The Swedish version of the Haemophilia Activity List

There has been increasing interest in the patient's perspective on outcome of treatment. The Haemophilia Activity List (HAL) has been developed as a disease-specific questionnaire for haemophilia patients and is a validated self-report measure of function developed according to WHO's International Classification of Functioning, Disability and Health. To validate HAL in Sweden. The Dutch and English versions of HAL were translated into Swedish using 'the forward-backward translation' method and merged into a final Swedish version. Validation was performed against the Swedish version of the questionnaires Arthritis Impact Measurement 2 (AIMS 2) and Impact on Participation and Autonomy (IPA). Two hundred and twenty-five patients with severe and moderate forms of haemophilia A and B from three centres were invited to participate in the study. Spearman's rank correlation test was used for validation, and internal consistency of the HAL was calculated with Cronbach's alpha. Eighty-four patients (39%) (18-80 years old) filled out the questionnaires. The internal consistency of the Swedish version of HAL was high, with Cronbach's alpha being 0.98-0.71. Function of the legs had the highest consistency and transportation had the lowest. The correlation was excellent between the HAL sum score and AIMS 2 physical (r = 0.84, P < 0.01), IPA autonomy indoors (r = 0.83, P < 0.01) and autonomy outdoors (r = 0.89, P < 0.01). The Swedish version of HAL has both internal consistency and convergent validity and may complement other functional tests to gather information on the patient's self-perceived ability.

Knowledge of disease and adherence in adult patients with haemophilia

Patients with moderate and severe haemophilia are evaluated on a regular basis at their haemophilia centres but patients with mild haemophilia are seen less often because of fewer problems related to their disease. The needs of patients with milder forms of haemophilia, however, are often underestimated, both by the patient and staff at healthcare facilities. This study evaluated the knowledge of disease and adherence to treatment among patients with severe, moderate and mild haemophilia. This was a prospective multicentre study performed in Haemophilia Centres in Scandinavia. A total of 413 (67%) of 612 patients aged >25 years with mild, moderate and severe haemophilia completed a self-administered questionnaire. The mean age of the respondents was 49.7 years (range 25-87 years). Of the 413 respondents, 150 had a mild, 86 had a moderate and 177 had a severe form of haemophilia. A total of 22 (5%) patients did not know the severity of their disease, and 230 (56%) patients knew the effect of factor concentrate in the blood. Of the 413 respondents, 53 (13%) of the cohort never treated a haemorrhage. Patients with mild haemophilia, P </= 0.001, were the least likely to treat a haemorrhage. The relative number of patients who were afraid of virus transmission by factor concentrate was about similar in the three groups, 27% of those with severe haemophilia, 26% with moderate and 24% with mild haemophilia. This study shows that the amount of knowledge among haemophilia patients about their disease and treatment is somewhat limited, and demonstrates the importance of continually providing information about haemophilia and treatment, especially to patients with a mild form of the disease.

False tendons in the left ventricle: 2-dimensional and M-mode echocardiographic findings

The M-mode and 2-dimensional echocardiographic findings in an 18-year-old man are described. The findings are compatible with the diagnosis of false tendons in the left ventricle.

Echocardiographic findings in a patient with left ventricular pseudoaneurysm

A 57-year-old woman, treated for a large anterior transmural myocardial infarction, was readmitted after 8 weeks because of progressive cardiac failure. Chest X-ray showed cardiomegaly with an atypical cardiac silhouette. Two-dimensional echocardiography disclosed a large left ventricular pseudoaneurysm. The patient underwent resection of the false aneurysm with repair of the left ventricular wall and recovered gradually. Different methods for diagnosing pseudoaneurysm are discussed.

Non-invasive beat-to-beat analysis of stroke volume and digital pulse volume in patients with complete heart block and artificial pacing

This study presents a beat-to-beat analysis of digital arterial pulse volume (DAPA), left ventricular end-diastolic diameter (LVEDD), and stroke volume (SV) and their correlation to PQ interval in ten patients with complete heart block and artificial cardiac pacing. DAPA was measured by strain-gauge plethysmography and LVEDD/SV by echocardiography. A close relationship was found between SV and DAPA (R = 0.83-0.97) in seven patients, who all drew considerable benefit from atrial contraction as regards SV and DAPA (increase with 35-94%). The optimal PQ interval was calculated to approximately 240 msec for DAPA and 180 msec for LVEDD and SV. It may be concluded that the present study demonstrates a close relationship between beat-to-beat variations of SV measured by echocardiography and plethysmographically recorded digital arterial pulse volume. These variables may be useful in clinical practice for assessing the hemodynamic effect of atrial contribution in patients with various forms of cardiac conduction disturbances. The two methods may, for instance, be useful for screening in order to pick out patients who may benefit from AV synchronous rather than ventricular pacing.

Effects on angina pectoris and exercise tests of a 2% nitroglycerin gel adhesive in patients on chronic beta-blockade. A placebo-controlled study

Twenty patients on chronic beta-blockade for angina pectoris were included in a double-blind randomized cross-over placebo-controlled study on a 2% nitroglycerin gel administered transdermally by an adhesive. Topinitro. The dose, 2.5-10 mg/day, was individually titrated and each treatment period was 28 days. The effect was evaluated by exercise tests and diary cards for anginal attacks and nitroglycerin tablets consumed. Results. In the 17 patients who completed the trial, active treatment did not influence systolic and diastolic blood pressure or resting and maximal heart rate. Maximal performance increased insignificantly from 92 +/- 23 to 96 +/- 20 W. The level at which 1 mm of ST depression appeared increased from 62 +/- 26 to 73 +/- 28 W (p less than 0.05). The number of attacks decreased significantly, from 92 +/- 30 to 14 +/- 28/4 weeks. The reduction in the number of sublingual nitroglycerin tablets consumed was insignificant. Conclusion. Nitroglycerin adhesive, in individual dosages, may improve signs and symptoms of ischemia.

Mitral annulus calcification, systolic anterior motion of the anterior mitral leaflet and outflow obstruction in two patients without hypertrophic cardiomyopathy. An echocardiographic report

Systolic anterior motion of the anterior mitral leaflet (SAM) and concomitant left ventricular outflow obstruction (LVOFO) are commonly seen in hypertrophic cardiomyopathy. However, SAM has also been described together with extensive anteroseptal wall infarction, pericardial exudation and in hypovolemic situations. This report presents two patients examined with M-mode echocardiography which demonstrates that SAM with LVOFO can also occur in association with mitral annulus calcification (MAC). A possible mechanism behind this entity would firstly be the anterior displacement of the mitral ring commonly seen in MAC. Secondly, extension of calcifications to the posterior wall will furthermore impair the LV contraction leading to loosely stretched chordae tendineae during systole and hence a motion of the anterior mitral valve along the blood stream (SAM) leading to LVOFO.

Ventricular arrhythmias and left ventricular dysfunction in familial cardiomyopathy

In familial cardiomyopathy (CM), different forms of myocardial abnormalities including asymmetric and symmetric hypertrophy and dilated left ventricles are presented, mostly showing varying hereditary penetrance. This study presents a family with CM including three major clinical manifestations: severe ventricular arrhythmias, repolarization abnormalities and left ventricular hypertrophy. This triad was strikingly consistent in the two generations examined. The familial pattern with an autosomal dominant inheritance did not show any linkage to the HLA region.

Early exercise tests after uncomplicated acute myocardial infarction before early discharge from hospital

As part of an early mobilization and early discharge scheme, 76 consecutive low-risk patients were selected from a population of 298 acute myocardial infarction (AMI) patients, to undergo an exercise test. The test was done on the 7th day after an AMI. The patients were 57 men and 19 women of mean age 57 and 68 years, respectively. Twelve patients were unable to complete the test, but no serious complications were observed. Average heart rate during the highest exercise load (50 W) was 106 beats/min. The following risk indices (RI) were considered abnormal and were looked for during or after exercise: 1) heart rate greater than 125 (n = 12), 2) major ventricular arrhythmias (n = 3), 3) angina pectoris (n = 9), 4) ST deviation of more than 1 mm (n = 11). Two RIs were found in 9 patients during the exercise test which led to prolonged hospitalization. One RI was found in 26 patients (34%). Eighty-eight per cent (n = 36) of the patients with normal exercise test had an uneventful recovery during the six-month observation period, in contrast to 35% (n = 9) of patients with heart rate greater than 125 recovered normally, a significantly lower number (p less than 0.05) than among patients with a normal exercise test. Reinfarction occurred in one patient with normal exercise test and in six (23%) of those with one RI (p less than 0.01) and two of those with two RIs (N.S.). We conclude that a submaximal bicycle exercise test seven days after an AMI is a safe and useful selection instrument for early discharge from hospital as well as a useful predicting instrument of future complications.

High-dose prenalterol in beta-blockade intoxication

This study presents a case of beta-blocker intoxication due to massive overdose of metoprolol (7.5 g). Prenalterol in a dose of 420 mg was given as antidote, in combination with epinephrine in intermittent doses. Resuscitation was performed during 4 hours because of mechanical asystole. The patient regained health in 24 hours after further repeated doses of 30 mg prenalterol. Prenalterol is valuable in the management of toxic doses of beta-blocking drugs, and a titration to extremely high doses of prenalterol might be necessary.

Early mobilization and discharge of patients with acute myocardial infarction. A prospective study using risk indicators and early exercise tests

Consecutive patients (n=184) surviving 48 hours in a coronary care unit were divided into one rapidly (RM) (n=55, 30%) and one conventionally mobilized (CM) group (n=129, 70%). The selection of RM patients was based on the absence of five early risk indicators (RI), reflecting electrical and mechanical heart dysfunction. During after-care, five late RIs were evaluated, including a submaximal bicycle exercise test to 50 W, which excluded nine (16%) additional patients from the RM group. After excluding four patients for non-cardiac reasons, the remaining 42 RM patients were rapidly mobilized and discharged after a mean of nine days, in contrast to a mean of 19 days in the CM group, comprising 121 patients. No RM patient dies in hospital and only one patient died during a six-month follow-up, compared to 17 (p less than 0.01) and 28 (p less than 0.01) patients respectively, in the CM group. Both reinfarction and mortality increased with the number of positive RIs. The early exercise test excluded four patients from the RM group. Altogether 22 of 45 patients showed some abnormality during exercise. Half of these 22 patients were readmitted due to cardiac complications during the follow-up period. These findings indicate that it is possible to identify a group of patients with AMI suitable for early discharge, and that an early exercise test in selected good risk patients is safe and identifies a group prone to complications during the early follow-up period.

M-mode echocardiographic mapping in differentiation of normal from dysfunctioning left ventricular myocardium. A study of patients with severe myocardial infarction and healthy controls

Seventeen severely ill patients with acute myocardial infarction (AMI) (12 men and 5 women; mean age 65) and 37 healthy persons with similar age and sex distribution were investigated. Regional left ventricular wall motion was studied in terms of mean wall velocity, in 16 segments, 8 basal and 8 apical, by M-mode echocardiographic (Echo) mapping from 6 probe positions. Adequate Echo registrations were obtained from 88% of the total of 864 segments. The best classification (88.5%) of normal and infarcted segments was obtained with a -30% deviation of mean systolic wall velocity (Vmean) values from the mean values of the control segments (CS). Non-infarcted segments (NIS) in the AMI group had significantly lower Vmean values than the CS (p less than 0.001). Subendocardially (SIS) and transmurally (TIS) infarcted segments could be clearly separated from both CS and NIS (p less than 0.001). Per cent deviation of Vmean from the mean value of the control segments (PD-V) for SIS varied considerably overlapping CS, NIS and TIS. With a PD-V between 0 and -30% the probability of NIS is 94%, SIS 6% and TIS less than 1%. A PD-V more than -66% was rarely seen among NIS (2%) but was the normal finding in TIS (94%).

Quantification of left ventricular wall dysfunction by M-mode echocardiographic mapping in heart failure following acute myocardial infarction

Echocardiographic mapping was performed in 44 patients on arrival in hospital and day 2 following acute myocardial infarction (AMI). To evaluate left ventricular (LV) function the per cent deviation of the mean systolic wall velocity (PD-V) from the normal was measured from 16 LV segments. Adequate data were obtained from 89% of the segments. The number of hypokinetic segments was somewhat higher in anterior than inferior AMI, reaching significance (p less than 0.05) on day 2. Dyskinetic segments were also more common in patients with anterior infarction (p less than 0.001), who also had significantly higher enzyme maxima than patients with inferior AMI (p less than 0.01). Enzyme maxima correlated well with the sum of PD-V from all hypokinetic segments on day 1 (r = 0.79, p less than 0.01). Compensatory hyperkinesia was more common in inferior than anterior AMI (p less than 0.001). Global LV function, estimated by subtracting the number of hyper- from hypokinetic segments (score sigma S:Adj), was significantly related to heart failure (Killip classification) (p less than 0.01) and the respiratory rate (r = 0.71, p less than 0.01) in the acute phase as well as to heart failure during the first post AMI month (New York Heart Association classification).

Evaluation of effects of nitroglycerin therapy by echocardiography

Echocardiography (Echo) is a convenient method in diagnosing and in quantification of cardiac abnormalities, although dependent on registration quality. M-mode and two-dimensional Echo give adequate information regarding heart dimensions and cavity volume but only indirect information of pressures. M-mode Echo gives an ideal opportunity to study left ventricular wall motion as an expression of systolic and diastolic function. Both inter and intra patient comparisons will be possible to perform. Improved wall function after intake of nitroglycerin and other nitrate preparations, has been reported in Echo studies both in resting state and in induced acute myocardial ischemia during exercise in man or in acute coronary occlusion in dogs.

NC100100, a new echo contrast agent for the assessment of myocardial perfusion--safety and comparison with technetium-99m sestamibi single-photon emission computed tomography in a randomized multicenter study

BACKGROUND AND HYPOTHESIS

Myocardial contrast echocardiography using second-generation agents has been proposed to study myocardial perfusion. A placebo-controlled, multicenter trial was conducted to evaluate the safety, optimal dose, and imaging mode for NC100100, a novel intravenous second-generation echo contrast agent, and to compare this technique with technetium-99m sestamibi (MIBI) single-photon emission computed tomography (SPECT).

METHODS

In a placebo-controlled, multicenter trial, 203 patients with myocardial infarction > 5 days and < 1 year previously underwent rest SPECT and MCE. Fundamental and harmonic imaging modes combined with continuous and electrocardiogram-- (ECG) triggered intermittent imaging were used. Six dose groups (0.030, 0.100, and 0.300 microliter particles/kg body weight for fundamental imaging; and 0.006, 0.030, and 0.150 microliter particles/kg body weight for harmonic imaging) were tested. A saline group was also included. Safety was followed for 72 h after contrast injection. Myocardial perfusion by MCE was compared with myocardial rest perfusion imaging using MIBI as a tracer.

RESULTS

NC100100 was well tolerated. No serious adverse events or deaths occurred. No clinically relevant changes in vital signs, laboratory parameters, and ECG recordings were noted. There was no significant difference between adverse events in the NC100100 (25.7%) and in the placebo group (17.9%, p = 0.3). Intermittent harmonic imaging using the intermediate dose was superior to all other modalities, allowing the assessment of perfusion in 76% of all segments. Eighty segments (96%) with normal perfusion by SPECT imaging also showed myocardial perfusion with MCE. However, a substantial percentage of segments (61-80%) with perfusion defects by SPECT imaging also showed opacification by MCE. This resulted in an overall agreement of 66-81% and a high specificity (80-96%), but in low sensitivity (20-39%) of MCE for the detection of perfusion defects.

CONCLUSION

NC100100 is safe in patients with myocardial infarction. Intermittent harmonic imaging with a dose of 0.03 microliter particles/kg body weight can be proposed as the best imaging protocol. Myocardial contrast echocardiography with NC 100100 provides perfusion information in approximately 76% of segments and results in myocardial opacification in the vast majority of segments with normal perfusion as assessed by SPECT. Although the discrepancies between MCE and SPECT with regard to the definition of perfusion defects requires further investigation, MCE with NC 100100 is a promising technique for the noninvasive assessment of myocardial perfusion.

Compliance with treatment and understanding of own disease in patients with severe and moderate haemophilia

It is well known that teenagers with chronic diseases have problems complying with their treatment. The aim of this study was to evaluate the patient's knowledge of haemophilia and his compliance to prophylactic treatment, and the age at which the patient took over the responsibility for his disease and to create educational material for teenagers and adolescents. This was a prospective multicentre study performed in Hemophilia Treatment Centres in Scandinavia. A total of 108 of 134 patients, between 13 and 25 years completed the questionnaire, a response rate of 80%. Eighty-three patients had a severe form of haemophilia, 24 patients in moderate form and one patient did not know the severity of his disease. Seventy-eight patients were on prophylactic treatment. The median age for starting prophylactic treatment was 3.0 years and the median age for the patient performing venepuncture was 11.6 years. Sixty-seven of 78 patients knew that the best time to give prophylactic treatment was in the morning. Even though the patients were on prophylactic treatment, 47 of 78 patients took additional treatment before sports activities. At a mean age of 14.1 years the patient himself had the responsibility for his disease and treatment. In the cohort of 108 patients, 73 were aware of their haemophilia heredity. This study shows a rather high degree of knowledge of haemophilia and compliance with treatment among the patients but it is of great importance for the nurse to continuously improve the patient's compliance and keep him aware of the benefit of regular treatment for his future well being.

Practice patterns in haemophilia A therapy - global progress towards optimal care

This paper reports the findings of a global survey of practice patterns for the management of patients with haemophilia A. A total of 147 haemophilia treatment centres worldwide responded to the questionnaire, supplying data for 16 115 patients with haemophilia A. From these responses, 38% (range: 25-48%) of patients were under 18 years old. Almost half (47%) of patients were reported to have mild or moderate haemophilia A, 48% had severe haemophilia A (no inhibitor) and 5% were inhibitor patients. Less than half of patients with severe haemophilia A received prophylactic therapy (37%, excluding inhibitor patients) and 54% received on-demand treatment; the remaining 9% were inhibitor patients. Primary prophylaxis rates for severe haemophilia ranged from 73% in Sweden to 17% in the USA. Most respondents (80%) ranked infrequent bleeds as one of the top five reasons for not administering prophylactic treatment, followed by venous access (60%) and cost (45%). Of patients with severe haemophilia (non-inhibitor), 32% on primary prophylaxis and 27% on secondary prophylaxis had indwelling catheters. Risk of infection and the patient's inability to maintain the line were the key concerns cited by nurses relating to venous access. The mean ratio of nurses to patients with haemophilia A was 1:69 and nurses felt that they were either fully (26%) or mostly (45%) autonomous in assessment and treatment decisions. Results from this current survey suggest that worldwide research should be continued so as to improve outcomes through the identification of optimal treatment protocols for the management of haemophilia A.

A 6-year follow-up of dosing, coagulation factor levels and bleedings in relation to joint status in the prophylactic treatment of haemophilia

The primary aim of this study was to investigate the possible relationship between coagulation factor level and bleeding frequency during prophylactic treatment of haemophilia after stratification of the patients according to joint scores. The secondary aim was to obtain a systematic overview of the doses of coagulation factors prescribed for prophylaxis at the Malmo haemophilia treatment centre during a 6-year period. A retrospective survey of medical records for the years 1997-2002 and pharmacokinetic study results from the 1990s was complemented by collection of blood samples for coagulation factor assay when needed. Information on the dosing and plasma levels of factor VIII or factor IX, joint scores and incidence of bleedings (joint bleeds and 'other bleeds') was compiled. The patients were stratified by age (0-6, 7-12, 13-18, 19-36 and >36 years) and joint score (0, 1-6 and >6). Individual pharmacokinetic parameters of plasma coagulation factor activities (FVIII:C and FIX:C) were estimated. Trough levels during the treatment were calculated, as well as the number of hours per week of treatment during which plasma FVIII:C/FIX:C fell below a 1, 2 or 3% target level. Fifty-one patients with haemophilia A (two moderate, 49 severe) and 13 with haemophilia B (all severe) were included, yielding data for 364 patient-years of treatment. There was a wide range of dosing schedules, the most common ones being three times a week or every other day for FVIII and twice a week or every third day for FIX. The overall relationship between FVIII:C/FIX:C levels and incidence of joint bleeding was very weak, even after stratification of the patients according to joint score. There was no relationship between coagulation factor level and incidence of other bleeds. In this cohort of patients on high-dose prophylactic treatment, dosing was based more on clinical outcome in terms of bleeding frequency than on the aim to maintain a 1% target level of FVIII:C/FIX:C. Some patients did not bleed in spite of a trough level of <1% and others did in spite of trough levels >3%. The practical implication of our findings is that dosing in prophylactic treatment of haemophilia should be individualized. Thus, proposed standard regimens should be implemented only after careful clinical consideration, with a high readiness for re-assessment and individual dose tailoring.

Determinants of left ventricular systolic function after acute myocardial infarction: the role of residual myocardial ischaemia

BACKGROUND

Left ventricular systolic function (LVSF) is one of the major determinants of survival after acute myocardial infarction (AMI). Some factors such as the infarct size and localization, and the patency of the infarct-related artery are known determinants of LVSF. However, the long-term effect of myocardial ischaemia on LVSF has been poorly studied in clinical settings.

OBJECTIVES

To assess the acute and long-term effects of myocardial ischaemia on LVSF in patients recovering from an AMI.

METHODS

A cohort of 74 patients recovering from AMI was studied. Myocardial ischaemia was detected by means of ambulatory electrocardiogram (ECG) monitoring at recruitment (4+/-2 days after AMI), exercise ECG test and stress echocardiography at discharge (7+/-4 days after AMI). LVSF was studied by means of two-dimensional echocardiography at recruitment, at discharge, and at 1, 3, 6 and 12 months after AMI.

RESULTS

Patients with myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had worse LVSF at recruitment than those without ischaemia. The presence of myocardial ischaemia on ambulatory ECG monitoring was an independent determinant of LVSF at recruitment together with infarct localization and size (assessed by creatine kinase MB isoenzyme (CK-MB) levels). Patients with signs of myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had a progressive left ventricular dysfunction compared with those without ischaemia.

CONCLUSIONS

Residual ischaemia is an independent determinant of LVSF after AMI and its presence implied a progressive worsening of the LVSF. Because left ventricular systolic dysfunction is a major determinant of survival after AMI, its precursors, among them residual myocardial ischaemia, should be identified. Treatment of ischaemia is known to be associated with improved prognosis and improved LVSF.

Adrenaline responsiveness in mild hypertension: no evidence for altered beta-adrenoceptor sensitivity

The effects of circulating adrenaline on cardiovascular function were studied in 14 subjects (mean age, 36.5 years; range, 19-46 years) with mild hypertension and in 14 normotensive controls, matched for age and sex. Adrenaline was infused i.v. in step-wise increasing doses (0.1, 0.2, 0.4, and 0.8 nmol/kg/min). Cardiovascular responses were evaluated by echocardiography and noninvasive blood pressure measurements. Noradrenaline, adrenaline, potassium, and cyclic adenosine monophosphate (cAMP) were determined in venous plasma. Systolic and diastolic blood pressure responses to adrenaline were similar in both groups. Adrenaline increased myocardial contractility and stroke volume, but less so in the hypertensive patients. Cardiac output was increased in the hypertensive patients at rest, but the signs of increased myocardial contractility disappeared during adrenaline infusion, most likely because of a reduced myocardial compliance. Increased heart rate and systemic vascular resistances were displayed by the hypertensive patients at all adrenaline concentrations studied, but the responses were similar in both groups. The adrenaline-induced decreases in potassium and increases in cAMP were also similar in both groups. The increases in myocardial contractility and in heart rate are compatible with an increased arousal in mild hypertension at rest. Mild hypertension does not appear to be associated with alterations of beta2-adrenoceptor sensitivity, and the findings do not support that adrenaline is involved in the pathogenesis of primary hypertension.

Accuracy and feasibility of contrast echocardiography for detection of perfusion defects in routine practice: comparison with wall motion and technetium-99m sestamibi single-photon emission computed tomography. The Nycomed NC100100 Investigators

OBJECTIVES

We sought to assess the feasibility and accuracy of myocardial contrast echocardiography (MCE) using standard imaging approaches for the detection of perfusion defects in patients who had a myocardial infarction (MI).

BACKGROUND

Myocardial contrast echocardiography may be more versatile than perfusion scintigraphy for identifying the presence and extent of perfusion defects after MI. However, its reliability in routine practice is unclear.

METHODS

Fundamental or harmonic MCE was performed with continuous or triggered imaging in 203 patients with a previous MI using bolus doses of a perfluorocarbon-filled contrast agent (NC100100). All patients underwent single-photon emission computed tomography (SPECT) after the injection of technetium-99m (Tc-99m) sestamibi at rest. Quantitative and semiquantitative SPECT, wall motion and digitized echocardiographic data were interpreted independently. The accuracy of MCE was assessed for detection of segments and patients with moderate and severe sestamibi-SPECT defects, as well as for detection of patients with extensive perfusion defects (>12% of left ventricle).

RESULTS

In segments with diagnostic MCE, the segmental sensitivity ranged from 14% to 65%, and the specificity varied from 78% to 95%, depending on the dose of contrast agent. Using both segment- and patient-based analysis, the greatest accuracy and proportion of interpretable images were obtained using harmonic imaging in the triggered mode. For the detection of extensive defects, the sensitivity varied from 13% to 48%, with specificity from 63% to 100%. Harmonic imaging remained the most accurate approach. Time since MI and SPECT defect location and intensity were all determinants of the MCE response. The extent of defects on MCE was less than the extent of either abnormal wall motion or SPECT abnormalities. The combination of wall motion and MCE assessment gave the best balance of sensitivity (46% to 55%) and specificity (82% to 83%).

CONCLUSIONS

Although MCE is specific, it has limited sensitivity for detection of moderate or severe perfusion defects, and it underestimates the extent of SPECT defects. The best results are obtained by integration with wall motion. More sophisticated methods of acquisition and interpretation are needed to enhance the feasibility of this technique in routine practice.

Changes in cardiac diastolic dimensions precede hypertrophy in early stages of hypertension

BACKGROUND

Left ventricular hypertrophy (LVH) has been identified as a main target organ change resulting from hypertension, also being a long-term predictor of myocardial infarction, stroke and cardiovascular death. However, very few longitudinal studies exist following the development of LVH in the hypertensive process.

METHODS

The present longitudinal study investigated a population based group of borderline hypertensive men (BHT, n = 66, diastolic blood pressure (BP) 85-94 mm Hg). M-mode echocardiography was performed at baseline and after 3 years, and anthropometrical data recorded.

RESULTS

There was no increase in LVH indices over the 3-year period, while there was a statistically significant increase in aortic root dimension (P < 0.001), left atrial diameter in diastole (LADD, P < 0.001), left ventricular diameter in diastole (LVDD, P < 0.001) and peak systolic wall stress (PSWS, P < 0.01) and a significant decrease in left ventricular ejection time (LVET, P < 0.01). Baseline BP levels correlated to PSWS (P < 0.05) but not to LVH indices, whereas body mass index (BMI) correlated significantly to wall thickness (P < 0.05) and LV mass (P < 0.05).

CONCLUSIONS

LVH indices did not increase over a 3-year period. However, there was a significant increase in aortic root dimension, LADD, LVDD and PSWS, and a significantly shortened LVET, suggesting that these changes precede any increase in LVH. Finally, BMI showed stronger correlation to LVH indices than did BP levels.

Diastolic and systolic function as predictors of exercise capacity after myocardial infarction in young Men

We evaluated the power of measurements of left ventricular (LV) systolic and diastolic function for predicting exercise capacity in 97 young male survivors of a myocardial infarction. The patients were evaluated with M-mode echocardiography, a symptom-limited exercise test and coronary and LV angiography. In univariate analyses, maximum exercise workload was most closely related to the atrial emptying index, an index of diastolic function (r = 0.37, p < 0.005), but not to LV ejection fraction (r = 0.001, NS). This relationship was stronger in the 42 patients without signs of ischemia during exercise (r = 0.51, p < 0.005). Multivariate analyses indicated that the atrial emptying index (p < 0.005) provided independent contribution to the prediction of maximum exercise capacity. LV diastolic function but not LV systolic function was related to exercise capacity in young survivors of myocardial infarction.

Markers of risk after acute myocardial infarction. A comparison of clinical variables, ambulatory and exercise electrocardiography, echocardiography, and stress echocardiography

BACKGROUND

Short-term mortality after myocardial infarction has decreased continuously among members of selected populations. Nonetheless, the long-term prognosis among members of unselected populations remains bad. Further research in risk stratification is therefore needed. In the present study we tested the additive value of clinical variables, echocadiography, ambulatory electrocardiography, exercise testing, and stress echocardiography in assessing the long-term prognosis after acute myocardial infarction.

METHODS

Two-dimensional echocardiography and ambulatory electrocardiography (analysis of ST-segment changes and of heart rate variability) were performed for 74 patients aged < 75 years who had had an acute myocardial infarction. Before their discharge from hospital, 70 patients were subjected to a combined exercise test and stress echocardiography. The time of follow-up was > or = 3 years.

RESULTS

During follow-up 18 patients died, and 38 suffered cardiac events defined as death, nonfatal reinfarction and the need for revascularization. We first tested 31 covariates in a univariate regression analysis. A subsequent multivariate analysis was performed in two stages. During the first of these, clinical variables (a history of systemic hypertension, infarct localization, and diabetes mellitus) and variables derived from noninvasive tests (new-onset wall-motion abnormality during stress echocardiography, ST-segment depression and heart-rate variability during ambulatory electrocardiography, the ejection fraction by echocardiography at rest, and the double product during exercise tests) predicted mortality. After the second stage, however, the only remaining independent predictors of mortality were the presence of a new-onset wall-motion abnormality (P < 0.0001, relative risk 13.5, 95% confidence interval 3.6-51.3), ST-segment depression during ambulatory electrocardiography (P = 0.003, relative risk 5.0, 95% confidence interval 1.7-15.7) and a decreased heart rate variability (P = 0.007).

CONCLUSIONS

The only variables that were of independent value in assessing the long-term mortality were those expressing residual myocardial ischemia and the cardiovascular sympatho-vagal balance. It is, therefore, recommended that one should monitor these variables for patients recovering from an acute myocardial infarction.

Heart rate variability as a means of assessing prognosis after acute myocardial infarction. A 3-year follow-up study

AIMS

The present study evaluated the prognostic value of heart rate variability after acute myocardial infarction in comparison with other known risk factors. The cut-off points that maximized the hazards ratio were also explored.

PATIENTS AND METHODS

Heart rate variability was assessed with 24 h ambulatory electrocardiography in 74 patients with acute myocardial infarction, 4 +/- 2 days after hospital admission and in 24 healthy controls. Patients were followed for 36 +/- 15 months.

RESULTS

During follow-up, 18 patients died, nine suffered a non-fatal infarction and 20 underwent revascularization procedures. Heart rate variability was higher in survivors than in non-survivors (P = 0.005). This difference was found at higher statistical levels when comparing non-survivors vs controls (P = 0.0002). A similar statistically significant difference was also found between survivors vs controls (P = 0.04). Patients suffering non-fatal infarction and cardiac events (defined as death, non-fatal infarction or revascularization) had a lower heart rate variability than those without (P = 0.03 and P = 0.03, respectively). With multivariate regression analysis, decreased heart rate variability independently predicted mortality and death or non-fatal infarction. The presence of a left ventricular ejection fraction < 40% and a history of systemic hypertension were, however, stronger predictors. The cut-off points that maximized the hazards ratio using the Cox model differed from those reported by others.

CONCLUSION

Decreased heart rate variability independently predicted poor prognosis after myocardial infarction. However, the cut-off points that should be used in clinical practice are still a matter for further investigation.

Stress-induced laboratory blood pressure in relation to ambulatory blood pressure and left ventricular mass among borderline hypertensive and normotensive individuals

Our primary aim in the present study was to investigate the association between blood pressure measured in the laboratory and in the ambulatory state in a group of middle-aged borderline hypertensive men and age-matched normotensive control subjects. In addition, we examined the relation between stress-induced blood pressure measurements and left ventricular mass. Blood pressure and heart rate were measured noninvasively during a standardized laboratory stress protocol and four times per hour throughout 24 hours. Borderline hypertensive subjects had significantly higher systolic and diastolic pressures than normotensive subjects during both the daytime (systolic pressure, 141.1 +/- 9.7 versus 130.9 +/- 8.6 mm Hg; diastolic pressure, 88.8 +/- 7.0 versus 79.4 +/- 6.2 mm Hg, P < .001) and nighttime (systolic pressure, 114.0 +/- 9.9 versus 107.1 +/- 8.3 mm Hg; diastolic pressure, 71.5 +/- 7.5 versus 64.6 +/- 7.2 mm Hg, P < .001). The borderline hypertensive group also displayed increased systolic pressure reactivity in the laboratory compared with the normotensive group. The groups did not differ significantly in left ventricular mass (index). In both borderline hypertensive and normotensive individuals, blood pressure levels during stress testing were closely related to ambulatory blood pressure levels (r = .51 to .82). Furthermore, stress-induced blood pressure levels were significantly correlated to left ventricular mass in borderline hypertensive (r = .33 to .40) but not normotensive subjects. Since stress-induced blood pressure levels were significantly associated with both ambulatory blood pressure levels and left ventricular mass in borderline hypertensive subjects, the addition of standardized stress testing to casual blood pressure measurements may improve risk estimation.

Benefit of converting enzyme inhibition on left ventricular volumes and ejection fraction in patients receiving beta-blockade after myocardial infarction. CONSENSUS II multiecho study group

Beta-blockers reduce infarct size and improve survival after acute myocardial infarction (MI). Post-MI angiotensin-converting enzyme inhibition also improves survival and may attenuate left ventricular (LV) dilatation. We evaluated the effect of early enalapril treatment on LV volumes and ejection fraction (EF) in patients on concomitant beta-blockade after MI. Intravenous enalaprilat or placebo was administered <24 hours after MI and was continued orally for 6 months. LV volumes were assessed by echocardiography 3 +/- 2 days, 1 and 6 months after MI. Change in LV diastolic volume during the first month was attenuated with enalapril (2.7 vs placebo 6.5 ml/m2 change; p < 0.05), and significantly lower LV diastolic and systolic volumes were observed with enalapril treatment compared with placebo at 1 month (enalapril 47.21 23.9 vs placebo 53.1/29.2 ml/m2; p < 0.05) and at 6 months (enalapril 47.9/24.8 vs placebo 53.8/29.6 ml/m2; p < 0.05). EF was also significantly higher 1 month after MI in these patients (enalapril 50.4% vs placebo 46.4%; p < 0.05). Our date demonstrate that early enalapril treatment attenuates LV volume expansion and maintains lower LV volumes and higher EF in patients receiving concurrent beta-blockade after MI. A possible additive effect of combined therapy should be evaluated prospectively.

Prognostic value of predischarge exercise stress echocardiography after acute myocardial infarction

A predischarge exercise test was performed by 70 patients 7 +/- 4 days (mean +/- SD) after acute myocardial infarction (AMI) to determine the short- and long-term prognostic value of predischarge exercise stress echocardiography (Ex-Echo) compared with exercise stress electrocardiography (Ex-ECG). Two-dimensional echocardiograms were obtained at rest and immediately after exercise; a wall motion score index was obtained both at rest and immediately after exercise. Results of the Ex-Echo were positive in 27 patients (39%), whereas those of Ex-ECG were positive in 34 (49%). The wall motion index after exercise was lower in patients who died during follow-up (85 vs 98, p = 0.01) and in those with cardiac events, defined as death, nonfatal reinfarction, or revascularization (88 vs 98, p = 0.005). More patients with a positive Ex-Echo result had short-term cardiac events (within 2 weeks) than patients with a negative Ex-Echo (6 [22%] vs 2 [5%], p = 0.04). The same was true for long-term mortality (12 [44%] vs 3 [7%], p = 0.0002), reinfarctions (10 [37%] vs 4 [9%], p = 0.01), revascularization procedures (11 [41%] vs 7 [16%], p = 0.023), and cardiac events (22 [81%] vs 12 [28%], p < 0.0001). Survival time was shorter in patients with positive compared with negative Ex-Echo results (34% difference between groups, 95% confidence interval [CI] 10% to 58%, p = 0.002). The same applied for cumulative survival free from cardiac events (43%, p = 0.001, 95% CI 9% to 77%.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic value of exercise stress testing versus ambulatory electrocardiography after acute myocardial infarction: a 3 year follow-up study

BACKGROUND

The aim of this study was to evaluate the prognostic significance of myocardial ischemia detected by ambulatory ECG monitoring (AEM) and exercise stress testing (ExT) following acute myocardial infarction.

METHODS

The prognostic value of AEM versus ExT was studied prospectively in 74 patients with a recent acute myocardial infarction. Myocardial ischemia was diagnosed by the presence of ST-segment depression occurring during AEM or ExT 4 +/- 2 and 7 +/- 4 days after hospital admission respectively. ST-segment depression during AEM was defined as a horizontal/downsloping depression of > or = 0.1 mV from the reference baseline, measured 80 ms after the J point, elapsing > or = 1 min. ST-segment depression at ExT was determined as > or = 1mm horizontal or downsloping ST-segment depression in at least two consecutive ECG leads.

RESULTS

Twenty-two patients (30%) showed ST-segment depression during AEM and 34 (49%) on ExT. During a mean follow-up period of 3 years (36 +/- 15 months), 10 patients (45%) with ST-segment depression on AEM died compared with eight (15%) without; 12 patients (35%) with ST-segment depression on ExT died versus three (8%) without. Death or reinfarction occurred in 13 patients (59%) with ST-segment depression on AEM versus nine (17%) without, and in 13 patients (38%) with ST-segment depression on ExT compared with six (17%) without. Revascularization procedures were similar in patients with or without ST-segment depression during AEM and ExT. Cardiac events defined as death, nonfatal reinfarction or revascularization, occurred in 18 patients (82%) with ST-segment depression on AEM versus 20 (38%) without, and in 23 patients (68%) with ST-segment depression on ExT versus 11 (31%) without. Survival analysis using Kaplan-Meier curves showed that patients showing no ST-segment depression with either technique had longer survival times than did patients showing ST-segment depression on either AEM or ExT, or showing ST-segment depression with both techniques. This was also true when analyzing the cumulative survival rate until the occurrence of any endpoint. With multivariate regression analysis, ST-segment depression on AEM was the variable most strongly predictive of mortality, followed by ST-segment depression on ExT, hypertension, and diabetes.

CONCLUSIONS

These findings illustrate the ability AEM and Ext independently to predict long-term cardiac mortality and morbidity rates in patients recovering from acute myocardial infarction. The combined use of these techniques is useful for detecting patients at high risk after acute myocardial infarction.

Long-term prognostic significance of M mode echocardiography in young men after myocardial infarction

OBJECTIVE

To evaluate the power of measurements of left ventricular size and function for predicting long term (82 month) mortality by performing echocardiography in 97 men who had survived an acute myocardial infarction.

SETTING

University hospital specialising in cardiology.

PARTICIPANTS

97 consecutive male patients who had survived a myocardial infarction.

MAIN OUTCOME MEASURES

The additive prognostic value of functional measurements to that provided by primary risk factors (smoking habits and lipoprotein levels), radiological heart size, exercise capacity, and number of major coronary arteries with haemodynamically significant stenoses was evaluated. An echo index was calculated from three echocardiographic variables (yielding one score point each if: left ventricular diameter at the end of diastole (LVDD) > or = 5.7 cm, left ventricular fractional shortening < or = 24%, and E point-separation (EPSS) > or = 10 mm).

MAIN OUTCOME

17 cardiac deaths occurred during follow up.

RESULTS

Univariate analysis showed that treatment with loop diuretics for heart failure (P < 0.01), LVDD (P < 0.01), left ventricular diameter at the end of systole (LVDS) (P < 0.001), left atrial diameter (P < 0.001), fractional shortening (P < 0.05), and echo index (P < 0.001) were all associated with cardiac death. Angiographically determined regional wall motion disturbances (P < 0.005) and angiographic ejection fraction (P < 0.001) were also associated with cardiac death, as was the number of major coronary arteries with significant stenosis (P < 0.05). When all significant echocardiographic variables from univariate analysis were entered into Cox proportional hazards survival analysis, LVDS and left atrial diameter contributed independently to the prediction of cardiac death. If angiographic data were also entered into the model, the echo index made an independent contribution to the prediction of cardiac death.

CONCLUSIONS

Among young male patients with a previous myocardial infarction, a simple M mode echocardiographic examination can identify high and low risk patients and improve the prediction of cardiac death made from clinical information, exercise test, chest x ray and angiographically determined ejection fraction.

ST-segment depression on ambulatory electrocardiography in the early in-hospital period after acute myocardial infarction predicts early and late mortality: a short-term and a 3-year follow-up study

A surveillance study was conducted to determine the in-hospital and long-term prognostic value of ST-segment depression assessed by ambulatory electrocardiographic monitoring (AEM) during the early in-hospital period after acute myocardial infarction (AMI). ST-segment depression (STD) was determined by computer analysis of 24-h ECG tapes as a horizontal or downsloping change in ST level by > 0.1 mV from the reference base line. The ST level was measured 80 ms after the J point of all normally conducted complexes for > or = 1 min. All computer-detected ST events were verified by one trained reader. Tapes corresponding to 74 patients were analyzed. In addition, 23 tapes corresponding to age- and gender-matched controls were also analyzed. Patients were divided into two groups: 22 patients (30%) showed STD (Group A), and 52 patients (70%) had no episode of STD (Group B). Among controls, 1 person (4%) showed STD. During the early follow-up period (14 +/- 11 days after hospital admission), cardiac events occurred in 11 patients [7 (32%) in Group A and 4(8%) in Group B, p < 0.01], including 6 cardiac death [5 (23%) in Group A and 1 (2%) in Group B, p < 0.01], 3 acute coronary artery bypass surgeries [2 (9%) in Group A and 1 (2%) in Group B, p = NS], and 2 nonfatal myocardial infractions (both in Group A, p = NS). During a mean follow-up period of 3 years (36 +/- 15 months), 18 patients died [10 (45%) in Group A and 8 (15%) in Group B, p = 0.01]. Eleven deaths were sudden [7 (32%) in Group A and 4 (8%) in Group B, p < 0.01]. Eighteen AMI occurred [11 (50%) in Group A and 7 (13%) in Group B, p < 0.005]. Twenty patients underwent revascularization procedures [7 (32%) in Group A and 13 (25%) in Group B, p = NS].(ABSTRACT TRUNCATED AT 250 WORDS)

Structural cardiac changes in relation to 24-h ambulatory blood pressure levels in borderline hypertension

OBJECTIVES

To investigate left ventricular hypertrophy (LVH) in relation to 24-h ambulatory blood pressure (24-ABPM) and insulin levels in borderline hypertension.

DESIGN

A case-control study.

SUBJECTS

Borderline hypertensive men (diastolic blood pressure (DBP) 85-94 mmHg, n = 69) and age-matched normotensive controls (DBP < or = 80 mmHg, n = 69) from a population screening programme.

MAIN OUTCOME MEASURES

Echocardiography (M-mode), insulin (RIA) and 24-APBM (Del Mar P-IV) levels.

RESULTS

The borderline group showed a significant increase in septal thickness (10.4 +/- 1.5 vs. 9.7 +/- 1.5 mm, P < 0.01), peak systolic wall stress (218 +/- 38 vs. 202 +/- 38 10(3) dynes cm-2, P < 0.05) and a decrease in LV ejection time (28.4 +/- 2.5 vs. 29.5 +/- 2.1s, P < 0.01). The septum vs. posterior wall thickness ratio was significantly higher in the borderline group (1.13 +/- 0.14 vs. 1.06 +/- 0.14, P < 0.01). Casual BP levels did not correlate with LVH indices, while 24-ABPM systolic levels correlated strongly with LVH indices in the borderline group (r = 0.22-0.52, P < 0.05) but not in the normotensive group. Insulin levels correlates strongly with LVH indices in the normotensive group (r = 0.34-0.47, P < 0.01) but not the borderline, group.

CONCLUSIONS

Signs of asymmetric LVH and altered ventricular function are already detectable in borderline hypertension. The data also suggest that early structural cardiac changes are related to ambulatory blood pressure profile, but not to casual blood pressure or trophic factors such as insulin.

Assessment and significance of ST-segment changes detected by ambulatory electrocardiography after acute myocardial infarction

This study assessed the prognostic value of ST-segment changes detected by ambulatory electrocardiographic monitoring during the early in-hospital period after acute myocardial infarction. New methods for defining the ST-segment reference level and for measuring ST-segment elevation were used. ST-segment depression was defined as a change in ST level by > or = 0.1 mV 80 ms after the J point, elapsing > or = 1 minute. ST-segment elevation was defined as a deviation by > or = 0.15 mV, elapsing > or = 1 minute, and measured at the J point. An interval of > or = 2 minutes was required before another discrete episode was counted. Four ST-segment reference levels were automatically calculated: (1) "isoelectric," (2) "nearest to normal," (3) "24-hour median," and (4) "first-hour median." During a mean follow-up period of 3 years (mean 36 +/- 15 months), 47 cardiac events occurred in 38 patients: 18 deaths, 9 nonfatal reinfarctions, and 20 revascularization procedures. More deaths occurred in patients with than without ST elevation-24-hour median (22% vs 5%, p = 0.03), and in patients with than without ST depression-isoelectric (61% vs 32%, p = 0.02), and in patients with than without ST-depression-24-hour median (61% vs 23%, p = 0.003). "All cardiac events" (deaths, infarctions, or revascularization procedures) occurred more often in patients with than without ST depression-isoelectric (55% vs 22%, p = 0.003), and in patients with than without ST-depression-24-hour median (47% vs 17%, p = 0.004). Sensitivity, specificity, and accuracy of ST depression/elevation-24-hour median to assess mortality were 78%, 71%, and 73%, respectively.

Long-term prognostic importance of exercise echocardiography after an episode of unstable angina

The aim of this study was to determine whether exercise echocardiography gives long-term prognostic information in patients with unstable angina. Treadmill exercise echocardiography was performed before discharge in 33 consecutive patients (23 men, 10 women) with unstable angina. A wall motion score index (WMSI) was calculated from visual interpretation of 9 left-ventricular segments, registered with two-dimensional echocardiography. Within an 8-year follow-up period, there were 10 medical events (2 cardiac deaths and 8 myocardial infarctions). New or worsening wall motion abnormalities and a low WMSI immediately after the exercise test were associated with subsequent myocardial infarction or cardiac death during follow-up (p < 0.05). Only 1 of the patients with a WMSI above the median suffered a myocardial infarction, which was not fatal. In contrast, 9 (56%) of the 16 patients with a WMSI below the median suffered myocardial infarction or cardiac death during follow-up. These findings in patients with unstable angina suggest that exercise echocardiography is a sensitive method for detecting those with increased risk of myocardial infarction or cardiac death. These high-risk patients might benefit from a more aggressive therapeutic approach.

Response of plasma neuropeptide Y and noradrenaline to dynamic exercise and ramipril treatment in patients with congestive heart failure

Forty-two patients with congestive heart failure were studied in order to clarify whether the plasma level of neuropeptide Y-like immunoreactivity (NPY-LI) rises in parallel with plasma noradrenaline (NA) during physical exercise in congestive heart failure (CHF). All patients were studied in a randomized placebo-controlled trial with the ACE-inhibitor ramipril during 12 weeks to determine whether ACE-inhibition alters the response of plasma NPY-LI to exercise. The patients were treated with diuretics and had stable congestive heart failure (NYHA classes II-III). Plasma NPY-LI was 50 +/- 5 pmol l-1 (mean +/- standard error of the mean) at rest and 60 +/- 6 pmol l-1 at the end of exercise at baseline (P < 0.01). The corresponding values for plasma NA were 2.8 +/- 0.2 nmol l-1 and 15.3 +/- 1.2 nmol l-1 (P < 0.001). Before ACE-inhibition, there was a correlation between high NPY-LI and NA values after exercise. After treatment with ramipril or placebo for 12 weeks, there was no difference in plasma NPY-LI and NA at rest or after exercise between the two treatment groups. The maximal exercise time was unchanged. It is concluded that plasma NPY-LI and NA were elevated at rest in CHF. The additional rise of plasma NPY-LI and NA after exercise was attenuated in CHF compared to healthy individuals. ACE-inhibition with ramipril did not alter plasma NPY-LI or NA at rest or after exercise compared to placebo.

Assessment of left ventricular wall motion in angina pectoris by two-dimensional echocardiography and myocardial perfusion by technetium-99m sestamibi tomography during adenosine-induced coronary vasodilation and comparison with coronary angiography

Myocardial perfusion and regional wall motion during adenosine-induced coronary vasodilation were assessed in 40 patients with angina pectoris by technetium-99m sestamibi single-photon emission computed tomography (SPECT) and simultaneous 2-dimensional echocardiography. Adenosine was infused intravenously at a dose of 140 micrograms/kg body weight per minute for 6 minutes, and technetium-99m sestamibi was injected at 3 minutes. Adenosine caused a significant decrease in systolic and diastolic blood pressure and a significant increase in heart rate and the heart rate-blood pressure product. Adverse effects were mild and transient and no patient required aminophylline. Completely or partially reversible defects on SPECT were present in 28 patients, a fixed defect was seen in 4 patients, and no defect was seen in 8 patients. Two-dimensional echocardiography revealed a new or worsening wall motion abnormality in 21 patients, a fixed abnormality in 4 patients and no abnormality in 15. Transient perfusion defects were associated with transient wall motion abnormalities in 71% of cases. The overall sensitivity, specificity and predictive accuracy of adenosine echocardiography in detecting significant coronary artery disease (> 50% diameter stenosis) were 74, 100 and 78%, respectively, whereas those of adenosine SPECT were 94, 100 and 95%, respectively (p < 0.05, NS, and < 0.05, respectively). Thus adenosine technetium-99m sestamibi SPECT has a higher sensitivity and predictive accuracy than adenosine echocardiography, suggesting that adenosine-induced perfusion defects are not always associated with wall motion abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic dosing in prophylactic treatment of hemophilia A

The aim of this study was to investigate individual pharmacokinetics as a tool for dosing of factor VIII (FVIII) in severe hemophilia A. It is assumed that effective prophylaxis against bleedings is maintained if the plasma FVIII:C activity is kept above 1 U/dl, and the present study is based on this assumption. A current standard dosage regimen for FVIII is 25-40 U/kg up to three times weekly. However, there is considerable individual variation in the pharmacokinetics of FVIII:C. Individual pharmacokinetic data were used to computer-simulate plasma activity curves after repeated doses in 8 patients. Going from prophylaxis regimens of normally 2-3 infusions per week to dosing every 2 days would theoretically reduce their average FVIII consumption by 43% with maintained or increased trough levels of FVIII:C. Daily dosing would reduce their mean FVIII usage by 82%. Modified dosage regimens, infusions every 2 days, were implemented in the patients, and plasma samples were drawn to verify the pharmacokinetic models. The feasibility of the method to generally raise trough levels with a decreased consumption of FVIII was confirmed. Dosing of coagulation factors according to kinetic principles can result in more cost-effective utilization of these very expensive preparations.

Prevalence and significance of transient--predominantly asymptomatic--myocardial ischemia on Holter monitoring in unstable angina pectoris, and correlation with exercise test and thallium-201 myocardial perfusion imaging

The prevalence and clinical significance of transient myocardial ischemia was evaluated prospectively in 43 patients with a clinical diagnosis of unstable angina. Continuous 2-channel Holter electrocardiographic monitoring was begun < 24 hours after admission. In 3,558 hours of recordings (mean 83 +/- 20 hours/patient), there were 1,671 episodes of transient ischemia; > 90% were asymptomatic. All patients but 1 had at least 1 episode of transient ischemia. Twenty-two patients (group 1) had a total ischemic duration of > or = 30 minutes/day, whereas 21 patients (group 2) had a total ischemic duration of < 30 minutes/day. A predischarge symptom-limited exercise test was performed in 40 of these patients after medical stabilization and 39 patients underwent exercise thallium-201 imaging, an average of 3 days after the exercise test. During a follow-up period of 39.9 +/- 9 months (range 28 to 49), 4 patients developed myocardial infarction and 22 required revascularization because of medically refractory angina. There were significantly more patients with total cardiac events (myocardial infarction or a need for revascularization) in group 1 than in group 2 (p < 0.05). Among patients undergoing an exercise test and exercise thallium-201 imaging, a positive exercise electrocardiogram and the presence of a reversible thallium-201 perfusion defect were also significant predictors of subsequent cardiac events (p < 0.05 and p < 0.001, respectively). The results of the Holter recordings did not add significantly more prognostic information.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of exercise thallium-201 myocardial perfusion imaging compared to stress echocardiography and clinical variables in patients with unstable angina who respond to medical treatment

The prognostic value of thallium-201 imaging in patients with unstable angina is not well established. Forty consecutive patients with unstable angina who had responded to medical therapy underwent predischarge symptom-limited exercise testing and 39 of them underwent exercise thallium-201 imaging, on average 3 days after the exercise test. Exercise echocardiography was performed in 36 of these patients in conjunction with the predischarge exercise test. Patients with previous myocardial infarction, coronary revascularization, left bundle branch block and dilated cardiomyopathy were not included in the study. An echocardiographic wall-motion score index was derived by analyzing left ventricular regional wall motion. During a follow-up period of 30 +/- 6.4 months, 3 patients had a non-fatal myocardial infarction and 20 required revascularization because of a recurrence of severe medically refractory angina. Univariate predictors of cardiac events (non-fatal myocardial infarction or a need for revascularization) during follow-up included ST-depression during exercise, positive exercise echocardiography, a low exercise wall-motion score index, the presence of thallium-201 redistribution and the number of myocardial segments with thallium-201 redistribution. However, stepwise logistic regression analysis revealed that the presence of thallium-201 redistribution was the only significant non-invasive predictor (P < 0.005) of a cardiac event among patients who underwent predischarge exercise testing and exercise thallium-201 imaging. Among patients undergoing exercise echocardiography and exercise thallium-201 imaging, the number of segments with thallium-201 redistribution was the only significant predictor (P < 0.0005) of future cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive ambulatory 24 h blood pressures and basal blood pressures predict development of sustained hypertension from a borderline state

A sample of 143 male borderline hypertensives aged 35 to 45, screened from a population cohort, were subjected to psychological stress, static work, and ambulatory 24 h blood pressure (BP) monitoring to assess the predictive power of BP reactivity in the development of established hypertension. After 1 year, a follow-up showed that 21 subjects (14.7%) had developed established hypertension (causal diastolic (D) BP > or = 95 mm Hg), 25 subjects (15.7%) had become normotensive (causal DBP < 85 mm Hg), and 97 (67.8%) remained within the borderline range (causal DBP 85 to 94 mm Hg). Those who developed established hypertension had considerably higher initial basal resting blood pressures than those who remained borderline: systolic (S) BP 134.2 +/- 12.5 v 127.6 +/- 10.7 mm Hg, P < .05 and DBP 86.8 +/- 7.9 v 80.4 +/- 7.0 mm Hg, P < .01. They had also somewhat higher BP values during mental arithmetic exercises and hand-grip work (peak DBP 101.1 +/- 8.8 v 96.8 +/- 8.7 mm Hg, P < .05, and 131.4 +/- 14.8 v 123.5 +/- 12.9 mm Hg, P < .05, respectively). Those subjects who developed established hypertension had significantly higher 24 h mean blood pressures than those who remained borderline (24 h SBP 133.3 +/- 11.4 v 126.0 +/- 10.1 mm Hg, P < .01, and DBP 84.7 +/- 5.7 v 81.6 +/- 6.8 mm Hg, P < .05). This difference was attributed mainly to the differences found during daytime (07:00 to 19:00) hours but was also found to be nominally dependent upon those found during nighttime (01:00 to 07:00) hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Early exercise thallium-201 single photon emission computed tomography in unstable angina: a prospective study

To evaluate the safety and diagnostic value of early symptom-limited exercise electrocardiography (ECG) and exercise thallium-201 single photon emission computed tomography (SPECT) in unstable angina (UA), 39 patients were studied prospectively soon after stabilization on medical treatment. No patient had a history of myocardial infarction (MI) or revascularization and patients with left bundle branch block were excluded. Exercise ECG and exercise thallium-201 SPECT were performed 8 +/- 4 days and 11 +/- 6 days respectively after admission to hospital. Seventeen out of 39 patients (44%) had positive exercise ECGs and 22 (56%) negative or inconclusive ones. Exercise thallium-201 SPECT was positive in 26 patients (67%) and negative in 13 patients (33%). Thirty-one patients underwent coronary arteriography and 24 of them proved to have significant coronary artery disease (CAD). The sensitivity, specificity and positive predictive value of exercise ECG in detecting CAD are 62%, 86%, and 94% respectively while the corresponding results are 96%, 100%, and 100% for exercise thallium-201 SPECT. Therefore, it is concluded that the early symptom-limited exercise test is safe in medically stabilized patients with UA. Early exercise thallium-201 SPECT is highly sensitive and predictive of the presence of significant CAD among patients in the early recovery phase of UA and can be used in selecting this group of patients for coronary angiography and other therapeutic strategies.

Exercise echocardiography after stabilization of unstable angina: correlation with exercise thallium-201 single photon emission computed tomography

The diagnostic usefulness of predischarge exercise echocardiography in 35 patients with unstable angina who responded to medical therapy was correlated with exercise thallium-201 single photon emission computed tomography (TI-SPECT) performed, on the average, three days after the exercise echocardiography. None of the patients had myocardial infarction prior to hospitalization or before TI-SPECT and none had left bundle-branch block on their rest electrocardiogram (ECG). Exercise echocardiography was positive in 21 patients and TI-SPECT in 24. The results of the two techniques were concordant in 28 of 35 patients (agreement = 80%, k = 0.57 +/- 0.14, p less than 0.001). Wall-by-wall comparison of the distribution of exercise-induced wall motion abnormalities with reversible thallium defects showed complete or partial correlation in all of 19 patients in whom both the tests were positive. A positive exercise ECG and positive exercise echocardiography identified 11 of 11 patients with angiographically verified significant coronary artery disease (CAD) and 11 of 12 patients (92%) with positive TI-SPECT. Thus, exercise echocardiography is a valuable addition to routine predischarge exercise test in the noninvasive diagnosis of myocardial ischemia and shows a good correlation with TI-SPECT in detecting and localizing ischemia in patients with unstable angina stabilized on medical therapy.

Effects of sympatho-adrenal activation on the finger microcirculation in mild hypertension

Finger skin circulatory responses to three forms of sympatho-adrenal activation were investigated in 14 patients with mild hypertension and 14 matched normotensive controls. Finger nailfold skin capillary blood cell velocity was measured by video-photometric capillaroscopy and finger pulse volume by strain-gauge plethysmography (digital arterial pulse amplitude; DAPA). DAPA decreased more markedly in the normotensive as compared with the hypertensive group during mental arithmetic stress (38 vs. 19%; P less than 0.05) and a cold pressor test (55 vs. 32%; P less than 0.05). Intravenous infusions of adrenaline (0.1-0.8 nmol/kg/min) decreased DAPA in normotensives but not in hypertensives (P less than 0.05). Capillary blood cell velocity was similar in the two groups at rest and decreased promptly and to a similar extent in both groups following mental arithmetic, adrenaline infusion and the cold pressor test (by approximately 60, 60 and 35%, respectively). It is concluded that mental stress and the cold pressor test induce instantaneous and marked effects on the skin circulation via neurogenic activation. The less marked effect on DAPA in the hypertensive group may reflect an elevation of basal vascular tone and/or early structural vascular changes in mild hypertension. The discrepancy between total finger and capillary circulatory responses to adrenaline may be attributable to different adrenoceptor populations and/or sensitivity in arteriovenous shunts, as compared with precapillary vessels.