Prognostic Value of Real Time Myocardial Contrast Echocardiography after Percutaneous Coronary Intervention

Real time myocardial contrast echocardiography (RTMCE) is a cost‐effective and simple method to quantify coronary flow reserve (CFR). We aimed to determine the value of RTMCE to predict cardiac events after percutaneous coronary intervention (PCI). We have studied myocardial blood volume (A), velocity (β), flow indexes (MBF, A × β), and vasodilator reserve (stress‐to‐rest ratios) in 36 patients with acute coronary syndrome (ACS) who underwent PCI. CFR (MBF at stress/MBF at rest) was calculated for each patient. Perfusion scores were used for visual interpretation by MCE and correlation with TIMI flow grade. In qualitative RTMCE assessment, post‐PCI visual perfusion scores were higher than pre‐PCI (Z = ?7.26, P < 0.01). Among 271 arteries with TIMI flow grade 3 post‐PCI, 72 (36%) did not reach visual perfusion score 1. The β‐ and A × β‐reserve of the abnormal segments supplied by obstructed arteries increased after PCI comparing to pre‐PCI values (P < 0.01). Patients with adverse cardiac events had significantly lower β‐ and lower A × β‐reserve than patients without adverse cardiac events. In the former group, the CFR was ≥ 1.5 both pre‐ and post‐PCI. CFR estimation by RTMCE can quantify myocardial perfusion in patients with ACS who underwent PCI. The parameters β‐reserve and CFR combined might predict cardiac events on the follow‐up.     

Microvascular Dysfunction in Dilated Cardiomyopathy: A Quantitative Stress Perfusion Cardiovascular Magnetic Resonance Study

ObjectivesThis study sought to quantify myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) in dilated cardiomyopathy (DCM) and examine the relationship between myocardial perfusion and adverse left ventricular (LV) remodeling.BackgroundAlthough regarded as a nonischemic condition, DCM has been associated with microvascular dysfunction, which is postulated to play a role in its pathogenesis. However, the relationship of the resulting perfusion abnormalities to myocardial fibrosis and the degree of LV remodeling is unclear.MethodsA total of 65 patients and 35 healthy control subjects underwent adenosine (140 μg/kg/min) stress perfusion cardiovascular magnetic resonance with late gadolinium enhancement imaging. Stress and rest MBF and MPR were derived using a modified Fermi-constrained deconvolution algorithm.ResultsPatients had significantly higher global rest MBF compared with control subjects (1.73 ± 0.42 ml/g/min vs. 1.14 ± 0.42 ml/g/min; p < 0.001). In contrast, global stress MBF was significantly lower versus control subjects (3.07 ± 1.02 ml/g/min vs. 3.53 ± 0.79 ml/g/min; p = 0.02), resulting in impaired MPR in the DCM group (1.83 ± 0.58 vs. 3.50 ± 1.45; p < 0.001). Global stress MBF (2.70 ± 0.89 ml/g/min vs. 3.44 ± 1.03 ml/g/min; p = 0.017) and global MPR (1.67 ± 0.61 vs. 1.99 ± 0.50; p = 0.047) were significantly reduced in patients with DCM with LV ejection fraction ≤35% compared with those with LV ejection fraction >35%. Segments with fibrosis had lower rest MBF (mean difference: −0.12 ml/g/min; 95% confidence interval: −0.23 to −0.01 ml/g/min; p = 0.035) and lower stress MBF (mean difference: −0.15 ml/g/min; 95% confidence interval: −0.28 to −0.03 ml/g/min; p = 0.013).ConclusionsPatients with DCM exhibit microvascular dysfunction, the severity of which is associated with the degree of LV impairment. However, rest MBF is elevated rather than reduced in DCM. If microvascular dysfunction contributes to the pathogenesis of DCM, then the underlying mechanism is more likely to involve stress-induced repetitive stunning rather than chronic myocardial hypoperfusion.     

Dynamic changes in microcirculatory blood flow during dobutamine stress assessed by quantitative myocardial contrast echocardiography

Background: Although dobutamine‐atropine stress echocardiography (DASE) has been widely used for evaluating patients with coronary artery disease (CAD), dynamic changes that occur at microcirculatory level during each stage of stress have not been demonstrated in humans. Aim: We sought to determine variations in myocardial blood flow (MBF) during DASE using quantitative real time myocardial contrast echocardiography (RTMCE). Methods: We studied 45 patients who underwent coronary angiography and RTMCE. Replenishment velocity of microbubbles in the myocardium (β) and MBF reserves were obtained at baseline, intermediate stage (70% of maximal predicted heart rate), peak stress, and recovery phase. Results: β and MBF reserves were lower in patients with than without CAD at intermediate (1.65 vs. 2.10; P = 0.001 and 2.44 vs. 3.23; P = 0.004) and peak (1.63 vs. 3.00; P < 0.001 and 2.14 vs. 3.98; P < 0.001, respectively). In patients without CAD, β, and MBF reserves increased from intermediate to peak and decreased at recovery, while in those without CAD reserves did not change significantly. Optimal cutoff values of β reserve at intermediate, peak, and recovery were 1.78, 2.09, and 1.70, with areas under the curves of 0.80 (95%CI = 0.67–0.94), 0.89 (95%CI = 0.79–0.99), and 0.69 (95%CI = 0.53–0.85). Sensitivity, specificity and accuracy for detecting CAD at intermediate stage were 68% (95%CI = 48–89), 85% (95%CI = 71–98), and 78% (95%CI = 66–90), at peak stress were 79% (95%CI = 61–97), 96% (95%CI = 89–100), and 89% (95%CI = 80–98), and at recovery were 74% (95%CI = 54–93), 65% (95%CI = 47–84), and 69% (95%CI = 55–82), respectively. Conclusion: RTMCE allows for quantification of dynamic changes in microcirculatory blood flow at each stage of DASE. The best parameter for detecting CAD in all stages was β reserve. (Echocardiography 2011;28:993‐1001)     

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BackgroundVery few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.MethodEndothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.ResultsThere was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.ConclusionStudy found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.     

Transient endothelial dysfunction following flow-mediated dilation assessment

Flow-mediated dilation (FMD) is a widely used tool to investigate endothelial function. However, FMD assessment may cause mechanical damage to the arterial endothelium. In this study we investigated the effect of FMD assessment on endothelial function. We studied 20 healthy subjects (26 ± 6 years; 12 males). FMD was assessed by measuring brachial artery dilation in response to hyperemia after 5 min of forearm cuff inflation. Subjects were studied on 2 subsequent days. On day 1 they underwent two consecutive FMD measures, with the second test (FMD2) performed 15 min after the first test (FMD1). On day 2, the subjects were randomized to receive either placebo (saline) or intravenous l-arginine (10 g in 20 min). At the end of the infusion, patients underwent two consecutive FMD measures following the same protocol as on day 1. Asymmetric dimethyl-arginine (ADMA) serum levels were assessed on day 2 before FMD1 and FMD2. On day 1, FMD2 was lower than FMD1 in both groups (placebo 6.47 ± 2.1 vs. 7.86 ± 1.8%, P < 0.01; arginine 6.13 ± 2.6 vs. 7.76 ± 2.7%, P < 0.01). On day 2, a significant reduction of FMD was observed during FMD2 compared to FMD1 in the placebo group (5.82 ± 1.7 vs. 7.44 ± 2.2%, P < 0.001), but not in the arginine group (7.19 ± 1.5 vs. 7.27 ± 1.5, P = 0.67). ADMA levels significantly increased compared to baseline after FMD1 (0.59 ± 0.12–0.91 ± 0.64 μmol/l, P = 0.036), with similar changes in the two groups. FMD assessment induces a significant impairment of endothelial function. An increase of endogenous NO synthesis inhibitors seems responsible for the phenomenon that is reversed by l-arginine administration.     

Effect of Add‐on Aliskiren to Type 1 Angiotensin Receptor Blocker Therapy on Endothelial Function and Autonomic Nervous System in Hypertensive Patients With Ischemic Heart Disease

The aim of this study was to evaluate the add‐on effect of aliskiren to valsartan on endothelial‐dependent vasodilation in hypertensive patients with ischemic heart disease (IHD). After 4 weeks of treatment with 80 mg of valsartan, 28 patients were allocated to either continued treatment with valsartan or an add‐on treatment with valsartan plus 150 mg of aliskiren. Aliskiren significantly decreased plasma renin activity, whereas endothelium‐dependent vasodilation measured by flow‐mediated dilation (FMD) did not change. In contrast, heart rate significantly decreased (73.1 ± 9.8 to 66.3 ± 7.0 beats per minute at baseline and 24 weeks, respectively [P = .009]) and the standard deviation of the R‐R intervals (SDNN) significantly increased in the aliskiren group. The add‐on aliskiren to valsartan therapy may not improve endothelial functions, although it significantly reduced resting heart rate via regulation of the autonomic nervous system in hypertensive patients with IHD.     

Diagnosis of Microvascular Angina Using Cardiac Magnetic Resonance

Background

In patients with angina and nonobstructive coronary artery disease (NOCAD), confirming symptoms due to coronary microvascular dysfunction (CMD) remains challenging. Cardiac magnetic resonance (CMR) assesses myocardial perfusion with high spatial resolution and is widely used for diagnosing obstructive coronary artery disease (CAD).

New Approach for Rotational Dyssynchrony Using Three‐Dimensional Speckle Tracking Echocardiography

Left ventricular (LV) twist can be evaluated using two‐dimensional speckle tracking echocardiography (2DSTE) by analyzing difference between apical and basal rotation. However, it is unable to evaluate global rotational dyssynchrony because it cannot assess mid‐wall rotation. Recently developed three‐dimensional STE (3DSTE) can investigate LV global rotational dyssynchrony. In this study, we investigated the role of torsion on the long‐term effects of cardiac resynchronization therapy (CRT) using 3DSTE. We evaluated 43 patients by 3DSTE: 12 CRT responders, 14 CRT nonresponders, and 17 healthy normal controls. Regional torsion and rotation were assessed using 3DSTE across 16 segments during CRT‐off (native conduction) and CRT‐on. The following parameters were calculated: global peak twist, Δ global peak twist (difference between CRT‐on and CRT‐off), and torsion delay index. The torsion delay index was considered to be the rotational energy lost by rotational dyssynchrony. Global peak twist did not show significant differences between the responders and nonresponders during CRT‐off (4.0 ± 3.4° vs. 2.8 ± 2.3°, P = 0.295), but it significantly improved in responders compared to nonresponders after CRT‐on (5.4 ± 3.5° vs. 2.6 ± 2.6°, P = 0.029). The torsion delay index during CRT‐off was significantly higher in responders compared to nonresponders and normal controls (18.5 ± 11.3 vs. 8.6 ± 3.8 and 7.8 ± 5.5, P = 0.010 and P = 0.004, respectively). The torsion delay index during CRT‐off significantly correlated with the Δ global peak twist (r = 0.503, P = 0.009). Improvement in LV global peak twist, which is one of the mechanisms for the long‐term effects of CRT correlated with the torsion delay index during native conduction that can only be calculated by 3DSTE.     

Coronary Circulatory Indexes in Non-Infarct-Related Vascular Territories in a Porcine Acute Myocardial Infarction Model

ObjectivesThe aim of this study was to evaluate temporal changes in coronary hemodynamic and physiological indexes in the non-infarct-related artery (IRA), which might be affected by adjacent infarcted myocardium, using an experimental animal model of acute myocardial infarction.BackgroundThere has been debate on the reliability of fractional flow reserve and resting pressure-derived indexes, including instantaneous wave-free ratio, in the non-IRA in patients with acute ST-segment elevation myocardial infarction.MethodsIn Yorkshire swine, acute myocardial infarction was simulated with selective balloon occlusion at the left circumflex coronary artery as the IRA for 30 min. Non-IRA stenosis was created using bare-metal stent implantation in the left anterior descending coronary artery 4 weeks before the experiments. Serial changes in systemic hemodynamic status, coronary pressure, and Doppler-derived coronary flow velocity were measured in a nonoccluded left anterior descending coronary artery as the non-IRA from baseline, balloon occlusion of the left circumflex coronary artery, and 15 min after reperfusion of the left circumflex coronary artery.ResultsAmong the 6 experimental subjects, the median diameter stenosis of the non-IRA was 33.9% (interquartile range: 21.7% to 46.1%). During balloon occlusion of the IRA, there were transient significant changes in both resting and hyperemic aortic pressure, distal coronary pressure, averaged peak velocity, transstenotic pressure gradient, and microvascular resistance of the non-IRA (p < 0.020 for all). After reperfusion of the IRA, the resting averaged peak velocity (p = 0.002) and resting transstenotic pressure gradient (p = 0.004) were significantly increased and resting microvascular resistance (p = 0.004) was significantly decreased compared with their values in the baseline phase. However, the hyperemic averaged peak velocity (p = 0.479), hyperemic transstenotic pressure gradient (p = 0.778), and hyperemic microvascular resistance (p = 0.816) were not significantly different compared with those in the baseline phase. After reperfusion, fractional flow reserve in the non-IRA was not significantly different (0.94 ± 0.01 vs. 0.93 ± 0.01; p = 0.353), while coronary flow reserve (1.93 ± 0.07 vs. 1.36 ± 0.07; p = 0.025) and instantaneous wave-free ratio (0.97 ± 0.01 vs. 0.93 ± 0.01; p = 0.001) were significantly lower than baseline values.ConclusionsIn a porcine model of acute myocardial infarction, occlusion of the IRA induced significant changes in systemic hemodynamic status and coronary circulatory indexes of the non-IRA. However, after reperfusion of the IRA, fractional flow reserve did not change significantly, whereas coronary flow reserve and instantaneous wave-free ratio showed significant changes compared with baseline values.     

Chronic administration of Sildenafil improves markers of endothelial function in men with Type 2 diabetes

Objective Diabetic patients have a reduced endothelial response to phosphodiesterase‐5 inhibitors. The aim of this study was to determine the effects of chronic therapy with sildenafil on endothelial function in patients with Type 2 diabetes mellitus (DM2). Methods In a double‐blind, placebo‐controlled parallel design, 20 patients without erectile dysfunction randomly received a loading dose of sildenafil (100 mg) for 3 days, followed by either sildenafil 25 mg three times a day (t.d.s.) for 4 weeks or sildenafil 25 mg t.d.s. for 4 days followed by placebo t.d.s. for 3 weeks. Results After 1 week, flow‐mediated dilatation (FMD) improved significantly (> 50% compared with baseline) in patients allocated to both sildenafil arms (62 and 64%, respectively). In patients allocated to chronic sildenafil, a progressive increase in percentage of patients with FMD improvement was noted (78, 86 and 94% at 2, 3 and 4 weeks, respectively) while a progressive decrease in the placebo group occurred (45, 18 and 6% at 2, 3 and 4 weeks, respectively). At the end of the study, a significant improvement in FMD compared with baseline was noted after chronic sildenafil (FMD from 6.8 ± 0.5 to 12.5 ± 0.7%, P = 0.01 vs. baseline). A decrease in endothelin‐1 levels and an increase in nitrite/nitrate levels were found after chronic sildenafil; significant changes from baseline in C‐reactive protein, interleukin 6, intercellular adhesion molecule and vascular adhesion molecule levels were also found. Conclusions In DM2 patients, daily sildenafil administration improves endothelial function and reduces markers of vascular inflammation, suggesting that the diabetes‐induced impairment of endothelial function may be improved by prolonged phosphodiesterase‐5 inhibition. Diabet. Med. 25, 37–44 (2008)     

Qualitative and quantitative real time myocardial contrast echocardiography for detecting hibernating myocardium

Background: Real time myocardial contrast echocardiography (RTMCE) is an emerging imaging modality for assessing myocardial perfusion that allows for noninvasive quantification of regional myocardial blood flow (MBF). Aim: We sought to assess the value of qualitative analysis of myocardial perfusion and quantitative assessment of myocardial blood flow (MBF) by RTMCE for predicting regional function recovery in patients with ischemic heart disease who underwent coronary artery bypass grafting (CABG). Methods: Twenty‐four patients with coronary disease and left ventricular systolic dysfunction (ejection fraction <45%) underwent RTMCE before and 3 months after CABG. RTMCE was performed using continuous intravenous infusion of commercially available contrast agent with low mechanical index power modulation imaging. Viability was defined by qualitative assessment of myocardial perfusion as homogenous opacification at rest in ≥2 segments of anterior or ≥1 segment of posterior territory. Viability by quantitative assessment of MBF was determined by receiver‐operating characteristics curve analysis. Results: Regional function recovery was observed in 74% of territories considered viable by qualitative analysis of myocardial perfusion and 40% of nonviable (P = 0.03). Sensitivity, specificity, positive and negative predictive values of qualitative RTMCE for detecting regional function recovery were 74%, 60%, 77%, and 56%, respectively. Cutoff value of MBF for predicting regional function recovery was 1.76 (AUC = 0.77; 95% CI = 0.62–0.92). MBF obtained by RTMCE had sensitivity of 91%, specificity of 50%, positive predictive value of 75%, and negative predictive value of 78%. Conclusion: Qualitative and quantitative RTMCE provide good accuracy for predicting regional function recovery after CABG. Determination of MBF increases the sensitivity for detecting hibernating myocardium. (Echocardiography 2011;28:342‐349)     

Improved outcome for children with non‐high risk acute lymphoblastic leukaemia after using an ALL IC‐BFM 2002‐based protocol in Shanghai,China

We report the outcome of 92 non‐high risk children with acute lymphoblastic leukaemia (ALL) following a Berlin‐Frankfürt‐Münster (BFM) Intercontinental ALL ‐based protocol. Compared with a matched historical control group, we found a lower incidence of treatment‐related early death (1·2% vs. 10·9%, P = 0·015), a higher 6‐year event‐free survival (75·4 ± 4·9% vs. 58·2 ± 6·7%, P = 0·02), reduced total in‐hospital costs per person (US $) (10267·0 vs. 18331·0, P < 0·001) and fewer total in‐hospital days (164 vs. 296, P < 0·001). This ALL‐BFM based protocol was quite tolerable in our institution and will be extended to high‐risk patients.     

Correlation of Echocardiographic Epicardial Fat Thickness with Severity of Coronary Artery Disease in Patients with Acute Myocardial Infarction

The aim of this study was to test the hypotheses that epicardial adipose tissue (EAT) can be a marker of severe coronary artery disease in patients with acute myocardial infarction. Overall, 373 cases who underwent coronary angiography were classified into 2 groups by SYNTAX score: low‐score and high‐score group. EAT was measured by transthoracic echocardiography. Obtained data were compared using Pearson correlation analyses and univariate and multiple logistic regression analysis. The results showed that EAT in the high‐score group was significantly greater than in the normal group (5.6 ± 1.1 vs. 4.1 ± 1.0 mm, P < 0.01). EAT had a positive correlation with SYNTAX score (r = 0.61, P < 0.01). Receiver operating characteristic (ROC) curve analyses showed that EAT could reliably discriminate patients with high SYNTAX score (≥33) [AUC: 0.86, 95% confidence interval (CI): 0.822–0.898, P < 0.01]. Multivariate regression analyses showed that EAT was an independent predictor for major in‐hospital events. These data showed an association between EAT and SYNTAX score.     

Systolic Papillary Muscle Dyssynchrony Predicts Recurrence of Mitral Regurgitation in Patients with Ischemic Cardiomyopathy (ICM) Undergoing Mitral Valve Repair

Objective: We investigated the impact of papillary muscle dyssynchrony (DYS‐PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA). Methods: One hundred forty‐four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS‐PAP was performed by applying two‐dimensional (2D) speckle‐tracking imaging. Results: In patients with MR recurrence, DYS‐PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS‐PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS‐PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/β before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS‐PAP (OR: 5.4 [95% CI: 3.1–7.7], P < 0.001), α (OR: 5.0 [2.6–6.7], P < 0.001), and α/β (OR: 3.9 [2.5–5.7], p < 0.001) were predictors of recurrent MR. A DYS‐PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7–1], P < 0.001). Conclusions: A DYS‐PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated.     

Liraglutide decreases energy expenditure and does not affect the fat fraction of supraclavicular brown adipose tissue in patients with type 2 diabetes

Background and aimsSeveral studies have shown that glucagon-like peptide-1 (GLP-1) analogues can affect resting energy expenditure, and preclinical studies suggest that they may activate brown adipose tissue (BAT). The aim of the present study was to investigate the effect of treatment with liraglutide on energy metabolism and BAT fat fraction in patients with type 2 diabetes.Methods and resultsIn a 26-week double-blind, placebo-controlled trial, 50 patients with type 2 diabetes were randomized to treatment with liraglutide (1.8 mg/day) or placebo added to standard care. At baseline and after treatment for 4, 12 and 26 weeks, we assessed resting energy expenditure (REE) by indirect calorimetry. Furthermore, at baseline and after 26 weeks, we determined the fat fraction in the supraclavicular BAT depot using chemical-shift water-fat MRI at 3T. Liraglutide reduced REE after 4 weeks, which persisted after 12 weeks and tended to be present after 26 weeks (week 26 vs baseline: liraglutide −52 ± 128 kcal/day; P = 0.071, placebo +44 ± 144 kcal/day; P = 0.153, between group P = 0.057). Treatment with liraglutide for 26 weeks did not decrease the fat fraction in supraclavicular BAT (−0.4 ± 1.7%; P = 0.447) compared to placebo (−0.4 ± 1.4%; P = 0.420; between group P = 0.911).ConclusionTreatment with liraglutide decreases REE in the first 12 weeks and tends to decrease this after 26 weeks without affecting the fat fraction in the supraclavicular BAT depot. These findings suggest reduction in energy intake rather than an increase in REE to contribute to the liraglutide-induced weight loss.Trial registry numberNCT01761318.     

Left Main Coronary In‐Stent Intimal Hyperplasia and Hemodynamics as Detected by Contrast‐Enhanced Transesophageal Echocardiography

Patients and methods: In‐stent hemodynamics were studied by transesophageal echocardiography (TEE) in a group of 54 patients after left main coronary artery stenting, during a 6‐month follow‐up. TEE was performed within 24 hours after stenting and at 1‐ and 3‐month follow‐up. Pulsed wave and color Doppler signals were enhanced by IV administration of Levovist. Results: Angiographic immediate success was obtained in all patients. No in‐hospital death occurred. Ten patients (18.4%) complained of recurrent angina at the follow‐up of 4.8 ± 1.2 months. Both TEE and coronary angiography confirmed in‐stent restenosis in all. Thirty‐nine patients (68.5%) remained symptoms free. Mean late loss in these patients was 0.69 ± 0.20 mm. A linear significant positive relation between mean late loss values and diastolic coronary velocity (r: 0.89, P < 0.001) was found. After 3‐ and 6‐month follow‐up, PDV showed a significant increase in comparison with basal values (0.7 ± 0.3 and 0.6 ± 0.26 vs. 0.32 ± 0.2 cm/sec, P < 0.01). All patients with restenosis showed a significant increase of diastolic coronary velocity in comparison with basal values (2.89 ± 0.25 cm/sec, P < 0.001). Conclusion: TEE can predict the development of in‐stent intimal hyperplasia in patients with unprotected left main coronary artery stenting.     

Serial Doppler Echocardiographic Assessment of Diastolic Dysfunction during Acute Myocardial Infarction

Objectives: We performed serial Doppler echocardiography in patients with ST‐elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) to describe the temporal changes in Doppler parameters following STEMI. Background: Data on comprehensive Doppler assessment of diastolic dysfunction following STEMI, incorporating tissue Doppler imaging (TDI), are lacking. Severe diastolic dysfunction in stable patients usually manifests as a restrictive mitral filling pattern (RFP), reduced TDI‐derived annular velocities (E'), and elevated E/E' ratios >15. Methods: Twenty‐eight patients (19 males, mean age 60 ± 10 years) with a first‐ever STEMI who underwent PCI were prospectively assessed with echocardiography and invasive left ventricular end‐diastolic pressure (LVEDP) measurements prior to PCI. Repeat echocardiograms were performed at day 3 and 12 months. Results: During STEMI: (i) LVEDP was significantly elevated but decreased post revascularization (26.1 ± 6.2 vs. 20.8 ± 5.2 mmHg, P = 0.002); (ii) the predominant mitral inflow pattern was an abnormal relaxation pattern (n = 14 [50%]), whereas restrictive filling pattern was only observed in seven (25%) patients; (iii) E' velocities were only modestly reduced (septal E' 7.4 ± 2.2 cm/sec, lateral E' 9.6 ± 2.2 cm/sec), and (iv) a septal E/E'ratio >15 seen in only one patient, whereas all other patients had an E/E' ratio of 8–15. Serial TDI showed that E'velocity decreased at day 3 (septal E' 7.4 ± 2.1 cm/sec vs. 5.9 ± 1.6 cm/sec, P = 0.002) and remained reduced at 1 year follow‐up, suggesting persistence of diastolic dysfunction. Conclusions: During STEMI, contrary to findings in stable patients, the predominant Doppler manifestation of the severe diastolic dysfunction and elevated LVEDP was an abnormal relaxation mitral inflow pattern accompanied by E/E' ratios of 8–15. Serial Doppler assessment suggests incomplete diastolic recovery following STEMI.     

Quantitative Myocardial Contrast Supine Bicycle Stress Echocardiography for Detection of Coronary Artery Disease

Background: If compared with two‐dimensional echocardiography (2DE), quantitative myocardial contrast echocardiography (MCE) improves detection of coronary artery disease (CAD) during pharmacological stress, but there is paucity of data regarding quantitative MCE performed during supine bicycle stress. Objectives: To determine the feasibility and accuracy of quantitative MCE and assess its incremental benefit over 2DE for detection of CAD during supine bicycle stress. Methods: Sixty‐one consecutive patients (47 males, 14 females, mean age 57 ± 12 years) with suspected CAD, who were scheduled for coronary angiography, underwent 2DE and MCE supine bicycle stress. The diagnosis of obstructive CAD (≥50% stenosis) was based on inducible wall‐motion and myocardial perfusion abnormalities. For quantitative myocardial perfusion analysis, A, β, and Aβ reserve were derived from myocardial contrast replenishment curves. Results: Quantitative coronary angiography revealed ≥50% stenosis in 41, ≥70% stenosis in 18, single vessel disease in 24, and multivessel disease in 17 patients. If compared with 2DE, quantitative MCE was more sensitive (71% vs. 93%; P < 0.05) and more accurate (74% vs. 89%; P < 0.05) to detect obstructive CAD. The sensitivity of 2DE and quantitative MCE was 61% and 91% (P < 0.05) in 50–69% stenosis, and 63% and 92% (P < 0.05) in single vessel disease. No difference in sensitivity between 2DE and quantitative MCE was found in subjects with ≥70% stenosis (83% vs. 94%, P = NS) and multivessel disease (82% vs. 94%, P = NS). Conclusions: Quantitative MCE enhances sensitivity and accuracy of supine bicycle stress 2DE for detection of obstructive CAD, and this incremental benefit is especially present in less severe disease.     

Effect of pioglitazone on insulin sensitivity,vascular function and cardiovascular inflammatory markers in insulin‐resistant non‐diabetic Asian Indians

Aims To determine the effects of pioglitazone (30 mg once daily for 16 weeks) on insulin sensitivity, insulin‐mediated vasodilation, vascular inflammatory markers, fat distribution and lipids in Asian Indians and Caucasians of European ancestry. Methods Cross‐sectional study. Eighteen non‐diabetic Asian Indians and 17 Caucasians of comparable age (34 ± 3 vs. 36 ± 3 years) and body mass index (26.0 ± 1.2 vs. 24.7 ± 1.0 kg/m²) had measurements of insulin sensitivity (M, insulin clamp at 6 pmol/kg per min), abdominal fat (computed tomographic scan at L4‐L5), endothelial‐dependent (reactive hyperaemia, RH) and ‐independent (0.4 mg sublingual nitroglycerin, TNG) vasodilation using brachial artery ultrasound before and after the 2‐h clamp at baseline and after pioglitazone therapy. Results Asian Indians were insulin resistant compared with Causasians during the baseline clamp (M = 25.6 ± 1.7 vs. 41.1 ± 2.2 µmol/kg per min, P < 0.0001) and improved significantly after pioglitazone (to 33.9 ± 1.7 µmol/kg per min, P < 0.001). Vasodilatory responses to RH and TNG were similar in Asian Indians and Caucasians at baseline and did not change. Insulin‐mediated vasodilation improved after pioglitazone in Asian Indians, but not in Caucasians, and correlated with the change in insulin sensitivity (r = 0.52, P = 0.03). C‐reactive protein (CRP) was higher in Asian Indians vs. Caucasians (1.6 ± 0.4 vs. 0.9 ± 0.2 mg/l) and was negatively correlated with insulin sensitivity (r = ?0.53, P = 0.02). In the Asian Indian group, CRP and plasminogen activator inhibitor‐1 decreased and adiponectin increased after pioglitazone, but there were no significant changes in total or visceral fat. Conclusions These results demonstrate that insulin‐resistant Asian Indians respond favourably to an insulin sensitizer with improvements in insulin sensitivity, cardiovascular and inflammatory risk markers, and vascular responses to insulin. These agents may have a role in decreasing the risk of diabetes and cardiovascular disease in this high‐risk population.     

Psychosocial and Cardiometabolic Health of Patients With Differing Body Mass Index Completing Cardiac Rehabilitation

BackgroundIt remains unclear whether cardiac rehabilitation (CR) provides similar benefits to patients with varying levels of body mass index (BMI). We assessed the psychosocial and cardiometabolic health of patients with increased BMI who completed CR.MethodsThe records of 582 patients who completed a 3-month outpatient CR program were analyzed. On the basis of their BMI at baseline, patients were categorized as normal (18.5-24.9 kg/m²), overweight (25.0-29.9 kg/m²), obese (30.0-34.9 kg/m²), or severely obese (≥ 35.0 kg/m²). Analysis of covariance was used to compare health-related quality of life (ie, Physical Component Summary [PCS] and Mental Component Summary scores), anxiety, depression, and cardiometabolic health indicators between BMI categories after CR.ResultsAt baseline, patients with severe obesity, when compared with those with normal BMI, had lower PCS scores (39.7 ± 8.5 vs 44.4 ± 8.4, P < 0.001), elevated levels of anxiety (7.0 ± 3.7 vs 4.8 ± 3.2, P = 0.001) and depression (5.5 ± 4.4 vs 3.4 ± 3.7, P < 0.001), higher glycated hemoglobin A1C (6.5 ± 1.1 vs 5.6 ± 0.7%, P < 0.001) and triglycerides (1.6 ± 0.5 vs 1.1 ± 0.4 mmol/L, P < 0.001), and lower high-density lipoprotein cholesterol (1.1 ± 0.3 vs 1.2 ± 0.4 mmol/L, P = 0.006). After CR, notwithstanding a greater percent weight reduction in obesity (−3.5% ± 6.9% vs +1.1% ± 7.0%, P = 0.002) and severe obesity (−6.5% ± 6.9% vs +1.1% ± 7.0%, P < 0.001), smaller improvements in PCS scores were seen in the obese (4.1 ± 7.4 vs 6.9 ± 7.6, P = 0.011) and severely obese (4.1 ± 7.6 vs 6.9 ± 7.6, P = 0.039) when compared with those with normal BMI.ConclusionsPoorer psychosocial and cardiometabolic health at baseline coupled with smaller improvements in the PCS score suggest that patients with obesity and severe obesity will benefit from enhanced care in the CR setting.