Altered left ventricular volume and ejection fraction responses to supine dynamic exercise in athletes.

Two-dimensional echocardiography was used to determine the responses of left ventricular volumes, ejection fraction and segmental left ventricular motion to supine dynamic exercise in 22 professional athletes, comparing these responses with those in 22 age- and gender-matched healthy untrained individuals. End-systolic volume was significantly greater at rest and during exercise in the athletes (50 +/- 6 versus 29 +/- 4 ml and 40 +/- 5 versus 17 +/- 4 ml, respectively, p less than 0.001 for both). It decreased during exercise in all the untrained subjects, but did not change or increased in nine athletes (41%). End-diastolic volume was greater in the athletes at rest (143 +/- 12 versus 98 +/- 9 ml) and during exercise (157 +/- 14 versus 121 +/- 13 ml, p less than 0.01 for both). It increased in all the untrained subjects, but decreased or did not change in six athletes (27%). Ejection fraction was significantly lower in the athletes at rest and during exercise (65 +/- 4% versus 70 +/- 5% and 73 +/- 5% versus 86 +/- 5%, p less than 0.01 and 0.001, respectively); the values augmented normally in all the untrained subjects, but increased only by less than 5% units, did not change or decreased in nine athletes (41%). Eight athletes (36.5%) failed to demonstrate the expected symmetric hyperkinetic wall motion changes during exercise, which were seen in all the untrained subjects. No correlation was found between atypical responses to exercise and electrocardiographic patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve prolapse in psoriatic arthritis.

Twenty-five patients with psoriatic arthritis were studied by echocardiography in view of the known association of related seronegative arthropathies with aortic-valve lesions. The study group included 15 men and ten women with a mean age of 46.5 +/- 14.6 years. Twenty-two patients suffered from peripheral disease whereas three also had axial involvement. No aortic-valve lesions were found; however, mitral-valve prolapse (MVP) was detected in 14 patients (56%), nine men and five women. The mean age, mean duration of psoriasis, and mean duration of arthritis were similar in patients with and without MVP. HLA tissue typing, which was done in nine patients with MVP, revealed only one patient with HLA-B27. There was no predominance of any of the typical antigens found in psoriasis (HLA-B13, HLA-Cw6). In a control group of 32 psoriatic patients without arthritis, only two (6.4%) suffered from MVP.

Echocardiographic evaluation of the effects of gallopamil on left ventricular function.

Two-dimensional echocardiography was used to determine global and regional left ventricular function in 32 patients treated with gallopamil (methoxyverapamil) for angina pectoris. Ejection fraction (EF), pressure/volume ratio (PVR), and segmental wall motion were assessed. Evaluations were made before therapy (T1) and repeated 3 weeks later; this assessment included examination 2 and 8 hours after the morning dose (T2 and T3, respectively). Patients were randomized to either a placebo group or three study groups (25, 37.5, and 50 mg t.i.d.). In the 37.5 and 50 mg groups there was an increase in EF (T1 = 53.8% and 54.5%, T2 = 57.9% and 60.1%, and T3 = 57.6% and 60%) and PVR values (T1 = 5.2 and 7.2 mm Hg/ml/m2, T2 = 5.8 and 7.7 mm Hg/ml/m2, and T3 = 5.9 and 7.6 mm Hg/ml/m2, respectively). Wall motion remained the same or improved in 92.3% of the patients. In conclusion, gallopamil had no cardiodepressant effects in most patients. On the contrary, EF, PVR, and segmental contractility tended to improve with the higher doses.

Persistence of arrhythmia exercise response in healthy young men.

This study assesses the persistence of arrhythmia at rest or during exercise tests, or both, after a mean follow-up period of 6.7 years in 76 young men (mean age 21.5 years) without evidence of organic heart disease. The exercise test was performed using a near-maximal protocol based on progressively increasing intermittent work loads, each of 5 minutes' duration. The initial work load was 50 W. The electrocardiogram was continuously registered throughout all stages of the examination. Arrhythmia was defined as the occurrence of greater than or equal to 1 supraventricular or 1 ventricular premature beat at any stage of the examination. At the follow-up examination, the rate of persistence of arrhythmia did not differ significantly among the subgroups, irrespective of follow-up interval, type of arrhythmia, or arrhythmia patterns of response to exercise. Two-dimensional echocardiography did not show any structural abnormalities and Doppler examination did not demonstrate significant abnormal flow patterns. Our data show that almost all patients continued to present arrhythmia after the follow-up period, without any evidence of development of organic heart disease. Moreover, the arrhythmia pattern of response to exercise remained constant throughout the years. At this time, arrhythmia without underlying heart disease seems to be of a benign natural course in these young men.

Effects of prolonged intensive versus moderate leg training on the untrained arm exercise response in angina pectoris.

To compare the effects of 2 different leg training intensities on the cardiocirculatory exercise response of the untrained arm, 58 patients with angina pectoris were randomized to either an intensive (at least 85% of symptom-limited exercise, n = 28) or a moderate (70 to 85% of symptom-limited exercise, n = 30) training group. Patients trained for 6 months, 2 times per week for 30 minutes each. Results of the 2 groups after training showed similar significant (p less than or equal to 0.001) decreases in heart rate (HR), systolic blood pressure (BP) and HR X BP product for trained legs and untrained arms at matched subanginal workloads and significant (p less than 0.01 to 0.001) increase in anginal threshold HR and HR X BP for the onset of 1 mm or more ST horizontal depression during testing of trained legs as well as of untrained arms. The improvement in exercise capacity at subanginal workloads results from decreased HR X BP product. In contrast, the significant increase in HR X BP product for the onset of ST-segment displacement and precipitation of anginal pain for both the trained and untrained limbs may imply an increase in myocardial blood flow. Thus, prolonged intensive or moderate training may significantly improve coronary blood flow in selected patients with angina pectoris. Patients with the highest anginal threshold HR and HR X BP product before training showed the most improvement at 6 months after training.

Painful versus silent myocardial ischemia during leg and arm exercise testing in stable angina pectoris.

When 51 patients with proven coronary heart disease and stable angina pectoris underwent exercise testing, 22 experienced painful myocardial ischemia during both leg and arm exercise testing (group L + A), whereas 29 patients had such episodes only during the leg testing (group L). Upright bicycle exercise was performed with the legs first, followed 2 days later by arm testing. Exercise was stopped when typical anginal pain and greater than 1-mm ST horizontal depression occurred during leg testing, and when greater than 1-mm ST horizontal depression was noted during arm testing. Heart rate, systolic blood pressure and rate-pressure product for leg and arm testing, either at the beginning of anginal pain or at the time when 1-mm ST depression was noted, were similar. Two-dimensional echocardiography showed that the L group had higher (p less than 0.01) end-systolic volume at rest and decreased (p less than 0.05) ejection fraction during exercise. Coronary angiography showed that the L group had a greater (p less than 0.001) number of patients with 3-vessel disease, a decreased (p less than 0.001) ejection fraction and less patients with 1-vessel disease. In these patients, absence of anginal pain during arm exercise suggests defective segmental transmission of pain sensation related to severe coronary artery disease. Thus, arm testing, in addition to leg testing, seems to be a simple and useful tool for the detection of severe coronary disease.

Left ventricular exercise echocardiographic abnormalities in apparently healthy men with exertional hypotension.

Of a total of 1,435 healthy untrained asymptomatic individuals referred for a routine periodic checkup, 23 subjects with exertional hypotension on upright bicycle stress testing were identified. All were male. This study assesses by means of echocardiography the responses to exercise of left ventricular (LV) volumes, ejection fraction and segmental LV contractility in these subjects. Exertional hypotension was defined as a decrease in systolic blood pressure to below the resting value at the end of stress test. Supine systolic blood pressure after exercise was significantly greater in the control group than in the study group (179 vs 121 mm Hg, respectively; p less than 0.001); there was no significant intra- or intergroup difference in the resting values. In the study group end-systolic volume was 37 ml at rest and 35 ml after exercise; ejection fraction varied from 65% at rest to 63% after exercise. The sex- and age-matched control group with a normal systolic blood pressure response to exercise showed a shift from 35 to 23 ml and 65 to 77%, respectively (p less than 0.01 and 0.001). Ejection fraction correlated well with radionuclide angiography values. Exertional hypotension was noted after both upright and supine exercise. The pattern of regional wall motion remained unchanged or was hypokinetic in 87% of the subjects; only 13% presented the normally expected hyperkinesia after exercise. This study demonstrates that exertional hypotension is accompanied by an abnormal LV performance.

Usefulness of heavy isometric exercise echocardiography for assessing left ventricular wall motion patterns late (> or = 6 months) after acute myocardial infarction.

The aim of this prospective study was to determine the effects of heavy isometric exercise on left ventricular (LV) wall motion patterns in patients who have had myocardial infarction, and to compare heavy isometric exercise with dynamic exercise for competence in eliciting LV wall motion abnormalities at equivalent rate-pressure products. Echocardiography was performed in 42 patients during supine bicycle ergometry and during heavy dynamometer stretching at 50% of maximal voluntary contraction. Systemic vascular resistance increased from 1,484 to 1,649 dynes s cm-5 (p < 0.05) during isometric exercise, and decreased significantly during dynamic exercise. Wall motion abnormalities or new asynergy were induced by isometric exercise in 120 segments, 107 of which (89%) showed significant stenosis of the perfusing coronary artery. Hypokinesia was the dominant pattern in the range of 76 to 90% narrowing; akinesia was dominant at 91 to 100% narrowing. Wall motion abnormalities were also documented in 13 segments (11%) assumed to be supplied by vessels with nonsignificant stenosis. Dyskinesia, seen in 7% of the segments, was equally distributed between both groups with significant stenosis. Sensitivity and positive predictive value in identifying specific coronary vessel disease was similar for both isometric and dynamic exercise. In conclusion, heavy isometric exercise in patients who have had myocardial infarction induces wall motion abnormalities of a severity proportional to the degree of coronary narrowing. This exercise method is similar to dynamic exercise for ability in identifying obstructions in a specific vessel. Furthermore, when compared at near-equal rate-pressure products, heavy isometric exercise is far superior in sensitivity to dynamic exercise.

Pronounced reduction of aortic flow velocity and acceleration during heavy isometric exercise in coronary artery disease.

Doppler-derived parameters of aortic flow were examined during heavy isometric exercise in 48 men with coronary artery disease (CAD) and in 48 gender- and age-matched healthy controls. The aim was to determine which parameters best separated the groups and to look for a possible relation between exercise-induced Doppler patterns and the extent of CAD. Isometric exercise was performed with a 2-hand bar dynamometer, and the subjects were required to perform 50% of maximal voluntary contraction for 2 minutes. Examination was performed with a pulsed Doppler transducer positioned at the suprasternal notch. Resting peak flow velocity, acceleration time, stroke volume index and cardiac index did not show significant differences between the groups. However, mean acceleration and stroke work were significantly lower in patients with CAD. In this group, exercise peak flow velocity decreased from 98 +/- 13 to 55 +/- 12 cm/s, flow velocity integral from 14 +/- 3 to 7 +/- 3 cm, mean acceleration from 11 +/- 0.9 to 4.7 +/- 1 m/s/s, and stroke volume index from 41 +/- 6 to 23 +/- 4 ml/m2 (p less than 0.001 for all). Cardiac index decreased from 2.7 +/- 0.4 to 2 +/- 0.2 liters/min/m2 (p less than 0.05). Acceleration time increased from 82 +/- 6 to 116 +/- 7 ms. In most of the indexes, the directional changes induced by isometric exercise were similar in patients with CAD and in normal control subjects. The differences compared with the rest values were significantly greater in the CAD group, and especially in patients presenting with 3-vessel disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular arrhythmias in rehabilitated and nonrehabilitated post-myocardial infarction patients with left ventricular dysfunction.

The incidence of ventricular arrhythmias in rehabilitated post-myocardial infarction (MI) patients with left ventricular dysfunction included in a long-term rehabilitation program was assessed and compared with that in similar patients who were not in such a program. Thirty-eight post-MI patients (2 to 19 years after the acute event) with ejection fraction < 40% were investigated by 48-hour Holter monitoring. They were divided into the following 3 groups: group I, 11 patients who underwent arm training for 60 months; group II, 11 patients who underwent calisthenics for 36 months; and group III, 16 patients who were not in any rehabilitation program; the age of the patients was 61 +/- 7, 61 +/- 6 and 61 +/- 9 years, respectively, (p = not significant). Ejection fraction at rest was 31 +/- 9 for group I, 29 +/- 7 for group II, and 29 +/- 7 for group III (p = not significant). There were no significant differences concerning the location of MI, and antiarrhythmic treatment received by patients from all groups. At the conclusion of 48-hour Holter monitoring, 2 blood samples were obtained for assessment of norepinephrine (at rest and after postural change). Quality of life was determined by a detailed questionnaire, including questions concerning social activity, life satisfaction and sexual function. After 36 and 60 months, an improvement in hemodynamic condition of patients in group I was noted. Quality of life was higher in the rehabilitated patients, with enhanced emotional stability, satisfaction with work and social life, and a high percentage of return to work (82 vs 40%).(ABSTRACT TRUNCATED AT 250 WORDS)

Rationale of exercise therapy in patients with angina pectoris with normal and impaired ventricular function.

The implementation of comprehensive coronary care (CCC), including multiple measures involving physical, psychologic, and pharmacologic procedures, together with a new concept of pharmacologic and surgical revascularization, have caused a remarkable improvement in the treatment of coronary patients with angina pectoris. The role of physical training per se is one measure of CCC and one must observe the fact that a single factor cannot be expected to influence a multifactorial disease. The irrefutable evidence that shows that physical training has an effect on longevity is lacking. On the other hand, a number of important physiologic and psychologic benefits have been found to be accompanying a prolonged physical training program in coronary patients suffering from angina pectoris before or after coronary artery bypass graft (CABG). The effect of training is an improvement of cardiocirculatory performance for given work tasks. This includes a decrease of heart rate, systolic blood pressure, the rate-pressure product, an increase of stroke volume, overall physical work performance, oxygen pulse, and in some instances, the rise of the angina pectoris threshold heart rate and threshold rate-pressure product in patients with angina pectoris.

Exercise response in young women with borderline hypertension.

We compared the response to dynamic exercise in 157 females (mean age 19 +/- 3 years) with borderline hypertension (BH) to findings in 105 normotensive controls. Near-maximal physical working capacity was 90 +/- 17 W in females with BH and 71 +/- 23 W for the controls (p less than 0.001). Mean heart rate, systolic and diastolic blood pressure, and pulse pressure levels both at rest and at exercise were significantly higher in BH patients (p less than 0.001 for all). Mean change between rest and exercise for all the above parameters was not significantly different among BH patients compared with controls. Nonspecific ST-T changes at rest (p less than 0.001) and exercise (p less than 0.005) were more common and mean corrected QT interval was significantly longer (p less than 0.001) in BH patients. The parallel exercise response that we found in BH and normotensives would not appear to substantiate the view that ergometry is particularly useful as a modality for diagnosing hypertension in young females.

Exercise response in young women with mitral valve prolapse.

To detect for possible evidence of autonomic nervous system dysfunction, we assessed exercise response in 198 young women with echocardiographically documented MVP. The same test was used to determine whether patients with or without physical symptoms or with various auscultatory findings responded differently. Compared with 105 age- and sex-matched healthy subjects, the MVP patients showed significantly higher mean heart rate, systolic blood pressure, pulse pressure and rate-pressure (double) product, at both rest and exercise; significantly lower mean near-maximal physical working capacity (PWC170); significantly higher incidence of both arrhythmias and nonspecific ST and T wave changes; and a significantly longer mean corrected QT interval. None of these findings was associated with the presence of physical symptoms or with specific auscultatory or echocardiographic findings. These observations strongly suggest an autonomic nervous system imbalance in some young women with MVP, irrespective of whether physical symptoms are present.

Electrocardiographic findings in brain death; description and presumed mechanism.

Electrocardiogram changes and pharmacologic responses were studied in 28 cases of brain death. Cardiac activity in this condition is possibly determined by the dynamic balance between the depressant action of hypothermia and the stimulating action of the sympathetic nervous system (without any vagal or central influence). The electrocardiographic alterations are the results of this dual influence, and are probably characteristic of this condition. In the initial stage of brain death the ECG shows J waves in the terminal part of the QRS, prolongation of the QT interval and the ST-T changes; in the advanced stages, progressive showing of the heart rate and the depolarization and repolarization processes are observed (manifested by gradual accentuation of the findings mentioned above); in the terminal stage dynamic electrocardiographic changes (among them, progressive depression of sinus activity, atrial fibrillation, atrioventricular and intraventricular conduction disturbances and severe ST-T changes) appear. It is possible that additional factors, like metabolic changes and possible myocardial damage in some instances, may have some influence on the electrocardiographic pattern. Final conclusions cannot be drawn from these preliminary observations. The atropine test was found to be an efficient and simple diagnostic aid in cases of brain death.

Doppler-derived aortic flow measurements during and after heavy isometric exercise in healthy men versus men with myocardial infarction.

Doppler echocardiography is a useful noninvasive determination of left ventricular function during dynamic exercise. Scarce data are available for the use of this technique during heavy isometric exercise. Therefore, Doppler-derived aortic flow indexes were assessed during and after 50% maximal upper-body isometric exercise in 25 healthy men (aged 47 +/- 6 years) and compared with those of 22 men (aged 48 +/- 9 years) who had suffered myocardial infarction. The heart rate increased (p = 0.01) in each of the groups from a mean of 68 +/- 12 at rest to 84 +/- 11 during isometric exercise. At rest, systolic blood pressure was higher (p = 0.05) in the patients with coronary artery disease. During exercise, the patients with cardiac disease, compared with the healthy volunteers, demonstrated a lesser reduction in flow velocity integral, stroke volume, and cardiac indexes (p = 0.001). Immediately on recovery, the patients with cardiac disease, compared with the healthy group, showed significantly greater (p = 0.001) increase in stroke volume and cardiac indexes. At 3 minute's recovery, the stroke volume index continued to increase in the patients with cardiac disease, while the healthy group showed a decrease to below its resting value. Although 50% of maximal upper-body isometric exercise caused similar heart rate and systolic blood pressure responses in healthy patients and patients with cardiac disease, there were significant group differences in Doppler-derived left ventricular systolic function indexes, which were greatest on immediate and 3 minute's recovery. The results suggest that this novel isometric test may be useful in clinical testing.

Long-term Holter ECG monitoring of athletes.

The purpose of the study was to detect the frequency and quality of rhythm disturbances in athletes during the late recovery period following a training session. Thirty-two athletes volunteered to participate. The ECG tracing was recorded by the use of a one-channel 12-h portable electrocardiograph cassette recorder. All subjects were instructed to keep a diary of symptoms and activities, and to record the onset of sleep and waking time. The tapes were analyzed using a rapid scanner with digital circuit for arrhythmia detection. Samples of all arrhythmic events were recorded for further analysis. The data from fitness testing, PWC170 and VO2max were higher than the mean values for active people of the same age group. The most common feature observed in our subjects, as expected, was sinus bradycardia. Most (91%) had a mild or pronounced sinus respiratory arrhythmia. Isolated atrial or ventricular premature contractions were observed in 6.2% of the subjects, intermittent first degree A-V block and second degree A-V block with Wenckebach periods were observed in 3.1%, high T-waves were found in 43.5%, and high take-off of ST segments were found in 53%. No symptoms, such as chest pain or palpitation, were recorded. The average heart rate when awake or asleep, including the longest RR interval, did not differ from the results of healthy individuals. The arrhythmias observed in our athletes were fewer than those reported in a normal population.

Usefulness of immediate postexercise two-dimensional echocardiography in post-myocardial infarction patients without ischemic ECG changes in stress testing: comparison with radionuclide angiography.

Of 38 post-myocardial infarction (MI) applicants for a cardiac rehabilitation program, 17 (45%) did not have ischemic ECG changes in exercise testing. Ten (59%) of these 17 patients had echocardiographic wall motion abnormalities at rest. Immediate postexercise two-dimensional echocardiography demonstrated exercise-induced changes in 8 (47%) patients (2 with normal and 6 with abnormal results from rest studies). The comparative radionuclide (RNA) examinations showed that there were 6 patients with abnormal findings from rest RNA; exercise-induced changes were detected in 7 (44%) of 16 patients (3 with normal and 4 with abnormal results from rest RNA tests). Statistical analyses, using RNA as reference point, revealed that the total correctly diagnosed cases for the echocardiographic rest studies was 13/17 (77%) and for the exercise studies, 13/16 (81%). The negative predictive values were 7/7 (100%) and 7/8 (88%), respectively. The corresponding positive predictive values were 6/10 (60%) and 6/8 (75%). The same pattern was observed when each segment (septal, apical, and posterolateral) was evaluated separately. The authors conclude that in post-MI patients with a negative stress test, the efficacy of postexercise echocardiography equals that of RNA in the identification of additional patients with ischemia.