Comparison of clinical efficacy and cost of a cardiac imaging strategy versus a traditional exercise test strategy for the investigation of patients with suspected stable coronary artery disease.

We evaluated the clinical efficacy and cost of a cardiac imaging strategy versus a traditional exercise tolerance test (ETT) strategy for the investigation of suspected stable coronary artery disease (CAD). We retrospectively collected data of consecutive patients seen in rapid access chest pain clinics at 2 UK hospitals for a period of 12 months. Hospital A investigated patients by performing ETT. Hospital B investigated patients using cardiac imaging test; 483 patients from hospital A and 295 from hospital B were included. In hospital A, 209 patients (43.3%) had contraindication to ETT. Of those who had ETT, 151 (55.1%) had negative ETT, 68 (24.8%) had equivocal ETT, and 55 (20.1%) had positive ETT, of which 53 (96.4%) had invasive coronary angiography (ICA), and of these 23 (43.4%) had obstructive CAD. In hospital B, 26 patients (8.8%) with low pretest probability had calcium score and 3 (11.5%) were positive leading to computed tomography coronary angiography; 98 patients (33.2%) with intermediate pretest probability had computed tomography coronary angiography and 5 (5.1%) were positive; 77 patients (26.1%) had stress echocardiogram and 6 (7.8%) were positive; and 57 patients (19.3%) had myocardial perfusion scintigraphy and 11 (19.3%) were positive. Hospital A performed 127 ICA (26.3% of population) and 52 (40.9%) had obstructive CAD. Hospital B performed 63 ICA (21.4% of population) and 32 (50.8%) had obstructive CAD. The average cost per patient in hospital A was £566.6 ± 490.0 ($875 ± 758) and in hospital B was £487.9 ± 469.6 ($750 ± 725) (p <0.001). In conclusion, our results suggest that a cardiac imaging pathway leads to fewer ICA and a higher yield of obstructive CAD at lower cost per patient.

Usefulness of a Z-score of E' versus raw E' velocities to detect left ventricular dysfunction in patients with mitral or aortic regurgitation or dilated cardiomyopathy.

Despite their potential as a sensitive measure of ventricular performance, tissue Doppler velocities vary with normal aging. This is inconvenient for nonspecialists to interpret and makes it difficult to use as an entry criterion for clinical studies. The age-adjusted tissue Doppler Z-scores might avoid these disadvantages and be more discriminant for myocardial impairment than the raw velocities. We conducted a meta-regression of studies reporting age-specific normal tissue Doppler velocities to determine a consensus formula for Z-scores (8 studies, 1,867 patients) that we then tested in an independent study at our institution. We next compared the Z-scores head-to-head with the raw velocities for their ability to distinguish a fresh set of 81 healthy subjects from groups in whom subtle ventricular dysfunction might be expected, including 50 patients with dilated cardiomyopathy, 50 with aortic regurgitation, and 50 with mitral regurgitation. The discriminant capacity, assessed by the area under the receiver operating characteristic curves, was higher for the Z-scores than for the raw velocities in each patient group. At the septal angle of the mitral annulus: dilated cardiomyopathy 0.95 versus 0.92 (p = 0.03), aortic regurgitation 0.83 versus 0.78 (p = 0.02), mitral regurgitation 0.85 versus 0.81 (p = 0.04). At the lateral angle: dilated cardiomyopathy 0.94 versus 0.88 (p = 0.005), aortic regurgitation 0.92 versus 0.83 (p = 0.001), mitral regurgitation 0.87 versus 0.85 (p = 0.31). In conclusion, the Z-scores of the tissue Doppler velocities were better than the raw velocities at detecting myocardial impairment in valvular or heart muscle disease. The calculation needs only the raw velocity and patient age. Tissue Doppler Z-scores could be used to create a novel, more sensitive, definition of ventricular dysfunction and might make it easier for nonspecialists to interpret the reports.

Triple-vessel percutaneous coronary revascularization in situs inversus dextrocardia.

Dextrocardia with situs inversus occurs in approximately one in 10,000 individuals of whom 20% have primary ciliary dyskinesia inherited as an autosomal recessive trait. These patients have a high incidence of congenital cardiac disease but their risk of coronary artery disease is similar to that of the general population. We report what is, to our knowledge, the first case of total triple-vessel coronary revascularization by percutaneous stent implantation in a 79-year-old woman with situs inversus dextrocardia. We describe the successful use of standard diagnostic and interventional guide catheters with counter rotation and transversely inversed image acquisition techniques. The case also highlights that the right precordial pain may represent cardiac ischemia in this population.

Evidence of improved regional myocardial function in patients with chronic stable angina and apparent normal ventricular function--a tissue Doppler study before and after percutaneous coronary intervention.

BACKGROUND: The aim of this study was to determine the impact of percutaneous coronary intervention (PCI) on myocardial function assessed by tissue Doppler echocardiography. METHODS: Myocardial tissue peak velocities were recorded at the lateral, septal, posterior, and inferior angles of the mitral annulus as well as at the lateral tricuspid annulus by pulsed-wave tissue Doppler echocardiography before PCI, as well as 1 day and 6 weeks after intervention. RESULTS: Twenty-four consecutive patients with chronic stable angina and preserved systolic left ventricular function (20 men; mean age, 64 +/- 9 years) undergoing PCI were studied. Compared with preinterventional values, early diastolic velocities improved at all sites (P < .05 for each). The most pronounced improvement occurred in the septal area. Similarly, systolic peak velocity improved in the septal, lateral, inferior, and right ventricular areas (P < .04 for each). CONCLUSIONS: Tissue Doppler parameters of diastolic and systolic function improve early after successful PCI, and this effect persists to 6 weeks after intervention.

Effect of coronary artery bypass surgery on myocardial function as assessed by tissue Doppler echocardiography.

OBJECTIVE: Coronary artery bypass graft (CABG) surgery may induce myocardial stunning and thereby affect cardiac function. We aimed to assess whether myocardial function is affected by CABG in patients with preserved preoperative systolic function. METHODS: Myocardial tissue peak velocities were recorded at the lateral and septal angle of the mitral annulus as well as at the lateral tricuspid annulus by pulsed wave tissue Doppler echocardiography before cardiac surgery, and then at 5 days, 6 weeks and 18 months after surgery. RESULTS: Thirty-two consecutive patients with preserved systolic left ventricular function (31 male, 63+/-10 years) undergoing CABG (9 with cardiopulmonary bypass on-pump, 23 beating heart off-pump) were included. Peak systolic velocity on tissue Doppler echocardiography was unchanged after surgery. In contrast, peak early diastolic velocities (E') improved significantly 5 days and 6 weeks after surgery in the septal area (6.2+/-2.3 to 7.4+/-2.6 and 7.6+/-2.6 cm/s, respectively; p<0.05) and at the left ventricular lateral wall (9.1+/-3.0 to 10.1+/-3.0 and 11.3+/-2.9 cm/s, respectively; p<0.05), and then declined slowly to preoperative values after 18 months. In contrast, right ventricular E' decreased significantly immediately after surgery (9.8+/-2.7 preoperatively to 7.7+/-1.7 cm/s at 5 days, p=0.005) with only incomplete recovery over time. This was similar in both the conventional and the off-pump CABG cohort. CONCLUSIONS: Left ventricular function did not deteriorate after CABG in patients with preserved preoperative systolic function. On the contrary, diastolic function improved immediately after CABG. Right ventricular function, in contrast, appeared to be damaged by surgery, to similar degrees regardless of whether patients underwent off-pump or on-pump surgery. Hypothermia and immune-inflammatory activation are, therefore, not plausible explanations for this decline in right ventricular function.

Midwall myocardial shortening in athletic left ventricular hypertrophy.

BACKGROUND: Patients with pathological left ventricular hypertrophy have depressed midwall systolic shortening in spite of normal indices of left ventricular chamber function and a reduced midwall function has been observed to be an independent predictor of cardiovascular risk. Whether midwall shortening is depressed in physiological hypertrophy is unknown. METHODS: Forty-two subjects, 27 athletes and 15 age- and sex-matched normal control subjects (group 1) were studied. The athletes were divided into those with eccentric hypertrophy (group 2) and those with concentric hypertrophy (group 3). Systolic left ventricular function was assessed at the midwall and endocardium using two-dimensional echocardiography in all subjects. RESULTS: Left ventricular mass index was significantly greater in both athletic groups than in controls (group 1, 101+/-5.8 g/m(2), group 2, 141+/-11.1*, group 3, 155+/-5.8*; *P<0.01 compared with group 1). Left ventricular systolic function assessed at the endocardium was similar among all three groups (ejection fraction: group 1, 66.2+/-2.38, group 2, 66.8+/-1.44, group 3, 63.7+/-1.66%; endocardial fractional shortening: group 1, 37.1+/-1.71, group 2, 37.6+/-1.13, group 3, 35.1+/-1.25%). However, fractional shortening at the midwall was reduced in the concentric hypertrophy athletes compared with the other two groups (midwall fractional shortening: group 1, 21.9+/-1.1, group 2, 21.9+/-0.86, group 3, 18.4+/-0.96*%; P<0.05 compared with groups 1 and 2). CONCLUSION: Subjects with physiological concentric hypertrophy have depressed midwall fractional shortening. This suggests that the observed discrepancy between midwall and endocardial shortening in patients with left ventricular hypertrophy is likely to be a function of the geometry and not necessarily a reflection of pathology within the myocardium.