAPD partially extended in surrounding regions, as anterior or septal, inferior or lateral myocardial segments, in these patients, the site of Q wave location was more variable, with prevalent Q wave in anterior leads, but with more incidence of Q waves in leads II III aVF, especially in patients with associated perfusion defect in inferior segments. Substantially, the same finding resulted in the 20 patients showing a pAPD extended in surrounding myocardial segments. CONCLUSION: In conclusion, the low diagnostic sensitivity of the ECG criteria of identification of apical MI is clearly demonstrated by our analysis carried out using SPECT perfusion scintigraphy, with ECG findings of anterior/anterior-septal myocardial necrosis in the patients with wAPD.