Transmitral flow changes during dipyridamole-induced ischemia. A Doppler-echocardiographic study

Diagnostic Potential of Carcinoembryonic Antigen and Ferritine in Tuberculous and Malignant Pleural Effusion

The aim of the study was to determine the diagnostic value of carcinoembryonic antigen (CEA) and ferritine in malignant and tuberculous non-bloody pleural effusion. The etiology of diseases was determined by cytologic, histologic and microbiologic methods. CEA concentration above 5 ng/ml and ferritine concentration above 200 ng/ml were considered to be positive. There was significant difference in the value of CEA measured in malignant and in tuberculous pleural effusion (P < 0.005) as well as in the sera (P < 0.01) of these two groups. There was no correlation between concentration of CEA and ferritine in malignant pleural effusion. Ratio between CEA and ferritine in effusions and sera was of no help in discrminating malignant from tuberculous effusions. No correlation between examined markers and physical status of patients was observed. The sensitivity and specificity of CEA assay in malignant pleural effusion was 65% and 90%, respectively, and for ferritine 67% and 80%, respectively. A high correlation was observed between the CEA concentration in malignant pleural effusion and sera patients (r = 0.95). Combined sensitivity and specificity of CEA and ferritine was 65.9% and 85%. Bayes theorem was used to calculate the positive predictive values for CEA and ferritine, which were 53% and 37%, respectively. Results obtained in the study show the relatively good diagnostic potential of CEA.

Diastolic indexes during dobutamine stress echocardiography in patients early after myocardial infarction

The aim of this study was to determine whether Doppler parameters assessed during dobutamine stress echocardiography in the early phase after myocardial infarction could discriminate patients with residual ischemia from those without. Thirty-six patients after a recent myocardial infarction with and without residual ischemia underwent dobutamine stress echocardiography, adenosine sestamibi scintigraphy, and coronary angiography within 2 weeks after the acute event. The only diastolic Doppler parameter discriminating the two groups was the isovolumic relaxation time (IVRT) measured at the peak of the dobutamine infusion. It became shorter in both groups but significantly more in patients without than in those with residual ischemia despite a larger increase in heart rate in the latter group. IVRT at rest was 78 +/- 18 msec and decreased with high-dose dobutamine to 54 +/- 11 msec in the control group and to 69 +/- 16 msec in the ischemic group (p < 0.01). In addition, the rate-corrected IVRT (IVRTc) was calculated: IVRTc = IVRT/sqrtRR. The value of IVRTc = 80 at peak dobutamine infusion is able to discriminate patients with residual ischemia from those without with a sensitivity of 80% and a specificity of 70%.

Usefulness of echocardiography and Doppler in the detection of segmental myocardial ischemia

Echocardiography and Doppler was performed in 20 patients during percutaneous transluminal coronary angioplasty of a right coronary artery to evaluate the usefulness of echocardiography and Doppler in the detection of segmental myocardial ischemia. Wall motion analysis was also compared to the occurrence of chest pain in relation to electrocardiographic and hemodynamic changes. Even in the case of small segmental myocardial ischemia, the two-dimensional echocardiographic evaluation of wall motion is superior to all other measured parameters. Contrary to this, the Doppler examination of transmitral flow is not sensitive enough in the detection of such small segmental myocardial ischemia, induced by right coronary artery occlusion.

Echocardiographic detection of acute myocardial ischemia during percutaneous transluminal coronary angioplasty

The usefulness of echocardiography and Doppler for the detection of acute myocardial ischemia was evaluated during right coronary artery occlusion in 20 patients. The echocardiographic findings were compared with the occurrence of chest pain, and to electrocardiographic and hemodynamic changes obtained during percutaneous transluminal coronary angioplasty. Our results confirm that, even in the case of small segmental myocardial ischemia, two-dimensional echocardiography is superior to all other measured parameters. In contrast, Doppler examination of transmitral flow is not sensitive enough for the detection of such small segmental myocardial ischemia induced by right coronary artery occlusion.

Dipyridamole echocardiography

Intravenous dipyridamole is a potent coronary vasodilator that has been extensively investigated over the past several years in the noninvasive assessment of patients with suspected coronary artery disease when exercise cannot be performed or is suboptimal. As an alternative to exercise studies, dipyridamole has been used in combination with different cardiac imaging techniques such as echocardiography, thallium scintigraphy, and radionuclide ventriculography. Extensive experience has been obtained with dipyridamole thallium-201 imaging for coronary artery disease screening, risk stratification, and prognosis after an acute coronary event. However, experience with the use of dipyridamole in combination with two-dimensional echocardiography has been limited. Dipyridamole increases coronary blood flow in nondiseased coronary vessels relative to coronary vessels with significant luminal narrowings. These provide the basis for detecting regional differences in flow by using different cardiac imaging techniques. Two-dimensional echocardiography would show regional wall-motion abnormalities in response to those regional differences in coronary blood flow. In this article, the most commonly used protocols, safety, and practicability of dipyridamole echocardiography are reviewed. As an alternative to exercise, dipyridamole echocardiography shares all the indications of a standard exercise test. Clinical applications of dipyridamole echocardiography include coronary artery disease screening, suspected coronary artery spasm, postmyocardial infarction risk stratification, evaluation of percutaneous transluminal coronary angioplasty results, and prognosis following an acute coronary event. Compared to conventional (ECG) exercise testing, dipyridamole echocardiography appears to be equally sensitive but more specific. Compared to atrial pacing, dipyridamole provokes ischemia at a lower rate pressure product and results in a greater ST segment depression suggesting that dipyridamole induces more profound myocardial ischemia than atrial pacing. Dipyridamole thallium and exercise thallium have shown to be equally sensitive and specific in the assessment of coronary artery disease. High dose dipyridamole echocardiography appeared to be equally sensitive and more specific. Experimental studies have demonstrated that dobutamine appears to be a more powerful pharmacological agent in inducing wall-motion abnormalities. Dipyridamole echocardiography as compared to stress echocardiography offers the advantage of obtaining better quality postintervention images. With regard to sensitivity and for coronary artery disease diagnosis, both techniques appear to render similar results. Although further studies are needed, the available data indicates that cardiac ultrasound imaging prior to and following the intravenous administration of dipyridamole may be an attractive alternative to thallium perfusion imaging in the clinical setting, particularly when radionuclide capabilities are not present.

Evaluation of dipyridamole-Doppler echocardiography for detection of myocardial ischemia and coronary artery disease

Doppler assessment of left ventricular filling and ejection during dipyridamole stress may supplement wall motion analysis for detection of myocardial ischemia and coronary artery disease (CAD). Thirty-four patients taking no cardioactive therapy were studied using intravenous dipyridamole (0.6 mg/kg) during 2-dimensional and pulsed Doppler echocardiography. Twelve patients had normal coronary arteries (group 1) and the remainder, who had significant CAD, were divided into groups 2 (n = 11) and 3 (n = 11). Only subjects in group 2 developed myocardial ischemia manifest as reversible regional asynergy and ST-segment depression. Heart rate increased (16 +/- 9 beats/min, p less than 0.01) and mean blood pressure decreased (-5 +/- 8 mm Hg, p = not significant) uniformly across groups. Exaggerated hyperkinesia of normally contracting wall segments was the common response to dipyridamole infusion in patients with CAD. The respective mean percent changes in peak early diastolic velocity, peak atrial velocity, their ratio and ejection peak velocity, and mean acceleration for groups 1 (20, 42, -13, 20 and 23%), 2 (22, 32, -2, 10 and 14%) and 3 (23, 33, -6, 16 and 18%) were similar. Comparisons between normal patients and those with CAD and between groups 2 and 3 revealed no significant differences in the effect of dipyridamole on any variable. However, a decrease in both peak velocity and mean acceleration of left ventricular ejection was seen in 3 of 4 group 2 patients who developed severe ischemia. Dipyridamole-Doppler echocardiography is insensitive for detection of CAD and appears unable to identify myocardial ischemia unless this is severe. Hemodynamic changes and compensatory wall motion induced by dipyridamole may explain these findings.

Influence of exercise-induced myocardial ischemia on the pattern of left ventricular diastolic filling: a Doppler echocardiographic study

Previous studies using Doppler echocardiography to evaluate left ventricular diastolic filling have shown that myocardial ischemia induced by coronary balloon angioplasty or atrial pacing results in a decrease in the left ventricular inflow peak early (E) to peak atrial (A) velocity ratio. To investigate the effects of exercise-induced ischemia on Doppler-derived filling variables, 20 patients with coronary artery disease and exercise-induced electrocardiographic changes and regional wall motion abnormalities determined by two-dimensional echocardiography were evaluated and compared with 20 patients without evidence of exercise-induced ischemia. Doppler echocardiography was performed at rest and immediately after exercise before the resolution of exercise-induced wall motion abnormalities. Peak E and A velocities increased from rest to postexercise in both the ischemic and nonischemic groups, although the ischemic group demonstrated a greater increase in peak E velocity (from 68 +/- 15 cm/s at rest to 88 +/- 22 cm/s after exercise) than the nonischemic group (70 +/- 13 to 77 +/- 18 cm/s) (p less than 0.05 for the difference in response between groups). Accompanying these changes was a slight increase in the peak E/A velocity ratio in the ischemic group (1.04 +/- 0.28 at rest to 1.13 +/- 0.42 after exercise) versus a decrease in the nonischemic group (1.07 +/- 0.30 to 0.90 +/- 0.28) (p less than 0.05 intergroup difference).(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of left ventricular filling in coronary artery disease and myocardial ischaemia after dipyridamole provocation

Doppler echocardiographic measurement of transmitral filling velocities seems to be a sensitive marker for resting left ventricular diastolic abnormalities in patients with coronary artery disease. The behaviour of these filling velocities during induced myocardial ischaemia, however, has not been fully studied. Left ventricular filling was assessed by pulsed Doppler ultrasound in 21 patients with angina pectoris and coronary artery disease and in five controls (patients with chest pain but without myocardial ischaemia). High dose dipyridamole infusion (0.9 mg/kg over 10 minutes) was used to provoke myocardial ischaemia, which was assessed by symptoms and electrocardiographic ST segment change. Doppler indices of diastolic filling were measured and the results expressed as percentage change from baseline values. Dipyridamole increased the heart rate and reduced systolic blood pressure equally in both groups. In the controls dipyridamole increased the peak filling velocities of both the early and atrial filling waves. In the 12 patients with coronary artery disease who did not develop evidence of myocardial ischaemia, the effect on left ventricular filling velocity resembled that in the controls though the time to peak change was delayed. Six of the nine patients with dipyridamole induced myocardial ischaemia had a significantly reduced maximum changes in early (+30% v +18%) and atrial (-0.2% v +33%) filling velocities compared with the controls. The remaining three patients had a decrease in early filling velocity (-20%) with an associated increase in atrial peak filling velocity (+21%). Dipyridamole increased diastolic filling velocities in the controls. In patients with coronary artery disease there was a variable change in diastolic filling indices which may be attributed either to the degree of myocardial ischaemia or to the different haemodynamic changes occurring during myocardial ischaemia.

ST segment depression elicited by dipyridamole infusion in asymptomatic hypertensive patients

In asymptomatic patients with essential hypertension, electrocardiographic changes suggestive of myocardial ischemia can be elicited by rapid pressure lowering or by pronounced coronary arteriolar dilation. The aim of this study was to assess whether dipyridamole infusion might induce ischemic-like electrocardiographic changes in asymptomatic essential hypertensive patients and to describe the clinical and echocardiographic correlates possibly associated with this response. We therefore studied a control group of 20 normotensive individuals and a group of 28 asymptomatic patients with mild-to-moderate essential hypertension. All underwent dipyridamole-echocardiography testing (12-lead electrocardiogram and two-dimensional echocardiographic monitoring with dipyridamole infusion, 0.84 mg/kg over 10'). No patient showed transient regional dyssynergy during dipyridamole infusion. None of the normotensive and 10 of 28 of the hypertensive participants had horizontal or downsloping ST segment depression more than 0.1 mV during dipyridamole (0% versus 36%, p less than 0.01). Hypertensive patients with ("responders") (n = 10) and without ("nonresponders") (n = 18) ST segment depression showed similar values of percent fractional shortening in baseline conditions (32 +/- 5 versus 33 +/- 6, p = NS) and at peak dipyridamole infusion (45 +/- 8 versus 43 +/- 5, p = NS). The peak early to peak late velocity ratio values (evaluated from transmitral flow tracings by Doppler technique) were also similar in baseline conditions (0.86 +/- 0.14 versus 0.94 +/- 0.30, p = NS) and at peak dipyridamole (0.72 +/- 0.15 versus 0.78 +/- 0.32, p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)