Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial.

OBJECTIVE: To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction. DESIGN: 262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3-5) pharmacological stress echocardiography (n = 132) or conventional pre-discharge (day 7-9) maximum symptom limited exercise ECG (n = 130). RESULTS: No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant). CONCLUSION: Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.

Stress echocardiography for risk stratification of diabetic patients with known or suspected coronary artery disease.

OBJECTIVE: Coronary artery disease (CAD) is a leading cause of mortality and morbidity in diabetic patients; therefore, their risk stratification is a relevant issue. Because exercise tolerance is frequently impaired in these patients, pharmacological stress echocardiography (SE) has been suggested as a valuable alternative. Our aim was to evaluate the prognostic value of this technique in diabetic patients with known or suspected CAD. RESEARCH DESIGN AND METHODS: A total of 259 consecutive diabetic patients underwent pharmacological SE (dobutamine in 108 patients and dipyridamole in 151 patients) and follow-up for 24 +/- 22 months. A comparison between the prognostic value of SE and exercise electrocardiography (ECG) was made in a subgroup of 120 subjects. RESULTS: A total of 13 cardiac deaths and 13 nonfatal infarctions occurred during follow-up, and 58 patients were revascularized. Univariate predictors of outcome were known CAD, positive SE, rest and peak wall motion score index (WMSI), and peak/rest WMSI variation. Peak WMSI was the only significant and independent prognostic indicator (odds ratio 11; 95% CI 4-29, P < 0.0001) on multivariate Cox's analysis. After adjustment for the most predictive clinical and exercise ECG variables, SE provided 43% additional prognostic information (gain in X(2) = 7, P < 0.01). Moreover, positive SE was associated with a significantly lower event-free survival. CONCLUSIONS: SE effectively predicts cardiac events in diabetic patients with known or suspected CAD and adds additional prognostic information as compared with exercise ECG.

Noninvasive risk stratification in women with uncomplicated acute myocardial infarction.

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

Evidence of walk-through phenomenon during echocardiographic dipyridamole stress test.

This case report deals with induced regional wall motion abnormalities that spontaneously disappeared during an echocardiographic stress test with dipyridamole. A patient underwent this test because of atypical chest discomfort and a positive result of exercise stress test. Transient septal, apical and anterior akinesia were observed after the first dose of dipyridamole, but they were short-lasting and did not return during the continuation of the test. Coronary angiography showed a critical stenosis of the left coronary artery. A mechanism similar to that responsible for the walk-through phenomenon might explain the observed findings. Thus stress echo with dipyridamole needs careful continuous monitoring, because transient wall motion abnormalities can otherwise be missed resulting in a false negative test.

Effects of left bundle branch block on myocardial FDG PET in patients without significant coronary artery stenoses.

UNLABELLED: Cardiac PET studies in patients with left bundle branch block (LBBB) are few, and the results are conflicting. In particular, even if a reduced uptake of FDG is reported, confirmation in a large group of patients and exact understanding of the underlying cause are lacking. METHODS: We selected 29 consecutive patients who had complete LBBB and no significant stenosis on coronary angiography scheduled for FDG and 13N-NH3 PET for myocardial viability evaluation at our center. Wall motion was evaluated using 2-dimensional echocardiography. Ten volunteers without coronary stenosis or LBBB served as a control group. RESULTS: All LBBB patients had a reverse mismatch in the septum, defined as reduced uptake of FDG in comparison with 13N-NH3. The mismatch extended to the anterior and inferior walls in 17 patients. The mean (+/-SD) septal-to-lateral ratio was 0.57 +/- 0.11 for FDG (range, 0.28-0.76) and 0.99 +/- 0.12 for 13N-NH3 (range, 0.75-1.18), with P < 0.0001. In contrast, no significant differences in uptake were seen in the control group, which had a septal-to-lateral ratio of 0.95 +/- 0.13 for FDG (range, 0.78-1.15; P < 0.01 with respect to LBBB patients) and 0.94 +/- 0.11 (range, 0.85-1.20) for 13N-NH3. CONCLUSION: Our study suggests that in LBBB patients without significant coronary stenosis, FDG uptake in the septum changes without a correlating change in perfusion. To avoid possible overestimation of necrosis, especially in the LAD territory, this phenomenon must be considered in evaluations of myocardial viability using FDG images.

Strategies for the early diagnosis of acute myocardial infarction using biochemical markers.

We evaluated different diagnostic strategies for the early diagnosis of acute myocardial infarction, combining sensitivity and specificity of different markers evaluated singly and using combination testing in parallel and serial modes. Myoglobin, cardiac troponin I (TnI), creatine kinase (CK), and CK-MB mass were tested in blood samples from 26 patients with acute myocardial infarction collected at admission (T0; mean = 3.3 hours from the onset of chest pain) and 3 and 6 hours later. The comparison group was made up of 70 patients with renal failure, skeletal muscle diseases, stable angina, unstable angina, and chest pain of nonischemic origin. Single tests showed different sensitivities in relation to the different release kinetics; myoglobin was the most sensitive (69% at T0) although less specific (46%), and TnI showed the highest specificity (90%) and a sensitivity of 54%. Combination testing in a parallel mode using myoglobin and TnI or CK-MB had the same sensitivity and specificity as myoglobin tested singly. The best combination in a serial mode is myoglobin and TnI (at T0 sensitivity, 54%; specificity, 98%), as confirmed by the analysis of the positive predictive value, the negative predictive value, and the accuracy evaluated as a function of different disease prevalences.

Dipyridamole stress echocardiography and exercise testing for risk stratification after uncomplicated myocardial infarction.

BACKGROUND: Risk stratification for subsequent cardiac events after an acute infarction can be obtained by exercise testing or dipyridamole stress echocardiography. It remains to be determined whether these modalities are equivalent and provide incremental information on top of clinical evaluation. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction of high dose dipyridamole coupled with echocardiography (stress echo) or maximal symptom-limited exercise testing. METHODS AND RESULTS: Ninety patients underwent dipyridamole stress echo and exercise testing at a mean +/- SD of 9 +/- 4 days after admission for acute uncomplicated first myocardial infarction. All patients were prospectively followed for 22 +/- 16 months. There were 9 hard events (3 cardiac deaths and 6 acute myocardial infarctions) and 12 soft events due to post MI angina (6 angioplasty and 6 bypass surgery procedures). Univariate predictor of hard events was rest-stress wall motion score index variation (p = 0.009); univariate predictors of all events (hard + soft) were: positive exercise testing (p = 0.001), positive stress echo (p = 0.001), rest-stress wall motion score index variation (p = 0.002), extent of ischemia at echo (p = 0.008). Multivariate analysis by Cox selected a non-Q wave infarction and rest-stress wall motion score index variation as predictors of death or reinfarction (overall chi-square for the model 12.2, p = 0.0022). CONCLUSIONS: Stress echo is superior to ergometric variables for predicting events after uncomplicated myocardial infarction.

Metabolic management of ischemic heart disease: clinical data with trimetazidine.

The metabolic management of heart disease represents a promising new strategy for ischemic syndromes. This review focuses on the clinical studies performed with trimetazidine, a cellular anti-ischemic agent, either as monotherapy or in combination with other drugs. Acute and chronic administration of trimetazidine significantly increased total work, exercise duration, and time to 1-mm ST segment depression, without any change in heart rate, systolic blood pressure, or rate-pressure product at the same workload, as compared with placebo. Chronic administration studies have been performed comparing the anti-ischemic effects of trimetazidine with nifedipine or propranolol in patients with chronic stable angina. In these studies, the number of anginal attacks was significantly decreased in all groups. Ergometric results showed that trimetazidine increased duration of exercise, time to 1-mm ST segment depression, time to angina, and decreased ST segment depression at peak exercise similarly to propranolol or nifedipine treatment. Rate-pressure product at the same workload remained unchanged in the patients treated with trimetazidine in comparison with baseline treatment, suggesting no effect of the drug on oxygen demand, whereas it was decreased during treatment with nifedipine and propanolol, because of the hemodynamic activity of these drugs. The therapeutic value of adding trimetazidine to either calcium antagonists or beta blockers in patients with ischemic heart disease has also been demonstrated. Unlike classic anti-ischemic agents, treatment with trimetazidine is not accompanied by any modification in hemodynamic parameters, confirming the experimental data showing a unique mechanism of action via a direct effect on the ischemic myocardium.

T wave normalization in infarct-related electrocardiographic leads during exercise testing for detection of residual viability: comparison with positron emission tomography.

OBJECTIVES: We investigated the sensitivity and specificity of exercise-induced T wave normalization (TWN) in infarct-related electrocardiographic leads (IRLs) for detection of residual viability in the infarct area. BACKGROUND: The meaning of exercise-induced TWN on IRLs is not yet well understood. Recent reports suggest that TWN during dobutamine echocardiography could indicate the presence of viable myocardium. METHODS: We evaluated 40 consecutive patients with a recent acute myocardial infarction and negative T waves in at least two IRLs. All patients underwent exercise testing; positron emission tomography (PET) with nitrogen-13 ammonia and fluorine-18 fluorodeoxyglucose; and coronary angiography. RESULTS: Twenty-four patients showed exercise-induced TWN: 18 at a work load < or =50 W (group la) and 6 at a work load > or =75 W (group 1b); 16 patients did not show TWN (group 2). On the PET study, viability in the infarct area was present in 17 patients (94%) from group la, in only 1 (16%) from group 1b and in 4 (25%) from group 2 (p < 0.0001). The sensitivity, specificity and diagnostic accuracy of exercise-induced TWN, in comparison with residual viability, were, respectively, 82%, 67%, 75% for TWN at every work load and 77%, 94%, 85% for TWN at a work load < or =50 W. Moreover, the sensitivity and diagnostic accuracy of TWN at the low work load were higher for anterior infarctions (87% and 88%, respectively). CONCLUSIONS: Exercise-induced TWN on IRLs at low work loads is a sensitive and specific index for the presence of residual viability in the infarct area. Sensitivity and diagnostic accuracy of this sign are higher for anterior infarctions.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up.

BACKGROUND AND HYPOTHESIS: The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms. METHODS: We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months. RESULTS: Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008). CONCLUSIONS: Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

[Echocardiography or stress scintigraphy with dipyridamole for the stratification of risk after acute myocardial infarction?]. / Ecocardiografia o scintigrafia da stress con dipiridamolo per la stratificazione del rischio dopo infarto miocardico acuto?

UNLABELLED: Increased risk of subsequent cardiac events after an acute infarction can be identified through dipyridamole infusion. It remains to be determined whether echocardiographic or scintigraphic imaging modes are equivalent. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction through high-dose dipyridamole coupled with echocardiography or scintigraphy via Tc 99m sestamibi SPECT imaging. METHODS AND RESULTS: Fifty-one patients underwent simultaneous dipyridamole stress echocardiography and scintigraphy at a mean +/- SD of 12 +/- 3 days after admission for acute uncomplicated myocardial infarction. A subgroup of 44 patients performed exercise testing according to maximal symptom limited protocol. All patients were followed prospectively for 346 +/- 273 days (range 11-959). Cardiac events occurred in 20 patients (39%), and 1 death, 2 myocardial reinfarctions and 17 cases of unstable angina were recorded. Univariate predictors of cardiac events were: positive dipyridamole echo (p < 0.001), ischemia in the infarct zone or in remote zones by echo (p < 0.001), ejection fraction < 40% (p = 0.042) and positive exercise testing (p = 0.003). Risk was best predicted by multivariate Cox analysis on the basis of 1) ischemia in remote zones by dipyridamole echo (p < 0.001) and 2) ischemia in the infarct zone by dipyridamole echo (p = 0.003), blood pressure at peak exercise < 150 mmHg (p = 0.010) and non-Q wave infarction (p = 0.003). CONCLUSIONS: Echocardiographic imaging during dipyridamole infusion is superior to sestamibi scintigraphy for predicting events after uncomplicated myocardial infarction.

[Combined use of bicycle ergometry test and echo-dipyridamole in stratification of risk after thrombolysed myocardial infarct]. / Uso combinato di test al cicloergometro ed eco-dipiridamolo per la stratificazione del rischio dopo infarto miocardico trombolisato.

AIM: Verify the value of the combined use of Dipyridamole Stress Echocardiography (DSE) and Exercise Testing (ET) for predicting cardiac events after Thrombolysed Myocardial Infarction (TMI). STUDY DESIGN: Prospective, with a medium follow-up of 221 days (range 30-446). CLINICAL SETTINGS: Coronary Care Unit with Cardiology Service. PATIENTS: 32 consecutive patients, 24 men and 8 women, mean age 61 years (range 39-72) with acute myocardial infarction. INTERVENTIONS: Systemic thrombolysis with PTPA. DSE and ET in therapeutic wash out 12 +/- 3 days after admission to the Coronary Care Unit. RESULTS: 9 patients had positive ET, 18 patients had negative ET, 5 patients did not perform ET. 19 patients had positive DSE, 13 patients had negative DSE. Patients with positive DSE had in 6 cases (group 1) WMA remote from the infarction area (WMAR), in 13 cases (group 2) WMA appeared in the infarct related area. Cardiac events occurred in 15 patients: 1 cardiovascular death, 1 myocardial re-infarction, 13 cases of unstable angina. 2 patients with negative DSE had cardiac events. All patients in group 1 had events, 1 patient with a previous positive ET, 3 patients with previous negative ET. 2 patients in this group didn't perform ET. 7 patients in group 2 had cardiac events, in all cases with a previous positive ET. 1 single patient in this group with negative ET had events. CONCLUSIONS: 1) Patients without WMA at DSE are at low risk for cardiac events after thrombolysed myocardial infarction. 2) Presence of WMAR appears to be associated with a higher risk, whatever the result of ET may be. 3) Patients without WMAR can be further stratified by ET in therapeutic wash out. High risk patients seem to be those with positive DSE and positive ET. 4) Combined use of DSE and ET seem to allow optimal risk stratification after thrombolysed myocardial infarction.

[Atrial fibrillation in a cohort of the elderly: etiopathogenic role of occult hyperthyroidism and diagnostic and therapeutic considerations. Results of the CASTEL (CArdiovascular STudy in the ELderly)]. / Fibrillazione atriale in una coorte di anziani: ruolo eziopatogenetico dell'ipertiroidismo occulto e considerazioni diagnostiche e terapeutiche. Risultati dello studio epidemiologico CASTEL (CArdiovascular STudy in the ELderly).

This work was performed in order to evaluate the weight of hyperthyroidism on the genesis of atrial fibrillation in elderly subjects. The data are from the CASTEL (CArdiovascular STudy in the ELderly), an epidemiologic study performed in a town of northern Italy (Castelfranco Veneto), whose 3088 elderly subjects were called and 2254 enrolled for a 7-year intervention trial. From 2224 elderly persons examined in the present study, 90 had atrial fibrillation (AF) as determined by the presence of Minnesota Code 8-3; the other 2134 were used as control population. In the 90 with AF and in the randomly chosen controls, the thyroid function was studied by means of the TRH-test. Taking into consideration an increase of TSH greater than 0.5 or greater than or greater than 1 muUI/ml over the basal value after TRH administration, 5.5% of subjects with atrial fibrillation had a suppressed response (i.e. hyperthyroidism); taking into consideration a peak value of TSH greater than or equal to 2.3 muUI/ml irrespective to the basal value, the prevalence of hyperthyroidism was higher (17.8%), but not different than in control subjects. In conclusion, hyperthyroidism is frequent in elderly subjects but it does not play a role in the pathophysiology of AF. On the contrary, AF may be explained in the majority of cases by concomitant cardiovascular disease, i.e. left atrial enlargement, arterial hypertension, myocardial ischemia, and heart failure.

The CASTEL project (CArdiovascular STudy in the ELderly): protocol, study design, and preliminary results of the initial survey.

The CASTEL (CArdiovascular STudy in the ELderly) has been performed in order to evaluate the prevalence of hypertension of people aged 65 years or more, to evaluate the cardiovascular risk of elderly subjects from a general population, to verify the feasibility and effectiveness of a systematic continuous community-based hypertension control program in the elderly, and finally to evaluate whether a population-based therapeutic intervention was able to extend to a great number of elderly hypertensive patients the benefits of a better control of hypertension. Only the preliminary results of the initial survey are described in this paper, since the final data collection will be available at the end of 1991. The prevalence of hypertension in elderly subjects of the CASTEL was 51.2% (44.6% for males, 52.2% for females), that of isolated systolic hypertension was 8.8% among the whole population sample (2254 subjects) and 23.4% among the subgroup of 850 hypertensives screened following the WHO criteria; 8 visits were performed during the initial screening and prevalence of hypertension regularly decreased from the first visit to the last one. Taking into consideration the mean of the last 2 blood pressure measurements performed during visit 8, average systolic blood pressure was 175.5 +/- 25.9 mmHg and diastolic 93.5 +/- 13.0 mmHg. Some correlations between blood pressure and other biological parameters are also discussed.