Elevation of urinary liver-type fatty acid binding protein after cardiac catheterization related to cardiovascular events.

PURPOSE: Contrast medium (CM) induces tubular hypoxia via endothelial damage due to direct cytotoxicity or viscosity. Urinary liver-type fatty acid binding protein (L-FABP) increases along with tubular hypoxia and may be a detector of systemic circulation injury. The aim of this study was to evaluate the clinical usefulness of detecting increases in urinary L-FABP levels due to administration of CM, as a prognostic biomarker for cardiovascular disease in patients without occurrence of CM-induced nephropathy undergoing cardiac catheterization procedure (CCP). METHODS: Retrospective longitudinal analyses of the relationship between urinary L-FABP levels and occurrence of cardiovascular events were performed (n=29). Urinary L-FABP was measured by ELISA before CCP, and at 6, 12, 24, and 48 hours after CCP. RESULTS: Urinary L-FABP levels were significantly higher at 12 hours (P<0.05) and 24 hours (P<0.005) after CCP compared with before CCP, only in the patients with occurrence of cardiovascular events (n=17), but not in those without cardiovascular events (n=12). The parameter with the largest area under the curve (0.816) for predicting the occurrence of cardiovascular events was the change in urinary L-FABP at 24 hours after CCP. The difference in urinary L-FABP levels (ΔL-FABP ≥11.0 µg/g creatinine) between before CCP and at 24 hours after CCP was a risk factor for the occurrence of cardiovascular events (hazard ratio, 4.93; 95% confidence interval, 1.27-19.13; P=0.021). CONCLUSION: Measurement of urinary L-FABP before CCP and at 24 hours after CCP in patients with mild to moderate renal dysfunction may be an important indicator for risk stratification of onset of cardiovascular events.

Safety of add-on tolvaptan in patients with furosemide-resistant congestive heart failure complicated by advanced chronic kidney disease: a sub-analysis of a pharmacokinetics/ pharmacodynamics study.

BACKGROUND: Treatment of congestive heart failure (CHF) with loop diuretics, such as furosemide, may be associated with complications, including worsening renal function and metabolic or electrolyte disturbances. Coadministration of tolvaptan, a selective vasopressin V2 receptor antagonist, can ameliorate such adverse events by reducing the required dose of loop diuretics; however, the safety of tolvaptan in patients with reduced renal function is not known. As a result, we conducted an exploratory clinical trial of tolvaptan in 22 patients with CHF and advanced chronic kidney disease (CKD). METHODS: We classified these patients into three groups according to their estimated glomerular filtration rate, namely, CKD stages G3b, G4, and G5. Patients were coadministered tolvaptan 15 mg once daily for 7 days after single administration of furosemide. We assessed patients' hemodynamic parameters, serum chemistry values, and body fluid status during the study. RESULTS: On day 8, serum sodium and potassium concentrations were significantly higher than baseline values in the G3b (p=0.020) and G5 groups (p=0.037), respectively. Although serum urea nitrogen and creatinine concentrations increased significantly in the G4 group (p=0.017 and p=0.012, respectively), no patient in any of the three groups showed decreased renal function on days 2 and 3. In addition, no significant changes in serum uric acid, blood pressure, or heart rate were observed in any patient in this study. CONCLUSION: In this short-term pilot study, coadministration of tolvaptan and furosemide appears to be safe in patients with heart failure and CKD.

Value of anatomical aortic valve area using real-time three-dimensional transoesophageal echocardiography in patients with aortic stenosis: a comparison between tricuspid and bicuspid aortic valves.

AIMS: Accurate assessment of disease severity is critical for appropriate treatment of patients with aortic stenosis (AS). This study investigated the influence of aortic-valve morphology on the determination of anatomical aortic-valve area (AVA) in patients with AS. METHODS AND RESULTS: This prospective study included 126 patients with AS who underwent transoesophageal echocardiography (TEE). Aortic-valve area was measured using (i) planimetric two-dimensional (2D) TEE, (ii) volumetric three-dimensional (3D) TEE, and (iii) the continuity equation (CE) obtained with transthoracic echocardiography. Of these, 20 patients also underwent contrast-enhanced multidetector computed tomography (MDCT). Aortic-valve area was measured from multiplanar reconstruction of the MDCT images. Of the 126 patients, 20 (15.9%) were diagnosed with bicuspid AS and 106 were diagnosed with tricuspid AS. There was an excellent correlation between AVAADCT and AVA3DTEE (r = 0.83, P < 0.001) and a somewhat lower correlation between AVAADCT and AVA2DTEE (r = 0.63, P = 0.006). In the tricuspid AS group, both AVA2DTEE and AVA3DTEE significantly correlated with AVACE (r = 0.63, mean difference 0.13 ± 0.24 cm(2), and r = 0.83, mean difference 0.03 ± 0.12 cm(2), respectively, both P < 0.001). In contrast, in the bicuspid AS group, AVA3DTEE significantly correlated with AVACE (r = 0.83, mean difference 0.10 ± 0.18 cm(2), P < 0.001), whereas AVA2DTEE did not (r = 0.42, mean difference 0.48 ± 0.32 cm(2), P = 0.066). CONCLUSION: Aortic-valve morphology influenced the assessment of anatomical AVA in patients with AS, and 3D TEE is useful for assessing anatomical AVA regardless of aortic-valve morphology.

Efficacy of tolvaptan added to furosemide in heart failure patients with advanced kidney dysfunction: a pharmacokinetic and pharmacodynamic study.

BACKGROUND AND OBJECTIVES: The pharmacokinetics and pharmacodynamics of tolvaptan (7.5 or 15 mg/day) in combination with furosemide have been investigated in heart failure (HF) patients with normal kidney function but not in HF patients with advanced kidney dysfunction. This study evaluated the efficacy of tolvaptan in HF patients with advanced kidney dysfunction (estimated glomerular filtration rate <45 mL/min/1.73 m(2)) by conducting a pharmacokinetic and pharmacodynamic study in these patients. METHODS: Tolvaptan (15 mg once daily) was administered orally for 7 days in combination with furosemide (40-200 mg). RESULTS: The peak plasma tolvaptan concentration and area under the plasma concentration-time curve were 379.41 ± 149.69 ng/mL and 4,657.38 ± 2,741.79 ng·h/mL, respectively, in HF patients with advanced kidney dysfunction. These values were greater in HF patients with advanced kidney dysfunction than values reported in the literature for healthy subjects and HF patients with normal kidney function. Urine volume increased and body weight decreased significantly compared with those before tolvaptan administration in HF patients with advanced kidney dysfunction. CONCLUSION: This study showed that adding tolvaptan to furosemide was effective in HF patients with advanced kidney dysfunction. This study also suggests that in these patients 15 mg/day of tolvaptan should be sufficient, and increasing the dose or the frequency of dosing to overcome diuretic resistance should not be necessary, and consideration should be given to using a lower dose and/or prolonging the dosing interval.

Metabolic planar imaging using 123I-ß-methyl-iodophenyl pentadecanoic acid identifies myocardial ischemic memory after intracoronary acetylcholine provocation tests in patients with vasospastic angina.

The aim of this study was to determine the diagnostic accuracy of early/delayed (123)I-ß-methyl-iodophenyl pentadecanoic acid ((123)I-BMIPP) planar images to detect disrupted fatty acid metabolism in patients with vasospastic angina (VSA). Heart-to-mediastinum (H/M) ratios and washout rates were calculated from early and late (15 minutes and 4 hours after tracer injection, respectively) planar (123)I-BMIPP images from 13 hypertensive control individuals (mean age, 69.5 years) and 37 patients with VSA (mean age, 62.8 years) 10.5 (mean) days after administering the intracoronary acetylcholine provocation test. Patients with VSA had significantly lower early H/M and delayed H/M ratios (early; 2.2 ± 0.3 versus 2.7 ± 0.5, P = 0.007; delayed: 1.8 ± 0.3 versus 2.4 ± 0.4, P < 0.001) and significantly greater washout rates (39.8 ± 11.8% versus 29.3 ± 11.7%, P = 0.011) than controls. The overall area under the curve defining the accuracy of diagnostic performance was 0.76 (95% confidence interval (CI): 0.59-0.92) and 0.85 (95% CI, 0.73-0.98) for the early and delayed H/M ratios and 0.74 (95% CI, 0.73-0.90) for washout rates. Planar (123)I-BMIPP imaging can diagnose coronary artery spasm with acceptable diagnostic performance and indicates that the delayed H/M ratio has a powerful ability to assess recent ischemia. This technique might be useful in the face of apparently normal coronary angiographic findings during the subacute and chronic phases after ischemic events.

Effects of continuous positive airway pressure therapy in three Japanese patients with obstructive sleep apnea and resistant hypertension.

The following three case reports present the effects of 6-month continuous positive airway pressure (CPAP) therapy on blood pressure (BP) in severe obstructive sleep apnea patients with resistant hypertension. Case 1 A 58-year-old woman exhibited a decreased 24-hour BP and changes in the nocturnal BP dipping pattern from non-dipper to dipper. Case 2 A 64-year-old man showed no improvements in nocturnal BP. Case 3 A 78-year-old man with ischemic cardiomyopathy exhibited changes in the nocturnal BP dipping pattern from non-dipper to dipper. These results suggest that 6-month CPAP therapy improves the nocturnal BP dipping status in some patients with obstructive sleep apnea and resistant hypertension.

Simple exercise echocardiography using a Master's two-step test for early detection of pulmonary arterial hypertension.

BACKGROUND: Early detection of pulmonary arterial hypertension (PAH) is indispensable, although, echocardiography at rest alone does not provide sufficient evidence for it. Here, this study aimed to investigate the usefulness of simple exercise echocardiography using a Master's two-step test for detecting early PAH. METHODS: This study included 52 connective tissue disease patients who had mild symptoms in World Health Organization functional classification 2, suspected as having early PAH, and underwent exercise echocardiography and right heart catheterization. Echocardiography was performed before and after the Master's two-step exercise test; the study patients were classified into the non-PAH (mean pulmonary arterial pressure <25 mmHg, n=37) or PAH (mean pulmonary arterial pressure ≥25 mmHg, n=15) groups. RESULTS: Rest systolic pulmonary artery pressure estimated using echocardiography did not significantly differ between the two groups; however, a significant difference in post-exercise systolic pulmonary artery pressure was found (non-PAH, 58.8±10.8 mmHg; PAH, 80.2±14.3 mmHg, p<0.0001). The multiple logistic regression analysis indicated post-exercise systolic pulmonary artery pressure as an independent predictor of PAH (p=0.013). The area under the curve by post-exercise systolic pulmonary artery pressure was 0.91 for PAH. Post-exercise systolic pulmonary artery pressure ≥69.6 mmHg predicted PAH with the sensitivity of 93% and the specificity of 90%. CONCLUSIONS: Simple exercise echocardiography using the Master's two-step test could detect PAH in mildly symptomatic connective tissue disease patients. The usefulness of this method should be verified for the early detection of PAH.

Early diastolic function during exertion influences exercise intolerance in patients with hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) patients with preserved left ventricular ejection fraction (LVEF) often develop dyspnea and exercise intolerance. Diastolic dysfunction may contribute to exercise intolerance in these patients. This study aimed to clarify our hypothesis as to whether diastolic function rather than systolic function would be associated with exercise intolerance in HCM using two-dimensional (2D) speckle tracking echocardiography during exercise. METHODS: Thirty-three HCM patients (mean age 59.3 ± 15.7 years) underwent 2D speckle tracking echocardiography at rest and during submaximal semi-supine bicycle exercise. Global longitudinal strain (LS), LS rate during systole (LSRs), early diastole (LSRe), and late diastole (LSRa) were measured. The symptom-limited cardiopulmonary exercise testing was performed using a cycle ergometer for measuring the peak oxygen consumption (peak [Formula: see text]). RESULTS: In the multivariate linear regression analysis, peak [Formula: see text] did not associate with strain or strain rate at rest. However, peak [Formula: see text] correlated with LS (ß = -0.403, p = 0.007), LSRe (ß = 6.041, p = 0.001), and LSRa (ß = 5.117, p = 0.021) during exercise after adjustment for age, gender, and heart rate. The first quartile peak [Formula: see text] (14.2 mL/min/kg) was assessed to predict exercise intolerance. The C-statistic of delta LSRe was 0.74, which was relatively greater than that of delta LS (0.70) and delta LSRa (0.58), indicating that early diastolic function rather than systolic and late diastolic function affects exercise intolerance. CONCLUSIONS: LSRe during exercise is closely associated with the peak [Formula: see text]. Early diastolic function during exercise is an important determinant of exercise capacity in patients with HCM.

Sleep disordered breathing in heart failure patients with reduced versus preserved ejection fraction.

BACKGROUND: This study aimed to investigate and compare prevalence of sleep disordered breathing (SDB) in Japanese patients with heart failure with reduced ejection fraction (HFrEF) versus those with HF with preserved EF (HFpEF). METHODS: This study consecutively included 101 Japanese patients (77 males) with de novo CHF. Echocardiography was performed twice, on admission and at discharge. All patients underwent portable overnight polygraphy within one week before discharge. The patients were stratified into two groups based on LVEF on admission, HFrEF (R group; LVEF<50%, n=82) or HFpEF (P group; LVEF≧50%, n=19); the prevalence of SDB and sleep study data were assessed. RESULTS: When patients with the apnea hypopnea index ≥15 were defined as having SDB, 50% of the study patients had SDB (OSA, 10%; CSA, 39%; MSA, 1%). No significant differences in the prevalence of SDB or sleep data as well as RVSP, E/e' or plasma brain natriuretic peptide (BNP) were found between the two groups. CONCLUSIONS: SDB was identified in 50% of de novo Japanese HF patients. When E/e', RVSP and plasma BNP did not significantly differ between the two groups, the prevalence of SDB was similar regardless of LVEF.

Association between heart rate at rest and myocardial perfusion in patients with acute myocardial infarction undergoing cardiac rehabilitation - a pilot study.

INTRODUCTION: This study was conducted to determine if there was a link among heart rate at rest (rHR), muscle volume changes, and single photon emission computed tomography (SPECT) parameters after 6-month cardiac rehabilitation in patients with acute myocardial infarction (AMI). MATERIAL AND METHODS: Twenty-nine consecutive AMI patients (mean age: 63.0 ±9.1 years) who received appropriate percutaneous coronary intervention on admission were enrolled. (99m)Tc-Sestamibi myocardial SPECT images were obtained at the early (30 min) and delayed (4 h) phases after tracer injection at 2 weeks (0M) and 6 months (6M) after the onset of AMI. Within a few days of SPECT, all patients underwent cardiopulmonary exercise test for evaluation of cardiac rehabilitation effects. Before the initiation of exercise test, leg muscle volume was measured. All patients were stratified into the ≥ 70 beats per minute (bpm) (n = 15) or < 70 bpm (n = 14) group based on rHR at 6M. RESULTS: There were no significant differences in the recanalization time, peak cardiac enzyme, or initial left ventricular ejection fraction between the two groups. After the 6-month training, the muscle volume changes in the lower limbs (< 70 bpm, 0.23 ±0.22; ≥ 70 bpm, -0.07 ±0.26, p < 0.05) were significantly greater in the < 70 bpm group than the ≥ 70 bpm group. The decreased rate of rHR had a significant correlation with the improved global severity (r = 0.62, p = 0.001) and extent (r = 0.48, p = 0.017) of left ventricle evaluated by (99m)Tc-Sestamibi myocardial SPECT delayed phase. CONCLUSIONS: The result of this preliminary study demonstrated that improved myocardial perfusion was closely related to decreased rHR after cardiac rehabilitation.

Relationship between left ventricular ejection fraction and mitral annular displacement derived by speckle tracking echocardiography in patients with different heart diseases.

BACKGROUND: Speckle tracking echocardiography (STE)-derived mitral annular displacement (MAD) utilizes the speckle tracking technique to measure strain vectors, which provides accurate estimates of left ventricular ejection fraction (LVEF). Here, we investigated a link between STE-derived MAD and LVEF in patients with different heart diseases and evaluated its clinical usefulness. METHODS: This study included 266 outpatients and 84 controls. Of the study patients, 52 patients had ischemic heart disease (IHD), 37 patients had dilated cardiomyopathy (DCM), 34 patients had hypertrophic cardiomyopathy (HCM), 74 patients had valvular heart disease (VHD), and 69 patients had hypertensive heart disease (HHD). STE continuously tracked annular motion throughout the cardiac cycle in the apical 4- and 2-chamber views. RESULTS: In all participants, the curvilinear relationship was found between STE-derived MAD and LVEF (R(2)=0.642). The strong correlation between STE-derived MAD and LVEF was also found in the patients with IHD (R(2)=0.733, p=0.001) and in those with DCM (R(2)=0.614, p=0.008). However, such a correlation was not found in the patients with HCM, VHD, or HHD. CONCLUSION: The specificity in the correlation between STE-derived MAD and LVEF was found in patients with each heart disease, which should be taken into account when assessing these parameters.

Identification of unusual reentry circuit sites of nonischemic ventricular outflow tract tachycardia.

BACKGROUND: Reentrant ventricular outflow tract (OT) tachycardia is rare in patients with nonischemic heart disease. The mechanism of ventricular tachycardia (VT) arising from the region of the aortic sinus of Valsalva (ASOV) is usually focal, rather than reentrant. Consequently, less is known about reentrant circuits in the OT and the aortic sinuses. The purpose of this study was to evaluate existence of reentry circuits in these areas using entrainment mapping techniques. METHODS: We performed electrophysiological study in 51 consecutive patients with idiopathic or nonischemic symptomatic VT arising from the OT. Six of these patients were found to have VT of reentrant mechanism with 8 VT morphologies. Entrainment mapping, electroanatomical mapping (in 2 patients), and radiofrequency catheter ablation were performed. RESULTS: Pacing entrained the VT at 93 sites, 52 of which were determined to be in the reentry circuit based on matching of the postpacing interval and VT cycle length. Of the reentry circuit sites, 6 were in the aortic sinus, 43 were below the aortic valve, and 3 were in the right OT below the pulmonary valve. Classification of reentry circuit sites identified 7 as exit, 1 as central-proximal, 19 as inner loop, and 25 as outer loop sites. Catheter ablation terminated VT at 4 of the 6 aortic sinus sites and 4 of the 46 OT sites (P = 0.0006). CONCLUSIONS: We definitively demonstrated involvement of the ASOV in OT reentrant tachycardia using entrainment mapping. It may be useful for successful VT ablation to identify reentry circuit localization.

[Sleep apnea and hypertension].

Obstructive sleep apnea (OSA) is strongly associated with hypertension. The seventh report of the joint national committee (JNC-VII) guidelines have placed OSA at the top of the list to induce secondary hypertension. Severe OSA patients revealed the high prevalence of hypertension. Compared with normal subjects, patients with OSA had a higher 24-hour blood pressure, especially nighttime blood pressure. More recently, prospective data showed that sleep apnea syndrome was an independent risk for onset of hypertension. There is a lot of evidence that demonstrates that treating OSA using continuous positive airway pressure (CPAP) is an effective for management of OSA.

Myocardial washout rate of technetium-99m-sestamibi in the chronic phase predicts myocardial damage in patients with previous myocardial infarction.

OBJECTIVE: This study aimed to clarify the correlation between the myocardial washout rate (WR) of technetium-99m hexakis 2-methoxy-isobutyl-isonitrile ((99m)Tc-sestamibi) and cardiac enzyme levels in patients with acute myocardial infarction (AMI) 6 months after the onset. METHODS: Sixty-one consecutive AMI patients (mean age, 66.2 ± 9.7 years) who underwent percutaneous coronary intervention (PCI) on admission were enrolled. Creatinine kinase MB isoenzyme (CK-MB) levels were measured every 3 h. (99m)Tc-sestamibi myocardial scintigraphic images were obtained at the early (30 min) and delayed (4 h) phases after tracer injection for calculating heart-to-mediastinum (H/M) ratios and global WRs at 2 weeks (0 M) and 6 months (6 M) after the onset of AMI. Regional WRs in the culprit lesions (culprit WR) and the extent score (ES) and severity score (SS) of myocardial damage were also calculated. RESULTS: PCI was performed 8.3 ± 7.7 h after AMI onset. At 6 M, the early H/M ratio (p = 0.04), delayed H/M ratio (p = 0.02), global WR (p = 0.01), culprit WR (p = 0.002), and delayed ES (p = 0.008) were alleviated. At 0 M, the peak CK-MB level correlated with the delayed H/M ratio (p = 0.003), global WR (p = 0.003), culprit WR (p < 0.001), early ES (p = 0.03), delayed ES (p = 0.01), early SS (p = 0.001), and delayed SS (p < 0.001). At 6 M, the peak CK-MB level correlated with the delayed H/M ratio (p < 0.001), global WR (p = 0.005), culprit WR (p = 0.001), early ES (p = 0.001), delayed ES (p < 0.001), early SS (p < 0.001), and delayed SS (p < 0.001). CONCLUSIONS: These results demonstrated that (99m)Tc-sestamibi WR in the chronic phase as well as that in the acute phase reflects the extent of initial myocardial damage in AMI patients after PCI. Moreover, it might indicate the myocardial condition in the clinical course.

The effects of depression on the course of functional limitations in patients with chronic heart failure.

BACKGROUND: This study examined whether depressive symptoms are associated with persistent functional limitations and severity classified according to the course of functional limitations in chronic heart failure (CHF) patients after discharge. METHODS AND RESULTS: The Performance Measure for Activities of Daily Living 8 (PMADL-8) was used to measure the course of functional limitations at 1, 3, and 5 months after discharge in a cohort of 148 patients. Depressive symptoms were assessed using the Hospital Anxiety and Depression Scale at 1 month after discharge. Repeated-measures logistic regression adjusting for potential confounders demonstrated that the depression groups had different persistent functional limitations (PMADL-8 scores ≥20 at 1, 3, and 5 months after discharge [χ(2) = 5.3; P < .05]). Using cluster analysis, we identified 4 distinctive courses of functional limitations, and there was a graded relationship between the severity of the course and depressive symptoms (χ(2) = 26.1; P < .001). CONCLUSIONS: In this prospective study, depression was associated with poorer functional limitations in CHF patients after discharge. The findings of this study suggest that depression may be a treatment target for improving functional limitations in CHF patients during the recovery phase.

Significance of 99mTc-sestamibi myocardial scintigraphy after percutaneous coronary intervention in patients with acute myocardial infarction.

BACKGROUND: This study was designed to clarify the significance of washout rate (WR) determined from 99mTc-sestamibi myocardial scintigraphic images and the levels of cardiac enzymes in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI). MATERIAL/METHODS: A total of 56 consecutive patients with AMI (mean age 65.8 ± 8.5 years), who underwent PCI on admission, were included. Cardiac enzyme, the MB isoenzyme of creatinine kinase (CK-MB), was measured every 3 h after admission. Two weeks after the onset of AMI, 99mTc-sestamibi myocardial scintigraphy was performed at early (30 min) and delayed (4 h) phases after tracer injection. The heart-to-mediastinum ratio (H/M) and WR were calculated from the planar images. RESULTS: PCI was performed at 9.4 ± 6.0 h after the onset of AMI. In 26 patients the culprit lesion was located in the right coronary artery and in 24 patients it was located in the left anterior descending coronary artery. The peak CK-MB was 274.1 ± 169.4 IU/L (13.5 ± 3.9 h). The early and delayed H/Ms and WR of 99mTc-sestamibi were 2.74 ± 0.58, 3.00 ± 0.70, and 58.8 ± 10.0%, respectively. The delayed H/M was significantly correlated with the peak CK-MB (r = -0.37, p = 0.005). The WR of 99mTc-sestamibi was also significantly correlated with the peak CK-MB (r = -0.34, p = 0.012). CONCLUSIONS: These results suggest that the WR determined from 99mTc-sestamibi myocardial scintigraphic images reflects the extent of myocardial damage in AMI patients.

The T wave inversion score is useful for evaluating the time-course of acute pulmonary embolism.

BACKGROUND: The 12-lead electrocardiogram (ECG) has relatively poor specificity for identifying acute pulmonary embolism (APE). The aim of this study was to investigate ECG abnormalities according to 2 different criteria and their usefulness for assessing changes in APE. METHODS AND RESULTS: Fifty-two APE patients underwent ECG examinations in the acute and chronic phases. ECG abnormalities were assessed according to Stein's criteria (QRS complex abnormalities and T wave inversion in any lead except aV(L), III, aV(R), or V1) and Kosuge's criteria (T wave inversion in any lead except aV(R) or aV(L)). Many patients had electrocardiographic abnormalities in the acute phase, but no specific abnormalities were found. According to Kosuge's criteria, the frequency of T wave inversion was higher than that of abnormal QRS complexes and T wave inversion according to Stein's criteria (P < 0.01). In 20 cases with preclinical ECG records, the time-course of changes in the T wave inversion score (total numbers of T wave inversions per patient) was examined. The peak T wave inversion score was noted at 3 days after onset (P < 0.01). CONCLUSIONS: These results suggest that the T wave inversion score, calculated according to Kosuge's criteria, is useful for predicting the time-course of APE.

Changes in mitral regurgitation and left ventricular geometry during exercise affect exercise capacity in patients with systolic heart failure.

AIMS: exercise may dramatically change the extent of functional mitral regurgitation (MR) and left ventricular (LV) geometry in patients with chronic heart failure (CHF). We hypothesized that dynamic changes in MR and LV geometry would affect exercise capacity. METHODS AND RESULTS: this study included 30 CHF patients with functional MR who underwent symptom-limited bicycle exercise stress echocardiography and cardiopulmonary exercise testing for quantitative assessment of MR (effective regurgitant orifice; ERO), and pulmonary artery systolic pressure (PASP). LV sphericity index was obtained from real-time three-dimensional echocardiograms. The patients were stratified into exercised-induced MR (EMR; n = 10, an increase in ERO by ≥13 mm(2)) or non-EMR (NEMR; n = 20, an increase in ERO by <13 mm(2)) group. At rest, no differences in LV volume and function, ERO, and PASP were found between the two groups. At peak exercise, PASP and sphericity index were significantly greater (all P < 0.01) in the EMR group. The EMR group revealed lower peak oxygen uptake (peak VO(2); P = 0.018) and greater minute ventilation/carbon dioxide production slope (VE/VCO(2) slope; P = 0.042) than the NEMR group. Peak VO(2) negatively correlated with changes in ERO (r = -0.628) and LV sphericity index (r = -0.437); meanwhile, VE/VCO(2) slope was well correlated with these changes (r = 0.414 and 0.364, respectively). A multivariate analysis identified that the change in ERO was the strongest predictor of peak VO(2) (P = 0.001). CONCLUSION: dynamic changes in MR and LV geometry contributed to the limitation of exercise capacity in patients with CHF.