Improved left ventricular diastolic filling in patients with coronary artery disease after percutaneous transluminal coronary angioplasty

Left ventricular (LV) diastolic filling is abnormal at rest in many patients with coronary artery disease (CAD), even in the presence of normal resting LV systolic function. To determine the effects of improved myocardial perfusion on impaired. LV diastolic filling, we studied 25 patients with one-vessel CAD by high-temporal-resolution radionuclide angiography before and after percutaneous transluminal coronary angioplasty (PTCA). No patient had ECG evidence of previous myocardial infarction. Despite normal regional and global LV systolic function at rest in all patents, LV diastolic filling was abnormal (peak LV filling rate [PFR] less than 2.5 end-diastolic volumes (EDV)/sec or time to PFR greater than 180 msec) in 17 of 25 patients. Twenty-three patients had abnormal LV systolic function during exercise. After successful PTCA, LV ejection fraction and heart rate at rest were unchanged, but LV ejection fraction during exercise increased, from 52 +/- 8% (+/- SD) to 63 +/- 5% (p less than 0.001). LV diastolic filling at rest improved: PFR increased from 2.3 +/- 0.6 to 2.8 +/- 0.5 EDV/sec (p less than 0.001) and time to PFR decreased from 181 +/- 22 to 160 +/- 18 msec (p less than 0.001). Thus, a reduction in exercise-induced LV systolic dysfunction after PTCA, reflecting a reduction in reversible ischemia, was associated with improved LV diastolic filling at rest. These data suggest that in many CAD patients with normal resting LV systolic function and without previous infarction, abnormalities of resting LV diastolic filling are not fixed, but appear to be reversible manifestations of impaired coronary flow.     

Addition of nifedipine to maximal nitrate and beta-adrenoreceptor blocker therapy in coronary artery disease

The effects of oral nifedipine on left ventricular (LV) diastolic function were assessed in 14 patients with coronary artery disease (CAD) who had symptoms despite therapy with beta-adrenoceptor blocking drugs and nitrates. Rest and exercise gated radionuclide ventriculography was performed before and a mean of 13 days after the addition of oral nifedipine (80 to 120 mg/day) to baseline medication. Ejection fraction did not increase in any patient during exercise. The addition of nifedipine slightly improved the LV ejection fraction response to exercise (control, 49 +/- 8% rest vs 44 +/- 9% exercise; nifedipine, 47 +/- 6% vs 48 +/- 8%). With nifedipine treatment, diastolic function improved, with a decrease in the time to peak filling rate (PFR) at rest (from 174 +/- 34 to 152 +/- 31 ms, p less than 0.005) and an increase in PFR with exercise (from 2.5 +/- 0.6 to 3.4 +/- 0.7 end-diastolic volume/s, p less than 0.0005). Using the ratio of PFR/peak ejection rate as a variable, preferential improvement of diastolic over systolic function occurred during exercise (1.03 +/- 0.29 baseline vs 1.4 +/- 0.43 with nifedipine, p less than 0.01). Duration of exercise increased by a mean of 21% with nifedipine (from 454 +/- 150 to 550 +/- 159 seconds, p less than 0.005); all 14 patients were limited by angina pectoris at baseline, whereas only 5 patients were limited by angina pectoris after nifedipine treatment. This study shows that global LV diastolic function is improved by oral nifedipine treatment both at rest and during exercise in patients on maximally tolerated doses of beta-adrenoreceptor blockers and nitrates, and is associated with improvement of symptoms and exercise tolerances.     

Clinical and hemodynamic significance of left ventricular diastolic volume changes by exercise radionuclide ventriculography in coronary artery disease

Recent studies have suggested that left ventricular (LV) dilatation during exercise radionuclide ventriculography may identify coronary artery disease (CAD). Coronary anatomy and LV end-diastolic pressure at catheterization were compared with results of supine exercise radionuclide ventriculography in 66 patients evaluated for chest pain. Forty-six patients had significant CAD (greater than 75% diameter stenosis) and 20 patients were normal. Radionuclide ventriculography was performed within 18 hours of catheterization, at rest and at peak exercise. Relative LV end-diastolic volumes were extrapolated from end-diastolic counts. LV end-diastolic counts increased during exercise in 19 of 20 normal subjects. In patients with CAD, LV end-diastolic counts increased in 35 (group A) and decreased in 11 (group B). The percent change in LV end-diastolic counts from rest to exercise, rest ejection fraction, exercise ejection fraction and rest LV end-diastolic pressure for each group were 20 +/- 23%, 60 +/- 13%, 67 +/- 13% and 8 +/- 3 mm Hg in normal subjects; 20 +/- 20%, 50 +/- 12%, 47 +/- 13% and 12 +/- 4 mm Hg in group A; and -9 +/- 8%, 54 +/- 21%, 49 +/- 18% and 21 +/- 7 mm Hg in group B (mean +/- standard deviation). An increase in LV end-diastolic counts was unrelated to ejection fraction response or presence of underlying CAD but only correlated to rest LV end-diastolic pressure (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Demonstration of exercise-induced painless myocardial ischemia in survivors of out-of-hospital ventricular fibrillation

To ascertain if myocardial ischemia is the mechanism of out-of-hospital ventricular fibrillation (VF), left ventricular (LV) function was assessed at rest and during submaximal exercise in 15 patients who survived out-of-hospital VF. They were separated into asymptomatic (9 patients, group A) and symptomatic (6 patients, group S) groups for a history of angina or myocardial infarction. Both groups had significant (at least 70% diameter stenosis) coronary artery disease. At catheterization no patient had angina during exercise, but 12 of 15 had ST depression or increased ST depression (group A, 1.9 +/- 1.4 mm; group S, 1.1 +/- 1.2 mm) and 11 had abnormal wall motion. From rest to exercise, patients in group S had increased LV end-diastolic pressure (from 21 +/- 9 to 37 +/- 11 mm Hg, p = 0.009) and volume (from 100 +/- 25 to 107 +/- 26 ml/m2, p = 0.006), with no significant change in LV ejection fraction (from 40 +/- 13 to 42 +/- 12%). In group A LV end-diastolic pressure increased from 19 +/- 4 to 31 +/- 8 mm Hg (p = 0.001), but neither end-diastolic volume nor ejection fraction changed significantly (from 83 +/- 13 to 92 +/- 23 ml/m2 and from 55 +/- 13% to 46 +/- 13%, respectively). Thus, patients with coronary artery disease who survive out-of-hospital VF may have evidence of myocardial ischemia during exercise without pain. Painless ischemia may have a role in out-of-hospital VF.     

Left ventricular hypertrophy and impaired diastolic filling in essential hypertension. Diastolic mechanisms for systolic dysfunction during exercise

Left ventricular ejection fraction is normal at rest but may respond abnormally to exercise in many patients with essential hypertension. To assess the determinants of the abnormal ejection fraction response to exercise, we performed radionuclide angiography at rest and during exercise in 41 hypertensive patients without coronary artery disease. In 22 patients (group 1), the ejection fraction increased more than 5% during exercise; in the other 19 patients (group 2), the ejection fraction either increased by less than 5% or decreased with exercise. Left ventricular diastolic filling was impaired at rest in patients in group 2 compared with group 1, with reduced peak filling rate (2.5 +/- 0.4 vs. 3.1 +/- 0.7 end-diastolic volume/sec; p less than 0.01) and prolonged time to peak filling rate (175 +/- 28 vs. 153 +/- 22 msec; p less than 0.01). Impaired diastolic filling in group 2 was associated with less augmentation in end-diastolic volume during exercise compared with group 1 (p less than 0.01). These observations were not dependent on the threshold value that was arbitrarily chosen to define an abnormal ejection fraction response, as there were significant correlations for the entire group between the magnitude of change in ejection fraction with exercise and both the resting peak filling rate (r = 0.46) and the change in end-diastolic volume with exercise (r = 0.62).(ABSTRACT TRUNCATED AT 250 WORDS)     

Left and right ventricular function during symptom-limited exercise in patients with isolated mitral stenosis

Ventricular function during exercise in patients with mitral stenosis has not been widely studied. Accordingly, 20 patients with isolated mitral stenosis were assessed during supine, symptom-limited equilibrium radionuclide ventriculographic studies. All patients had a normal left ventricular (LV) ejection fraction at rest (greater than or equal to 50 percent), and all were in sinus rhythm. Left ventricular ejection fraction rose (p less than 0.001) from 64 +/- 9 percent at rest to 74 +/- 11 percent during exercise. This normal response was due solely to a decrease (p less than 0.01) in exercise LV end-systolic volume. A significant (p less than 0.01) decrease in end-diastolic volume during exercise limited the increase in ejection fraction during exercise. The decrease in end-diastolic volume during exercise caused stroke volume to remain unchanged; cardiac output rose according to heart rate alone. Right ventricular (RV) ejection fraction did not rise with exercise due to an increase in end-systolic volume. With exercise, LV end-diastolic volume was smaller (p less than 0.05) with severe mitral stenosis compared to mild mitral stenosis. With exercise, RV ejection fraction was decreased (p less than 0.05) with severe compared to mild mitral stenosis. In conclusion, LV function during exercise is normal in patients with normal resting LV ejection fraction. A decrease in LV diastolic filling with exercise prevents a rise in stroke volume, and cardiac output increases by heart rate alone. With, exercise, RV ejection fraction does not rise, due to an increase in RV end-systolic volume.     

The effect of coronary artery bypass grafting on left ventricular systolic function at rest: evidence for preoperative subclinical myocardial ischemia

Successful coronary artery bypass grafting (CABG) improves exercise-induced left ventricular (LV) dysfunction in patients with coronary artery disease (CAD), but its potential for improving resting LV function remains controversial. To assess the influence of CABG on LV function at rest, 31 CAD patients without previous myocardial infarction were studied before and 6 months after CABG by radionuclide angiography after all cardiac medicines were withdrawn. No patient had angina or ischemic electrocardiographic changes at rest. In 27 patients with patent bypass grafts, CABG significantly increased LV ejection fraction during exercise (47 +/- 11% before to 63 +/- 9% after operation, p less than 0.001), indicating reduction in exercise-induced LV ischemia. Moreover, LV ejection fraction at rest also increased (55 +/- 9 to 60 +/- 8%, p less than 0.001), with 20 of 27 patients manifesting an increase compared with preoperative values. Eleven of these 20 patients had apparently normal LV function at rest (ejection fraction and regional wall motion) before CABG. LV regional ejection fraction was computed by dividing the LV region of interest into 20 sectors. Regional analysis indicated that improved ejection fraction at rest after CABG occurred in regions developing ischemia during exercise before CABG. In 4 patients with occluded grafts, the ejection fraction at rest was unchanged by CABG globally (59 +/- 8 to 58 +/- 9%, difference not significant) and regionally. Thus, LV global and regional function at rest improved after successful CABG, even in patients with normal global LV ejection fraction and no visually detectable wall motion abnormality before surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Preoperative left and right ventricular performance in combined aortic and mitral regurgitation and comparison with isolated aortic or mitral regurgitation

Left and right ventricular performance characteristics in operative candidates with combined aortic and mitral regurgitation (AR/MR) have not been well defined. Therefore, we determined radionuclide cineangiographic ejection fractions, as well as echocardiographic and hemodynamic parameters, in 8 symptomatic patients undergoing double-valve replacement with pure, severe AR/MR. In order to gain insight into the basis for the poor postoperative survival in patients with this intrinsically biventricular disease, we compared these results with those of 29 symptomatic patients with isolated AR and with 18 symptomatic patients with isolated MR, all also undergoing valve replacement. Before operation, patients with AR/MR had significantly lower left ventricular (LV) ejection fraction than patients with MR (rest, 40 +/- 9% vs 52 +/- 10%, p less than 0.025; exercise, 35 +/- 12% vs 54 +/- 12%, p less than 0.005) and tended to have lower LV ejection fraction than patients with AR alone (rest, 40 +/- 9% vs 45 +/- 12%, difference not significant; exercise, 35 +/- 12% vs 39 +/- 11%, difference not significant); right ventricular (RV) ejection fraction was lower in AR/MR than in AR (p less than 0.01), and tended to be lower than in MR (difference not significant). At average postoperative follow-up of 72 to 76 months (survivors in each group), symptomatic patients with AR/MR had significantly poorer survival than symptomatic patients with isolated MR (p less than 0.05) and were more likely to have persistent symptoms than patients with AR (p less than 0.05). These findings suggest that symptomatic patients with AR/MR have poorer LV and RV performance than similarly symptomatic operative candidates with AR or MR alone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effectiveness of preload reserve as a determinant of clinical status in patients with left ventricular systolic dysfunction. The SOLVD Investigators.

The hemodynamic determinants of clinical status in patients with left ventricular (LV) systolic dysfunction have not been established. In the present study, preload reserve--LV distension during exercise--was related to clinical status, and the effect of acute angiotensin-converting enzyme inhibition was examined in 97 patients with ejection fraction less than or equal to 0.35 enrolled in the trial, Studies of Left Ventricular Dysfunction (SOLVD). Sixty-one asymptomatic patients (group I) were compared with 36 patients with symptomatic heart failure (group II). Radionuclide LV volumes were measured at rest and during maximal cycle exercise. Group II patients had higher resting heart rates, end-diastolic and end-systolic volumes, and lower ejection fractions (all p less than 0.005). During exercise, only patients in group I had increased stroke volume (from 35 +/- 8 to 39 +/- 11 ml/m2 [mean +/- SD; p less than 0.0005]) due to an increase in end-diastolic volume (from 119 +/- 29 to 126 +/- 29 ml/m2 [p less than 0.0005]), contributing to a greater increase in LV minute output (p less than 0.0001, group I vs group II). After administration of intravenous enalapril (1.25 mg), LV end-diastolic volume response to exercise was augmented in group II (rest, 140 +/- 42; exercise, 148 +/- 43 ml/m2; p less than 0.0005) and LV output response increased slightly (p less than 0.05). Thus, in patients with asymptomatic systolic dysfunction, recruitment of preload during exercise is responsible for maintaining a stroke volume contribution to the cardiac output response.(ABSTRACT TRUNCATED AT 250 WORDS)     

Exercise first-pass radionuclide assessment of left and right ventricular function and valvular regurgitation in symptomatic mitral valve prolapse

The changes in right ventricular (RV) and left ventricular (LV) function and in regurgitant fractions on first-pass exercise radionuclide angiography (RNA) were assessed in 29 consecutive patients with symptomatic mitral valve prolapse (MVP). The mean right ventricular ejection fraction (RVEF) was 35 +/- 8% at rest and 46 +/- 15% after exercise (p less than 0.001). The mean left ventricular ejection fraction (LVEF) was 62 +/- 11% at rest and 74 +/- 13% after exercise (p less than 0.001). Seven of 29 patients had an abnormal RV response and 6 had an abnormal LV response. Eight had abnormal wall motion after exercise. A total of 12/29 patients (41%) had one or more abnormalities. The mean left-sided regurgitant fraction before exercise was 27 +/- 17% in 21/29 patients (72%) and 31 +/- 21% after exercise (p = ns). An additional 5 patients (17%) developed left-sided regurgitation after exercise. These findings indicate that wall motion abnormalities and abnormal RVEF and LVEF responses to exercise occur in symptomatic MVP patients. In addition, 26/29 (89.6%) had left-sided regurgitation after exercise. Since the presence of a murmur did not correlate with the presence of mitral regurgitation by RNA, then symptomatic patients with MVP should have first-pass exercise RNA to assess the presence of regurgitation at rest and after exercise. Antibiotic prophylaxis is recommended in MVP patients with systolic murmurs or with regurgitation. Since patients without murmurs can have regurgitation, further study is necessary to determine the need for endocarditis prophylaxis in these patients.     

Effect of propranolol and disopyramide on left ventricular function at rest and during exercise in hypertrophic cardiomyopathy.

In 19 patients with hypertrophic cardiomyopathy (15 males, 4 females, mean age 49.2 +/- 10.8 years) left ventricular function was studied with radionuclide ventriculography at rest and during exercise in a crossover design without intervention and after disopyramide and propranolol treatment. 15 of the 19 patients had a resting or latent intraventricular gradient of more than 30 mm Hg. Left ventricular function at rest and during exercise was evaluated before medication, 90 min after oral administration of 200 mg disopyramide or 160 mg propranolol and after 3 weeks of oral therapy with disopyramide 200 mg 2 times a day or propranolol 80 mg 4 times a day. After long-term treatment with disopyramide, resting ejection fraction decreased from 72 +/- 12 to 69 +/- 14% (p less than 0.01) and peak ejection rate (PER) decreased from 3.46 +/- 135 to 3.24 +/- 65 end-diastolic volume (EDV).s-1 (p less than 0.01). Peak filling rate (PFR) at rest decreased from 3.01 +/- 0.8 to 2.77 +/- 0.63 EDV.s-1 (p less than 0.05). Time to peak filling rate (TPFR) at rest and during exercise after acute and chronic therapy did not change compared to control values. Acute and long-term administration of propranolol lead to a significant reduction in heart rate at rest and during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left ventricular response to exercise and autonomic control mechanisms in end-stage renal disease

Left ventricular (LV) function during rest and during exercise was evaluated in patients with end-stage renal disease (ESRD) in whom other causes of LV dysfunction were eliminated through rigid selection criteria. Autonomic function was also assessed in these patients with Valsalva's maneuver and plasma catecholamine determinations. Echocardiography and radionuclide ventriculography in the group with ESRD revealed no abnormalities of LV wall motion or ejection fraction. During graded exercise, patients with ESRD achieved 85% of age-predicted heart rate, and no differences in exercise tolerance or LV function were observed. Valsalva's response was abnormal in patients with ESRD, and post exercise the norepinephrine level was markedly increased (12.5 +/- 1.43 vs 8.28 +/- 0.82 nmol/L). Our results fail to indicate an independent adverse effect of ESRD on LV function.     

Effect of exercise on left ventricular systolic function and reserve in morbid obesity

To assess the effect of exercise on left ventricular (LV) systolic function and reserve in morbid obesity, radionuclide left ventriculography was performed before and during supine, symptom-limited bicycle exercise in 23 patients whose body weight was greater than or equal to twice their ideal body weight. Echocardiography was performed before exercise. Resting LV ejection fraction was depressed in 13 patients and LV mass was increased in 10 patients. Exercise produced nonsignificant increases (of similar magnitude) in mean LV ejection fraction in the subgroups with normal and depressed resting LV ejection fraction. Exercise produced a significant increase in LV ejection fraction from 54 +/- 8 to 65 +/- 12% (p less than 0.005) in the subgroup with normal LV mass, but produced no significant change in LV ejection fraction in the subgroup with increased LV mass (53 +/- 10 at rest, 50 +/- 12% during exercise). Moreover, the LV exercise response (change in LV ejection fraction during exercise) in the subgroup with normal LV mass was significantly different from that in the subgroup with increased LV mass (p less than 0.005). There was a strong positive correlation between LV mass and the percent over ideal body weight (r = 0.912, p = 0.01) and a strong negative correlation between LV mass and LV exercise response (r = 0.829, p = 0.01). The results suggest that increased LV mass predisposes morbidly obese patients to impairment of LV systolic function during exercise.     

Scintigraphic evaluation of left ventricular function and correlation with autonomic cardiac neuropathy in diabetic patients.

Left ventricular function of 20 diabetic patients was investigated at rest and during hand-grip test using radionuclide ventriculography. The aim of the study was to discuss the correlation of cardiac function with autonomic cardiac neuropathy (ACN) in diabetic subjects. ACN was tested using heart rate response to valsalva maneuver, standing up, deep breathing; blood pressure response to standing up, sustained hand-grip, and additionally corrected QT (QTc) measurements. Plasma glucose regulation was screened with fructosamine levels. Ejection fraction (EF), peak ejection (PER) and filling rates (PFR), times to peak ejection (TPE) and filling (TPF), time to endsystole (TES), TES/T, TPE/T, TPF/T, 1/3 PER, 1/3 PFR, 1/3 EF, 1/3 FF (filling fraction) we calculated. Thirteen patients had ACN. Six patients (30%) had a low EF at rest. As a response to hand-grip, 14 patients (70%) showed a decrease in EF (9 ACN). PFR was low in 10 patients (50%) at rest and in 12 (60%) during hand-grip. The mean rest PER value of ACN+ patients (4.4 +/- 1.3) was significantly higher than that of controls (2.9 +/- 0.5) and patients without ACN (3.4 +/- 0.4; p < 0.05) as well as the mean 1/3 PER value (1.7 +/- 0.5 vs. 1.3 +/- 0.5; p < 0.05). Fourteen patients (70%) had a fall in PER 10 ACN) as a response to hand-grip. The mean TES/T value of patients with ACN (0.44 +/- 0.05) was significantly higher than of those without ACN (0.38 +/- 0.05; p < 0.05). In conclusion, diastolic dysfunction was detected frequently at rest. Systolic parameters were markedly impaired as a response to hand-grip in patients with ACN. Sympathetic overactivity was noted in ACN+ group at rest. Our results indicated that the patients with diabetes and ACN have subclinical left ventricular diastolic dysfunction and symphatic overactivity.     

Low-level exercise echocardiography fails to elicit left ventricular contractile reserve in patients with aortic stenosis, reduced ejection fraction, and low transvalvular gradient

BACKGROUND: Low-level exercise echocardiography is useful to assess left ventricular (LV) contractile reserve after an acute myocardial infarction. Whether low-level exercise can elicit LV contractile reserve in patients with severe aortic stenosis, reduced LV systolic function and low transvalvular gradient are unknown. Accordingly, the value of low-level exercise to elicit contractile reserve was assessed in these patients using dobutamine administration as the gold standard method. METHODS AND RESULTS: Seventeen patients with severely decreased aortic valve area (0.75 +/- 0.03 cm(2)), reduced LV ejection fraction (35 +/- 2%) and low mean transvalvular gradient (23 +/- 3 mmHg) underwent low-level exercise and dobutamine echocardiography. Ejection fraction increased by 23% (P < 0.001) with dobutamine and decreased by 8% (P = 0.2) with low-level exercise. Left ventricular outflow tract velocity time integral increased from 13 +/- 1 to 16.7 +/- 1 cm (P < 0.001) with dobutamine but did not change with low-level exercise (13 +/- 1 vs. 13.5 +/- 1, P = 0.5). CONCLUSION: Low-level exercise fails to elicit LV contractile reserve in patients with severe aortic stenosis, reduced LV systolic function, and low transvalvular gradient.     

The effects of diltiazem on cardiac function in silent ischemia after myocardial infarction

In a total group of 56 patients with an acute myocardial infarction who were maximally exercised at predischarge, 20 patients (36%) showed greater than or equal to 1 mm asymptomatic ST-T segment depression during exercise. The site of the infarction was anterior in 12 patients and inferior in eight patients. All 20 patients underwent repeated exercise radionuclide angiography 2 days later, 2 hours following oral intake of 120 mg of diltiazem. Double product was not significantly different before and after diltiazem, both at rest and during exercise. Maximal ST-T depression after diltiazem was reduced from 2.3 +/- 0.8 to 0.7 +/- 0.6 mm (p less than 0.01). Left ventricular (LV) ejection fraction at rest before diltiazem was 54.4 +/- 8.7% and after diltiazem was 56.2 +/- 11.3% (p = NS). During exercise, LV ejection fraction improved after diltiazem from 43.2 +/- 12.2% to 49.8 +/- 10.5% (p less than 0.05). Regional wall motion score (1 = normal, 2 = hypokinetic, 3 = akinetic, 4 = dyskinetic) at rest before diltiazem was 9.6 +/- 2.0 and after diltiazem was 9.1 +/- 1.8 (p = NS). During exercise, regional wall motion score improved after diltiazem from 5.8 +/- 1.3 to 4.3 +/- 1.1 (p less than 0.02). We conclude that silent ischemia occurs in a substantial number of patients after myocardial infarction and that diltiazem has acute beneficial effects on asymptomatic ST-T depression and on global and regional LV function in post-infarction patients with silent ischemia.     

Comparison of ambulatory left ventricular ejection fraction and blood pressure in systemic hypertension in patients with and without increased left ventricular mass.

To evaluate the effects of long-standing systemic hypertension on left ventricular (LV) function during daily activities, ambulatory radionuclide monitoring of LV ejection fraction (EF) and blood pressure was performed during exercise and other structured activities in 31 hypertensive patients. Patients were divided into 3 groups based on the absence of LV hypertrophy (group 1 [n = 16], LV mass 107 +/- 12 g/m2), presence of LV hypertrophy without electrocardiographic changes (group 2 [n = 10], LV mass 141 +/- 8 g/m2) and LV hypertrophy with associated electrocardiographic changes (group 3 [n = 5], LV mass 158 +/- 9 g/m2). The groups were similar with respect to age, baseline medication, treated and untreated blood pressure, resting EF and treadmill exercise time. Patients in group 3 had the longest history of hypertension. Peak filling rate was normal in group 1 (2.9 +/- 0.4 end-diastolic volume/s), but reduced at rest in groups 2 (2.4 +/- 0.4) and 3 (2.1 +/- 0.3). Patients in group 1 had normal EF responses to exercise and mental stress testing, as well as during routine ambulatory activities. Patients in group 2 had a blunted EF response to exercise, and those in group 3 had a significantly abnormal response. Both group 2 and 3 patients demonstrated abnormal EF responses to mental stress, as well as cold pressor testing in association with significant increases in mean arterial pressure and marked reduction in diastolic filling rate. Decreases in EF were also observed during routine patient monitoring in 3 group 3 patients and 4 group 2 patients. These events were associated with significantly increased blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is there a relationship between ambulatory intra-arterial blood pressure and left ventricular function?

The relationship between ambulatory intra-arterial blood pressure and left ventricular ejection fraction was examined in a group of 23 untreated hypertensive subjects who underwent concurrent radionuclide ventriculography. All patients had a normal ejection fraction at rest (range, 50-80%), and no significant correlation was found between blood pressure and resting ejection fraction. Sixty-one percent of patients failed to increase their ejection fraction by 5% on exercise; the mean daytime systolic pressure (168 +/- 15 mm Hg) was lower in this group than in those who had a normal exercise response (188 +/- 17 mm Hg; p less than 0.005). Thirty percent of patients had left ventricular hypertrophy based on electrocardiographic criteria; this group had a higher mean blood pressure (189 +/- 20 mm Hg) than the remainder (170 +/- 15 mm Hg; p less than 0.05). A closer correlation was demonstrated between blood pressure and ejection fraction response to exercise in the group with left ventricular hypertrophy (r = 0.8) than in the group without hypertrophy (r = 0.3). These results failed to demonstrate a linear relationship between blood pressure and ejection fraction. However, a relationship between the height of blood pressure and the development of left ventricular hypertrophy was shown, and myocardial response to exercise was increased in patients with left ventricular hypertrophy.     

Left ventricular ejection fraction response during exercise in asymptomatic systemic hypertension

To study the effect of mild-to-moderate elevations in diastolic blood pressure (BP) on systolic left ventricular (LV) function, 28 hypertensive patients and 20 normal subjects underwent upright exercise first-pass radionuclide angiography. All were asymptomatic, had normal rest and exercise electrocardiographic findings and no evidence of LV hypertrophy or coronary artery disease. LV function at rest was similar in the 2 groups, but with exercise hypertensive patients had a greater end-systolic volume (69 +/- 19 vs 51 +/- 19 ml, p less than 0.002) and lower ejection fraction (EF) (0.59 +/- 0.09 vs 0.72 +/- 0.07, p less than 0.0001), stroke volume (101 +/- 28 vs 130 +/- 36 ml, p less than 0.005) and peak oxygen uptake (23 +/- 7 vs 33 +/- 9 ml/kl/min, p less than 0.05). Hypertensive patients were separated into 3 groups: group 1-12 patients with an increase in EF with exercise greater than or equal to 0.05; group 2-7 patients with a change in EF with exercise less than 0.05; and group 3-9 patients with a decrease in EF with exercise greater than or equal to 0.05. Group 3 hypertensive patients were older, had a higher heart rate at rest and lower peak oxygen uptake. Rest LV function was similar in the 3 hypertensive subgroups, but exercise end-systolic volumes were higher in groups 2 and 3. Exercise thallium-201 images was normal in all but 1 of 14 hypertensive group 2 or 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effects of successful PTCA on left ventricular function: assessment by exercise echocardiography

To assess the usefulness of exercise echocardiography in the follow-up of patients after percutaneous transluminal coronary angioplasty (PTCA), we studied 56 patients at rest and immediately following exercise with two-dimensional echocardiography. Sixty-nine of 73 stress/echo studies (94%) were suitable for interpretation. Seventeen patients (group I) with significant coronary artery disease (CAD) were studied before and after PTCA. Sixteen patients with coronary disease not undergoing PTCA (group II) and 23 individuals without significant coronary disease (group III) served as age-matched controls. Left ventricular ejection fraction did not change significantly in group I patients prior to PTCA (56 +/- 7 versus 54 +/- 12, p = ns) or in group II patients (52 +/- 10 versus 56 +/- 15, p = ns), rest versus immediate after exercise measurements. Following angioplasty, left ventricular ejection fraction increased in group I patients from 55 +/- 7 to 65 +/- 8, p less than 0.001 from rest to exercise, and to a similar extent in group III individuals (55 +/- 6 to 66 +/- 8, p less than 0.001). Electrocardiographic (ECG) evidence of ischemia (greater than 1 mm ST segment depression) was found in 13 of 17 group I patients prior to PTCA and in 8 of 16 group II patients (CAD). None of the 25 normal patients and four of the group I patients following PTCA had abnormal ECG changes with exercise. New exercise-induced echocardiographic wall motion abnormalities were found in 12 of 17 group I patients prior to PTCA and in none of the group I patients following PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)