Sex differences in acute coronary syndromes: a never ending same old story or sign for improvement

Introduction

We previously described sex differences in baseline characteristics, interventional therapy and mortality in patients admitted for acute coronary syndromes (ASC) in Swiss hospitals and enrolled in the AMIS Plus registry between 1997 and 2006 (1). This present analysis aimed to reassess whether anything changed over the last 15 years.

Method

All AMIS Plus patients enrolled between 2007 and 2021 were included. Baseline characteristics, therapy and outcome were analysed according to sex and age groups. Multivariate analyses were performed to assess independent predictors of in-hospital mortality.

Results

Among 42,471 patients, 10,825 (25.5%) were women. Women were still older (71.6±12.6y vs. 64.2±12.6y for men), had more comorbidities (Charlson Comorbidity Index>1: 26.5% vs. 21.7%), were less likely to receive drug therapy (e.g., P2Y12 inhibitors 83.3% vs. 89.2% or statins 73.0% vs. 78.5%) and underwent percutaneous coronary intervention (PCI) less frequently (OR 0.77; 95% CI 0.73–0.83). These findings paralleled our observations for the period 1997–2006. However, the increase in PCI use over the years, particularly in women, led to a marked decrease in differences between men and women with respect to revascularization, from 16.6% in 2006 down to 2.0% in 2020. Unadjusted in-hospital mortality was higher in women (OR 1.55; 95% CI 1.41–1.70), but this significance disappeared after adjustment for baseline differences (OR 1.07; (95% CI 0.96–1.20)). However, in women under the age of 50 years, crude mortality (3.1% versus 1.6%) was significantly higher than in same-aged men; adjusted OR 1.78 (95% CI 0.99–3.20).

Conclusions

Sex differences in the baseline characteristics of ACS patients and the use of evidence-based drugs persisted but the sex gap in PCI access slowly but surely diminished. Female sex per se was not an independent predictor of in-hospital mortality in the overall population but it showed a strong trend among patients younger than 50 years of age.

Funding Acknowledgement

Type of funding sources: None.

Heart rate and mortality in myocardial infarction: incremental or bimodal correlation?

Introduction

Risk prediction scores adopted in acute coronary syndromes use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, a non-linear, bimodal relationship, with higher event rates at low or high HR, has been described, potentially hampering risk prediction accuracy.

Purpose

Our aim was to assess the prognostic impact of bradycardia, defined as admission HR <50 bpm, in myocardial infarction (MI) among patients enrolled in a large nationwide registry.

Methods

Data of patients enrolled between 1999 and 2021 stratified by admission HR were retrospectively analysed. The primary endpoint was in-hospital mortality. The secondary endpoint was a composite of death, cerebrovascular event, and reinfarction. Associations between HR and outcomes were assessed at univariate and multivariable logistic regression analyses, then verified after sequential propensity-score matchings among HR groups.

Results

51001 patients (median age 66 years, IQR 56–76) were included. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. Association of HR <50 bpm with mortality was recognised only at primary multivariable logistic regression analysis (OR 1.49; 95% CI 1.01–2.13 p=0.038) but not at multiple sensitivity analyses after exclusion of patients on negative chronotropic therapy. Three sequential propensity-score matching were performed among patients with HR <50 bpm at admission and those with HR 50–75 bpm, HR 76–100 bpm and HR >100 bpm at admission, identifying 1159, 1159 and 1158 matched pairs, respectively. After propensity-score matching, rates of primary and secondary endpoints equalled among groups with HR <100 bpm.

Conclusions

Bradycardia (HR <50 bpm) at admission in patients with MI identified a group with higher crude rate of adverse events. Nonetheless, the signal supporting an independent association between bradycardia at admission and short-term mortality is weak and was not confirmed after correction for relevant baseline differences by propensity score matching. These findings support the hypothesis that lower HR might not be causative for the worse outcomes, but rather serves as a marker of underlying morbidity.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The AMIS Plus registry is funded by unrestricted grants from the Swiss Heart Foundation and from Abbot AG, Amgen AG, AstraZeneca AG, Bayer (Schweiz) AG, Biotronik AG, Boston Scientific AG, B. Braun Medical AG, Daiichi-Sankyo/Lilly AG, Cordis Cardinal Health GmbH, Medtronic AG, Novartis Pharma Schweiz AG, Sanofi-Aventis (Schweiz) AG, SIS Medical AG, Terumo AG, Vascular Medical GmbH, all in Switzerland, and the Swiss Working Group for Interventional Cardiology. The sponsors did not play any role in the design, data collection, analysis, or interpretation of data.

Treatment and outcome of patients with acute myocardial infarction and chronic lung disease: insights from the nationwide AMIS Plus registry

Introduction

Little is known about patients with acute myocardial infarction (AMI) and chronic lung disease (CLD). The aim of our study was to analyze risk factors, treatment, and outcome of AMI patients with CLD over the last 20 years using the nationwide AMIS Plus registry.

Methods

All AMI patients enrolled in the AMIS Plus registry with data on CLD between January 2002 and December 2021 were included. Chronic lung disease was determined according to the definition used in the Charlson Comorbidity Index. Data on baseline characteristics, regular medication, immediate therapy within 24 hours, in-hospital interventions and treatments, in-hospital outcome, complications and discharge medication were analyzed using descriptive statistics and logistic regression.

Results

Among 53,680 AMI patients, 5.8% had a CLD. The CLD group included 26.6% female and 73.4% male patients. Gender distribution was similar in patients with and without CLD. Patients with CLD were significantly older (71.2 vs. 65.8 y; p<0.001), more frequently diagnosed with NSTEMI, had more comorbidities and were less frequently never smokers (17.4% vs. 35.3%; p<0.001) compared to patients without CLD. In addition, CLD patients were less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors and statins (all p<0.001), and were also less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p<0.001). Median length of stay was 2 days longer for CLD patients. Patients with CLD had more major adverse cardiac and cerebrovascular events in-hospital (10.3% vs. 5.9%; p<0.001) and higher crude in-hospital mortality (8.3% vs. 4.7%; p<0.001). However, multivariable regression analysis showed that CLD was not an independent predictor for in-hospital mortality (OR 1.19 (95% CI 0.98–1.45), p=0.081).

Conclusion

Patients with CLD were less likely to receive evidence-based medicine and had a worse in-hospital outcome compared to those without CLD. However, after adjustment, CLD was not an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca AG, Biotronik (Schweiz) AG

Long-term trends in treatment and outcomes of patients with diabetes and acute coronary syndromes: insights from the nationwide AMIS plus registry

Background

Although impressive advances in the treatment of patients with acute coronary syndromes (ACS) have been achieved over the last decades, morbidity and mortality of patients with diabetes and ACS remain substantial. This study aimed at investigating long-term trends in treatment and outcomes of patients with diabetes and ACS, using data from a large, prospective, nation-wide database.

Methods

Patients with ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) enrolled in the prospective AMIS Plus registry between 01/2003 and 12/2018 and available data on diabetes diagnosis were included in the analysis. Major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and cerebrovascular events were assessed for each 3-year period.

Results

Out of 49'413 ACS patients, 10'200 (20.6%) had diabetes (29.4% women). In diabetic patients, the percentage of women decreased from 32.3% in 2002–2004 to 25.9% in 2017–2019 (p<0.001). Diabetic patients were older (p<0.001), more frequently women (p<0.001), and had a higher body mass index (p<0.001). They less often underwent percutaneous coronary intervention (p<0.001) and were more frequently treated by coronary artery bypass grafting (p<0.001). Over the 18-year period, the percentage of diabetic patients undergoing PCI or CABG increased (p<0.001). While treatment with glycoprotein IIb/IIIa inhibitors, low-molecular weight heparin, and beta blockers decreased over time, administration of aspirin, P2Y12 inhibitors, lipid-lowering drugs, and unfractionated heparin increased. Rates of MACE were 9.5% and 5.2% in diabetic and non-diabetic patients (p<0.001). Rates of mortality (7.7% versus 4.1%, p<0.001), recurrent myocardial infarction (1.5% versus 0.9%, p<0.001), and cerebrovascular events (1.2% versus 0.6%, p<0.001) were higher in diabetic as compared with non-diabetic patients, with highest rates of MACE, mortality, and myocardial infarction observed in diabetic women. Rates of MACE decreased from 11.8% in 2002–2004 to 7.5% in 2017–2019 in diabetic patients (p for trend <0.001). While rates of mortality (9.4% to 5.9%, p for trend =0.001) and rates of recurrent myocardial infarction (3.4% to 0.9%, p for trend <0.001) decreased over time, rates of cerebrovascular events remained stable (p for trend =0.34). Trends were the same in diabetic women and men.

Conclusions

Rates of MACE significantly decreased over the 18-year period in both diabetic women and men, with highest rates observed in diabetic women. Despite the observed improvements, rates of MACE remained 50% higher in diabetic as compared with non-diabetic patients. These findings emphasize that advanced strategies particularly targeting the vulnerable high-risk diabetic patient population are warranted to further improve quality of care in ACS.

Funding Acknowledgement

Type of funding sources: None.

Achievement of guideline recommended LDL-C goals in patients with acute myocardial infarction (AMI) in Switzerland

Background

In 2016 and subsequently again in 2019 the ESC/EAS Guidelines for the Management of Dyslipidaemia established a more intensive reduction of LDL cholesterol (LDL-C) treatment recommendations. We aim to characterize patients with acute myocardial infarction (AMI) with regards to achievement of recommended LDL-C goals and their current lipid lowering therapy.

Methods

We retrospectively analysed patients with AMI admitted to Swiss hospitals between 2016 and 2020. Patients were classified as “very high risk” due to prior atherosclerotic cardiovascular disease (ACSVD) events including at least one of the following: Myocardial infarction (MI), stroke, peripheral arterial disease (PAD) and type 2 diabetes mellitus with target organ damage. The remaining patients were classified as “other risk”. LDL-C treatment recommendation goals for the “very high risk” population were set to 1.8mmol/L (2016 ESC/EAS Guidelines) or 1.4mmol/L (2019 ESC/EAS Guidelines) and for the “other risk” population to 2.6mmol/L or 1.8mmol/L. To identify differences between the two groups the Mann-Whitney test was used and for differences within a group the Kruskal-Wallis test. In-hospital outcomes were summarised as major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 7114 patients included, 18.4% were categorized as “very high risk” and 81.6% as “other risk” (p<0.001). In general, the “very high risk” patients were older (69.2y vs. 63.6y, p<0.001), more likely to be men (78.8% vs. 75.3%, p=0.007), had poorer in-hospital outcomes (6.0% vs. 3.4%, p<0.001) and were more often on lipid lowering treatment (statin/ezetimibe/combination) (LLT) prior to admission (64.8% vs 14.0%, p<0.001). The overall LDL-C median for the “very high risk” population was significantly lower than for the “other risk” population (2.4mmol/L vs. 3.5mmol/L, p<0.001). In addition, median (IQR) LDL-C increased in the “other risk” group over the years from 3.5mmol/L (2.7; 4.2) in 2016 to 3.7mmol/L (3.1; 4.4) in 2020. In contrast, no change in LDL-C was observed in the patients at higher risk (Fig. 1).

Patients in the “other risk” group were more likely to miss the recommended LDL-C goals (2016 Guidelines: 80.0% vs. 75.4%, 2019 Guidelines: 94.2% vs. 89.1%). Patients without LLT prior to admission had a higher chance of not reaching the recommendations compared to patients with LLT prior to admission (without LLT: 2016: 85.3% vs. 91.0%, 2019: 96.1% vs. 96.6%), (with LLT: 2016: 50.8% vs. 66.8%, 2019: 83.2% vs.85.2%) (Fig. 2).

Conclusion

Median LDL-C levels have tended to increase in recent years in patients with very high CV risk and AMI admitted to Swiss hospitals. Despite existing lipid lowering therapies only few patients met guideline recommended LDL-C goals. Our results indicate that clinical implementation of guidelines remains to be optimised with regards to achievement of LDL-C goals to reduce CV risk and improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. LDL-C developmentFigure 2. Recommended LDL-C goal achievement

The impact of the COVID-19 pandemic on the management and outcomes of STEMI patients in Switzerland

Introduction

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world, with potential repercussions on the quality of care of patients with other diseases. From a cardiological perspective, there have been concerns that the pandemic may have impacted the management of the most acute cardiovascular conditions.

Purpose

We evaluated the impact of the COVID-19 pandemic on the management of ST-elevation myocardial infarction (STEMI) in Switzerland by assessing a range of quality-of-care metrics during the first year of the pandemic, as compared with the preceding year.

Methods

Data on STEMI patients hospitalised in Switzerland from 1st January 2019 to 31st December 2020 were obtained from the Acute Myocardial Infarction in Switzerland (AMIS) registry. Symptom-to-first-medical-contact (symptom-to-FMC) time, symptom-to-door time, and door-to-balloon (DTB) time were compared between 2020 and 2019 in an analysis by year and by month. Additionally, rates of in-hospital all-cause mortality and in-hospital major adverse cardiovascular events (MACE: all-cause mortality, MI, stroke) were compared.

Results

Data on 2192 STEMI patients were available. Compared with the preceding 12 months, the first year of the pandemic was not associated with a significant change in median symptom-to-FMC time (2020: 90 minutes vs 2019: 95 minutes, p=0.32) or median symptom-to-door time (2020: 145 min vs 2019: 157 min, p=0.51). In 2020, February (start of the pandemic) and March (start of national lockdown) were associated with increased DTB times as compared with the same months of 2019 (+7 minutes, +10 minutes, respectively). However, overall median door-to-balloon times remained stable (2020: 40 min vs 2019: 39 min, p=0.06). Furthermore, there was no significant difference in the proportion of patients undergoing percutaneous coronary intervention (2020: 95.6% vs 2019: 95.1%, p=0.54). Finally, there were no significant differences in median length of stay (2020: 4 days vs 2019: 157 min, p=0.51), in-hospital all-cause mortality (2020: 4.9% vs. 2019: 4.2%, p=0.41) or MACE (2020: 6.2% vs. 2019: 5.6%, p=0.52).

Conclusions

Although there are some limitations associated with the present study inherent to its retrospective observational design (for instance, a potentially important number of late comers may not have been included in the registry), the data suggest that despite the impact of COVID-19 on the healthcare system in Switzerland in 2020, STEMI management as defined by a range of quality-of-care metrics remained effective and efficient.

Funding Acknowledgement

Type of funding sources: None.

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome

Introduction

The association between alcohol consumption and the occurrence of coronary heart disease is well described in literature. Data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking.

Purpose

We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS.

Methods

Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. The primary endpoint was all-cause in-hospital mortality, while secondary endpoints were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcomes comparisons according to quantity of daily alcohol intake were also performed.

Results

Records concerning alcohol consumption were available in 25707 patients; 5298 of them (21%) fulfilled the criteria of regular alcohol consumption. Daily alcohol intake was reported in 4059 (77%), of these patients (regular drinkers) with 2640 light drinkers (≤2 drinks/day) and 1419 heavy drinkers (>2 drinks/day). Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared to abstainers/occasional drinkers.

In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared to light drinkers (5.4% vs. 3.3% and 7.0% vs. 4.4%, both p=0.001). When tested together with GRACE risk score parameters, heavy alcohol consumption was independently associated to in-hospital mortality (p=0.004).

Conclusions

Heavy alcohol consumption is an additional independent predictor of in-hospital mortality in patients presenting with ACS.

Figure 1. Study flowchart.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Swiss Heart Foundation

Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p<0.001), had more often diabetes (20.0% vs. 16.9%, p<0.001), but less often MI history (11.2% vs. 14.9%, p<0.001) and less often pain at presentation (92.0% vs. 94.8%, p<0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p<0.001) and diabetes (+27.1 min, p<0.001). Conversely, pain at admission (−46.3 min, p<0.001) and MI history (−32.9 min, p<0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation

P2807Clinical outcomes with cobalt chromium biolimus eluting drug-eluting stents compared with stainless steel biolimus eluting drug-eluting stents in all-comers patients

Aims

Thinner stent struts may improve deliverability, conformability and reduce vessel injury. We report the first clinical outcomes of the thinner strut (84–88um) cobalt chromium biolimus eluting stent from the Biomatrix Alpha registry and compare these with objective performance criteria from the stainless steel BioMatrix Flex arm of the Leaders study.

Methods

A total of 1257 patients were studied: 400 patients from 12 centres receiving ≥1 Biomatrix Alpha stent were prospectively enrolled into the Biomatrix Alpha registry and then underwent a pre-specified comparison with 857 patients who received a Biomatrix Flex stent in the Leaders study. The primary endpoint was major adverse cardiac events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) or clinically driven target vessel revascularization (TVR) at 9 months. Assuming a 9.2% event rate with BioMatrix Flex, a one-sided type I error (α) of 0.05, and a 4% non-inferiority margin, a sample size of 400 in the Biomatrix alpha registry had >80% power to conclude non-inferiority.

Results

Baseline characteristics in the Alpha registry were typical of an all-comers population with a mean age of 64.7±11.3, diabetes 19%, current smoking 21%, dyslipidemia 57%, hypertension 57%, total stent length per lesion 25.49±13.45, mean stents per procedure 1.59±0.88 and overlapping stents in 13.4%. Observed MACE at 9 months with Alpha was 3.94% (upper limit 5.98%) vs. 9.28% MACE rate with Flex stents in Leaders, which met pre-specified criteria for non-inferiority (p<0.001) and on post hoc testing for superiority yielded p<0.001 for Alpha vs Flex. Secondary endpoints with Alpha included clinically-driven TVR 2.6%, all-cause mortality rate 1.51% and definite/probable stent thrombosis 0.25%.

While both Alpha and Leaders enrolled all-comers, Alpha included longer total stent length per lesion (25.49 vs 23.85mm, p<0.001) and more stents per procedure (mean 1.59 vs 1.34; p<0.001) but fewer patients with diabetes (19% vs 26%; p=0.0087), dyslipidemia (57 vs 65%; p=0.0037), prior MI (18.8% vs 32.2%; p<0.001) or acute coronary syndrome (41% vs 55%; p<0.001). To correct for these imbalances and to assess robustness further, a propensity score at the patient level data was undertaken (total sample size of 1257 patients; 400 from the Alpha registry and 857 from the LEADERS study). A propensity score stratification method was used obtaining 5 quintiles for adjusted analysis (each of the 5, containing 251 or 252 patients, 20%). In each of the strata as well as at the aggregate level, a p valve<0.005 was obtained confirming non-inferiority for the primary endpoint.

Conclusion

The thinner strut (84–88um) cobalt chromium Biomatrix Alpha stent demonstrated low MACE rates at 9 months which were non-inferior to MACE outcomes with the stainless steel Biomatrix Flex in the Leaders study. The robustness of this finding was further confirmed by a propensity score analysis.

Acknowledgement/Funding

Biosensors

Enhanced coronary vasoconstriction after PTCA in patients with acute ischemia

Coronary vasoconstriction of the distal vessel segment has been reported after percutaneous transluminal coronary angiography (PTCA), which was explained by increased vasoconstrictor influences. In patients with acute ischemia these changes may be even enhanced. Thus, vasomotion of the epicardial coronary arteries was studied before and after PTCA in patients with acute ischemia due to unstable angina or acute infarction.

METHODS

52 patients were divided into 2 groups: Group 1 (controls) consisted of 31 patients who underwent elective (PTCA) and group 2 of 21 patients who underwent emergency PTCA for unstable angina or acute infarction. Coronary artery dimensions proximal and distal to the culprit lesion were determined by quantitative coronary angiography before and after PTCA as well as after 0.2 mg nitroglycerin i.c. at the end of the procedure.

RESULTS

Stenosis severity was similar before and after PTCA in both groups (before, 91 +/- 8% in group 1 vs 90 +/- 9% in group 2; after, 28 +/- 9% vs 23 +/- 10%, resp.). Heart rate and mean blood pressure remained unchanged. In the group with acute ischemia no vasodilation of the proximal (2 +/- 3%) and distal vessel (-1 +/- 4%) occurred after PTCA, whereas in the control group significant vasodilation of both vessel segments (11 +/- 2% resp. 13 +/- 3%) was found. The response to nitroglycerin was maintained in both groups. In the control group there was a significant correlation between stenosis severity and percent diameter change of the distal vessel segment. However, in the acute ischemic group this relationship was shifted downwards suggesting an enhanced vasoconstrictor response in these patients.

CONCLUSIONS

Epicardial coronary arteries in patients with acute ischemia show an enhanced vasoconstriction after PTCA. Nevertheless, the response to nitroglycerin is maintained suggesting that functional (endothelial dysfunction) rather than structural factors are responsible for this phenomenon.

[Bromocriptine-induced pleuropneumopathy]

A 64-year-old man was diagnosed to have Parkinson's disease when aged 42 years and since then has been treated with levodopa and benserazide (up to 875 mg daily). Bromocriptine (up to 35 mg daily) was added to the medication 9 years ago. 3 1/2 years ago he developed exertional dyspnoea (NYHA class II-III) and lost 5 kg in weight. Chest radiography demonstrated pleural effusion and interstitial pulmonary changes in both lung bases. Erythrocyte sedimentation rate was 37 mm in the first hour and the white cell count 10,400/microliters. Extensive tests failed to find malignant tumour or any infectious-inflammatory condition. As it was suspected that the pleuropulmonary changes were associated with the bromocriptine intake, it was discontinued and biperiden and selegiline substituted for it. The pleural effusion regressed almost completely within 8 weeks, and the laboratory tests pointing to inflammation disappeared completely. Clinical, biochemical and radiological tests have remained normal for the last 3 years. The clinical course makes a causal relationship between bromocriptine intake and the pleuropulmonary changes highly probable.

[Quantitative Doppler echocardiography in the evaluation of heart diseases]

Doppler ultrasound is an established noninvasive method in cardiology. The most important indications are: 1. stenosis/insufficiencies of atrioventricular/semilunar valves, 2. dysfunction of artificial valves, 3. atrial and ventricular septal defects, 4. intraventricular pressure gradients, e.g. in hypertensive cardiomyopathy, 5. determination of the systolic pulmonary artery pressure. Color Doppler and pulsed wave Doppler as mainly used for quantitative and semiquantitative-, continuous wave Doppler mainly for quantitative analyses. Doppler it can be obtained qualitative and semiquantitative, from continuous wave Doppler quantitative information about the velocity of blood flow.

Quantification of mitral regurgitation with amplitude-weighted mean velocity from continuous wave Doppler spectra

Amplitude-weighted mean velocity from continuous wave (CW) Doppler spectra was used to measure aortic flow (QAo) and left ventricular mitral inflow (QLVin). These flows were used to quantify mitral regurgitation fraction: RFm = (QLVin-QAo).QLVin-1.100(%).QLVin was calculated from the diastolic time integral of amplitude-weighted mean velocity that was derived from CW spectra with the transducer placed in the apical window and the CW beam directed toward the left ventricular inflow tract. QAo was obtained from the systolic time integral of amplitude-weighted mean velocity by using the same apical window and directing the CW beam toward the left ventricular outflow tract. In 20 normal subjects, RFm ranged between -6.2% and +8% (mean, -0.8%). In 25 patients with pure mitral regurgitation, RFm obtained by Doppler (y) was compared with RFm calculated from biplane left ventriculography and the Fick method (x). The correlation was r = 0.96, SEE = 6.1% of the mean or 12% of the angio-Fick mean; the regression line was y = 0.96x + 0.18; mean y = 49%, mean x = 51%. It is concluded that RFm can be determined accurately by using amplitude-weight mean velocities from CW Doppler spectra. The advantages of this method are its independence from the measurement of the left ventricular inflow or outflow tract area.