The utility of the standard 12-lead electrocardiogram in the prediction of proximal right coronary artery occlusion in acute inferior myocardial infarction.

Prior studies have proposed several electrocardiogram criteria for identifying patients with acute inferior ST-segment elevation myocardial infarction (iSTEMI) caused by obstruction of the proximal part of the right coronary artery (RCA). We applied 11 of these criteria and three new ones to the admission electrocardiograms of 80 patients admitted with an acute iSTEMI in order to evaluate their utility. All patients received thrombolytic treatment and underwent coronary angiography during the hospitalization. Four previously described criteria (ST-segment depression in lead V1, ST-segment depression in leads V1-V3, maximum ST-segment depression in the precordial leads, and ST-segment depression in lead V3 of 1) were useful in identifying patients with obstruction of the proximal part of the RCA. Among the six criteria, ST depression in V1-V3 had the highest specificity (77.2%) and positive predictive value (56.5%), and a new criterion-the arithmetic sum of the ST-elevation in V3/ST-elevation in III < 0.5--had the highest sensitivity (80.9%) and negative predictive value (86.7%). Six criteria were helpful in identifying patients with acute iSTEMI caused by obstruction of the proximal part of the RCA. One of these has not been previously reported and has the higher specificity and negative predictive value.

Effects of renin-angiotensin system inhibition on left atrial function of hypertensive patients: an echocardiographic tissue deformation imaging study.

BACKGROUND: Although renin-angiotensin system (RAS) inhibitors have beneficial effects on left ventricular myocardium, their effect on left atrial (LA) function remains unknown. The aim of this study was to evaluate the effect of treatment with RAS inhibitors on LA function of patients with essential hypertension. METHODS: Forty hypertensive patients (17 males, mean age 47.1 +/- 1.5, mean blood pressure 158.3 +/- 1.8/97.1 +/- 0.7 mm Hg) were studied using LA strain and strain rate (SR) imaging before and after 9 months of treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). RESULTS: Standard echocardiographic parameters of LA function (LA volumes, ejection fraction, active and passive emptying fraction, and ejection force), as well as left ventricular diastolic indexes did not change with RAS-blocking treatment. However, peak systolic LA strain and SR were significantly higher at study end compared to baseline (77.8 +/- 5.2% vs. 63.3 +/- 4.1%, P < 0.001 and 3.9 +/- 0.2 s(-1) vs. 3.1 +/- 0.2 s(-1), P < 0.0001, respectively). No correlation was found between changes in systolic or diastolic blood pressure, and changes in strain or SR change during treatment. CONCLUSIONS: LA strain and SR imaging improved after reduction of blood pressure with RAS inhibitors in hypertensive patients, whereas standard LA echocardiographic parameters remained unchanged. LA strain/SR values may have a role in detecting subclinical myocardial involvement in essential hypertension at an early stage; the association between change in these indexes after antihypertensive treatment and clinical outcome merits further evaluation.

Differences in echocardiographic characteristics of functional mitral regurgitation in ischaemic versus idiopathic dilated cardiomyopathy: a pilot study.

INTRODUCTION: Functional mitral regurgitation (FMR) is a common complication in patients with ischaemic (ICM) or idiopathic dilated cardiomyopathy (DCM), as a consequence of left ventricular (LV) remodelling. The aim of this study was to elucidate the differences in FMR between patients with ICM and DCM utilising conventional and tissue Doppler echocardiography. METHODS: We studied 21 patients with ICM and 17 with DCM using conventional and tissue Doppler echocardiography. The severity of FMR was assessed quantitatively and by the PISA method. The 2 groups were similar in terms of NYHA class, LV ejection fraction and pharmacological treatment. RESULTS: Patients with ICM had higher pulmonary artery systolic pressures (48 +/- 16 vs. 38 +/- 10 mmHg, p=0.04), more severe FMR as assessed by colour Doppler (1.9 +/- 0.9 vs. 1.1 +/- 0.5, p=0.006), and a larger effective regurgitant orifice (0.17 +/- 0.07 vs. 0.1 +/- 0.05 cm(2), p=0.003) and tenting area (2.3 +/- 0.8 vs. 1.7 +/- 0.7 cm(2), p=0.02). In addition, ICM subjects had lower mitral annular systolic (Sm 2.3 +/- 0.8 vs. 3.4 +/- 0.9 cm/s, p<0.001) and diastolic (Em 2.5 +/- 1 vs. 3.8 +/- 1.5 cm/s, p=0.005; Am 3.1 +/- 1.4 vs. 4.3 +/- 1.7 cm/s, p=0.02) myocardial velocities, and a higher ratio of early transmitral filling velocity to early mitral annular diastolic velocity (LV E/Em 42 +/- 29 vs. 22.7 +/- 7.6, p=0.008) compared to DCM patients. Systolic and diastolic mitral annular velocities were significantly correlated with effective regurgitant orifice. Tenting area >1.27 cm(2) exhibited the highest sensitivity and regurgitant volume >24 ml the highest specificity for predicting ischaemic aetiology of LV dysfunction. However, only age and Sm were independent predictors of the diagnosis of ICM rather than DCM. CONCLUSIONS: Mitral apparatus deformity, incomplete closure of mitral leaflets and global remodelling are more prominent in patients with ICM and lead to more severe FMR than in patients with DCM.

Right ventricular function in ischemic or idiopathic dilated cardiomyopathy.

BACKGROUND: Differentiation between ischemic (ICM) and dilated cardiomyopathy (DCM) has important therapeutic implications because the former may benefit from coronary revascularization. The aim of this study was to investigate right ventricular (RV) function using tissue Doppler echocardiography (TDE) and compare the TDE parameters of the RV among patients with ICM and DCM. METHODS AND RESULTS: Forty-two patients with ICM and 40 patients with DCM were studied with conventional echocardiography and TDE. The 2 groups did not differ in terms of New York Heart Association class, left ventricular ejection fraction and pharmacological treatment. Patients with ICM had higher pulmonary artery systolic pressure (44.4 mmHg vs 34.7 mmHg, p=0.006) and lower tricuspid annular motion systolic (RV Sa 0.06 m/s vs 0.09 m/s, p<0.0001), and diastolic velocities (RV Ea 0.05 m/s vs 0.07 m/s, p=0.0003, RV Aa 0.075 m/s vs 0.11 m/s, p=0.0016). They also exhibited a higher ratio of early transtricuspid filling velocity to early diastolic velocity of the tricuspid annulus (RV E/Ea 8.2 vs 5.7, p=0.0008). Age, pulmonary artery systolic pressure and tricuspid Sa were significant independent predictors of the diagnosis of ICM. CONCLUSIONS: RV dysfunction is more pronounced in patients with ICM than in patients with DCM. The RV TDE parameters can be used to complement clinical and conventional echocardiographic findings in the assessment of patients with ICM and DCM.

Early diastolic impairment of diabetic heart: the significance of right ventricle.

BACKGROUND: Left ventricular diastolic dysfunction represents the earliest preclinical manifestation of diabetic cardiomyopathy. Right ventricular function has not been studied in depth yet in diabetic patients, although the right ventricle has an important contribution to the overall cardiac function. This study was designed to assess diastolic and systolic ventricular function in both ventricles, in patients with type 1 diabetes, free from coronary artery disease and hypertension. METHODS: We studied 66 type 1 diabetic patients and 66 age- and sex-matched normal subjects by conventional and tissue Doppler echocardiography. A possible correlation was examined for age, diabetes duration and echocardiographic measurements of left ventricular and right ventricular functions with univariate analysis. RESULTS: Type 1 diabetic patients were found to have impaired diastolic function in both ventricles with either conventional or tissue Doppler echocardiography. On the contrary, systolic function in both ventricles was preserved in our diabetic population. The measured indexes showed an expected correlation with age and diabetes duration except from systolic velocity in tricuspid annulus determined by color tissue Doppler. Moreover, significant correlations were found among parameters of left and right ventricular function. CONCLUSIONS: Patients with type 1 diabetes mellitus have impaired diastolic function, and particularly relaxation, in both ventricles before the development of myocardial systolic dysfunction. These alterations in myocardial function may be attributed to ventricular interdependence as well as to the uniform effect of diabetes to cardiac function.