Complete Heart Block in Systemic Sclerosis with Characterization on Cardiac MRI.

Cardiac involvement of infiltrative disease, such as systemic sclerosis, carries significant morbidity and mortality. All parts of the heart may be affected, although the conduction system is less commonly involved. We report a rare case of systemic sclerosis causing third-degree atrioventricular block and the first known reported case to use cardiac magnetic resonance imaging (CMR) as a diagnostic and prognostic instrument. It is not known whether using cardiac CMR in systemic sclerosis with cardiac involvement could lead to earlier intervention with escalation of medical therapy or earlier referral for transplant evaluation.

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis.

OBJECTIVE:: To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis. METHODS:: A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05). RESULTS:: Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength. CONCLUSION:: Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

Comparative Assessment of Mitral Regurgitation Severity by Transthoracic Echocardiography and Cardiac Magnetic Resonance Using an Integrative and Quantitative Approach.

Although transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) are validated in quantitation of mitral regurgitation (MR), discrepancies may occur. This study assesses the agreement between TTE and CMR in MR and evaluates characteristics and clinical outcome of patients with discrepancy. From our institutional database, 70 subjects with MR underwent both TTE and CMR within 30 days (median 3 days). MR was evaluated semiquantitatively (n = 70) using a 4-grade scale and quantitatively (n = 60) with calculation of regurgitant volume (RVol) and regurgitant fraction (RF). Of the 70 subjects, qualitative assessment by TTE yielded 30 subjects with mild MR, 17 moderate, and 23 moderately severe or severe MR. Exact concordance in MR grade was seen in 50% and increased to 91% when considering concordance within one grade of severity (κ = 0.44). A modest correlation was observed for RVol and RF between both methods (r = 0.59 and 0.54, respectively, p <0.0001). Ten patients had a significant discrepancy in quantitative MR (difference in RF >20%); the frequency of secondary MR was higher (100% vs 46%; p = 0.003) in patients with discrepancy. Although interobserver variability in RF was higher with TTE compared with CMR (-5.5 ± 15% vs 0.1 ± 7.3%), patients with discrepancy were equally distributed by severity and clinical outcome without an overestimation by either method. In conclusion, there is a modest agreement between TTE and CMR in assessing MR severity. In patients with discrepancy, there is a higher prevalence of functional MR, without a consistent overestimation of MR severity by either method.

Feasibility, safety and accuracy of regadenoson-atropine (REGAT) stress echocardiography for the diagnosis of coronary artery disease: an angiographic correlative study.

Regadenoson (REG), a selective A2A receptor vasodilator, has not been widely evaluated in stress echocardiography (SE). We report results of 45 patients participating in REG + atropine (REGAT) SE protocol conducted in a single-center prospective trial. The REGAT study enrolled subjects before a clinically indicated cardiac catheterization for suspected coronary artery disease (CAD). After rest imaging, a 2 mg Atropine (AT) bolus followed by 400 mcg of REG was given. Standard stress imaging views were obtained and interpreted in blinded fashion. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated using cardiac catheterization >70 % stenosis as gold standard. Additional endpoints included major adverse cardiac events (MACE) and patient questionnaire responses. The mean duration of REGAT was 18 ± 7.2 min. There were no MACE, with only transient side-effects of dry mouth, shortness of breath, and headache. The incidence of significant CAD was 51.1 %. The sensitivity and specificity for significant stenosis was 60.9 and 86.4 %, with a PPV and NPV of 82.4 and 67.9 %. By coronary territories, the sensitivity, specificity, PPV, and NPV were: left anterior descending artery 58.8, 92.9, 83.3, and 78.8 %; left circumflex artery 6.7, 93.3, 33.3, and 67.7 %; and right coronary artery 16.7, 93.9, 50, and 75.6 %. Over 90 % of subjects reported feeling comfortable, with 83 % preferring REGAT as a future stress modality. The REGAT protocol is fast, safe, and well-tolerated with good specificity for CAD detection, but its low sensitivity and NPV precludes it from being an imaging modality for routine use.

The diastolic stress test: a new approach to an old problem.

The evaluation of ischemic heart disease is the cornerstone of clinical Cardiology. Although there are many means of ischemic evaluation, all are with their own limitations. While perfusion-based studies are highly sensitive, they lack specificity. Conversely, systolic wall motion analysis with echocardiography tends to have high specificity; however, the sensitivity may be limited by short duration of systolic abnormalities when present. With the advent of Doppler echocardiography, and more specifically tissue Doppler imaging, and strain and strain rate imaging, a more comprehensive evaluation of the left ventricular function is available, including diastole. Diastolic abnormalities in the setting of ischemia are now being studied using these new parameters and have been suggested as a reliable marker of ischemia. Exercise-induced abnormalities in diastolic parameters have improved sensitivities and specificities over traditional stress testing and persist longer than systolic abnormalities. A review of the medical literature regarding the subject will be discussed here.

Meta-analysis of adverse cardiovascular events associated with echocardiographic contrast agents.

In October 2007, the Federal Drug Agency issued a black box warning for contrast agents used in patients undergoing echocardiography and restricted their use in patients with acute coronary syndrome, a decompensated heart, and respiratory failure. We performed a systemic review and meta-analysis to study the adverse effects of contrast agents used with respect to myocardial infarction and all-cause mortality. MEDLINE, EMBASE, BIOSIS, and Cochrane databases from inception to October 2009 were searched for studies that reported myocardial infarction and all-cause mortality after the use of contrast agents for echocardiography. A total of 8 studies were included in the present meta-analysis. A random-effect model was used, and between-studies heterogeneity was estimated with I(2). A total of 8 studies reported death as an outcome and only 4 reported myocardial infarction. The incidence of death in the contrast group was 0.34% (726 of 211,162 patients) compared to 0.9% (45,970 of 5,078,666 patients) in the noncontrast group. The pooled odds ratio was 0.57 (95% confidence interval 0.32 to 1.01, p = 0.05). The reported incidence of myocardial infarction in the contrast group was 0.15% (86 of 57,264 patients) compared to 0.2% (92 of 44,503 patients) in the noncontrast group. The pooled odds ratio was 0.85 (95% confidence interval 0.35 to 2.05, p = 0.72). Significant heterogeneity was seen among the studies. In conclusion, the cumulative evidence has suggested that the use of contrast agents for echocardiography is safe and not associated with a greater incidence of myocardial infarction or and mortality.

Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort.

OBJECTIVES: The aim of this study was to evaluate the impact of echocardiographic contrast utilization on patient diagnosis and management. BACKGROUND: Contrast echocardiography (CE) has improved visualization of endocardial borders. However, its impact on patient management has not been evaluated previously. METHODS: We prospectively enrolled 632 consecutive patients with technically difficult echocardiographic studies who received intravenous contrast (Definity, Lantheus Medical Imaging, Billerica, Massachusetts). Quality of studies, number of left ventricular (LV) segments visualized, estimated ejection fraction, presence of apical thrombus, and management decisions were compared before and after contrast. RESULTS: After CE, the percent of uninterpretable studies decreased from 11.7% to 0.3% and technically difficult studies decreased from 86.7% to 9.8% (p < 0.0001). Before contrast, 11.6 +/- 3.3 of 17 LV segments were seen, which improved after CE to 16.8 +/- 1.1 (p < 0.0001). An LV thrombus was suspected in 35 patients and was definite in 3 patients before CE. After contrast, only 1 patient had a suspected thrombus, and 5 additional patients with thrombus were identified (p < 0.0001). A significant impact of CE on management was observed: additional diagnostic procedures were avoided in 32.8% of patients and drug management was altered in 10.4%, with a total impact (procedures avoided, change in drugs, or both) observed in 35.6% of patients. The impact of contrast increased with worsening quality of nonenhanced study, the highest being in intensive care units. A cost-benefit analysis showed a significant savings using contrast ($122/patient). CONCLUSIONS: The utilization of CE in technically difficult cases improves endocardial visualization and impacts cardiac diagnosis, resource utilization, and patient management.

Safety of contrast administration for endocardial enhancement during stress echocardiography compared with noncontrast stress.

The aim was to evaluate the safety of stress echocardiography using contrast (CE) for endocardial enhancement compared with a noncontrast (NCE) cohort in a large nonselect population. The recent Food and Drug Administration warning cited lack of data for safety regarding the use of contrast in conjunction with stress echocardiography. A detailed record review was performed for 5,069 consecutive patients who underwent stress echocardiography (58% pharmacologic, 42% exercise) during an 8-year period. Contrast use, hemodynamics, and adverse clinical and electrocardiographic events were evaluated until time of discharge from the laboratory. Contrast was administered to 2,914 patients (58%) and was higher in in-patients (66%) and during dobutamine stress (67%). Compared with the NCE group, the CE group was older (median age 61 vs 58 years) and had more depressed left ventricular ejection fraction <50% (14% vs 11%; all p <0.001). The CE group experienced more chest pain (11% vs 8%; p = 0.001), back pain (0.6% vs 0.05%; p <0.001), and premature ventricular contractions (odds ratio 1.42, 95% confidence interval 1.19 to 1.69, p <0.001). There was no sustained ventricular tachycardia, ventricular fibrillation, cardiac arrest, or death in either group. One uncomplicated acute myocardial infarction and 1 anaphylactoid reaction occurred in the CE group, and none occurred in the NCE group (p = 0.51). Rates of clinically significant arrhythmias were similar in both groups (CE 2.1% vs NCE 1.9%; p = 0.8). In conclusion, although CE of echocardiographic images was used more often in patients with a higher cardiac risk profile, the risk of major adverse events was very small in both the CE and NCE stress echocardiography cohorts.