Sujet(s)
Traumatismes cranioencéphaliques/thérapie , Adolescent , Algorithmes , Souffrance cérébrale chronique/étiologie , Souffrance cérébrale chronique/prévention et contrôle , Enfant , Enfant d'âge préscolaire , Association thérapeutique , Traumatismes cranioencéphaliques/classification , Traumatismes cranioencéphaliques/complications , Traumatismes cranioencéphaliques/épidémiologie , Traumatismes cranioencéphaliques/prévention et contrôle , Femelle , Premiers secours/instrumentation , Premiers secours/méthodes , Humains , Incidence , Italie/épidémiologie , Mâle , Monitorage physiologique , Transfert de patient , Centres de traumatologie , Indices de gravité des traumatismes , Résultat thérapeutiqueRÉSUMÉ
The risk of overlooking an underlying acute coronary syndrome remains an important challenge in patients complaining of chest pain but who have a non-diagnostic ECG (CP). Indeed, myocardial scintigraphy associated with exercise testing (exercise SPET) represents a valuable tool for excluding coronary artery disease (CAD) especially in patients with CP and delayed presentation to the emergency department. We sought to implement diagnoses of CAD in the early triage of CP patients by exercise gated SPET and compare diagnoses with outcomes. A total of 306 consecutive patients presenting with CP were found to be free of CAD at first line work-up including clinical evaluation, markers of myocardial injury and echocardiogram. These patients were studied initially with exercise SPET, and those with perfusion defects underwent angiography, while those with normal scans were discharged and followed up. Patients with positive scans (34%, n=105) had documented coronary stenoses in 43% (n=45); patients with negative scans (66%, n=201) had evidence of non-fatal coronary events at 6 months in 1.5% (n=3). When imaging was analysed with gating by the presence of transmural perfusion defects associated with wall motion abnormalities (n=86), only one patient, among 19 excluded, was recognized as having coronary stenosis by angiography (SPET vs gated SPET: negative predictive value 98.5% and 98%, respectively, P=NS; diagnostic accuracy 79% and 85%, respectively; P< or =0.03). Therefore, implementation of myocardial perfusion imaging in the early triage of patients with suspected acute coronary syndromes was effectively obtained by early exercise gated SPET, especially in patients with transmural myocardial perfusion defects associated with wall motion abnormalities.
Sujet(s)
Douleur thoracique/diagnostic , Maladie des artères coronaires/imagerie diagnostique , Techniques d'aide à la décision , Gestion des soins aux patients/méthodes , Appréciation des risques/méthodes , Tomographie par émission monophotonique/méthodes , Triage/méthodes , Maladie aigüe , Douleur thoracique/étiologie , Maladie des artères coronaires/complications , Maladie des artères coronaires/diagnostic , Épreuve d'effort , Femelle , Humains , Mâle , Adulte d'âge moyen , Reproductibilité des résultats , Facteurs de risque , Sensibilité et spécificité , SyndromeRÉSUMÉ
Chest pain (CP) represents a frequent reason for presentation at the emergency department (ED). A large proportion of patients have non-diagnostic ECG on presentation, and in many cases several hours have elapsed since onset of symptoms. Acute rest myocardial scintigraphy (rest SPET) has been shown to have a relevant role in the detection of patients at risk for coronary events, but its sensitivity and negative predictive value are optimal only within the first 3 h following onset of symptoms. In those with delayed presentation, exercise SPET alone, as a screening approach, appears more promising, but its feasibility and diagnostic role in the ED are still unresolved. A total of 231 consecutive patients with a recent-onset (<24 h) first episode of CP had a negative first-line work-up including ECG, troponins, creatine kinase-MB and echocardiography. These patients were considered at low risk for short-term coronary events. Patients were studied with rest SPET if they presented <3 h after onset of CP and exercise SPET if they presented after > or =3 h. The end-points of the study were detection of significant coronary artery disease (CAD) by angiography and major coronary events or cardiac death at 6 months. Eighty patients (35%) underwent rest SPET, while 151 (65%) underwent exercise SPET. Two of the 159 patients with negative SPET had evidence of critical CAD at 6-month follow-up (one patient in the rest SPET group and one in the exercise SPET group; P=NS). Of the 72 patients (31%) with a positive scan, 34 (15%) had documented CAD (16 patients in the rest SPET group and 18 in the exercise SPET group; P=NS). Sensitivity, specificity, accuracy and predictive value were not statistically different between the two groups. In conclusion, the accuracy of exercise SPET in patients with CP and delayed presentation to the ED is comparable to that of validated rest SPET in patients with early presentation. Owing to the high negative predictive value (99%), exercise SPET is especially valuable as a screening tool for the exclusion of CAD in low-risk patients and implementation of early discharge.
Sujet(s)
Douleur thoracique/diagnostic , Électrocardiographie , Coeur/imagerie diagnostique , Ischémie myocardique/imagerie diagnostique , Radiopharmaceutiques , Tomographie par émission monophotonique , Sujet âgé , Service hospitalier d'urgences , Épreuve d'effort , Femelle , Humains , Mâle , Adulte d'âge moyen , Ischémie myocardique/diagnostic , Composés organiques du phosphore , Composés organiques du technétium , Valeur prédictive des tests , Facteurs de risque , Technétium (99mTc) sestamibiRÉSUMÉ
OBJECTIVES AND BACKGROUND: Dobutamine stress echocardiography and 99mTc-tetrofosmin single-photon emission computed tomography (T-SPECT) were performed simultaneously in subjects in whom coronary artery disease (CAD) had been proven or excluded at coronary angiography, in order to establish their accuracy and agreement in the diagnosis of CAD, and in localisation and evaluation of the extension of ischaemia. No simultaneous comparison of the two techniques has been performed previously. METHODS: Seventy patients (50 men, mean age 63 +/- 10 years, 21 with previous myocardial infarction) underwent simultaneous dobutamine stress echocardiography and T-SPECT. The response to stress was blindly and independently analysed, adopting a 16-region segmentation and referring to the three major coronary arteries. RESULTS: Sixty-two patients (agreement 89%, kappa = 0.776) and 91% of left ventricular regions (kappa = 0.665) were classified concordantly, independently of the presence or absence of previous myocardial infarction (90%, kappa = 0.740 versus 91%, kappa = 0.589, respectively). At coronary angiography, 47 patients had CAD (disease prevalence 67%). The sensitivity and specificity of stress echocardiography for the diagnosis of anterior descending, circumflex and right coronary artery disease were 62, 78 and 73%, and 79, 79 and 83%, respectively. The corresponding values for T-SPECT were 70, 75 and 78%, and 94, 79 and 90%, respectively. CONCLUSIONS: These data indicate a high concordance between wall motion abnormalities observed using stress echocardiography and perfusion defects observed using T-SPECT; their sensitivity in identifying critical stenoses was similar. Inadequate stressor amounts, and less frequently hyperdynamic regional response may reduce the accuracy of stress echocardiography, while dobutamine effects on coronary flow may prevent T-SPECT from showing subtle flow maldistributions in the presence of worsened wall motion.
Sujet(s)
Maladie coronarienne/diagnostic , Dobutamine , Composés organiques du phosphore , Composés organiques du technétium , Tomographie par émission monophotonique , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Coronarographie , Échocardiographie , Épreuve d'effort , Femelle , Humains , Mâle , Adulte d'âge moyen , RadiopharmaceutiquesRÉSUMÉ
We selected 73 consecutive patients without myocardial-infarction, hypertrophic cardiomyopathy or hypertension complaining of effort chest discomfort/dyspnoea, and/or reporting exercise ischaemic ECG changes, and submitted them to simultaneous dobutamine stress echocardiography (DSE) and 99mTc tetrofosmin SPECT (T SPECT) and to coronary angiography to evaluate the clinical impact of intraventricular obstruction (IVO) during dobutamine infusion. Sixteen patients (22%, 7 males, mean age+/-SD 63+/-8 years, group 1) developed IVO (mean CW Doppler velocity+/-SD: 3.8+/-1.0 m/s) and 57 (41 males, mean age+/-SD 63+/-10 years, group 2) did not. The two groups had similar incidence of angina and ischaemic ECG changes at exercise tolerance test. DSE did not demonstrate wall motion abnormalities in any group 1 patient while T SPECT showed a perfusion defect in the only one with coronary artery disease (CAD). DSE reproduced symptoms in a higher percentage of patients with than without IVO, while there was no statistical difference in the reproduction of ischaemic ECG changes, despite CAD prevalence was much lower in group 1. Group 1 patients remained asymptomatic on beta-blockers at 12-month follow-up. Dobutamine-induced IVO, by reproducing symptoms, suggests that IVO plays a role in the clinical setting in patients without CAD complaining of unexplained reduced effort tolerance who should undergo DSE.
Sujet(s)
Cardiotoniques/effets indésirables , Dobutamine/effets indésirables , Échocardiographie-doppler , Obstacle à l'éjection ventriculaire/induit chimiquement , Adulte , Sujet âgé , Vitesse du flux sanguin , Coronarographie , Maladie coronarienne/diagnostic , Électrocardiographie , Épreuve d'effort/effets indésirables , Études de suivi , Ventricules cardiaques/imagerie diagnostique , Humains , Perfusions veineuses , Mâle , Adulte d'âge moyen , Prévalence , Débit systolique , Tomographie par émission monophotonique , Obstacle à l'éjection ventriculaire/épidémiologie , Obstacle à l'éjection ventriculaire/physiopathologie , Enregistrement sur magnétoscopeRÉSUMÉ
The study aim was to assess whether post-ejection thickening (PT) is an useful marker of viable myocardium in patients with chronic coronary artery disease. Twenty-three patients with critical coronary stenoses were submitted to dobutamine and dipyridamole stress-echocardiographies and dipyridamole-early-redistribution 201Tl SPECT within 15 days from coronary arteriography. They were selected for the presence of PT in segments that could be optimally studied by M-mode echocardiography and were hypo-akinetic in basal conditions. PT (occurring between end-ejection and mitral valve opening) was found in 58% of dysfunctional, critically perfused regions. Ninety-eight percent of the regions with PT and 6% of those without PT improved during low-dose dobutamine stress-echocardiography. Segments with PT had, respectively, higher and lower SPECT early-redistribution thallium activity than dysfunctional segments without PT and normokinetic regions. Therefore, regions with PT were viable and had a moderate decrease in coronary perfusion. Akinetic segments without PT did not show any inotropic reserve. After revascularization almost all the segments with PT improved. In conclusion, PT is a pattern of myocardial contraction easily detected by M-mode echocardiography in the clinical setting. If the results of this study are further confirmed, PT may become a sign for the recognition of myocardial viability.
Sujet(s)
Maladie coronarienne/physiopathologie , Coeur/physiopathologie , Débit systolique/physiologie , Adulte , Angioplastie , Marqueurs biologiques , Cardiotoniques , Maladie chronique , Pontage aortocoronarien , Maladie coronarienne/imagerie diagnostique , Dipyridamole , Dobutamine , Épreuve d'effort , Femelle , Humains , Mâle , Adulte d'âge moyen , Contraction myocardique , Tomographie par émission monophotonique , Échographie , VasodilatateursRÉSUMÉ
Serious complications of treatment in hypertensive crises have been reported for nearly all drugs, so that testing of further antihypertensive drugs in the management of hypertensive emergencies is desirable. In the present study, the clinical efficacy and effects on cardiac function of intravenously infused clonidine were tested in 20 hypertensives with severely elevated blood pressure (diastolic blood pressure over 130 mm Hg). In all patients, the normalization of blood pressure was achieved together with a reduction in total and peripheral vascular resistance. Heart rate showed a slight and brief decrease. Cardiac performance (determined by radionuclide angiocardiography) was improved as indicated by the significant increase in ejection fraction and decrease in both end-diastolic and end-systolic volumes. The dosage of clonidine was progressively increased until a normal blood pressure (mean blood pressure less than or equal to 105 mm Hg) was obtained. The total mean dose required for control of blood pressure was 403 +/- 97.8 micrograms, administered over a mean period of 32 +/- 5.9 min. Side effects, represented by dry mouth and drowsiness, were well tolerated and of short duration. It is concluded that clonidine is an effective and safe alternative in the treatment of hypertensive emergencies.
Sujet(s)
Antihypertenseurs/usage thérapeutique , Clonidine/usage thérapeutique , Hypertension artérielle/traitement médicamenteux , Adulte , Sujet âgé , Pression sanguine/effets des médicaments et des substances chimiques , Clonidine/effets indésirables , Urgences , Femelle , Rythme cardiaque/effets des médicaments et des substances chimiques , Humains , Hypertension artérielle/physiopathologie , Mâle , Adulte d'âge moyenSujet(s)
Folklore , Hypnose/histoire , Médecine traditionnelle/histoire , Europe , Histoire moderne 1601-RÉSUMÉ
Clonidine administration by i.v. infusion in 12 patients with hypertension emergencies (diastolic blood pressure over 130 mmHg) resulted in the normalization of blood pressure (BP) in all patients. Lowering of BP was associated with a reduction in total and lower limb vascular resistance. Heart rate showed a slight and brief decrease. Cardiac performance (determined by radionuclide angiocardiography) was improved as indicated by the significant increase of ejection fraction and decrease of both end-diastolic and end-systolic volumes. The dosage of clonidine was progressively increased until a normal BP (mean BP less than or equal to 105 mmHg) was obtained. In all patients a normal BP was achieved and in none was an initial hypertension effect observed. The total mean dose required for control of BP was 382.5 +/- 98.3 micrograms, administered over a mean period of 26.5 +/- 4.6 min. Side-effects, represented by dry mouth and drowsiness, were well tolerated and of short duration. It is concluded that clonidine is an effective and safe alternative in the treatment of hypertensive emergencies.
Sujet(s)
Antihypertenseurs/usage thérapeutique , Clonidine/usage thérapeutique , Hémodynamique/effets des médicaments et des substances chimiques , Hypertension artérielle/traitement médicamenteux , Adulte , Angiocardiographie , Antihypertenseurs/pharmacologie , Pression sanguine/effets des médicaments et des substances chimiques , Clonidine/pharmacologie , Évaluation de médicament , Femelle , Rythme cardiaque/effets des médicaments et des substances chimiques , Humains , Hypertension artérielle/physiopathologie , Mâle , Adulte d'âge moyen , Résistance vasculaire/effets des médicaments et des substances chimiquesRÉSUMÉ
Whether physical training, soon after myocardial infarction (MI), has effects upon intrinsic cardiac function at rest and during exertion remains unresolved. We have evaluated ventricular function using radionuclide angiography at rest and during stress testing before and after 3 months' physical training. This has been correlated with the site of MI and with changes in the ST segment during the maximal exercise test performed before the postmyocardial infarction rehabilitation program. We have studied 27 patients, mean age 54 +/- 10 years, in NYHA class I or II. Twelve showed no changes in the ST segment during erogmetric stress test (group 1); seven showed ST segment depression greater than 1 mm in leads different from those of MI (group 2); eight showed ST segment elevation of 2 mm (group 3). Twelve patients had had anterior MI only (AMI group); twelve inferior MI only (IMI group). After rehabilitation, all patients showed an increased work capacity and a decreased double product at the same work load. In the total group, significant increases were found in the left ventricular ejection fraction (LVEF) and in the contractile regional performance (LVwm) at rest, as well as a lesser decrease in the LVEF during handgrip test. Group 1 showed a significant increase in LVEF, associated with a decrease in left ventricular end-diastolic volume (EDV) at rest. Group 2 showed unchanged variables after rehabilitation. Group 3 showed a better LVEF during handgrip with an increase of EDV at rest. The AMI group showed a better LVEF and LVwm at rest and a better LVEF during handgrip. IMI group showed a better right ventricular ejection fraction during handgrip without improvement in LVEF. No patient with IMI had septal asynergy. We conclude that the effects of rehabilitation were linked to the site of MI and to the functional dynamic status of both ventricles.