Dobutamine-induced ST-segment elevation in patients with acute myocardial infarction and the role of myocardial ischemia, viability, and ventricular dyssynergy.

We analyzed the relation between dobutamine-induced Q-wave ST-segment elevation and regional contraction during low (5 to 10 microg/kg/min) and high doses (20 to 40 microg/kg/min) of dobutamine in a series of 391 dobutamine echocardiographic tests performed 10 +/- 2 days after a first uncomplicated acute myocardial infarction (AMI). ST-segment elevation was defined as > or = 1 mm new or additional J-point elevation with a horizontal or upsloping ST segment lasting 80 ms. Wall motion score index at rest was derived using a 16 segment-4 grade score model. Patients with dobutamine-induced ST-segment elevation had a higher wall motion score index at rest (anterior wall AMI: 1.67 +/- 0.27 vs 1.43 +/- 0.30, p = 0.0001; inferior wall AMI: 1.44 +/- 0.27 vs 1.30 +/- 0.18, p = 0.0001) and similar incidence and extent of myocardial viability and homozonal ischemia in comparison with those without ST-segment elevation. The sensitivity, specificity, and accuracy of dobutamine-induced ST-segment elevation for detecting residual homozonal ischemia were 51%, 55%, and 54%, respectively, in patients with anterior wall AMI, and 42%, 68%, and 58%, respectively, in patients with inferior wall AMI. In conclusion, dobutamine-induced ST-segment elevation is not associated with higher incidence and extent of viable or jeopardized myocardium but rather to a greater extent of wall motion abnormalities at rest. Thus, this finding does not represent a clinically reliable discriminator for selecting patients for coronary angiography and possible revascularization procedures.

Incidence and correlates of complex ventricular arrhythmias during dobutamine stress echocardiography after acute myocardial infarction.

Although previous studies have confirmed the safety of dobutamine stress echocardiography, complex ventricular arrhythmias have been reported. Our aim was (1) to identify the markers of increased arrhythmic risk during dobutamine stress echocardiography and (2) to assess whether the occurrence of major ventricular arrhythmias during the test may represent a clinically useful marker of electrical instability. Three hundred and seventy-seven consecutive survivors from acute myocardial infarction, off cardioactive therapy, underwent dobutamine stress echocardiography 11.4 days after the acute event. Holter monitoring with assessment of heart rate variability and echocardiographic determination of left ventricular ejection fraction. In addition, exercise stress testing, signal averaged ECG and coronary angiography were carried out, respectively, in 357, 150 and 273 patients. Ten subjects showed complex ventricular arrhythmias (eight non-sustained and one sustained ventricular tachycardia and one ventricular fibrillation) during dobutamine stress echocardiography (group A), whilst 366 did not (group B). Complex ventricular arrhythmias were detected by Holter monitoring in 8/10 patients in group A and 45/367 patients in group B (odds ratio 28.6, 95% CI 5.4-92.2) and by exercise testing in 4/10 patients in group A and 33/347 patients in group B (odds ratio 6.3, 95% CI 1.4-27.2). Ejection fraction < 40% was present in 3/10 patients in group A and 50/367 in group B (odds ratio 2.7, 95% CI 0.3-12.2), whilst multivessel disease was present, respectively, in 8/10 and 176/263 patients (odds ratio 1.9, 95% CI 0.3-25.5). Reduced heart rate variability and the presence of late potentials on signal averaged ECG were found in, respectively, 40/367 and 13/140 patients in group B, but none were found in group A. A total of 61 events (35 CABG, 15 PTCA, four cardiac deaths and seven non-fatal reinfarctions) occurred during the follow-up (11.4 months, range 6 to 20): four in group A and 57 in group B. No documented major arrhythmic event was reported. We conclude that (1) complex arrhythmias during dobutamine stress may occur in patients early after acute myocardial infarction; (2) the preexisting evidence of frequent, as well as repetitive, arrhythmias represents a potential marker of increased risk in this connection and, finally, (3) dobutamine-induced arrhythmias seem to represent an uncommon, even though potentially dangerous, event but not a useful new "window' on electrical instability of post-MI patients.

Dobutamine stress echocardiography for the identification of multivessel coronary artery disease after uncomplicated myocardial infarction: the importance of test end-point.

Our aim was to verify whether the sensitivity of pharmachological stress echocardiography for multivessel disease after acute myocardial infarction may be improved by a more aggressive protocol, i.e. not considering the appearance of the first wall motion abnormality as the absolute end-point if it occurs in the infarcted area without clinical or instrumental markers of extensive ischemia or left ventricular dysfunction. One-hundred twenty-one consecutive patients (age 32-71 years) prospectively underwent dobutamine-atropine stress echo (dobutamine infusion up to 40 micrograms/kg/min with additional atropine 1 mg) 11.8 +/- 4.8 days after uncomplicated myocardial infarction and coronary angiography within 6 weeks. Criteria for stopping the test were: significant ST depression or elevation, typical chest pain, major arrhythmias and left ventricular dysfunction. The test was considered as positive if a deterioration of basal wall motion pattern was observed: it was defined homozonally positive (the deterioration occurred in the myocardial area fed by the culprit vessel) or heterozonally positive (the deterioration occurred in a different vascular area). A coronary stenosis > 70% of vessel lumen was defined as critical. Thirty-four patients showed a negative test result. Among the 87 patients with positive test, 65 had no further wall motion deterioration from the first-induced wall motion abnormality (WMA) to peak test (Group A), whereas nine patients showed further homozonal (Group B) and 13 further heterozonal (Group C) asynergies. Sensitivity, specificity and accuracy of dobutamine stress echocardiography for multivessel disease were, respectively, 63%, 96% and 82% using the first-induced wall motion abnormality as test end-point, whilst they were 84% (P < 0.01), 93% and 89% according to the aggressive approach previously described. Dobutamine stress time of patients with multivessel disease was higher in Groups B and C (13.1 +/- 3.6 min) than in Group A (9.8 +/- 3.7 min, P < 0.01) and, finally, the mean obstruction of non-culprit vessel was higher in Group A (62.2%) than in Group C (47.4%, P < 0.05). No major complications were found. We conclude that the sensitivity of dobutamine stress echocardiography for multivessel disease following recent myocardial infarction is critically dependent on the test end-point. It may be improved by a more aggressive approach capable to identify less severe heterozonal coronary lesions.

Determination of agreement between cardiopulmonary and standard ECG stress testing in coronary artery disease.

The agreement between the results of standard ECG (CX) and cardiopulmonary (CPX) exercise stress tests performed in randomized sequence was evaluated in 40 patients with known coronary artery disease but who were not taking cardioactive therapy. Systolic blood pressure and heart rate were significantly higher during CPX only at low workload (less than 100 W). Exercise time and rate-pressure product at both peak exercise and ischaemic threshold were not significantly different between the two tests, even though their variability exceeded the value of 20%, which is generally accepted as the cut-off point for defining CX parameters as reproducible. However, the metabolic response to exercise, assessed by means of blood lactate kinetics analysis, was highly reproducible between the two tests. We conclude that the provocative role of exercise testing is not altered by the gas exchange analysis technique used in CAD patients. However, the common indexes of myocardial as well as of global physical performance may be influenced, thus requiring caution in comparing data with those derived from CX or from reference values.

Gastric emptying of a physiologic mixed solid-liquid meal.

The purposes of this study were to use a noninvasive scintigraphic technique to measure gastric emptying of liquids and solids simultaneously, to study the interactions between emptying of the liquid and solid components of meals in normal subjects, and to employ dual isotope gastric scintigraphy to evaluate gastric emptying of liquids and solids in patients with clinical evidence of gastric outlet obstruction. The solid component of the test meal consisted of chicken liver, labeled in vivo with Tc-99m sulfur colloid, and the liquid component was water mixed with In-111 DTPA. The rates of emptying were quantitated using a gamma camera on line to a digital computer. Twenty normal subjects were studied using this combined solid-liquid meal. Ten of them also ingested a liquid meal alone and ten a solid meal alone. Liquid emptied from the stomach significantly more rapidly than did solids. The emptying curve for liquids was exponential compared to a linear emptying curve for solids. The gastric emptying rate of the liquid component was slowed significantly by simultaneous ingestion of solids, but the emptying rate of solids was not affected by liquids. Several patients with clinical gastric outlet obstruction were evaluated. Both combined and selective abnormalities for gastric emptying of liquids and solids were demonstrated.

The value of serum thyroglobulin measurement as a marker of cancer recurrence in the follow-up of patients previously treated for differentiated thyroid tumor.

In order to verify the value of serum thyrogolbulin (hTg) determination to detect cancer recurrence, 104 patients previously treated with surgical and 131I total thyroid ablation of differentiated thyroid cancer were studied. Comparison of serum hTg results and 131I total body scans (131I TBS) was attempted. In 87 patients with negative 131 I TBS, serum hTg was undetectable in 80% of the patients whereas in 20% detectable amounts of hTg were measured. In 57 patients with positive 131I TBS, serum hTg was measurable in 72% of the patients whereas in 20% was undetectable. These contrasting results of serum hTg measurement and 131I TBS suggest to us the usefulness to use both tests in the detection of thyroid cancer recurrence.

Human cord blood concentrations of thyrotropin, thyroglobulin, and iodothyronines after maternal administration of thyrotropin-releasing hormone.

TRH or saline was administered to 214 term pregnant women at various time intervals (8-820 min) before delivery. Cord blood (CB) was obtained, and plasma TSH, T4, T3, rT3, and thyroglobulin concentrations were measured by specific RIA. CB TSH was significantly elevated within 20 min after TRH administration and remained elevated for 180 min. CB T3 rose significantly by 60 min and remained elevated for 820 min. CB T4 was significantly increased from 120 to 820 min after TRH administration. There was no significant change in the CB thyroglobulin concentration. These findings demonstrate for the first time that TRH crosses the human placenta, that the fetal pituitary is responsive to TRH, and that endogenous TSH stimulates the fetal thyroid.

Effects of somatostatin in a case of severe hypoglycemia due to nesidioblastosis.

The Authors have studied the effects of somatostatin (SRIF) treatment in an infant affected by hypoglycemia due to nesidioblastosis. During iv infusion with SRIF we observed a marked increase of blood glucose levels; concomitantly insulin secretion was almost completely suppressed. In contrast, during treatment with protamine zinc-somatostatin (PZ-SRIF), a long acting SRIF preparation, the blood glucose levels did not rise and insulin concentrations were inappropriately elevated. Therefore in this case the long term treatment of hypoglycemia due to nesidioblastosis with PZ-somatostatin was unfeasible.

Serum concentrations of myoglobin, creatine kinase, lactate dehydrogenase and cardiac isoenzymes in euthyroid, hypothyroid and hyperthyroid subjects.

Serum concentrations of myoglobin, creatine kinase and lactate dehydrogenase were measured in 33 euthyroid, 21 hyperthyroid and 15 hypothyroid subjects. The results showed that myoglobin, creatine kinase and lactate dehydrogenase were increased and decreased in the hypo- and hyperthyroid states, respectively. In addition, the concentrations of myoglobin, creatine kinase and lactate dehydrogenase values were inversely related to both the thyroxine and triiodothyronine concentrations. To study the origin of the increased muscle protein values observed in hypothyroidism, the cardiac isoenzyme fractions were measured; the results obtained support the view that the muscle enzymes are mainly derived from skeletal muscles.

3,3',5'-Triiodothyronine concentrations in amniotic fluid at different stages of pregnancy.

Since it is feasible to detect reverse T3 (rT3) in amniotic fluid, we investigated the possibility as to whether measurements of amniotic rT3 could be useful in diagnosing fetal hypothyroidism during pregnancy. In 55 amniotic fluid samples, obtained at different stages of pregnancy, we have documented increasing concentrations of this hormone. The results obtained are conflicting with previous reports. The reason for this discrepancy is not clear, however methodological differences in rT3 determination should be taken in account. The large scatter of rT3 values in amniotic fluid suggests that the diagnosis of neonatal hypothyroidism based on measurement of rT3 may require caution.