Systolic time intervals and left ventricular function in acute myocardial infarction

Reintroducing Heart Sounds for Early Detection of Acute Myocardial Ischemia in a Porcine Model - Correlation of Acoustic Cardiography With Gold Standard of Pressure-Volume Analysis

Background

Acoustic cardiography is a hybrid technique that couples heart sounds recording with ECG providing insights into electrical-mechanical activity of the heart in an unsupervised, non-invasive and inexpensive manner. During myocardial ischemia hemodynamic abnormalities appear in the first minutes and we hypothesize a putative diagnostic role of acoustic cardiography for prompt detection of cardiac dysfunction for future patient management improvement.

Methods and Results

Ten female Swiss large white pigs underwent permanent distal coronary occlusion as a model of acute myocardial ischemia. Acoustic cardiography analyses were performed prior, during and after coronary occlusion. Pressure-volume analysis was conducted in parallel as an invasive method of hemodynamic assessment for comparison. Similar systolic and diastolic intervals obtained with the two techniques were significantly correlated [Q to min dP/dt vs. Q to second heart sound (r² = 0.9583, p < 0.0001), PV diastolic filling time vs. AC perfusion time (r² = 0.9686, p < 0.0001)]. Indexes of systolic and diastolic impairment correlated with quantifiable features of heart sounds [Tau vs. fourth heart sound Display Value (r² = 0.2721, p < 0.0001) cardiac output vs. third heart sound Display Value (r² = 0.0791 p = 0.0023)]. Additionally, acoustic cardiography diastolic time (AUC 0.675, p = 0.008), perfusion time (AUC 0.649, p = 0.024) and third heart sound Display Value (AUC 0.654, p = 0.019) emerged as possible indicators of coronary occlusion. Finally, these three parameters, when joined with heart rate into a composite joint-index, represent the best model in our experience for ischemia detection (AUC 0.770, p < 0.001).

Conclusion

In the rapidly evolving setting of acute myocardial ischemia, acoustic cardiography provided meaningful insights of mechanical dysfunction in a prompt and non-invasive manner. These findings should propel interest in resurrecting this technique for future translational studies as well as reconsidering its reintroduction in the clinical setting.

Hemodynamic correlates of the third heart sound and systolic time intervals

Bedside diagnostic tools remain important in the care of patients with heart failure. Over the past two centuries, cardiac auscultation and phonocardiography have been essential in understanding cardiac pathophysiology and caring for patients with heart disease. Diastolic heart sounds (S3 and S4) and systolic time intervals have been particularly useful in this regard. Unfortunately, auscultation skills have declined considerably, and systolic time intervals have traditionally required carotid pulse tracings. Newer technology allows the automated detection of heart sounds and measurement of systolic time intervals in a simple, inexpensive, noninvasive system. Using the newer system, the authors present data on the hemodynamic correlates of the S3 and abnormal systolic time intervals. These data serve as the foundation for using the system to better understand the test characteristics and pathophysiology of the S3 and systolic time intervals, and help to define their use in improving the bedside diagnosis and management of patients with heart failure.

Left ventricular systolic time intervals in patients with acute myocardial infarction

Left ventricular systolic time intervals were measured daily during 601 episodes of acute myocardial infarction. The ratio of pre-ejection period to ejection period during the first 24 hours permitted patients to be arranged in six prognostic groups with mortalities while in hospital ranging from 4 to 60 per cent. The only factors completely independent of the systolic time intervals which were shown statistically to be associated with high mortality while in hospital were defects in atrioventricular and intraventricular conduction.

A study of systolic time intervals during uninterrupted exercise

A method has been developed for obtaining measurements of the systolic time intervals during uninterrupted graded exercise in the upright position on a bicycle ergometer. The method has been applied to 112 subjects divided into 4 groups: two of normal subjects below and above the age of 40, respectively (mean ages 30 and 48 years), and two of patients (mean ages for each about 50 years), both with coronary insufficiency, but one without and the other with abnormality of left ventricular function as shown by ventriculography. The measurements obtained yield linear relations between total electromechanical systole (QS2) and heart rate, between pre-ejection period (PEP) and RR interval for each subject. The average standard deviation about the regression is less than 6 ms for all three regression lines; the average correlation coefficient is greater than 0-93. The younger group of normal subjects have a significantly shorter PEP compared to the older group. Indices have been derived which separate the patient groups from each other and from the normal subjects. Using these indices 86 per cent of all the subjects were correctly classified according to the group to which they belonged. It is concluded that measurements of STI during uninterrupted exercise offer valuable information in the assessment of cardiac patients.

Usefulness of systolic time intervals in coronary artery disease

This review summarizes current knowledge concerning the value of systolic time intervals in coronary artery disease. Although the usual pattern of prolongation of the preejection period (PEP) and shortening of the left ventricular ejection time (LVET) characteristic of left ventricular failure is seen in acute myocardial infarction, the systolic time intervals (as well as all other measures) are profoundly influenced by adrenergic hyperactivity characteristics of this disorder. Adrenergic stimulation normally shortens both the PEP and LVET indexes and decreases the PEP/LVET ratio. The degree of shortening of electromechanical systole (QS2) is directed related to the excessive adrenergic tone. Patients with the greatest systolic time interval abnormalities have a poorer prognosis, a greater incidence of congestive heart failure and more abnormalities of directly measured indexes of left ventricular performance. The systolic time intervals are useful for assessing left ventricular performance in chronic coronary artery disease as well. In chronic coronary artery disease the PEP/LVET ratio and angiographically determined left ventricular ejection fraction are closely correlated ( r = -0.76), but the level of this correlation is less than that in other forms of left ventricular disease. The left ventricular ejection time index is prolonged after exercise in patients with angina pectoris when compared with findings in normal subjects. Failure of the ischemic ventricle to respond to adrenergic stimulation is the most likely mechanism. Addition of the postexercise left ventricular ejection time to standard treadmill stress testing identifies a significant number of patients (23 percent) who would have had false negative results by electrocardiographic criteria alone. In addition, this index provides confirmatory evidence in those with apparently positive electrocardiographic test data. The systolic time intervals have been useful in assessing both medical and surgical therapy in coronary artery disease. The test can be performed repeatedly and provides a measure of both left ventricular performance and extent of adrenergic hyperactivity. Thus, evaluation of therapy represents the most useful future application of systolic time intervals.