Echocardiographic assessment of left ventricular function in coronary arterial disease.

This investigation was designed to determine the role of echocardiography in the assessment of left ventricular function in patients with significant coronary arterial disease. Satisfactory echocardiograms were obtained in 43 patients with coronary arterial disease. The ventriculographic ejection fraction was determined by the area length method. The echocardiographic left ventricular end-diastolic dimension was increased to more than 5-4 cm in 17 patients. Fifteen of these patients had an ejection fraction of 0-45 or less. Three patients had a normal left ventricular end-diastolic dimension but an ejection fraction of less than 0-45. Twenty-three patients had an ejection fraction of more than 0-45 and a normal left ventricular end-diastolic dimension. The left ventricular end-diastolic dimension index was increased (greater than 3 cm/m2) in 15 patients, all of whom had ejection fraction of less than 0-45. Three patients had a normal left ventricular end-diastolic dimension index and an ejection fraction of less than 0-45. Twenty-five patients had a left ventricular end-diastolic dimension index of less than 3 cm/m2 or less and an ejection fraction of more than 0-45. The percentage fractional shortening of the echocardiographic left ventricular dimension was reduced in 25 patients. In 18 of these the ejection fraction was 0-45 or less. The percentage fractional shortening of the left ventricle was normal in 18 patients. In 2 of them the ejection fraction was less than 0-45. In summary, increase of the left ventricular end-diastolic dimension or left ventricular end-diastolic dimension index is usually associated with a critical reduction of the ejection fraction as determined by ventriculography. Since the ejection fraction is an important determinant of mortality related to bypass graft surgery, echocardiography should be useful in the detection of patients with a poor prognosis.     

Phasic abnormalities of left ventricular emptying in coronary artery disease.

Seventy subjects with suspected coronary artery disease were studied by radionuclide angiocardiography. Delayed or paradoxically emptying regions of the left ventricle were detected by a relatively new nuclear technique--phase imaging. The results were assessed in the light of cardiac catheterisation findings. Compared with 19 normals, regions with abnormally high phase (and therefore late emptying) were found in 42 of 61 subjects with coronary disease. High phase values were associated with total occlusion of a major coronary artery, low ejection fraction, and extensive wall motion abnormalities. The phase image greatly facilitated the calculation of contractile segment ejection fraction in 14 cases of left ventricular aneurysm. In three of these postoperative left ventricular ejection fraction agreed closely with preoperative contractile segment ejection fraction and there was a distinct improvement in the phase image after aneurysmectomy.     

Myocardial metabolism of glutamate and left ventricular function in patients with coronary arterial disease

Fractional myocardial extraction of glutamate, glutamine, ammonia, glucose and lactate was studied in 35 male patients during rest and atrial pacing. Fourteen patients had no coronary arterial disease. In 21 patients with coronary arterial disease and left ventricular dysfunction the increased myocardial extraction of glutamate at rest positively correlated with increased extraction of glucose, lactate and glutamine release, while it was inversely related to ammonia release. In 9 of these 21 patients pacing did not affect either left ventricular contractile function or myocardial metabolism of all studied compounds. In the other 12 patients pacing caused a decrease in left ventricular ejection fraction, velocity of circumferential fiber shortening and new regional wall motion abnormalities. A more pronounced pacing-induced left ventricular dysfunction was accompanied by myocardial lactate production and 2-fold decrease in myocardial glutamate extraction which was associated with the reduction of glutamine release and increased myocardial ammonia production. Possible relationships between alterations in myocardial glutamate metabolism and diminished ventricular performance have been reviewed. The results suggest the importance of myocardial glutamate extraction for the contractile function of human ischemic heart.     

Intramyocardial coronary arterial changes in rheumatic mitral valve disease. Relation to left ventricular function

A retrospective analysis of intramyocardial coronary arterial changes was done in excised papillary muscles obtained at surgery in 46 cases with rheumatic mitral valve disease (RMVD). The findings were correlated with left ventricular function. Vessel wall thickening with obliteration of the lumen was found in 15 patients (32.6%) while adventitial and perivascular fibrosis was found in 12 cases (26%). Patients with microarteriopathy had significantly higher left ventricular and diastolic pressure (p less than 0.05), lower ejection fraction (p less than 0.001), and lower cardiac index (p less than 0.01), as compared to patients with no microarteriopathy. The incidence of left ventricular dysfunction and surgical mortality was higher in patients with microarteriopathy (80 and 47%, respectively) than in those with normal microvasculature (26 and 13%, respectively). As a test for predicting left ventricular dysfunction and surgical mortality a positive biopsy was moderately sensitive (sensitivity 60 and 64%, respectively) and highly specific (specificity 88 and 77%, respectively). Successful outcome after mitral valve replacement was correctly predicted by a negative biopsy result in 87% cases. We conclude that in RMVD, microarteriopathy is associated with left ventricular dysfunction and poor postoperative prognosis.     

Detection of diastolic left ventricular function abnormalities in patients with coronary artery disease and normal systolic function

We angiographically calculated left ventricular (LV) filling in 50 patients, all of whom had normal systolic LV function and 21 (42%) of whom had coronary artery disease. Five volume determinations were made: at end systole (ESV), first third (DV 1/3, half (DV 1/2), and second third of diastole (DV 2/3), and at the end of diastole (EDV). To assess different modalities of filling, we calculated filling fractions in the first third (FF 1/3) as the ratio of volume filled in the first third diastole (DV 1/3-ESV) over total diastolic filling (EDV-ESV). Similar filling fractions (FF) were calculated at half (FF 1 /2), second third (FF 2/3), and last third (FF 3/3) of diastole. We found significant differences between normal and coronary artery disease patients as follows: FF 1/3: 37.4± 14.9 versus 23.8±11.9%, respectively (p<0.002); FF 1/2: 58.6±14.7 versus 45.3±15.1% (p<0.005); FF 2/3: 33.8±15.2 versus 39.0±10.4% (NS), and differences in the opposite direction in the FF 3/3: 28.8± 15.2 versus 37.2±11.9% (p<0.02), respectively. We conclude that LV filling is accomplished differently in patients with coronary artery disease even if they have normal systolic function.     

血糖异常的冠心病患者左室舒张功能与动脉僵硬度的关系

目的 通过测定左室舒张功能、动脉僵硬度,探讨糖尿病对冠心病患者左室舒张功能和动脉僵硬度的影响,及左室舒张功能与动脉倡硬度之间的相关性.方法 将患者分为对照组、单纯冠心病绀、冠心病合并糖尿病组3组.测得左室舒张末压力(LVEDP)、左室压力衰退时间常数(tan)等左室舒张功能指标及脉搏波速度(c-f PWV)、校正心率后反射波增强指数(AIx@75)等反映患者动脉僵硬度指标.结果 冠心病合并糖尿病组c-fPWV[(8.79±1.59)cm/s]显著高于对照组[(6.83±1.14)cm/s]及单纯冠心病组[(7.43±1.42)cm/s].相关性分析显示AIx@75同tau指数之间存在正性相关性联系.结论 合并糖尿病的冠心病患者同对照组及单纯冠心病组相比动脉僵硬度更差,舒张功能差异未显示出统计学意义;动脉僵硬度同舒张功能不全间可能存在着一定的相关性.

Abstract：

Objectives By measuring left ventricular diastolic function and arterial stiffness,this study aims to probe into the effect of diabetes mellitus(DM) on left ventricular diastolic function and arterial stiffness,and evaluate the correlation between left ventricular diastolic funotion and arterial stiffness.Methods Seventy-six inpatients were enrolled.According to their coronary angiography,OGTF test results and past history of DM,patients were divided into controlled,CHD(coronary heart disease with no DM),and CHD+DM groups.Through invasive hemodynamic monitoring during left ventricular angiography,left ventricular end-diastolic pressure(LVEDP)and tan index were collected.Carotid-femoral pulse wave velocity(c-f PWV),reflected wave augmentation index (AIx@75) and other data reflecting the degree of arterial stiffness were collected bedside with non-invasive means.SPSS 18.0 was used for statistical analysis.Results No significant difference was found between groups for LVEDP,tau index,and AIx@75.In terms of c-f PMV,The CHD+DM group(8.79±1.59)cm/s differed significantly from the CHD group (7.43±1.42)cm/s and the controlled group(6.83±1.14)cm/s.No correlations were found between c-f PMV and LVEDP or tau index.A positive correlation was found between AIx@75 and tau index.Conclusions Compared with the controlled group and CHD patients with no DM,CHD+DM patients show worse arterial stiffness with no difference in ventricular diastolic function.There is a positive correlation between arterial stiffness and diastolic dysfunction.     

Electrocardiographic abnormalities and left ventricular systolic function in Chagas' heart disease

In chagasic patients, the electrocardiogram becomes abnormal very late in the course of the disease. Most clinical studies concerning cardiac autonomic function of chagasic patients have been carried out in this very late stage of the disease. The purpose of this study was to assess accurately the left ventricular systolic function of chagasic patients with abnormal electrocardiograms. We performed left ventricular contrast cineangiography in 44 patients with positive complement fixation test for Chagas' disease and abnormal electrocardiograms. On the basis of the electrocardiographic abnormalities found in the electrocardiogram taken the night before the hemodynamic procedure, we divided our patients into three subgroups; those with rhythm disturbances, those with ventricular conduction abnormalities, and those with rhythm disturbances plus ventricular conduction abnormalities. The chagasic patients with only cardiac rhythm disturbances, had left ventricular volumes and ejection fractions which were similar to those of controls. On the other hand, the left ventricular volumes of the chagasic patients with ventricular conduction defects, although slightly larger, were still not different from those of controls. Finally, the chagasic patients, with cardiac rhythm disturbances and left ventricular conduction defects, had the largest left ventricular volumes (P less than 0.05), and the lowest ejection fractions (P less than 0.001) of all three subgroups. These findings clearly indicate that chagasic patients, in this very late stage of the disease, have a very variable degree of left ventricular systolic dysfunction. Furthermore, our results show a distinct tendency for the left ventricular volumes to increase, and for the ejection fraction to decrease; when the electrocardiogram becomes progressively more abnormal, and "mixed" electrocardiographic abnormalities appear.(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes in left ventricular function with effort in the coronary patient. l.]

The altered haemodynamics of the coronary patient have been investigated in 30 patients both at rest and under conditions of maximal effort as carried out on the bicycle ergometer under the usual conditions for an exercise electrocardiogram. Patients with angina of effort but no previous infarction have normal left ventricular function at rest; under the ischaemia induced by exercise there is acute dysfunction of the left ventricle as witnessed by a reduction in maximal cardiac output, a raised end-diastolic pressure, and changes in compliance which are more marked than those in contractility. Patients with a healed infarct but without sequelae have a rigid left ventricle, but it is not failing; they show normal changes in dP/dt max and in the indices of left ventricular work, but a pathological form of negative peak of dP/dt, of end-diastolic pressure, and of deltaP/deltaV (which reflects myocardial compliance). Patients who have had an infarction with sequelae such as angina or attacks of left ventricular failure have filling pressures which are already elevated at rest, and cardiac failure, which becomes evident on exercise.     

Relation between left ventricular filling pressure and angiographic findings in coronary heart disease. Ventriculography used as a stress test.

In 80 male patients with coronary heart disease maximum diastolic pressure in the left ventricle (LVMDP) (usually the top of the a wave), and 'post a' end-diastolic pressure (LVEDP) before and 2 and 3 minutes after ventriculography were correlated to angiographic estimates of left ventricular function (aneurysm, ejection fraction (EF), and to lesions shown by selective coronary arteriography using a score system (coronary artery lesions index, CALI). A significant correlation between CALI and LVEDP (or LVMDP) could not be shown either before or after ventriculography. Before ventriculography, however, LVEDP and LVMDP were good predictors of left ventricular dyskinesia (aneurysm and/or EF less than 50%). A positive and significant correlation between CALI and the LVEDP (and LVMDP) increments following ventriculography (delta LVEDP, delta LVMDP) was found in patients with LVEDP (or LVMDP) below 12 mmHg before ventriculography. Using delta LVEDP the correlation coefficient was 0-51 (n = 41, P less than 0-001, 95 per cent confidence interval 0-24 to 0-88). Using delta LVMDP r = 0-47 (n = 41, 0-001 less than P less than 0-01). Delta LVEDP greater than 12 mmHg was found only in patients with triple vessel disease.     

Radionuclide measurements of diastolic function for assessing early left ventricular abnormalities in the hypertensive patient.

Three measurements of diastolic filling were compared in 29 patients with essential hypertension and 27 age matched normotensive controls. Systolic function was normal in all but one of the patients. The mean (1SD) first one third filling fraction (a measurement of early diastolic filling) was significantly lower in the hypertensive groups (0.27 (0.24] than in the control group (0.45 (0.16)). The hypertensive group was subdivided into those with electrocardiographic abnormalities and those without. In the subgroup with a normal electrocardiogram the mean (1SD) first one third filling fraction measurement (0.28 (0.16)) was significantly lower than in the control group. In the subgroup with an abnormal electrocardiogram, the first one third filling fraction was even lower (0.24 (0.9)). In addition, the time to peak filling rate (213 (56) ms) was significantly longer in the subgroup with the abnormal electrocardiogram than in the control group (164 (45) ms). However, the interobserver reproducibility of the time to peak filling measurement was poor. The peak filling rate was low in the subgroup with an abnormal electrocardiogram, but not significantly different from the normal controls. The discriminatory value of the three diastolic measurements did not improve with exercise. These results showed an early diastolic filling abnormality in essential hypertension that did not appear to be caused by disease of the large coronary vessels as it was present in patients with normal wall motion and a normal exercise electrocardiogram. The occurrence of diastolic abnormalities when systolic function is still normal may mark an early stage in the development of hypertensive heart failure, at a time when the process is still potentially reversible.     

Coronary angioplasty and left ventricular function in single vessel coronary artery disease.

Left ventricular function was investigated in 86 patients with single vessel coronary artery disease before and three to six months after successful angioplasty. Before angioplasty thallium-201 perfusion scintigraphy and technetium-99m gated equilibrium ventriculography in most patients showed that stress testing (exercise and ice water stimulation and isometric handgrip respectively) induced myocardial perfusion defects that were associated with a mean (SD) drop in left ventricular ejection fraction from 64 (6)% to 56 (7)%. After angioplasty there was residual coronary stenosis of less than or equal to 20% of the diameter of the vessel in 78 patients (group 1) and of between 20 and 50% in eight patients (group 2). After the procedure the perfusion defects seen during stress resolved in 86% of group 1 and in 87% of group 2. Despite the apparent improvement in myocardial perfusion left ventricular dysfunction persisted in group 2--that is during stress the left ventricular ejection fraction fell from 65% (6) to 56% (5). In group 1, on the other hand, the improvement in myocardial perfusion was associated with significant improvement in left ventricular function with a normal increase in ejection fraction from 63 (5) at rest to 67 (6) during stress. Radionuclide studies, one to six weeks after angioplasty in 30 group 1 patients showed continuing left ventricular decompensation during stress in nine (30%) of them despite correction of perfusion defects. But reinvestigation three to six months after the procedure showed recovery of left ventricular function with an increase in ejection fraction from 66 (5) at rest to 69 (7) during stress. These data indicate that coronary angioplasty procedures that give a residual stenosis of </= 20% improve myocardial perfusion and the response of the left ventricle to stress. The functional improvement may be delayed for up to three months, however, possibly because arterial healing at the angioplasty site is delayed. On the other hand, when the residual stenosis is between 21 and 50% of the diameter of the vessel subclinical left ventricular dysfunction during stress may persist indefinitely.     

Effects of the dipyridamole test on left ventricular function in coronary artery disease.

The dipyridamole stress test is used with thallium-201 to detect areas of inhomogeneity of blood flow that point to coronary artery disease (CAD). It is unclear whether dipyridamole produces inhomogeneous perfusion only or whether it actually decreases net flow in the obstructed vessels and produces true ischemia. It is also unclear what effect dipyridamole has on global and segmental left ventricular function. Therefore, ejection fraction, segmental wall motion and ventricular volume equivalents were measured before and after dipyridamole in 113 patients and 32 normal subjects. Ejection fraction responded in an abnormal fashion in 98 patients (87%), decreasing from 49 +/- 11% to 43 +/- 13% (p less than 0.0001), whereas it increased in 29 normal subjects (90%) from 57 +/- 6% to 64 +/- 10% (p less than 0.0001). Wall motion worsened distinctly in 75 patients (66%), and pressure/volume ratio deteriorated in 72%. The effect of dipyridamole lasted between 10 and 25 minutes, but was promptly reversed by aminophylline. These findings indicate that dipyridamole generally induces true ischemia in CAD. Furthermore, the degree of dysfunction is related to the angiographically assessed severity of CAD. The shortness of breath (seen in 10% of patients) may be partially explained by the findings, and it seems advisable to give aminophylline to every patient in order to promptly correct left ventricular dysfunction.     

Relation between left ventricular midwall function and coronary vasodilator capacity in arterial hypertension

In systemic hypertension, depressed left ventricular midwall shortening predicts an adverse outcome and is associated with increased left ventricular relative wall thickness, which has been proposed as an independent predictor of cardiovascular risk and reduced coronary reserve. This study was designed to investigate whether depressed midwall shortening is associated with more critical impairment of coronary function and with exercise-induced myocardial ischemia. Sixty untreated hypertensive patients without coronary artery stenosis and 20 normotensive volunteers underwent exercise ECG testing, standard and transesophageal echocardiography to assess the occurrence of exercise-induced myocardial ischemia, left ventricular mass, geometry, and midwall shortening, and coronary vasodilator capacity. Compared with hypertensive patients with normal midwall shortening, those with depressed function (n=15) had higher minimum coronary resistance (1.19+/-0.27 versus 1.39+/-0.20 mm Hg/cm per second, P<0.01) and prevalence of exercise-induced myocardial ischemia (36 versus 67%, P<0.05). Within the hypertensive group, midwall shortening was inversely related to minimum coronary resistance (r=-0.42, P<0.01). Compared with patients with an exercise ECG test negative for myocardial ischemia, those with a positive test result (n=26) had higher minimum coronary resistance (1.13+/-0.21 versus 1.38+/-0.27 mm Hg/cm per second, P<0.01) and lower midwall shortening (104+/-16 versus 93+/-14%, P<0.01). We conclude that hypertensive patients with depressed midwall shortening have more severe impairment of coronary function and a higher prevalence of exercise-induced myocardial ischemia as compared with hypertensive patients with normal midwall shortening. These findings suggest that a decrease in myocardial performance may be related, at least in part, to chronic intermittent myocardial ischemia caused by a critical impairment of coronary vasodilator capacity.     

B-Type natriuretic peptide levels predict extent and severity of coronary artery disease in non-ST elevation acute coronary syndrome and normal left ventricular function

Background

B-type natriuretic peptide has been used as a biological marker for prognosis in patients with acute coronary syndrome (ACS). However, a relation between the quantity of BNP levels and the severity of coronary artery disease has not been systematically evaluated.

Methods

197 patients with ACS without ST elevation with normal LV systolic function were enrolled. BNP was measured in all recruited patients within 12 h of hospitalization. All patients underwent coronary angiography. We correlated BNP levels in patients with unstable angina (USAP) and non ST-elevation myocardial infarction (NSTEMI) with angiographic disease severity including Gensini Score.

Results

BNP levels were significantly higher in the NSTEMI group in comparison to the USAP Group (161 ± 149.3 vs 79.6 ± 94.2 pg/mL; p < 0.001). BNP levels rose significantly with increasing number of vessels involved (1-vessel = 51.4 ± 31.6; 2-vessels = 114.0 ± 67.8; 3 vessels = 265.4 ± 188.8 pg/mL, p < 0.001). Most importantly, BNP> 80 pg/ml was found to strongly predict the presence of Triple vessel disease (odds ratio 18.87; 95% confidence intervals 5.36–66.36), and Double vessel disease (odds ratio 3.62; 95% confidence intervals 1.75–7.47). In single vessel group, BNP was significantly higher when LAD was involved vessel (64.78 vs 49.76 pg/mL, p < 0.05).Gensini Score showed a strong correlation with BNP levels (r = 0.675, p < 0.01), and Gensini Score was significantly higher in those with BNP> 80 pg/ml (40.9 ± 29.7 vs 13.4 ± 16.5 p < 0.001).

Conclusion

Circulating BNP levels appear elevated in Non ST Elevation ACS, even in the absence of LV systolic dysfunction. High BNP levels are associated with multi-vessel disease and diffuse coronary atherosclerosis.     

PCI和CABG术对高龄慢性冠脉闭塞病变患者QT、QTc和JT离散度的影响及与心功能的相关性

目的对高龄冠心病患者行经皮冠状动脉介入治疗（PCI）和冠状动脉搭桥术（CABG）术前、后的QT间期离散度（QTd）、校正QT间期离散度（QTcd）、JT间期离散度（JTd）的变化及与心功能相关性的研究。方法利用标准同步12导联心电图和二维彩色多普勒超声心动图对51例行PCI和CABG手术前后的高龄冠心病患者的QTd、QTcd和JTd离散度和心功能进行检测。结果高龄冠脉闭塞患者PCI与CABG术后的QTd、QTcd及JTd较手术前均显著缩短（P<0.01）,高龄冠脉闭塞患者PCI与CABG术后的心功能指数（LVEF,E）明显增加（P<0.01）。高龄冠脉闭塞患者PCI与CABG术后的QTd及JTd的显著缩短与LVEF的增加呈正相关。结论对于高龄患者严重狭窄或完全闭塞的冠状动脉由于尚有存活心肌,再通后部分存活心肌可恢复电、机械功能,这对挽救这些存活心肌具有重要意义。     

Prediction of the extent of coronary artery disease with the evaluation of left ventricular wall motion abnormalities during atrial pacing. A cross-sectional echocardiographic study

In patients with coronary artery disease, left ventricular performance during stress is affected by the degree of coronary stenosis. In order to verify whether there exists a relationship between the extent of wall motion abnormalities detectable during atrial pacing and the degree of coronary obstruction, 76 patients, without previous myocardial infarction, were studied. Each patient underwent cross-sectional echocardiography during transesophageal atrial pacing and exercise electrocardiography before coronary angiography. Of the 76 patients, 46 had significant coronary artery disease (stenosis ⩾ 75% of at least one major coronary vessel), while 30 had normal coronaries or a stenosis of less than 75%. Eighteen patients had single-, 14 had two-and 14 had three-vessel disease. For each patient a coronary score was obtained: the score used took into consideration the site, number and severity of the stenosis. This score was then correlated with the wall motion score, obtained from the analysis of 9 segments of the left ventricle. A weak correlation was obtained between wall motion score at rest and coronary score (r = −0.42), while the correlation between coronary score and the difference between wall motion score at rest and during transesophageal atrial pacing was slightly better (r = 0.53); this correlation further improved if wall motion score during pacing was considered (r = −0.63). If the patients with discordant diagnostic tests (echocardiography during transesophageal atrial pacing and exercise electrocardiography) were excluded, the correlation coefficient between coronary score and wall motion score during pacing increased even more (r = −0.77).In conclusion: (1) analysis of wall motion of the left ventricle during atrial pacing is useful for the non-invasive evaluation of the severity of coronary disease; (2) cross-sectional echocardiography during atrial pacing, apart from being a useful diagnostic tool, is also a help in judging the degree of severity of coronary artery disease.     

冠心病患者左室肥大、室性心律失常和心率变化的相关研究

为了解左室肥大、室性心律失常和心率变化在冠心病中的相关性，对１０９例冠心病患者分为伴左室肥大组和无左室肥大组进行２４ｈ动态心电图监测，结果发现左室肥大组患者室性早搏Ｌｏｗｎ级别、室性心动过速发生率、平均心率均明显增高．研究还发现冠心病患者最高心率与最低心率之差与Ｌｏｗｎ级别呈明显负相关，Ｒｃｍ５＋Ｓｃｍｌ之和与室早Ｌｏｗｎ级别呈正相关．揭示冠心病左室肥大者易发恶性心律失常，低心率与恶性心律失常密切相关．     

Risk of death related to coronary arteriography: role of left coronary arterial lesions.

Seven deaths occurred within 5 days after study in 800 consecutive patients undergoing arteriography. All seven patients had severe anginal symptoms at rest or with minimal exertion, and all had extensive coronary artery disease. Four had left main coronary artery disease, and three had hemodynamically equivalent lesions involving both the proximal left anterior descending and circumflex branches. It is postulated that these deaths are due to a stress imposed upon patients in unstable condition with a particularly extensive myocardial perfusion deficit.