Left atrial dilatation in systolic heart failure: a marker of poor prognosis, not just a buffer between the left ventricle and pulmonary circulation.

BACKGROUND: The relation between systolic pulmonary pressure (sPAP) and left atrium in patients with heart failure (HF) is unclear. Diastolic dysfunction, expressed as restrictive mitral filling pattern (RMP), and functional mitral regurgitation (FMR) are associated with both LA enlargement and increased sPAP. We aimed to evaluate whether atrial dilation might modulate the consequences of RMP and FMR on the pulmonary circulation of patients with HF with reduced ejection fraction (HFrEF). METHODS: 1256 HFrEF patients were retrospectively recruited in four Italian centers. Left ventricular (LVD) and atrial (LAD) diameters were measure by m-mode, and EF were measured. RMP was defined as E-wave deceleration time lower than 140 ms. FMR was quantitatively measured. sPAP was evaluated based on maximal tricuspid regurgitant velocity and estimated right atrial pressure. RESULTS: Final study population was formed by 1005 patients because of unavailability of sPAP in 252 patients. Mean EF was 33 ± 3, 35% had RMP, 67% had mild, and 26% moderate-to-severe FMR. 69% of patients had increased sPAP. A significant association was observed between sPAP and EF, RMP, FMR, and LAD (p < 0.0001 for all). At multivariate analysis, LAD was positively associated with sPAP (p < 0.0001) independently of EF, RMP, and FMR. Analogously, LAD (p < 0.05) was associated with more severe symptoms and worse prognosis after adjustment for LV function and FMR. CONCLUSION: LA dilation was positively associated with sPAP independently of EF, RMP, and FMR. This highlights that LA size should be considered a marker of the severity of the disease.

Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study.

BACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (≤ 15) and lowest in patients with more B-lines (> 15) (log rank χ(2) 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.

Effects on survival of loop diuretic dosing in ambulatory patients with chronic heart failure using a propensity score analysis.

OBJECTIVE: To ascertain whether increasing doses of orally administered furosemide are associated with impaired survival in outpatients with chronic heart failure (CHF) and left ventricular (LV) systolic dysfunction. METHODS: Transthoracic echo-Doppler examination was carried out at baseline in 813 consecutive CHF outpatients with LV ejection fraction ≤ 45%. The total daily dose of furosemide was assessed for each patient. Chronic kidney disease (CKD) was defined by a glomerular filtration rate < 60 ml/min/1.73 m(2). The end-point was all-cause mortality. To control the prognostic effect of furosemide for the propensity of using high doses of the drug, the Cox model was stratified by the propensity score, itself computed from a multivariable logistic model. Mean follow up was 44 months. RESULTS: After stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide dose (HR 1.38, 95% CI 1.14-1.68, p < 0.001). A daily dose of 50 mg was identified as the best threshold value to predict a high risk of death within 3 years with an area under the ROC curve of 0.68 (95% CI 0.64-0.72). Increasing doses of furosemide were associated with an increased risk of death regardless of LV filling pattern, CKD and background therapy with ACE-inhibitors or beta-blockers. CONCLUSIONS: In outpatients with CHF, after stratification for the propensity score, the risk of death increased linearly across quartiles of furosemide daily dose. A threshold furosemide dose of 50 mg was related with the worse outcome.

Independence of restrictive filling pattern and LV ejection fraction with mortality in heart failure: an individual patient meta-analysis.

BACKGROUND: The Doppler echocardiographic restrictive mitral filling pattern (RFP) is an important prognostic indicator in patients with heart failure (HF), but the interaction between RFP, left ventricular ejection fraction (LVEF) and filling pattern remains uncertain. AIMS: To determine whether the RFP is predictive of mortality independently of LVEF in patients with HF. METHODS: Online databases were searched to identify studies assessing the relationship between prognosis and LV filling pattern in patients with HF. Individual patient data from 18 studies (3540 patients) were extracted and collated at the MeRGE Coordinating Centre (The University of Auckland). RESULTS: Overall, RFP was associated with higher all-cause mortality than the non-restrictive filling pattern: hazard ratio 2.42 (95% CI 2.06, 2.83). In multivariable analysis the RFP, LVEF, NYHA class and age were independent predictors of mortality. The prevalence of the RFP was inversely related to LVEF but remained a predictor of mortality even in those patients with preserved LVEF. CONCLUSIONS: The restrictive mitral filling pattern is a powerful predictor of mortality, independent of LVEF and age, in patients with HF. Doppler-derived LV filling patterns are an accessible marker from echocardiography that can readily be incorporated in risk stratification of all patients with HF.

Independent prognostic importance of a restrictive left ventricular filling pattern after myocardial infarction: an individual patient meta-analysis: Meta-Analysis Research Group in Echocardiography acute myocardial infarction.

BACKGROUND: Restrictive mitral filling pattern (RFP), the most severe form of diastolic dysfunction, is a predictor of outcome after acute myocardial infarction (AMI). Low power has precluded a definite conclusion on the independent importance of RFP, especially when overall systolic function is preserved. We undertook an individual patient meta-analysis to determine whether RFP is predictive of mortality independently of LV ejection fraction (LVEF), end-systolic volume index, and Killip class in patients after AMI. METHODS AND RESULTS: Twelve prospective studies (3396 patients) assessing the relationship between prognosis and Doppler echocardiographic LV filling pattern in patients after AMI were included. Individual patient data from each study were extracted and collated into a single database for analysis. RFP was associated with higher all-cause mortality (hazard ratio, 2.67; 95% CI, 2.23 to 3.20; P<0.001) and remained an independent predictor in multivariate analysis with age, gender, and LVEF. The overall prevalence of RFP was 20% but was highest (36%) in the quartile of patients with lowest LVEF (<39%) and lowest (9%) in patients with the highest LVEF (>53%; P<0.0001). RFP remained significant within each quartile of LVEF, and no interaction was found for RFP and LVEF (P=0.42). RFP also predicted mortality in patients with above- and below-median end-systolic volume index (1575 patients) and in different Killip classes (1746 patients). Importantly, when diabetes, current medication, and prior AMI were included in the model, RFP remained an independent predictor of outcome. CONCLUSIONS: Restrictive filling is an important independent predictor of mortality after AMI regardless of LVEF, end-systolic volume index, and Killip class.

Doxofylline: a new generation xanthine bronchodilator devoid of major cardiovascular adverse effects.

Doxofylline (7-(1,3-dioxalan-2-ylmethyl) theophylline) is a novel xanthine bronchodilator which differs from theophylline in that it contains a dioxalane group in position 7. Similarly to theophylline, its mechanism of action is related to the inhibition of phosphodiesterase activities, but in contrast it appears to have decreased affinities towards adenosine A1 and A2 receptors, which may account for its better safety profile. The bronchodilating activities of doxofylline have been demonstrated in clinical trials involving patients with either bronchial asthma or chronic obstructive pulmonary disease. In contrast to other bronchodilators, experimental and clinical studies have shown that the drug is devoid of direct stimulatory effects. This may be of importance because the arrhythmogenic actions of bronchodilators may have a negative impact on the survival of patients with respiratory diseases.

[Is a totally non-invasive assessment of the hemodynamic profile possible in patients with chronic heart failure?]. / E possibile una valutazione completamente non invasiva del profilo emodinamico dei pazienti con scompenso cardiaco cronico?

Relevant hemodynamic information can be obtained by a comprehensive Doppler echocardiographic examination in patients with various cardiac diseases. The assessment of left heart hemodynamics by Doppler echocardiography has been addressed by several investigators. The feasibility and the accuracy of methods for the estimation of left ventricular filling pressure and cardiac output have been validated by comparative right heart catheterization. Studies have shown that Doppler echocardiography can allow the measurement of pulmonary artery pressures from the pressure gradients across the tricuspid and pulmonary valves. The possibility of completely characterizing cardiac hemodynamics noninvasively has recently been documented: in patients with acute myocardial infarction, automated cardiac output measurement along with the assessment of left ventricular filling by Doppler echocardiography may be used for the identification of hemodynamic subsets. Although Doppler echocardiography can provide noninvasive measures of hemodynamic indices, its value has been disputed since the technique is patient-dependent, time-consuming and requires meticulous acquisition and interpretation by skilled operators. The use of contrast agents may improve the accessibility of both right-sided and left-sided Doppler signals, potentially increasing the number of patients to whom the noninvasive hemodynamic assessment could be applied.

Prognostic value of pulmonary venous flow Doppler signal in left ventricular dysfunction: contribution of the difference in duration of pulmonary venous and mitral flow at atrial contraction.

OBJECTIVES: We assessed the contribution of difference in duration of pulmonary venous and mitral flow at atrial contraction (ARd-Ad) for prognostic stratification of patients with left ventricular (LV) systolic dysfunction. BACKGROUND: Although pulmonary venous flow (PVF) variables may supplement mitral flow patterns in evaluating left ventricular (LV) diastolic function, their value to the prognostic stratification of patients has not been investigated. METHODS: Pulsed wave Doppler mitral and PVF velocity curves were recorded in 145 patients (mean age: 70 years) with LV systolic dysfunction secondary to ischemic or nonischemic cardiomyopathy who were followed for 15 +/- 8 months. In 38% of patients, PVF signal was enhanced by the intravenous (IV) administration of a galactose-based echo-contrast agent. Based on E-wave deceleration time < or = or >130 ms and ARd-Ad, patients were grouped into restrictive (group 1, n = 40), nonrestrictive with ARd-Ad > or =30 ms (group 2, n = 55) and nonrestrictive with ARd-Ad <30 ms (group 3, n = 50). RESULTS: During follow-up, 29 patients died from cardiac causes and 28 were hospitalized for worsening heart failure (HF). On multivariate Cox model, ARd-Ad > or =30 ms provided important prognostic information with regard to cardiac mortality and emerged as the single best predictor of cardiac events (cardiac mortality, hospitalization). The 24-month cardiac event-free survival was best (86.3%) for group 3; it was intermediate (37.9%) for group 2; and it was worst (22.9%) for group 1 (p < 0.0002 group 1 vs. 3; p < 0.0005 group 2 vs. 3; p < 0.0003 group 1 vs. group 2). CONCLUSIONS: Assessment of ARd-Ad exhibited an independent value in the prognostic evaluation of patients with LV systolic dysfunction. Moreover, it contributed to identify patients at low, intermediate and high risk of cardiac events.

Impact of blunted pulmonary venous flow on the outcome of patients with left ventricular systolic dysfunction secondary to either ischemic or idiopathic dilated cardiomyopathy.

The intravenous administration of echo contrast agents enhances the Doppler signal and makes the study of pulmonary venous flow (PVF) easily achievable by transthoracic echocardiography. The aim of this study was to evaluate whether PVF patterns play a role in predicting the outcome of patients with left ventricular (LV) systolic dysfunction. Thus, 115 patients (79 men, mean age 69 years) with LV dysfunction (ejection fraction [EF] <45%) due to either ischemic or idiopathic dilated cardiomyopathy were studied and followed-up for 1 year. A quantitative interrogation of all components of PVF was feasible in 69% of patients at standard transthoracic examination; after contrast enhancement, anterograde and retrograde flow velocities were measurable in 100% and 92% of patients, respectively. A blunted PVF (defined by a systolic-to-diastolic peak velocity ratio <1) was identified in 48 patients (42%), who had a worse clinical status, a lower LVEF, and a more severe pulmonary hypertension. Thirty-six patients had cardiac events at follow-up: sudden death in 4, progressive heart failure in 12, and hospitalization for worsening heart failure in 20 patients. Multivariate Cox proportional-hazards analysis revealed that advanced New York Heart Association class, male gender, and older age were independent predictors of mortality. However, blunted PVF, reduced LVEF, older age, and increased heart rate in descending order of power were independent predictors of heart failure hospitalizations and deaths from end-stage heart failure. In conclusion, the assessments of PVF may effectively contribute to the characterization of patients with LV dysfunction and to the prediction of their outcome.

Effect of acute increase of interstitial myocardial fluid on ventricular function in isolated working rat hearts.

An acute increase of myocardial interstitial fluid may affect ventricular function. In the present study we evaluated the effects of acute changes of myocardial tissue fluid on cardiac function and ultrastructural morphometry. Isolated rat hearts were perfused for 100 min in the working heart mode. Hearts were distributed into 5 groups: controls [perfused with Krebs-Henseleit (KH) isotonic buffer to rat plasma, KH, 287 mOsm], moderate hyposmotic perfusion (75% Hyposm: perfusion with 75% diluted KH, 216 mOsm), highly hyposmotic perfusion (60% Hyposm: perfusion with 60% diluted KH, 170 mOsm), afterload increase (Pre-over: isotonic perfused hearts subjected to an increase of afterload from 72 to 145 cm H2O) and ion dilution (Ion-dil: hearts perfused with a 60% KH with 115 mM sucrose, isotonic, 287 mOsm). We evaluated functional changes, markers of cellular necrosis or damage (CPK, LDH and purine release in coronary effluent), heart weight changes (weight gain and ww/dw ratio) and ultrastructural morphometry (analysis of cell damage, interstitial area, and mitochondrial alterations by a computerized image analysis system). The ww/dw ratio increased significantly only in 60% Hyposm (+140%, p < 0.001) and Pre-over (+63%, p < 0.001 vs control) groups. An impaired myocardial function in 60% Hyposm, Pre-over and Ion-dil groups was observed with cardiac failure at 50, 60 and 60 min, respectively. Enzyme release was significant higher in 60% Hyposm and Pre-over groups and was related to heart weight gain (r = 0.85, p < 0.001). Ultrastructural analysis confirmed a significant increase of interstitial space area (ISA) and mitochondrial damage in 60% Hyposm and Pre-over groups (p < 0.001); a significant (p < 0.05) increase was observed in the Ion-dil group; in 75% Hyposm group, a significant increase of mitochondrial damage was detected (p < 0.05). In brief, a higher functional and morphological deterioration was observed in hearts in which a more evident interstitial edema was detected (60% Hyposm and Pre-over groups). We conclude that, in the experimental condition, an acute increase of myocardial interstitial tissue fluid directly compromises left ventricular function and contributes to the ultrastructural damage to the myocardium.

[Pulmonary hypertension in patients with left ventricular dysfunction studied with contrast-enhanced Doppler echocardiography: relations with diastolic parameters and prognostic implications]. / Studio dell'ipertensione polmonare in pazienti con disfunzione ventricolare sinistra mediante eco-Doppler con contrasto: rapporti con i parametri diastolici e implicazioni prognostiche.

In patients with left ventricular dysfunction, the prognostic value of both pulmonary hypertension and mitral flow patterns has been recognized. However, the effect of the association of different degrees of pulmonary hypertension on prognosis and the corresponding left ventricular diastolic dysfunction is not clear. Accordingly, we considered the impact on survival of a categorization based on the relationship between pulmonary artery pressure and left ventricular diastolic dysfunction, as assessed by mitral and pulmonary venous flow analyses. Transthoracic Doppler echocardiography was carried out in 92 patients with ejection fraction < 45%, pulmonary artery systolic pressure > 25 mmHg and sinus rhythm. Tricuspid regurgitant velocity and Doppler parameters derived from transmitral and pulmonary venous flows were evaluated. In the case of inadequate baseline tracings, weak or poor Doppler signals were enhanced by intravenous injection of a galactose-based contrast agent (Levovist 8 ml suspension at a concentration of 400 mg/ml). To select those whose pulmonary hypertension was either proportional or unproportional to left side filling pressures, patients were divided as follows: Group 1 (n = 69) with low discrepancies and Group 2 (n = 23) with marked discrepancies between Doppler estimates of pulmonary artery systolic pressure and left side filling abnormalities. The patients of each group were also classified according to their mitral flow pattern: abnormal relaxation, pseudonormal and restrictive. Mean pulmonary artery systolic pressure was 49 +/- 16 mmHg in the total population, 43 +/- 11 mmHg in Group 1 and 68 +/- 14 mmHg in Group 2 (p < 0.0001). Several mitral and pulmonary venous flow variables significantly correlated with pulmonary artery systolic pressure in the total population and in the study groups. The best correlations were observed in Group 1 as regards the ratio of reverse-to-forward atrial wave duration (r = 0.83), E wave deceleration rate (r = 0.81), E wave deceleration time (r = -0.81) and the systolic fraction of pulmonary venous flow peak velocities (r = -0.75). In Group 1, the lower heart failure-free survival rate at 10 months was observed in patients with restrictive pattern (68%) as opposed to those with pseudonormal (94%) and abnormal relaxation patterns (97%). The overall heart failure-free survival rate in Group 2 was 86%. In conclusion, the classification according to the relationship between pulmonary hypertension and the alterations of left chamber filling may contribute to the prognostic stratification of patients with left ventricular dysfunction. The patients with pulmonary hypertension proportional to the increase in left chamber filling pressures and restrictive pattern exhibited the worst prognosis.

Left ventricular size and function in patients with noninsulin-dependent diabetes and postinfarction total or subtotal coronary occlusions.

The aim of this study was to establish the effects of postinfarction total or subtotal coronary occlusion on left ventricular remodeling in patients with noninsulin-dependent diabetes (NIDD) compared with the effects in postinfarct nondiabetic patients. The authors selected 100 patients submitted to coronary angiography between 1 and 5 weeks after acute myocardial infarction (T0: 20.5+/-15.4 days) and classified into three groups: G1: NIDD with coronary occlusion/subocclusion (n=24), G2: controls with coronary occlusion/subocclusion (n=43), G3: controls without coronary occlusion/subocclusion (n=33). At time zero (T0) the following parameters were evaluated: end-systolic and end-diastolic volume indexes (ESVi, EDVi), ejection fraction (EF), echocardiographic wall motion score index (WMI), presence of left ventricular aneurysm, and triple-vessel coronary disease. The frequencies of major cardiovascular events were recorded during follow-up. Significantly greater ESVi and EDVi were noted in G2 compared with G3 (P<0.0001), while no significant differences were observed between NIDD patients and controls. Although left ventricular global and segmental dysfunctions were increased in diabetics, controls with coronary occlusion/subocclusion presented more pronounced EF reduction (P<0.0001 G2 vs G3) and higher elevation in WMI (P<0.005 G2 vs G3). Cardiac events during follow-up were elevated in G1 and G2, particularly as regards the occurrence of congestive heart failure. The authors conclude that NIDD seems to influence in a positive way left ventricular remodeling associated with postinfarct total or subtotal coronary occlusion.

[Dipyridamole-echocardiography test in the diagnosis of vasomotor angina]. / Il test ecodipiridamolo nella diagnosi di angina vaso-motoria.

Dipyridamole-atropine echocardiography testing is used extensively for the diagnosis of coronary artery disease and it is highly effective in diagnosing "organic" coronary artery disease by inducing myocardial ischemia via three different mechanisms: maximal coronary artery vasodilatation with phoenomena of flow-maldistribution caused by dipyridamole, increase in myocardial oxygen consumption and reduction of the oxygen supply to the myocardium caused by atropine. Moreover, the abrupt withdrawal of the coronary artery vasodilatation caused by aminophylline, which is routinely infused at the end of the test, may trigger coronary artery spasms in patients with variant angina, thus enhancing the diagnostic power of the test. We report two clinical cases of patients with rest angina and angiographically normal coronary arteries, in whom coronary artery spasm was induced by administering aminophylline during the stress test.

Prior myocardial infarction and prognostic outcome in patients with unstable angina in a postdischarge follow-up.

The authors investigated how a previous myocardial infarction (MI) affects the prognosis of unstable angina pectoris in patients with maintained or slightly reduced left ventricular performance. From January 1991 to August 1993, 131 patients hospitalized with the diagnosis of Braunwald's class II-III unstable angina and ejection fraction > 40% were included. The enrolled patients were divided into two groups: (1) group I: unstable angina with prior MI (n = 70, 49 men, 21 women, aged between fifty-one and eighty years, mean: 65.7 +/- 8.5 years, Braunwald's class III: 71.4%), (2) group II: unstable angina with previous infarction (n = 61, 31 men, 30 women, aged between forty-nine and eighty, mean: 66.3 +/- 7.9 years, Braunwald's class III: 83.6%). The follow-up varied between six and twenty-four months. The frequency of major cardiovascular events (deaths, MI, reinfarction, heart failure, and recurrent unstable angina) and the number of revascularization procedures (percutaneous transluminal coronary angioplasty [PTCA] and coronary artery bypass grafting [CABG]) established during follow-up were evaluated. Hospitalization was 10.1 +/- 2.9 days in group I and 8.6 +/- 2.6 days in group II (P < 0.01). The duration of the follow-up was comparable between the two groups. Based upon predischarge noninvasive evaluation, patients in both groups were selected to undergo coronary and ventricular angiography: 38 of 70 (55.7%) in group I and 39 of 61 (62.3%) in group II; among them, 52.9% in group I and 24.6% in group II (P < 0.05) were submitted to coronary revascularization, while the others received medical treatments: 33 of 70 in group I and 46 of 61 in group II (P < 0.05). In the subset of patients submitted to angiography, the severity of coronary disease did not differ between the groups, and group I showed a statistically lower ejection fraction than group II (P < 0.005). The frequency of major cardiovascular events demonstrated a mortality rate of 2.9% in group I and 1.6% in group II. Acute MI/reinfarction accounted for 2.9% of the cases in group I and 3.3% in group II. Heart failure was present in 2.9% of group I. Recurrence of unstable angina was diagnosed in 11.4% of group I and 6.5% of group II. CABG and PTCA were performed, respectively in 7.1% and 5.7% in group I and in 6.6% and 4.9% in group II. During follow-up 75.7% of patients in group I and 80.3% in group II were asymptomatic. No significant differences in the frequency of cardiovascular events were reported between the two groups. As result of more aggressive therapeutic approaches following the detection of residual ischemia in patients with prior infarction, the authors conclude that the prognosis of unstable angina in the group with previous infarction does not seem to differ from that of unstable angina in the absence of prior necrosis in patients whose left ventricular function is maintained or slightly decreased.

NIDDM as unfavorable factor to the postinfarctual ventricular function in the elderly: echocardiography study.

BACKGROUND: Aging and diabetes mellitus have been recognized as strong predictors of heart failure in patients with acute myocardial infarction. The aim of this study was to assess, by echocardiography, the influence of aging and non-insulin-dependent diabetes mellitus on the changes of left ventricular parietal kinesis in patients with acute myocardial infarction over the 6 months after hospitalization. METHODS: The study population consisted of 82 patients (42 male, 40 female) aged 70 years, consecutively admitted to coronary care unit with acute myocardial infarction from January 1991 to May 1993. They were divided into two groups: group 1 comprised 36 patients with non-insulin-dependent diabetes mellitus, aged 78.8 +/- 6.02 years, 17 men and 19 women; group 2 comprised 46 patients without diabetes aged 78.7 +/- 6.9 years, 25 men and 21 women. Echocardiography was performed at admission to the unit (T0), at discharge (T1), and after 6 months of follow-up (T2). The echocardiographic wall motion score index was calculated by considering the number of akinetic and dyskinetic left ventricular wall segments. Fatal and non-fatal incidents of heart failure were also considered and a multivariate analysis was applied to identify the clinical and instrumental parameters that were independent predictors of wall motion score index changes and heart failure events. RESULTS: At T1 the two groups were comparable in localization of acute myocardial infarction, previous myocardial infarction, creatinine kinase serum peak, ECG score and wall motion score index. A statistically significant reduction in akinesia (P < 0.001) was observed in group 2 at T1 and T2, but was not seen in group 1. At T2 the difference in wall motion score index between the groups became significant (P < 0.05). The occurrence of heart failure was significantly higher in group 1 than in group 2 either during hospitalization (P < 0.03) or during follow-up (P < 0.004). The multivariate analysis identified non-insulin-dependent diabetes mellitus as an independent predictor of lacking recovery in LV kinesis (P < 0.01) and of heart failure development (P < 0.001). CONCLUSION: In elderly patients with non-insulin-dependent diabetes mellitus lack of recovery in wall motion score index after acute myocardial infarction seems to be an important factor, with a higher heart failure prevalence adversely affecting the in-hospital and long-term outcome. Non-insulin-dependent diabetes mellitus appears to be an important factor related to this unfavorable outcome.