Prognostic value of dipyridamole echocardiography early after myocardial infarction in elderly patients. Echo Persantine Italian Cooperative (EPIC) Study Group.

OBJECTIVES: This study was conducted to assess the feasibility, safety and prognostic value of dipyridamole echocardiography in elderly patients recovering from an uncomplicated acute myocardial infarction in a subset analysis performed on the patients entered in the subproject "residual ischemia" of the Echo Persantine Italian Cooperative Study (EPIC). BACKGROUND: Coronary heart disease accounts for two thirds of all deaths in the age group > 65 years, and > 50% of all patients admitted to the hospital with acute myocardial infarction are > 65 years old. The prognostic value of dipyridamole-induced left ventricular dysfunction was clearly established in patients evaluated early after acute infarction. METHODS: In a subgroup analysis of the Echo Persantine Italian Cooperative Study (EPIC), we assessed the value of dipyridamole echocardiography in predicting cardiac events in 190 elderly (> or = 65 years) patients (age 68.4 +/- 3.3 years, range 65 to 78; 147 men and 43 women) evaluated early (mean 10 days) after uncomplicated acute myocardial infarction and followed up for 14 +/- 9.8 months. RESULTS: There was no major side effect during dipyridamole echocardiography. A positive test result occurred in 85 patients (44.7%). During follow-up, there were 62 events (14 cardiac deaths, 7 nonfatal reinfarctions, 21 cases of class III or IV angina and 20 revascularization procedures). Of these 62 events, 44 occurred among 85 patients with positive dipyridamole echocardiography and 18 among 105 patients with negative dipyridamole echocardiography (52% vs. 17%, p < 0.001). Spontaneous events (death, reinfarction, angina) occurred in 31 patients with positive and in 11 with negative dipyridamole echocardiography (36% vs. 10%, p < 0.001). Hard events (myocardial infarction or death) occurred in 14 patients with positive and 7 with negative dipyridamole echocardiography (16% vs. 6%, p < 0.05). Death occurred in 11 patients with positive and in 3 with negative dipyridamole echocardiography (13% vs. 3%, p < 0.01). The positive predictive value of positive dipyridamole echocardiography and negative predictive value of negative dipyridamole echocardiography as related to the occurrence of all events in the follow-up period (death, reinfarction, angina, revascularization procedures) were 52% and 83%, respectively. The relative risk (that is, the relative risk of occurrence of future cardiac events in the group with positive dipyridamole echocardiography compared with that in those with negative dipyridamole echocardiography) was 3 for all events and 4.4 for death. CONCLUSIONS: Dipyridamole echocardiography was well tolerated by elderly patients and proved to be very effective in prognostic stratification early after uncomplicated acute myocardial infarction, even when only survival was considered.

Stress echocardiographic results predict risk of reinfarction early after uncomplicated acute myocardial infarction: large-scale multicenter study. Echo Persantine International Cooperative (EPIC) Study Group.

OBJECTIVES: This study sought to assess the value of dipyridamole echocardiography in predicting reinfarction in patients evaluated early after uncomplicated acute myocardial infarction. BACKGROUND: The identification of future nonfatal reinfarction seems an elusive target for physiologic testing. However, a large sample population is needed to detect minor differences in phenomena with a low event rate. METHODS: We assessed the value of dipyridamole echocardiography in predicting reinfarction in 1,080 patients (mean [+/- SD] age 56 +/- 9 years; 926 men, 154 women) evaluated early (10 +/- 5 days) after uncomplicated acute myocardial infarction and followed up for 14 +/- 10 months. RESULTS: Submaximal studies due to limiting side effects occurred in 14 patients (1.3%); these test results were included in the analysis. Results of dipyridamole echocardiography were positive in 475 patients (44%). During follow-up, there were 50 reinfarctions: 45 nonfatal, 5 fatal (followed by cardiac death < or = 4 days after reinfarction). Reinfarction (either nonfatal or fatal) occurred in 30 patients with positive and 20 with negative results (6.3% vs. 3.3%, p < 0.01). Nonfatal reinfarction occurred in 25 patients with positive and 20 with negative results (5% vs. 3.3%, p < 0.05). Reinfarction was fatal in 5 of 30 patients with positive and in none of 20 with negative results (16.6% vs. 0%, p = 0.07). The relative risk of reinfarction was 1.9. CONCLUSIONS: Dipyridamole echocardiographic positivity identifies patients evaluated early after uncomplicated acute myocardial infarction at higher risk of reinfarction, especially fatal reinfarction.

The atropine factor in pharmacologic stress echocardiography. Echo Persantine (EPIC) and Echo Dobutamine International Cooperative (EDIC) Study Groups.

OBJECTIVES: This study sought to compare, head to head, the two most popular pharmacologic stress echocardiographic tests--dipyridamole and dobutamine--with state of the art protocols in a large multicenter prospective study. BACKGROUND: In the continuing quest for ideal diagnostic accuracy, pharmacologic stress echocardiography has quickly moved over the years from low to high dose regimens and is currently performed with atropine coadministration. METHODS: Dobutamine (up to 40 microgram/kg body weight per min) plus atropine (up to 1 mg over 4 h) and dipyridamole (up to 0.84 mg/kg per min over 10 h) plus atropine (up to 1 mg over 4 h) stress echocardiography was performed on different days, in random order and within 1 week in 360 patients with chest pain syndrome. Thirteen different echocardiographic laboratories, all fulfilling quality control criteria for stress echocardiographic reading, contributed to the study. RESULTS: No major complications occurred during either test. The test was interrupted before achievement of predetermined end points for limiting side effects in 37 dobutamine-atropine and 7 dipyridamole-atropine stress echocardiographic studies (feasibility 90% vs. 98%, p < 0.01). Diagnostic accuracy was assessed in a subset of 110 patients with no obvious rest dyssynergy (akinesia or dyskinesia) who underwent coronary angiography independently of test results and within 1 week of testing. Significant coronary artery disease (> or = 50% diameter reduction in at least one major coronary vessel by quantitative coronary angiography) was found in 92 patients. Sensitivity for detection of coronary artery disease was 84% (77 of 92) for dobutamine-atropine and 82% (75 of 92) for dipyridamole-atropine stress echocardiography (p = NS), with a specificity of 89% (16 of 18) for dobutamine-atropine and 94% (17 of 18) for dipyridamole-atropine stress echocardiography (p = NS). A significant correlation was present between peak wall motion score index during dipyridamole-atropine and dobutamine-atropine stress echocardiography (r = 0.83, p < 0.0001). CONCLUSIONS: Dobutamine-atropine and dipyridamole-atropine stress echocardiography are safe and feasible, although submaximal studies are more frequent with dobutamine. The two stresses have comparable accuracy in the detection of angiographically assessed coronary artery disease, although dobutamine is marginally more sensitive and dipyridamole marginally more specific. Stratification of the ischemic response in the space domain is also comparable with the two stresses.

Prognostic value of dipyridamole echocardiography early after uncomplicated myocardial infarction: a large-scale, multicenter trial. The EPIC Study Group.

PURPOSE: To determine the prognostic capability of the dipyridamole echocardiography test (DET) early after an acute myocardial infarction. PATIENTS AND METHODS: On the basis of 11 different echocardiographic laboratories, all with established experience in stress echocardiography and fulfilling quality-control requirements for stress echocardiographic readings, 925 patients were evaluated after a mean of 10 days from an acute myocardial infarction and followed up for a mean of 14 months. RESULTS: During the follow-up, there were 34 deaths and 37 nonfatal myocardial infarctions; 104 patients developed class III or IV angina and 149 had coronary revascularization procedures (bypass or angioplasty). Considering all spontaneous events (angina, reinfarction, and death), the most important univariate predictor was the presence of an inducible wall motion abnormality after dipyridamole administration (chi 2 = 45.8). With a Cox analysis, echocardiographic positivity, age, and male gender were found to have an independent and additive value. Considering survival (and, therefore, death as the only event), age was the most meaningful parameter, followed by the wall motion score index during dipyridamole administration (chi 2 = 12.1). Among other parameters, the resting wall motion score index was a significant predictor of death. In a multivariate analysis, the prognostic contributions of age (relative risk estimate = 1.08) and wall motion score index during dipyridamole administration (relative risk estimate = 4.1) were independent and additive. In particular, considering death only, the event rate was 2% in patients with negative DET results, 4% in patients with positive high-dose DET results, and 7% in patients with positive low-dose DET results. CONCLUSIONS: DET is feasible and safe early after uncomplicated myocardial infarction and allows effective risk stratification on the basis of the presence, severity, extent, and timing of the induced dyssynergy.

Safety of intravenous high-dose dipyridamole echocardiography. The Echo-Persantine International Cooperative Study Group.

Clinical data on 10,451 high-dose (up to 0.84 mg/kg over 10 minutes) dipyridamole-echocardiography tests (DET) performed in 9,122 patients were prospectively collected from 33 echocardiographic laboratories, each contributing greater than 100 tests. All patients were studied for documented or suspected coronary artery disease (1,117 early [less than 18 days] after acute myocardial infarction and 293 had unstable angina). Significant side effects including major adverse reactions and minor but limiting side effects occurred in 113 patients (1.2%). Major adverse reactions occurred in 7 cases (0.07%). In 6 of these cases, adverse reactions were associated with echocardiographically assessed ischemia and included 1 prolonged cardiac asystole (complicated by acute myocardial infarction and coma, with death after 23 days), 1 short-lasting cardiac asystole, 2 myocardial infarctions, 1 pulmonary edema and 1 sustained ventricular tachycardia. In all 6 cases, the cardiologist-echocardiographer performing the study had a limited experience (less than 100 tests) with DET, and at off-line reading in 5 cases, the obvious echo-positivity preceded the onset of complications by 1 to 5 minutes. The only ischemia-independent major side effect was a short-lasting cardiac asystole that was reversed by aminophylline and atropine. Significant side effects associated with echocardiographically assessed ischemia occurred in 89 additional cases (21 with and 68 without concomitant echocardiographically assessed myocardial ischemia). The most frequent of these side effects was hypotension or bradycardia, or both, which occurred in 40 patients with negative and 6 with positive DET. In all cases, side effects promptly subsided after aminophylline. In 1,857 cases, the high dose was not given for echo-positivity before the eighth minute.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind clinical evaluation of dimetophrine in chronically reduced arterial tension.

Thirty in-patients with chronically reduced arterial blood pressure and relevant subjective symptoms were treated over a 15-day period with oral doses of either 400 mg dimetophrine twice daily or placebo, according to a prospective, randomized, double-blind design. Systolic and diastolic blood pressures and heart rate were monitored at 5-day interval: subjective specific symptoms (scored 0 to 3 in order of increasing severity), haematology and haematochemistry were recorded before and after treatment. Both systolic and diastolic blood pressures increased significantly after dimetophrine all through the observation period. After 5 days, systolic blood pressure had already reached significantly higher values in comparison with the placebo-treated group, as did diastolic blood pressure by the 10th day. Overall, during the observation period, an increase from 82.7 +/- 1.0 to 112.3 +/- 2.1 mmHg was observed in systolic and from 54.3 +/- 1.3 to 62.7 +/- 1.4 mmHg in diastolic blood pressure with dimetophrine, whereas with placebo, systolic blood pressure increased from 80.4 +/- 1.5 to 93.7 +/- 2.9 mmHg and diastolic blood pressure remained unchanged (53.3 +/- 1.4 mmHg). Concomitantly, heart rate decreased significantly with dimetophrine from 88.1 +/- 2.5 to 77.2 +/- 1.4 beats/min, whereas it remained almost unchanged with placebo (from 83.9 +/- 2.5 to 80.0 +/- 1.9 beats/min). The associated symptoms (asthenia, paleness, drowsiness, fatigue, sweating, vertigo and headache) were largely relieved by dimetophrine (70.0% decrease) but not by placebo (37.4%). All symptoms except drowsiness and vertigo were reduced to a significantly larger extent with dimetophrine than with placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical therapy of the dissection of the ascending aorta. Experience in the use of the G. R. F. biological glue]. / Sulla terapia chirurgica della dissecazione dell'aorta ascendente. Esperienza nell'impiego della colla biologica G.R.F.

Nine patients with dissecting aneurysm of the ascending aorta (type A dissection) were operated upon. Six cases had an acute dissection, whereas three cases had a chronic type of dissection. The ascending aorta was replaced with a Dacron tubular prosthesis after solidification of the external and the internal layers of the two aortic stumps using a G.R.F. biological glue. Early and late results as well as the possible complications during the post-operative course are reported. Furthermore the advantages in using the G.R.F. glue are discussed in details. They are mainly represented by the excellent solidification of the aortic stumps, by the possibility to correct the aortic regurgitation without valve replacement and particularly by a good hemostasis of the surgical sutures.

[The natural development of arteriosclerotic coronary disease. Coronarographic study in time intervals]. / L'evoluzione naturale della coronaropatia aterosclerotica. Studio coronarografico seriato nel tempo.

In 96 patients with coronary artery disease a coronary arteriography was performed twice at least with some months' interval, in order to establish the rate of progression of coronary atherosclerosis and the factors which could affect this progression. It was possible to select patients with progression of the coronary arteria lesions from patients with no increase of coronary stenosis. From the angiographic point of view, the progression of angina and the appearance of myocardial infarction are connected with a general progression of arterial lesions on all main coronary branches. As to the electrocardiographic aspects, the ECG at rest give no informations about the evolution of the coronary disease. Among the risk factors the smoking only has some importance in order to predict the progression of the coronary atherosclerosis.

[Fixed subvalvular aortic stenosis. Monodimensional echocardiographic findings]. / Stenosi aortica sottovalvolare fissa. Reperti ecocardiografici monodimensionali.

19 patients affected by discrete subvalvular aortic stenosis were studied by M-mode echocardiography. The diagnosis was confirmed by cardiac catheterism and angiocardiography and by anatomic evidence in operative room. The most frequent echocardiographic pattern was the abnormal protosystolic movement of aortic valve leaflets, that was found in all the patients. A discrete linear echo in the outflow tract of the left ventricle was observed in almost half of the cases. In 40% of the cases the left ventricular outflow tract was narrowed. The relations between these echocardiographic patterns and the anatomical kinds of discrete subaortic stenosis are discussed. No correlations were found between echocardiographic patterns and severity of the subaortic stenosis.

Interhemispheric transfer of voluntary motor commands in man.

The lack of callosal fibres between homotopic areas of the hand in the sensorimotor cortex in man and its possible functional correlates were investigated in normal adult subjects by comparing simple reaction times (RTs) of voluntary movements triggered by a somaesthetic stimulus to the same or opposite side of the body. An air jet was delivered to the skin of distal (index finger) or proximal (shoulder) ipsi- or contralateral zones, and triggered voluntary extension of the index finger or flexion of the forearm. The RT was measured from the arrival of the stimulus to the skin to the onset of the surface EMG of the muscle extensor indicis proprius or biceps brachii. The RTs of the contralateral finger movements triggered by either proximal or distal skin stimuli were significantly longer than the RTs of the corresponding ipsilateral movements (mean difference 11.72 and 15.10 msec respectively). When the task was flexion of the forearm, the differences in RTs between contra- and ipsilateral movements were instead compatible with a transcallosal transfer (mean difference about 2 msec in both cases). It is concluded that transcallosal connections between hand sensorimotor areas are conceivably absent also in man. Furthermore, the delay in contralateral distal performance appears to be due to a lack of transfer of the command through the motor areas, rather than to a lack of transfer of the triggering cutaneous afferent information to the performing hemisphere.

[Aortic valve disease and coronary atherosclerosis. Clinical and coronarographic study (author's transl)]. / Valvulopatia aortica e aterosclerosi coronarica.

77 patients with aortic valve disease have undergone heart catheterization in prevision of valve replacement: in this group the incidence of angina pectoris and the incidence of coronary artery disease associated with the valvular disease have been evaluated. The most important data resulting from out study are: 1) High frequency of angina pectoris both aortic stenosis and in aortic regurgitation: respectively about 60% and 50%. 2) The frequency of coronary atherosclerosis associated with aortic valve disease is much higher in aortic stenosis than in aortic regurgitation: respectively 35% versus 15%. 3) Coronary atherosclerosis associated with aortic stenosis frequently occurs (about 30%) also in young-aged patients (under 40 years). On the contrary in case of aortic regurgitation it occurs much more frequently in elderly patients. 4) The absence of angina both in aortic stenosis and in aortic regurgitation virtually excludes the presence of associated coronary atherosclerosis. 5) The presence of angina in aortic stenosis indicated either severe valvular stenosis or associated coronary artery disease (in this case the valvular stenosis is mild or moderate). The presence of angina in aortic regurgitation indicates either severe impairment of left ventricular performance or associated coronary atherosclerosis.

[Prognostic stratification of non complicated acute myocardial infarct. Usefulness of the dipyridamole test with ecg-echo-thallium 201]. / Stratificazione prognostica dell'ima non complicato. Utilità del test al dipiridamolo con ecg-eco-tallio 201.

84 patients (pts) with recent first uncomplicated myocardial infarction underwent during the early post-infarction period, dipyridamole (D) test (EKG-ECHO-THALLIUM) and coronary arteriography in order to verify its feasibility, safety and usefulness in the detection of residual jeopardized but viable myocardium and in the diagnosis of multivessel disease. 69 pts performed a pre-discharge exercise test. During the execution of D test no major side effect occurred. The D-Echo was positive for residual ischemia in 41 pts (48.8%), the D-Thallium in 49 pts (58.3%) and the exercise test in 30 pts (43.5%). Both the imaging techniques allow the recognition of viable myocardium within the infarct zone (homozonal positivity) or outside the infarct zone (heterozonal positivity). The sensibility and specificity for multivessel disease are, respectively: with D-echo 50% and 100%; with D-thallium 60% and 100%; with exercise test 48% and 63%. D test has better diagnostic accuracy than exercise test in detecting multivessel disease; in particular we emphasized the excellent specificity of D-echo and D-thallium test. Poliparametric approach with D-test and exercise test gives a better stratification of the ischemic post-infarction risk.

Impact of tissue harmonic imaging in patients with distorted left ventricles: improvement in accuracy and reproducibility of visual, manual and automated echocardiographic assessment of left ventricular ejection fraction.

AIMS: The aim of this study was to assess the incremental value of tissue harmonic imaging vs conventional echocardiography for evaluating left ventricular ejection fraction by manual and automated quantitation as well as visual estimation in patients with distorted left ventricles. METHODS AND RESULTS: In 25 patients unselected for image quality and with distorted left ventricles who underwent a nuclear study, digital cineloops of standard apical views were acquired by both tissue harmonic imaging and conventional echocardiography and sent to six observers for analysis of visual and quantitative left ventricular ejection fraction. Tissue harmonic imaging improved both the correlation and agreement of all echo techniques with nuclear measures, compared with conventional echocardiography echo, reducing standard errors (SE) to below 10%: for the visual estimate SE=7.5%, for manual tracing SE=6.3% and for automated tracing SE=8%. Tissue harmonic imaging decreased inter-observer variability compared with conventional echocardiography echo for both visual assessment (12.4% vs 18.4%, P<0.05) and quantitative measures (for manual tracing, 8.2% vs 11.8%, P<0.05; for automated tracing, 7.8% vs 16.8%, P<0.05). CONCLUSIONS: In patients with distorted left ventricles unselected for image quality, tissue harmonic imaging improves accuracy and reproducibility of both visual and quantitative echocardiographic assessment of left ventricular ejection fraction. In particular, it promotes automated quantitation by reducing its high standard error into a clinically reasonable range.

Dipyridamole-echocardiography in coronary artery disease.

Regional wall motion impairment incurred by means of dipyridamole-induced ischemia, is regarded with higher sensitivity and specificity than the conventional findings in the ECG. Based on the latter considerations, a new test, the dipyridamole echocardiogram has been introduced in which the development of regional wall motion impairment is designated as the positive diagnostic criterion. Dipyridamole is a vasodilator of coronary arterioles. During the course of the examination, three consecutively occurring mechanisms are considered responsible for the appearance of dipyridamole-induced ischemia in the presence of coronary stenosis. The ischemia is initially attributed to a steal-effect, then to reflex-induced rise in rate-pressure product and, lastly, to a vasospastic component. In 680 patients with thoracic pain, on use of 0.84 mg/kg over ten minutes, there was a sensitivity of 74% in detection of angiographically-documented coronary artery disease, defined as greater than 70% stenosis in at least one major coronary artery, and a specificity of 95%. The onset of regional wall motion impairment after dipyridamole infusion was correlated with the severity of the disease, the localization of the wall motion impairment enabled delineation of the localization of the stenosis in the coronary vascular system. By means of the dipyridamole echocardiogram, the effectiveness of therapeutic measures such as PTCA, ACVB, medical antianginal treatment and thrombolysis can be assessed. Lastly, the dipyridamole echocardiogram provides important information with regard to prognosis.

[Left atrial myxoma: radioisotopic diagnosis]. / Mixoma atriale sinistro: diagnosi radioisotopica.

A case of left atrial Myxoma shown on an equilibrium radionuclide ventriculography is presented. The finding were consistent with the ecocardiographic patterns and the gross anatomy of the tumour. The analysis of various parameters obtained with gated radionuclide cardiac blood pool scan shows that the Fourier phase image is another method to detect and study this disease.

[Prognostic value of the dipyridamole-echocardiography test immediately after a non-complicated myocardial infarct: a large scale multicenter study. Echo Persantine Italian Cooperative Study]. / Valore prognostico del test eco-dipiridamolo subito dopo infarto miocardico recente non complicato: studio multicentrico su larga scala. Ricercatori Dello Studio EPIC.

BACKGROUND: Any new diagnostic test should follow a pathway similar to that of a new drug, from initial studies in highly selected populations under strictly controlled conditions, up to large scale multicenter trials more likely to represent the true performance of the test in the clinical arena. AIM OF THE STUDY: To evaluate the capability of prognostic stratification of high dose (up to 0.84 mg/kg over 10') dipyridamole-echocardiography test (DET) early after an acute myocardial infarction in a "phase IV" study, based upon 11 different echocardiographic laboratories, all with established experience in stress echo and fulfilling quality control requirements for stress echo readings. STUDY POPULATION: Nine-hundred twenty five patients were evaluated after a mean of 10 days from an acute myocardial infarction and followed up for a mean of 14 months. RESULTS: During DET, one major adverse reaction occurred, consisting of a prolonged ischemia resistant to aminophylline and nitrates, and progressing to small uncomplicated reinfarction. In 11 patients the lower dipyridamole dose (0.56 mg/kg over 4') gave limiting side effects. Patients were followed up for 14 +/- 9.9 months (range = 1.53). During the follow-up, there were 34 deaths and 37 non-fatal myocardial infarctions; 104 patients developed class III or IV angina, and 149 had coronary revascularization procedures (bypass or angioplasty). Considering all spontaneous events (angina, reinfarction and death), the most important univariate predictor was the result of DET (chi-square = 45.8). With a Cox analysis, echocardiographic positivity, age and sex were found to have an independent and additive value. Considering survival (and therefore death as the only event) age was the most meaningful parameter, followed by the Wall Motion Score Index during dipyridamole (chi-square = 12.1); among other parameters, the resting Wall Motion Score Index was a significant predictor of death. By Cox analysis, age (relative risk estimate = 1.02) and Wall Motion Score Index during dipyridamole (relative risk estimate = 14) showed an independent and additional prognostic value. In particular, considering death only, the event rate was of 2% in patients with negative DET, 4% in patients with high dose positive DET and 7% in patients with low dose positive DET. CONCLUSIONS: Dipyridamole echocardiography is feasible and safe early after uncomplicated myocardial infarction and allows an effective risk stratification on the basis of the presence, severity, extent and timing of the induced dyssynergy. In particular, the risk of death doubles in patients with high dose positivity and almost quadruples in patients with low dose positivity.

Exercise-electrocardiography and/or pharmacological stress echocardiography for non-invasive risk stratification early after uncomplicated myocardial infarction. A prospective international large scale multicentre study.

AIMS: The aim of the present study was to assess the relative prognostic value of clinical variables, the exercise electrocardiography test and the pharmacological stress echocardiography test either with dipyridamole or dobutamine early after a first uncomplicated acute myocardial infarction in a large, multicentre, prospective study. METHODS AND RESULTS: Seven hundred and fifty-nine in-hospital patients (age=56+/-10 years) with a recent and first clinical uncomplicated myocardial infarction, with baseline echocardiographic findings of satisfactory quality, an interpretable ECG and able to exercise underwent a resting 2D echocardiogram, a pharmacological stress test with either dipyridamole or dobutamine and an exercise electrocardiography test at a mean of 10 days from the infarction; they were followed-up for a median of 10 months. During the follow-up, there were 13 deaths, 23 non-fatal myocardial infarctions and 59 re-hospitalizations for unstable angina. When all spontaneous events were considered, with multivariate analysis, the difference between the wall motion score index at rest and peak stress (delta wall motion score index), and exercise duration were independent predictors of future spontaneous events (relative risk 7.2; 95% CI=2.73-19.1; P=0.000; relative risk 1.1, 95% CI=1.02-1.18; P=0.008, respectively). Kaplan-Meier survival estimates showed a better outcome for those patients with a negative pharmacological stress echocardiography test compared to patients with low dose positivity (94.7 vs 74.8%, P=0.000). CONCLUSION: Stress echocardiography tests provide stronger information than historical and exercise electrocardiography test variables. Pharmacological echocardiography as well as the exercise ECG is able to predict all spontaneously occurring events when the presence as well as the timing, severity, and extension of stress-induced wall motion abnormalities are considered.

Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study.

BACKGROUND: Residual viable myocardium identified by dobutamine stress after myocardial infarction may act as an unstable substrate for further events such as subsequent angina and reinfarction. However, in patients with severe global left ventricular dysfunction, viability might be protective rather than detrimental. The aim of this study was to assess the impact on survival of echocardiographically detected viability in medically treated patients with global left ventricular dysfunction evaluated after acute uncomplicated myocardial infarction. METHODS AND RESULTS: The data bank of the large-scale, prospective, multicenter, observational Echo Dobutamine International Cooperative (EDIC) study was interrogated to select 314 medically treated patients (271 men; age, 58+/-9 years) who underwent low-dose (1.6). Patients were followed up for 9+/-7 months. Low-dose dobutamine stress echocardiography identified myocardial viability in 130 patients (52%). Dobutamine-atropine stress echocardiography was positive for ischemia in 148 patients (47%) and negative in 166 patients (53%). During the follow-up, there were 12 cardiac deaths (3.8% of the total population). With the use of Cox proportional hazards model, delta low-dose WMSI (the variation between rest WMSI and low-dose WMSI) was shown to exert a protective effect by reducing cardiac death by 0.8 for each decrease in WMSI at low-dose dobutamine (coefficient, -0.2; hazard ratio, 0.8; P<0.03); WMSI at peak stress was the best predictor of cardiac death in this set of patients (hazard ratio, 14.9; P<0.0018). CONCLUSIONS: In medically treated patients with severe global left ventricular dysfunction early after acute uncomplicated myocardial infarction, the presence of myocardial viability identified as inotropic reserve after low-dose dobutamine is associated with a higher probability of survival. The higher the number of segments showing improvement of function, the better the impact is of myocardial viability on survival. The presence of inducible ischemia in this set of patients is the best predictor of cardiac death.

The relative value of exercise-electrocardiography and dipyridamole stress echocardiography for risk stratification early after uncomplicated myocardial infarction. The EPIC (Echo Persantine International Cooperative) Study Group.

BACKGROUND: Rational prognostic algorithm should be developed considering the logical progression of the information as it becomes available to the physician, with clinical data first, ECG data second and stress imaging data last. The aim of the present study was to assess in a clinically realistic fashion the relative prognostic value of exercise electrocardiography test (EET) and dipyridamole-echocardiography test (DET) early after first acute uncomplicated myocardial infarction. METHODS AND RESULTS: Five hundred and forty-seven in-hospital patients (age = 56 +/- 9 years) with recent clinically uncomplicated first myocardial infarction, baseline echocardiographic findings of satisfactory quality, interpretable ECG and capability to exercise underwent a resting 2D echocardiogram, a DET and an EET at a mean of 10 days from the infarction and were followed up for 16.2 +/- 11 months. During the follow-up, there were 17 cardiac deaths, 19 non-fatal myocardial infarctions and 49 unstable angina. When cardiac death was considered as the only significant event, with multivariate analysis, peak dipyridamole Wall Motion Score Index was the only significant predictor (chi 2 = 5.66; p = 0.013; relative risk estimate = 4.7; confidence intervals = 1.35-16.08). In presence of a negative exercise electrocardiography test for both chest pain and electrocardiographic criteria, the death rate was 2%. CONCLUSION: DET provides stronger information in comparison with historical and EET variables. However, a negative maximal EET is sufficient to identify a very low risk subset in whom additional testing may not be warranted.

The prognostic value of myocardial viability recognized by low dose dipyridamole echocardiography in patients with chronic ischaemic left ventricular dysfunction.

AIMS: The aim of this study was to assess the prognostic value of myocardial viability recognized as a contractile response to vasodilator stimulation in patients with left ventricular dysfunction in a large scale, prospective, multicentre, observational study. METHODS AND RESULTS: Three hundred and seven patients (mean age 60 +/- 10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction and severe left ventricular dysfunction (ejection fraction <35%; mean ejection fraction: 28 +/- 7%) were enrolled in the study. Each patient underwent low dose dipyridamole echo (0.28 mg x kg(-1) in 4 min). Myocardial viability was identified as an improvement of >0.20 in the wall motion score index. By selection, all patients were followed up for a median of 36 months. One-hundred and twenty-four were revascularized either by coronary artery bypass grafting (n=83) or coronary angioplasty (n=41). The only end-point analysed was cardiac death. In the revascularized group, cardiac death occurred in one of the 41 patients with and in 16 of the 83 patients without a viable myocardium (2.4% vs 19.3%, P<0.01). Outcome, as estimated by Kaplan-Meier survival, was better for patients with, compared to patients without, a viable myocardium, who underwent coronary revascularization (97.6 vs 77.4%, P=0.01). Using a Cox proportional hazards model, the presence of myocardial viability was shown to exert a protective effect on survival (chi-square 4.6, hazard ratio 0.1, 95% CI 0.01-0.8, P<0.03). The survival rate in medically treated patients was lower than in revascularized patients irrespective of the presence of a viable myocardium (79.7% vs 86.2, P=ns). CONCLUSION: In severe left ventricular ischaemic dysfunction, myocardial viability, as assessed by low dose dipyridamole echo, is associated with improved survival in revascularized patients.