Lupus cardiomyopathy: cardiac mechanics, hemodynamics, and coronary blood flow in uncomplicated systemic lupus erythematosus

Heart failure in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by a constellation of cardiovascular (CV) and non-CV manifestations. Even though CV complications such as accelerated atherosclerosis and elevated risk of myocardial infarction (MI) have been recognized for many years, there is limited evidence regarding SLE and its association with heart failure (HF). Traditional risk factors of atherosclerotic CV disease, as well as various SLE manifestations and therapies, independently or together, increase the risk of HF in this population. There is a need for sufficiently powered intervention studies focusing on specific risk factors to improve CV outcomes in SLE patients.

Large pericardial effusions due to systemic lupus erythematosus: a report of eight cases

The aim of this study was to describe the clinical, echocardiographic and laboratory characteristics of large pericardial effusions and cardiac tamponade secondary to systemic lupus erythematosus (SLE). An ongoing prospective study was conducted at Tygerberg Academic Hospital, South Africa between 1996 and 2002. All patients older than 13 years presenting with large pericardial effusions (.10 mm) requiring pericardiocentesis were included. Eight cases (out of 258) were diagnosed with SLE. The mean (SD) age was 29.5 (10.7) years. Common clinical features were Raynaud’s phenomenon, arthralgia and lupus nephritis class III/IV. Echocardiography showed Libman-Sacks endocarditis (LSE) in all the mitral valves. Two patients developed transient left ventricular dysfunction; both these patients had pancarditis. Typical serological findings included antinuclear antibodies, anti-double stranded DNA antibodies, low complement C4 levels and low C3 levels. CRP was elevated in six cases. Treatment consisted of oral steroids and complete drainage of the pericardial effusions. No repeat pericardial effusions or constrictive pericarditis developed amongst the survivors (3.1 years follow up). This study concludes that large pericardial effusions due to SLE are rare, and associated with nephritis, LSE and myocardial dysfunction. Treatment with steroids and complete drainage is associated with a good cardiac outcome.

Evaluation of early cardiac dysfunction in patients with systemic lupus erythematosus with or without anticardiolipin antibodies

The aim of this study was to use transthoracic Doppler echocardiographic (TTE) imaging methods to identify cardiac dysfunction, an indicator of subclinical atherosclerosis in asymptomatic systemic lupus erythematosus (SLE) patients in terms of cardiac effects. This study involved 80 patients: a study group ( n = 50) and control group ( n = 30). They were categorized into four subgroups: anticardiolipin antibodies (aCL) (+) ( n = 14) and aCL (−) ( n = 36); systemic lupus erythematosus disease activity index (SLEDAI) ≥ 6 ( n = 15) and SLEDAI < 6 ( n = 35); disease period ≥ 5 years ( n = 21) and disease period < 5 years ( n = 29); major organ involvement (+) ( n = 19), major organ involvement (−) ( n = 31). The ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity (E/E′) for the study group was found to be higher than the control ( p < 0.01). Systolic septal motion velocity (Ssm) was lower in the study group compared with the control ( p < 0.01). Left atrium (LA) dimension was greater in the study group than the control ( p < 0.01). Ssm was found to be lower in the aCL (+) patients compared with the control and aCL (−) groups ( p < 0.01, p < 0.05, respectively). LA dimension was greater in the aCL (+) and (−) groups compared with the control, ( p < 0.01, p < 0.05, respectively) and aCL groups compared with each other ( p < 0.05). The E/E′ ratio for the aCL (+) and (−) groups was found to be greater than the control ( p < 0.05). In the study, both the Ssm and the late diastolic septal velocity (sA′) was found to be lower in the SLEDAI ≥6 group compared with SLEDAI<6 group, ( p < 0.001, p < 0.05, respectively). LA dimension was statistically greater in the SLEDAI ≥6 group compared with the SLEDAI <6 group ( p < 0.001). E′ and early diastolic septal velocity (sE′) were statistically lower in the disease period >5 years group compared with the disease period <5 years group ( p < 0.01, p < 0.05, respectively). Carrying out regular scans with TTE image of SLE patients is important in order to identify early cardiac involvement during monitoring and treatment. Identifying early cardiac involvement in SLE may lead to a reduction in mortality and morbidity rates.

Subclinical deterioration of left ventricular function in patients with juvenile-onset systemic lupus erythematosus

OBJECTIVES

Patients with systemic lupus erythematosus (SLE) have a higher risk of myocardial involvement, which can result in ventricular dysfunction. Little is known about the chronic influence of SLE on heart function in children and adolescents. This is the first study to demonstrate long-term changes in left ventricular function in patients with juvenile-onset SLE.

METHODS

This was a longitudinal study of 92 patients with juvenile-onset SLE. Two-dimensional echocardiography was performed by a single pediatric cardiologist at baseline, with follow-up at six-month intervals. Clinical and laboratory parameters, disease activity, treatment, nailfold capillaroscopy, and the traditional risk factors for atherosclerosis were evaluated. The baseline comparison of ventricular function was performed against 50 age-matched controls, and the follow-up results were analyzed using generalized estimating equations.

RESULTS

The patients' mean age at baseline was 15.9 ± 4.3 years, the mean disease duration was 3.6 ± 3.2 years, and the mean follow-up duration was 4.5 ± 1.6 years. At baseline, the mean left ventricular ejection fraction (LVEF) was 74.7 ± 5.6% and the mean E/A ratio of left ventricular diastolic filling was 1.7 ± 0.3 (E: the peak velocity at rapid left ventricular filling; A: the peak velocity during left atrial contraction). The LVEF of the SLE patients was similar to the healthy controls and it did not change during the follow-up period. In contrast, the E/A ratio was lower in the SLE patients than in the healthy controls (1.7 ± 0.3 versus 1.88 ± 0.37; p = 0.002), and it decreased significantly with time (B ± SE, -0.013 ± 0.006, p = 0.023). In multiple analyses, abnormal microvasculature in nailfold capillaroscopy had a negative effect on LVEF progression (p = 0.039). Disease duration of SLE and proteinuria were risk factors associated with the descent of E/A ratio (p = 0.014 and p = 0.015, respectively).

CONCLUSION

In patients with juvenile-onset SLE who were free of cardiac symptoms, there was evidence of declining ventricular diastolic function with time. Abnormal nailfold microvasculature, proteinuria and longer disease duration were the main risk factors for worsening of ventricular function.

Comparative efficiency of quinidine and verapamil in the maintenance of sinus rhythm after DC conversion of atrial fibrillation. A controlled clinical trial

Fifty-three patients with chronic atrial fibrillation participated in a randomized cross-over trial in order to compare the ability of two drug regimens to establish and maintain sinus rhythm. The patients were given orally either sustained release quinidine 0.4 g twice day or verapamil 80 mg three times a day. Thirty-one patients tried both regimens. Quinidine was found to have a greater ability to induce conversion to sinus rhythm by drug alone (p less than 0.05) and also a greater ability to maintain sinus rhythm after conversion (after 3 months p less than 0.05). There was, however, also a significantly larger proportion of patients on quinidine who were withdrawn from the study due to side effects and two patients on quinidine died outside hospital. The study indicate that quinidine is somewhat superior to verapamil both in the establishing and preserving of sinus rhythm in subjects who are able to tolerate the drug.

[Inflammatory cardiac diseases by primary extracardial diseases]

As systemic immunological disorders, internal diseases in gastroenterology, rheumatology and infectiology can, in addition to the bowels, potentially involve the musculo-skeletal system, the immunological system and heart structures. All structures and functions of the heart can be affected. Pericarditis in lupus erythematosus and chronic inflammatory bowel disease, myocarditis in HIV infection and lyme disease are examples of cardiac manifestations of internal diseases. The pathogenetic causes can be manifold, such as direct cytotoxic effects in HIV or Borrelia burgdorferi infections, induced vasculitis and local activation of coagulation factors as in lupus erythematosus or chronic inflammatory bowel disease. Improved treatment options have led to more long-lasting courses of internal diseases, such as in infectious diseases, lupus erythematosus and chronic inflammatory bowel disease, thus cardiovascular complications such as pericarditis and myocarditis gain increasing importance as a consequence of chronic disease and therapy-related damage.

Myocarditis in systemic lupus erythematosus

Although clinical manifestations of myocarditis in systemic lupus erythematosus are uncommon, noninvasive cardiac testing may detect subclinical cases. The pathogenesis of myocarditis in systemic lupus erythematosus has been ascribed to many factors, including autoimmunity, medications, and coexisting diseases. Lupus myocarditis merits urgent clinical attention because of the likely progression to arrhythmias, conduction disturbances and heart block, dilated cardiomyopathy, and heart failure. Endomyocardial biopsy can be used to identify the underlying inflammatory histopathology. Usual therapy includes high-dose corticosteroids, in addition to standard cardiac medications.

Atrial fibrillation associated with systemic lupus erythematosus and use of methylprednisolone

Systemic lupus erythematosus is known to have cardiac manifestations consisting of pericarditis, myocarditis, endocarditis, and coronary vasculitis. Pericarditis is the most common cardiac manifestation of systemic lupus erythematosus. Myocarditis may be suspected in patients presenting with unexplained tachycardia, conduction disturbances, unexplained systolic dysfunction with or without heart failure, or arrhythmias. The development of arrhythmias in systemic lupus erythematosus could be secondary to pericarditis, myocarditis, or ischemia caused by coronary vasculitis. The development of atrial fibrillation in systemic lupus erythematosus is not commonly reported. There have been few reports on the patients developing atrial fibrillation after being started on methylprednisolone therapy. Described here is a case of the development of atrial fibrillation in a newly diagnosed 37-year-old patient with systemic lupus erythematosus who was started on intravenous methylprednisolone therapy.

Cardiac abnormalities in SLE: pancarditis

Many patients with systemic lupus erythematosus (SLE) develop cardiac manifestations during the course of their disease. Pericarditis is most commonly seen, with a reported prevalence of 60%. Myocardial involvement is present in only a minority of patients. In recent years, due to better noninvasive diagnostic techniques, valvular abnormalities can be demonstrated in an increasing number of patients. Depending on the technique used, valvulopathy can be demonstrated in up to 77% of SLE patients. Although most of the valvular lesions will be present without any symptoms, valve incompetence can result in congestive heart failure. Valvular lesions are associated with IgG anticardiolipin antibodies (aCL) and disease duration. We present a patient with SLE and secondary antiphospholipid syndrome (APS) who developed acute congestive heart failure due to pancarditis. Endocarditis, together with left ventricular dysfunction and pericardial effusion, were present. The endocarditis caused hemodynamically significant mitral valve insufficiency due to thickening of the mitral cusps. Just two weeks prior to the occurrence of congestive heart failure echocardiography had been normal. Treatment with high dose corticosteroids resulted in a gradual, almost complete recovery. Literature concerning cardiac manifestations in lupus is reviewed.

Abnormal QT dispersion in Behçet's disease

Behçet's disease, which was originally described by Hulusi Behçet in 1937, is a generalized chronic inflammatory disease characterized by recurrent oral and genital ulcerations, ocular and dermal manifestations. Cardiac manifestations include pericarditis, myocarditis, conduction system disturbances, coronary arteritis, mitral valve insufficiency, dilated cardiomyopathy, ventricular arrhythmias and sudden cardiac death. There is little knowledge about the mechanism of ventricular arrhythmias in Behçet's disease. In this study, we examined the value of dispersion of ventricular repolarization as a diagnostic tool to assess the risk for ventricular arrhythmias and sudden cardiac death in Behçet's disease. We examined 38 patients (age: 34 +/- 4.6 years, 20F, 18M) with Behçet's disease and 30 age-matched healthy subjects were selected to serve as the control group. Repolarization dispersion parameters were calculated as the difference between maximal and minimal values of QT, QTc, JT and JTC from 12-lead ECG recordings at 25 or 50 mm/s. We found QTd, QTc-d, JTd and JTc-d intervals of 60.65 +/- 16.1, 78.45 +/- 11.4, 71.51 +/- 18.3 and 92.33 +/- 15.4 ms in Behçet's disease patients, these values in control subjects were 40.1 +/- 9.7, 56.36 +/- 7.5, 41.66 +/- 4.3 and 53.92 +/- 9.2 ms respectively (p < 0.001). Striking increases in QT and JT dispersion indicating regional inhomogeneity of ventricular repolarization were noted in patients with Behçet's disease. This new finding suggests a possible explanation for the presence of ventricular arrhythmias in patients with Behçet's disease.

Angina pectoris in patients with aortic stenosis and normal coronary arteries. Mechanisms and pathophysiological concepts

BACKGROUND

The incidence of angina pectoris (AP) in patients with severe aortic stenosis (AS) and normal coronary arteries has been reported to be 30% to 40%. The exact pathophysiological mechanism, however, is not known. The purpose of this work was to evaluate the various hemodynamic and angiographic determinants of myocardial perfusion in 61 patients with severe AS.

METHODS AND RESULTS

In a retrospective analysis, 61 patients with severe AS and without significant coronary artery disease were studied. Thirty-three patients with atypical chest pain and angiographically normal arteries served as control subjects. Patients were divided into two groups: 32 with AP and 29 without AP. Quantitative coronary angiography was performed in 59 patients and 22 control subjects. Coronary flow reserve was determined in 29 patients and 7 control subjects by use of coronary sinus thermodilution technique. Patients with AP had a lower left ventricular (LV) muscle mass, an increased LV peak systolic pressure, and increased wall stress than those without AP. Vessels of the left coronary artery were smaller and coronary flow reserve was lower in patients with AP than in those without. Inadequate L V hypertrophy with an increased wall stress was found in patients with AP but not in patients without AP.

CONCLUSIONS

Myocardial ischemia in patients with severe AS can occur in the absence of coronary artery disease and appears to be due to inadequate LV hypertrophy with high systolic and diastolic wall stresses and a reduced coronary flow reserve. The cause of inadequate LV hypertrophy, however, remains unclear.

Behçet's disease and cardiac arrhythmia

Only few cases of cardiac conduction disturbances and arrhythmias have been reported in Behçet's disease. We recently observed the case of a 16-year-old woman with Behçet's disease in whom cardiac arrhythmia became the main clinical symptom. This observation and a review of the literature led us to the conclusion that arrhythmia could represent the clinical manifestation of an underlying myocarditis due to Behçet's disease and can be regarded as a feature of cardiac involvement of the disease.

Doppler evaluation of left ventricular diastolic filling in Behçet's disease

Although cardiac involvement such as pericarditis, myocarditis, coronary arteritis and valvular disease in Behçet's disease occurs, few studies have assessed left ventricular diastolic function. This study assesses the prevalence of both systolic and diastolic left ventricular dysfunction in patients with Behçet's disease who have no clinical cardiac manifestations. Twenty-two patients (12 women and 10 men, mean age 34 +/- 2.4 years) underwent full clinical examination, electrocardiography, M-mode, two-dimensional, and Doppler echocardiography. The mean disease duration was 5 +/- 4.7 years (range, 1 month-16 years). As age and sex-matched control group of 20 healthy subjects was also studied. Prolonged isovolumic relaxation time, prolonged deceleration time, reversal of the early and late peak transmitral diastolic flow velocities, late peak transmitral diastolic flow velocities (E/A ratio) and increased atrial filling fraction were noted in five patients. It is concluded that left ventricular dysfunction occurs frequently in patients with Behçet's disease and Doppler echocardiography may be valuable in detecting diastolic filling abnormalities as an early sign of cardiac involvement.

The left ventricle in systemic lupus erythematosus: initial observations and a five-year follow-up in a university medical center population

The objectives of this study were to determine the natural history of abnormalities in left ventricular size and function in patients with systemic lupus erythematosus and to determine whether changes in ventricular function can be attributed to a primary lupus cardiomyopathy. The design was a prospective 5-year follow-up study in a university hospital. There were 28 patients with systemic lupus erythematosis who were enrolled in an echocardiographic study from 1985 to 1986 and who were available for follow-up echocardiographic examinations. Patients were prospectively subgrouped according to the presence or absence of systemic hypertension. Twenty healthy volunteers participated as normal control subjects. Measurements of left ventricular mass index, mean wall thickness, volumes, and ejection fraction and Doppler indices of mitral inflow were performed on all patients and control subjects. Increases in left ventricular mass index, mean wall thickness, and end-systolic volume and decreases in ejection fraction were seen in the patients with lupus when compared with control subjects (p < or = 0.05) and were related to the presence of hypertension and coronary artery disease. In the group of patients without hypertension, no significant differences in left ventricular mass index, volumes, or ejection fraction were detected when compared with the control group. The normotensive patients did demonstrate mild abnormalities of mitral inflow that did not worsen during the follow-up period. It was concluded that abnormalities of systolic and diastolic left ventricular function are common in patients with lupus, are progressive over time, and are related to the coexistence of hypertension and coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous and coronary flow reserve in patients with microvascular angina

Microvascular angina is characterized by exercise-induced angina in patients with normal coronary arteries and reduced coronary flow reserve. Recently, a generalized disorder of abnormal vascular reactivity in microvascular angina has been postulated. Therefore, coronary flow reserve was determined by the coronary sinus thermodilution technique and compared with the cutaneous flux ratio in 6 control subjects (group 1) and 12 patients with microvascular angina (group 2). Coronary flow reserve was calculated from maximal coronary flow after 0.5 mg/kg of dipyridamole divided by flow at rest. Cutaneous flow ratio was estimated by laser Doppler fluxmetry (right forearm) before and after 4 min of suprasystolic blood pressure occlusion. Coronary flow at rest was identical in the two groups, but after maximal vasodilation with dipyridamole, coronary flow was higher in group 1 than in group 2 (p less than 0.05). Coronary flow reserve differed significantly between the two groups (2.9 in group 1 and 1.3 in group 2; p less than 0.001). Cutaneous Doppler flux at rest was higher in group 1 than in group 2 (p less than 0.05). However, the hyperemic response was identical in both groups. It is concluded that the cutaneous flux ratio in patients with microvascular angina is not impaired. Local peripheral vasomotor tone appears to be increased in patients with microvascular angina because cutaneous flow at rest is reduced. Thus, a generalized disorder of abnormal vascular reactivity cannot be confirmed in patients with microvascular angina.

Impairment of left ventricular diastolic function in systemic lupus erythematosus

Left ventricular (LV) diastolic performance was evaluated with pulsed-wave Doppler echocardiography in a cross-sectional population of patients with systemic lupus erythematosus (SLE) in search of subclinical myocardial involvement. Such involvement is reported to occur infrequently, despite pathohistologic evidence of myocarditis in up to 70% of patients with SLE. Thirty-five consecutive patients with SLE were evaluated, 14 with active and 21 with inactive disease, and were compared with 30 age-matched healthy control subjects. Twenty-six patients were restudied at 7 months. All had normal LV systolic function, normal pericardial and valvular structures, and no significant valvular regurgitation on Doppler echocardiography. In SLE patients with active disease, indexes of LV diastolic function differed significantly from the inactive group and from control subjects, with marked prolongation of isovolumic relaxation time (104 +/- 18 vs 74 +/- 13 ms, p = 0.0001), as well as reduced peak early diastolic filling velocity (E) (0.69 +/- 0.19 vs 0.83 +/- 0.17 ms, p = 0.01), reduced ratio of early to late diastolic flow velocity (E/A) (1.15 +/- 0.53 vs 1.47 +/- 0.35, p = 0.02), and prolonged mitral pressure halftime (74 +/- 14 vs 65 +/- 8 ms p = 0.01). Similar significant differences were found between the active and inactive SLE patient groups. SLE patients with inactive disease differed from control subjects in only mild prolongation of mitral pressure halftime. Abnormal prolongation of isovolumic relaxation (greater than 100 ms) was found to be the most useful marker of diastolic impairment, being present in 64% of SLE patients with active disease and in 14% of patients with inactive disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial systolic function in systemic lupus erythematosus: a study based on radionuclide ventriculography

We assessed left ventricular systolic function by means of radionuclide ventriculography in 20 consecutive unselected patients with systemic lupus erythematosus. All patients had normal left ventricular systolic function (defined as ejection fraction greater than 45%) in a resting state. Regional wall motion abnormalities were, however, seen in 4 patients (20%). Of these 20 patients, 8 were able to exercise on a bicycle ergometer. These patients were subjected to exercise radionuclide ventriculography. Of these 8 patients, 3 (37.5%) had an abnormal ventriculographic response to exercise (as evidenced by a subnormal rise in ejection fraction or a fall, appearance of a new regional wall motion abnormality or worsening of a pre-existing one). This probably reflects subclinical left ventricular dysfunction unmasked by the stress of exercise. The clinical significance of these abnormalities on long-term myocardial function and their possible reversibility with remission of the disease needs to be assessed in future studies.

Doppler echocardiographic evaluation of left ventricular diastolic function in patients with systemic lupus erythematosus

Subclinical myocardial involvement frequently occurs in patients with systemic lupus erythematosus (SLE). In this study, left ventricular diastolic function was assessed in 58 patients (54 female and 4 male; mean age 32 +/- 11 years) and in 40 sex-matched and age-matched healthy control subjects (37 female and 3 male; mean age 33 +/- 9 years) by means of pulsed Doppler echocardiography. All subjects had no clinical evidence of overt myocardial disease or abnormal left ventricular systolic function. Compared with the control group, patients with SLE had significantly prolonged isovolumic relaxation time (62 +/- 12 vs 80 +/- 14 msec; p less than 0.01), reduced peak early diastolic flow velocity (peak E) (82 +/- 18 vs 76 +/- 16 cm/sec; p less than 0.05), increased peak late diastolic flow velocity (peak A) (45 +/- 7 vs 53 +/- 8 cm/sec; p less than 0.01), reduced E/A ratio (1.81 +/- 0.32 vs 1.46 +/- 0.29; p less than 0.001), and lower deceleration rate of early diastolic flow velocity (EF slope) (489 +/- 151 vs 361 +/- 185 cm/sec2; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac involvement in systemic lupus erythematosus detected by echocardiography

Cardiac involvement in patients with systemic lupus erythematosus (SLE) was assessed by full echocardiography and continuous wave Doppler in 50 consecutive patients and 50 age- and sex-matched control subjects in a prospective, blinded study. The left ventricular ejection fraction was decreased in patients compared to control subjects (61 +/- 9 vs 68 +/- 7%, p less than 0.001), whereas interventricular septum (12 +/- 3 vs 9 +/- 1 mm, p less than 0.001), and posterior wall dimension (9 +/- 2 vs 8 +/- 1 mm, p less than 0.001), left ventricular mass (186 +/- 54 vs 130 +/- 32 g, p less than 0.001) and mitral valve Doppler A:E ratio (0.8 +/- 0.2 vs 0.7 +/- 0.1, p less than 0.01) were increased. Pericardial effusion was detected in 27 patients and 5 control subjects, and valvular regurgitation was more frequent in the patients (aortic 2 vs 0; mitral 23 vs 5, p less than 0.001; tricuspid 34 vs 22, p less than 0.01 and pulmonary 28 vs 17, p less than 0.05). Mitral or aortic regurgitation was more common in patients with active SLE (60 vs 40%, difference not significant) but was not related to the duration of SLE (r = 0.02), duration of prednisone therapy (r = -0.13) or current dosage of prednisone (r = 0.01). This study demonstrates that pericardial effusion, valvular regurgitation and myocardial abnormalities are frequently present in patients with SLE.

The significance of coronary reserve in clinical heart disease

The clinical syndrome "coronary insufficiency with normal coronary arteriogram" is found in approximately 10% to 20% of patients with exercise-induced coronary insufficiency. In most of these cases, disturbances of the coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis), in rheologic diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia) and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia). The clinical diagnosis is based on the usual diagnostic procedures (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin), as well as on newer functionally oriented diagnostic procedures (determinations of coronary blood flow and coronary vascular reserve, production of lactate, serologic findings, histology and immune histology of peripheral arteries, measurements of viscosities in both plasma and blood). Many clinically relevant disturbances in the coronary microcirculation can thus be detected and treated on a rational basis by management of the underlying main disease, that is, by treatment of the vascular, rheologic and metabolic disorders. Persistent angina pectoris in the presence of a normal coronary arteriogram does not represent an end to coronary diagnostic procedures, but introduces the clinical task of using all diagnostic possibilities to enable functional and therapeutic assessment of the coronary microcirculation.

Coronary flow reserve as a physiologic measure of stenosis severity

PART I: Coronary flow reserve indicates functional stenosis severity, but may be altered by physiologic conditions unrelated to stenosis geometry. To assess the effects of changing physiologic conditions on coronary flow reserve, aortic pressure and heart rate-blood pressure (rate-pressure) product were altered by phenylephrine and nitroprusside in 11 dogs. There was a total of 366 measurements, 26 without and 340 with acute stenoses of the left circumflex artery by a calibrated stenoser, providing percent area stenosis with flow reserve measured by flow meter after the administration of intracoronary adenosine. Absolute coronary flow reserve (maximal flow/rest flow) with no stenosis was 5.9 +/- 1.5 (1 SD) at control study, 7.0 +/- 2.2 after phenylephrine and 4.6 +/- 2.0 after nitroprusside, ranging from 2.0 to 12.1 depending on aortic pressure and rate-pressure product. However, relative coronary flow reserve (maximal flow with stenosis/normal maximal flow without stenosis) was independent of aortic pressure and rate-pressure product. Over the range of aortic pressures and rate-pressure products, the size of 1 SD expressed as a percent of mean absolute coronary flow reserve was +/- 43% without stenosis, and for each category of stenosis severity from 0 to 100% narrowing, it averaged +/- 45% compared with +/- 17% for relative coronary flow reserve. For example, for a 65% stenosis, absolute flow reserve was 5.2 +/- 1.7 (+/- 33% variation), whereas relative flow reserve was 0.9 +/- 0.09 (+/- 10% variation), where 1.0 is normal. Therefore, absolute coronary flow reserve by flow meter was highly variable for fixed stenoses depending on aortic pressure and rate-pressure product, whereas relative flow reserve more accurately and specifically described stenosis severity independent of physiologic conditions. Together, absolute and relative coronary flow reserve provide a more complete description of physiologic stenosis severity than either does alone. PART II: Coronary flow reserve directly measured by a flow meter is altered not only by stenosis, but also by physiologic variables. Stenosis flow reserve is derived from length, percent stenosis, absolute diameters and shape by quantitative coronary arteriography using standardized physiologic conditions. To study the relative merits of absolute coronary flow reserve measured by flow meter and stenosis flow reserve determined by quantitative coronary arteriography for assessing stenosis severity, aortic pressure and rate-pressure product were altered by phenylephrine and nitroprusside in 11 dogs, with 366 stenoses of the left circumflex artery by a calibrated stenoser providing percent area stenosis as described in Part I.(ABSTRACT TRUNCATED AT 400 WORDS)

Four-year follow-up study in patients with angina pectoris and normal coronary arteriograms ("syndrome X")

In patients with typical stress-induced anginal pain, normal coronary arteries, and unimpaired left ventricular performance at rest ("syndrome X"), a reduced coronary dilatory capacity, abnormal lactate metabolism during stress, and reduction of left ventricular functional reserve have been described. A group of 40 patients with syndrome X was followed for several years to determine their long-term prognosis. In 27 patients pulmonary artery pressure and in 19 patients left ventricular ejection fraction were reassessed during rest and exercise approximately 4 years after the initial examination. In patients with stress-induced ST-segment depression, these variables did not change during the observation period. In patients with constant or rate-dependent left bundle branch block, however, there was significant deterioration of left ventricular performance during rest (pulmonary artery mean pressure, 16 +/- 3 vs. 17 +/- 4 mm Hg, p = NS; left ventricular ejection fraction, 62 +/- 5% vs. 55 +/- 5%, p less than 0.05) and exercise (pulmonary artery, 30 +/- 6 vs. 39 +/- 10 mm Hg, p less than 0.005; left ventricular ejection fraction, 59 +/- 6% vs. 49 +/- 5%, p less than 0.01). These findings suggest that in syndrome X two subgroups with distinctly different prognoses may be defined: In patients with stress-induced ST-segment depression during exercise, left ventricular performance remains well preserved; however, in patients with either constant or rate-dependent left bundle branch block, there is significant deterioration of left ventricular function within several years.

Myocardial ischemia without atherosclerosis

Myocardial ischemia in the presence of normal epicardial coronary arteries can be caused by an abnormality in the microcirculation or myocardial cell or by hypertrophy resulting in depressed coronary vasodilator reserve. Newly developed methods of assessing coronary blood flow and velocity make definitive diagnosis possible. Treatment, which may be difficult, includes therapy for the underlying cause, a calcium blocker, and nitrates.

Endomyocardial biopsy in diagnosis and management of cardiovascular manifestations of systemic lupus erythematosus (SLE)

In recent years, the cardiovascular manifestations of systemic lupus erythematosus have became more apparent as a consequence of both prolonged survival and improvement in diagnostic modalities. We report the case of a 16-year old woman with systemic lupus erythematosus in whom the presence of cardiomyopathy was characterized by endomyocardial biopsy. This diagnostic technique also showed that the histologic hallmark of lupus myocardiopathy persisted despite corticosteroid and plasmapheresis, suggesting the need of a careful cardiac follow-up in these patients.

Abnormal coronary vasomotion during exercise in patients with normal coronary arteries and reduced coronary flow reserve

A reduced coronary flow reserve has been reported in patients with ischemialike symptoms and normal coronary arteries. In 13 such patients, both coronary vasomotion and flow reserve were studied. The luminal area of the proximal and distal third of the left anterior descending and left circumflex artery were determined by biplane quantitative coronary arteriography using a computer-assisted system. Patients were studied at rest, during submaximal supine bicycle exercise (4.0 minutes, 116 W), and 5 minutes after sublingual administration of 1.6 mg nitroglycerin. Heart rate, mean pulmonary pressure, and mean aortic pressure as well as the percent change of both proximal and distal luminal area were determined. In 10 of the 13 patients, coronary sinus blood flow was measured by coronary sinus thermodilution technique at rest and after dipyridamole infusion (0.5 mg/kg in 15 minutes) 10 +/- 5 days after quantitative coronary arteriography. Coronary flow ratio (dipyridamole/rest) and coronary resistance ratio (rest/dipyridamole) were determined in these patients. Patients were divided into two groups according to the behavior of the coronary vessels during exercise (vasodilation, group 1; vasoconstriction, group 2). Coronary vasodilation of the proximal (luminal area +26%, p less than 0.001) and distal (+45%, p less than 0.001) artery was observed in seven patients (group 1) during exercise and after sublingual nitroglycerin (+46%, p less than 0.001; and +99%, p less than 0.001, respectively). In group 2 (n = 6), however, there was coronary vasoconstriction of the distal vessel segments (-24%, p less than 0.001) during exercise, whereas the proximal coronary artery showed vasodilation (+26%, p less than 0.001) during exercise. After sublingual nitroglycerin, both vessel segments elicited vasodilation (distal coronary, +44%, p less than 0.001; proximal coronary artery, +47%, p less than 0.001). Coronary flow ratio amounted to 2.5 in group 1 and 1.2 in group 2 (p less than 0.05) and coronary resistance ratio to 2.7 in group 1 and to 1.2 in group 2 (p less than 0.05), respectively. Thus, among patients with ischemialike symptoms and normal coronary arteries, there is a group of patients (group 2) with an abnormal dilator response of the distal coronary arteries to the physiologic dilator stimulus of exercise and a reduced dilator capacity of the resistance vessels after dipyridamole (abnormal coronary vasodilator syndrome). The nature of this exercise-induced distal coronary vasoconstriction is not clear but might be due to an abnormal neurohumoral tone that may cause or contribute to the blunted vascular response during exercise.

Coronary hemodynamics in hypertensive heart disease. Basic concepts, clinical consequences, and experimental analysis of regression of hypertensive microangiopathy

Myocardial hypertrophy may influence coronary hemodynamics variably. Therefore, coronary sinus blood flow (gas chromatic argon technique) was determined in patients with left ventricular hypertrophy, with or without dilatation, associated with entirely normal coronary arteriographic results: 12 patients with hypertrophic obstructive cardiomyopathy (left ventricular mass-to-volume ratio, 3.66 +/- 0.52 g/ml), 22 patients with hypertensive heart disease due to essential hypertension (left ventricular mass-to-volume ratio, 2.12 +/- 0.26 g/ml), 18 patients with hypertensive dilatation (left ventricular mass-to-volume ratio, 1.6 +/- 0.48 g/ml), six patients with aortic stenosis (left ventricular mass-to-volume ratio, 1.99 +/- 0.41 g/ml), 12 patients with aortic incompetence, and 20 patients with normal heart function. Coronary sinus blood flow was determined as a control value and as the value following intravenous injection of dipyridamole (0.5 mg/kg of body weight). Coronary reserve was calculated as the ratio of coronary resistance before and after dipyridamole. Normal coronary reserve averaged 4.89 +/- 0.11. Similar values, despite marked left ventricular hypertrophy, were present for both hypertrophic obstructive cardiomyopathy (4.4 +/- 0.19) and aortic stenosis (4.66 +/- 0.12), whereas coronary reserve was considerably reduced in the concentrically hypertrophied hypertensive hearts (3.22 +/- 0.19) (p less than 0.001). Moderate decrease in coronary reserve was found in aortic incompetence and in dilated essential hypertension. These results indicate that patients with nonhypertensive hypertrophy, despite left ventricular mass augmentation, may have normal coronary reserve, whereas at a comparable degree of left ventricular hypertrophy, patients with hypertensive hypertrophy have a specific reduction in coronary reserve. Independent from vascular effects, ventricular dilatation may result in deterioration of coronary reserve because of an abnormal component of coronary vascular resistance. These results were also verified in experimental hypertension. Moreover, prevention and/or regression of the impaired coronary circulation in experimental hypertensive heart disease, most probably due to the reduction of smooth muscle layers of the media of coronary resistance vessels, could be achieved by long-term vasodilator therapy.

Cardiovascular involvement in systemic lupus erythematosus

SLE is an inflammatory disease of unknown etiology with the potential of affecting virtually all organ systems. Cardiovascular involvement occurs frequently, although it is often mild enough not to cause clinical concern. Pericarditis is most commonly subclinical, noted only on echocardiogram. Pericardial fluid, which can accumulate rapidly enough to cause tamponade, is inflammatory in nature and can totally mimic infection. The occurrence of Libman-Sacks endocarditis, usually a pathological diagnosis of little clinical significance, has little if any correlation with the presence of audible murmurs. However, valve replacement is occasionally necessary secondary to sterile destruction. These valvular lesions can also embolize or become infected. The incidence of ischemic coronary disease is increased, both secondary to premature atherosclerosis and, rarely, coronary arteritis. Conduction disease and arrhythmias are infrequently reported in adult patients, but congenital CHB has been noted in children born to mothers who have circulating anti-Ro antibody. Evidence is accumulating that suggests there is a mild cardiomyopathy associated with SLE that may be due to thrombotic or inflammatory microvascular coronary disease. Acute clinical myocarditis also rarely occurs. Therapeutically, at present, a reasonable course would seem to be to limit all known possible contributing factors to premature coronary artery and myocardial disease (hypertension, hypercholesterolemia, smoking, steroid therapy, etc), to be vigilant about recognizing the rarer complications associated with SLE (infectious pericarditis and endocarditis, coronary arteritis, pericardial tamponade, clinical myocarditis), and to remember that these uncommon complications are indeed uncommon. The importance of vigorously treating systemic hypertension cannot be overstressed.

Alterations in myocardial systolic and diastolic function in patients with active systemic lupus erythematosus

Echocardiographic studies were performed to evaluate myocardial function in active patients with systemic lupus erythematosus (SLE). Fourteen patients were studied in the active stage before corticosteroid therapy (active SLE); 10 of them were reexamined after therapy (inactive SLE). Computer-assisted analysis of digitized echoes of the left ventricular dimension was performed. The peak rate of change in dimension during systole (-dD/dt) was reduced in active SLE compared with normal control subjects (2.57 +/- 0.15 cm/sec vs 3.37 +/- 0.14 cm/sec, p less than 0.01). The peak rate of change in dimension during diastole (+dD/dt) was also reduced in active SLE compared with normal control subjects (3.16 +/- 0.19 cm/sec vs 4.41 +/- 0.20 cm/sec, p less than 0.01). After therapy, -dD/dt in inactive SLE was improved compared with active SLE (from 2.56 +/- 0.20 cm/sec to 3.13 +/- 0.19 cm/sec, p less than 0.001). Positive dD/dt in inactive SLE was also improved compared with active SLE (from 3.29 +/- 0.22 cm/sec to 4.23 +/- 0.23 cm/sec, p less than 0.01). No significant differences were found between inactive SLE and normal control subjects as to -dD/dt and +dD/dt. Significant correlations were found between anti-DNA antibody titers and both -dD/dt and +dD/dt (r = -0.97 p less than 0.0001, and r = -0.71 p less than 0.05, respectively). These results suggest that active SLE patients have left ventricular dysfunction that may be caused by an immunopathologic mechanism in SLE.

Cardiac energetics in clinical heart disease

Systolic wall stress is the main determinant of myocardial O2 consumption in chronic clinical heart disease as well as following acute inotropic pharmacological interventions. The fundamental relationship between stress and O2 consumption may be modified by alterations in myocardial contractility and/or left ventricular function parameters; these, however, contribute to the overall energy demand by a maximum 10-15%. The therapeutic consequences in chronic heart disease--with regard to left ventricular function and myocardial energy demand--has implications for the degree of left ventricular hypertrophy and dilatation.

Histologic evidence for small-vessel coronary artery disease in patients with angina pectoris and patent large coronary arteries

We studied six patients who suffered from angina pectoris but had angiographically patent major coronary arteries. Two of the patients suffered also from congestive heart failure. Three patients had supraventricular tachyarrhythmias. Three patients had conduction disturbances. During coronary angiography the patients had significantly reduced flow velocity of angiographic contrast medium compared with that in a control group. Echocardiographic and Doppler flow studies showed a tendency for symmetrical thickening of the left ventricular wall, enlargement of the right ventricle, and reduced compliance of both ventricles. Right ventricular endomyocardial biopsy revealed pathologic small coronary arteries with fibromuscular hyperplasia, hypertrophy of the media, myointimal proliferation, and endothelial degeneration. Capillaries had swollen endothelial cells encroaching on the lumen. Myocardial hypertrophy, lipofuscin deposition, and patchy fibrosis were also observed. These cases show that small-vessel coronary artery disease can cause classic angina pectoris. The diagnosis can be suspected when the coronary angiogram shows large patent arteries with slow flow of the angiographic contrast medium and it can be confirmed by endomyocardial biopsy.

Cardiovascular manifestations of systemic lupus erythematosus

SLE affects most aspects of cardiac function, and recent studies have reported increasing cardiovascular morbidity and mortality. Pathologically, SLE is characterized by a pancarditis involving pericardium, myocardium, endocardium, and coronary arteries. In autopsy series, pericarditis has been found in 43% to 100% (mean 62%, Table I), and myocarditis was found in 8% to 78% (mean 40%, Table II), but both have been underdiagnosed clinically. Libman-Sacks lesions have been noted in 25% to 100% (mean 43%) and infective endocarditis in 1.1% to 4.9% of clinical and autopsy studies (Table III). Coronary disease may be due to arteritis, which should be treated with high-dose steroids, or it may be due to atherosclerosis, which is amenable to medical or surgical therapy. Valvular disease has been treated surgically, but with a combined surgical mortality as high as 25%. Aortic insufficiency and mitral regurgitation are the most common valvular problems, although aortic and mitral stenosis have also been reported. Hypertension has been noted in 14% to 69%, and heart failure in 5% to 44%. Evidence for a lupus cardiomyopathy, which may be subclinical, is reviewed. While steroids may ameliorate SLE pancarditis, they have also been associated with hypertension, LV hypertrophy, purulent and constrictive pericarditis, mitral regurgitation, and perhaps accelerated atherosclerosis. It remains to be seen if improved diagnosis and treatment of the cardiovascular manifestations of SLE can enhance survival.

Coronary dilatory capacity in idiopathic dilated cardiomyopathy: analysis of 16 patients

Hemodynamic function and overall coronary blood flow (argon technique) were measured in 16 patients with idiopathic dilated cardiomyopathy (IDC) and in 12 patients without detectable heart disease (control subjects) referred for precordial pain. In patients with IDC, coronary blood flow was normal at rest (78 +/- 17 ml/100 g-min versus 78 +/- 9 in control subjects). During maximal inducible coronary vasodilation (dipyridamole, 0.5 mg/kg), coronary blood flow was significantly reduced (142 +/- 38 ml/100 g.min versus 301 +/- 64 in control subjects; p less than 0.001). Consequently, obtainable minimal coronary resistance was increased in IDC (0.54 +/- 0.20 mm Hg/ml/100 g.min versus 0.23 +/- 0.04 in control subjects; p less than 0.001). In patients with IDC, left ventricular (LV) end-diastolic pressure was significantly increased (19 +/- 11 mm Hg versus 6 +/- 3 in control subjects; p less than 0.005), and the LV ejection fraction was diminished (36 +/- 11% versus 72 +/- 3% in control subjects; p less than 0.001). In patients with IDC, LV end-diastolic pressure correlated significantly with the obtained minimal coronary resistance after application of dipyridamole (r = 0.85; p less than 0.001). LV catheter biopsy specimens revealed no alterations in myocardial microvasculature. Thus, coronary dilatory capacity is impaired in patients with IDC, due partially to an increase in extravascular component of coronary resistance.

[Disturbances in coronary microcirculation (author's transl)]

The clinical syndrome "coronary insufficiency at normal coronary arteriogram" is found in approximately 10-20 per cent of patients with exercise-induced coronary insufficiency. In most of these cases disturbances of coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis etc.), in rheological diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia etc.) and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia, hyperlipoproteinemia). The clinical diagnosis is based on usual diagnostic programs (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin etc.), as well as on a newer, functionally orientated diagnostic procedures (determinations of coronary blood flow and of coronary vascular reserve, production of lactate, serological findings, histology and immune histology of peripheral arteries, measurements of viscosities in both, plasma and blood etc.). Many clinically relevant disturbances in coronary microcirculation can thus be detected and therefore can be treated on a rational basis by the management of the internal main disease, this is by the treatment of the vascular, rheological and metabolic disorders. Persistent angina pectoris, in the presence of normal coronary arteriogram, represents no termination of coronary diagnostics, but moreover implies the clinical task for using newer diagnostic possibilities in order to enable functional and therapeutical assessment of coronary microcirculation.

Cardiovascular abnormalities in systemic lupus erythematosus

Echocardiographic examinations of 21 unselected patients with systemic lupus erythematosus revealed a wide variety of abnormalities. The abnormalities consisted of substantial pericardial effusion in five patients (24%) and a thickened pericardium in six patients(29%); significantly larger left atrial and left ventricular dimensions and significantly smaller ejection fraction percentages, fractional shortening of the left ventricle, and rate of early diastolic mitral valve closure compared to that in a control group of subjects; and paradoxical and hypokinetic movement of the septum in one patient (5%) each. The presence of pericardial effusion and a thickened septum and a decrease in the ejection fraction percentage, fractional shortening of the left ventricle, and mitral valve diastolic closing velocity showed no correlation with previous hypertension, the presence or absence of anemia, renal failure, serum levels of proteins, and duration of patients' illnesses. Long-term follow-up studies to determine the implications of these subclinical cardiac abnormalities using noninvasive techniques (such as echocardiography) is vitally important.

Reduced coronary dilatory capacity and ultrastructural changes of the myocardium in patients with angina pectoris but normal coronary arteriograms

Hemodynamic and metabolic studies were performed in 15 patients without heart disease (controls, group A), in 21 patients with typical stress-induced anginal pain but normal coronary and left ventricular angiograms (angina pectoris with normal arteriogram, group B), and in 10 patients with angiographically proved coronary artery disease (CAD, group C). Coronary dilatory capacity, determined by measuring total myocardial blood flow at rest and during maximal coronary vasodilatation (dipyridamole, 0.5 mg/kg i.v.), was markedly reduced in group B and C patients. In group B patients, left ventricular catheter biopsy specimens revealed no evidence of small-vessel disease, but did show histologic alterations of mitochondria. During atrial pacing, the control subjects showed no changes in myocardial lactate uptake, whereas in group B patients, myocardial lactate production occurred. In contrast to controls, patients in group B showed a significant decline in ejection fraction and circumferential fiber shortening during isometric exercise. These findings suggest that myocardial ischemia is the cause of angina pectoris in patients who have angina but normal coronary arteriograms.

Systolic stress, coronary hemodynamics and metabolic reserve in experimental and clinical cardiac hypertrophy

The degree of LV hypertrophy may be determined by the relationships between mass-to-volume ratio and systolic wall stress. Systolic wall stress correlates directly with the MVO2 and inversely with LV function. In chronic hypertrophic heart disease (a) normal stress, (b) low stress and (c) high stress hypertrophy may occur. Low stress hypertrophy has normal LV function and normal or decreased MVO2, whereas high stress hypertrophy mostly has depressed function and an increased MVO2. The MVO2 is directly correlated to LV mass. This relationship is influenced by the variable degree of LV mass, by the mass-to-volume ratio and by inotropic interventions. Systolic stress reserve, the ratio of maximum to instantaneous systolic wall stress, averages 4.5. Similar reserves are present for the coronary (4.9) and for the metabolic reserve (4.6). It is concluded that systolic wall stress represents one of the major determinants of LV performance and of myocardial oxygen consumption.