The differing prognostic utility of exercise radionuclide ventriculography in coronary artery disease patients with and without prior myocardial infarction

Previous studies have documented the prognostic utility of left ventricular ejection fraction response to exercise primarily in populations without prior myocardial infarction. We undertook a study to assess the prognostic utility of exercise left ventricular ejection fraction and segmental wall motion response during exercise radionuclide ventriculography in coronary artery disease patients with and without prior myocardial infarction. Methods. We examined the comparative prognostic utility of left ventricular ejection fraction and segmental wall motion response during upright bicycle exercise radionuclide ventriculography in 419 coronary artery disease patients with (n=217) and without (n=202) prior myocardial infarction using univariate and multivariate hierarchical regression analyses. Results. During an average followup period of 61 months, 96 patients (23%) suffered cardiac events, including 55/217 (25%) of the patients with prior myocardial infarction and 41/200 (21%) of the patients without prior myocardial infarction (p=ns). Both cumulative Kaplan-Meier survival analyses and stepwise hierarchical Cox survival analyses demonstrated that peak left ventricular ejection fraction <55% was a significant predictor of cardiac events in patients without prior myocardial infarction (p=0.04), whereas an exercise wall motion worsening score 2 was a significant predictor in patients with a prior myocardial infarction (p=0.0001). Conclusions. The prognostic utility of exercise radionuclide ventriculography variables differ according to the presence or absence of prior myocardial infarction. Global function, assessed by peak left ventricular ejection fraction, adds the greatest prognostic information in patients without prior myocardial infarction, whereas regional function, assessed by exercise wall motion worsening, is the best predictor among patients with prior myocardial infarction.     

Prospective comparison of exercise digital subtraction and exercise first pass radionuclide ventriculography

In order to test the comparative sensitivities of first-pass radionuclide and digital subtraction ventriculography in detecting wall motion abnormalities during exercise, 29 patients referred for coronary angiography were submitted to both types of stress ventriculograms. Resting and exercise ventriculograms by both techniques were reviewed by independent observers and the five equal ventricular wall segments were graded as normal, mildly, moderately, severely hypokinetic, akinetic, or dyskinetic. Of the 29 patients, 24 had arteriographically defined ischemic potential (at least greater than 50% obstruction of a major coronary artery supplying viable myocardium). Exercise digital subtraction ventriculography correctly identified 17 (71%) of these by a worsening of wall motion during exercise, while radionuclide ventriculography identified only eight (33%) by the wall motion response. When either a worsening of wall motion or the failure to increase ejection fraction by at least 5 points were used as criteria for an abnormal test, the sensitivities of digital and radionuclide ventriculographies were 96% and 79%, respectively. Though the number of patients without ischemic potential (5 patients) was too small to judge the relative specificities, digital subtraction ventriculography appears to be more sensitive than radionuclide ventriculography in identifying exercise-induced wall motion abnormalities and in predicting coronary occlusions.     

The application of radionuclide ventriculography to cardiac screening

Screening asymptomatic individuals for latent coronary disease often requires sequential testing because exercise electrocardiography typically produces more false positive than true positive results in a population with a low prevalence of coronary disease. Cardiac scintigraphy is a technique that may be employed as a confirmatory test in lieu of coronary arteriography to further evaluate the significance of a positive exercise electrocardiogram. Radionuclide ventriculography was employed in 98 asymptomatic individuals who were considered to be at moderate risk of heart disease after risk factor analysis and exercise electrocardiography. Seventeen (17%) patients had an abnormal study and underwent cardiac catheterization. Seven had coronary artery disease, two had cardiomyopathy, and eight were normal. Eighty-one (83%) patients had a normal study. Because the sensitivity of radionuclide ventriculography is 63-80%, it was postulated that 2 to 5 individuals with disease were missed. Thus, from a population with an 11-14% prevalence of disease, two subsets were identified. A large subset in which a prevalence of 2-6% could be estimated was separated from a much smaller one in which a prevalence of approximately 50% was demonstrated.     

Prognostic value of predischarge radionuclide ventriculography at rest and exercise after acute myocardial infarction treated with thrombolytic therapy or primary coronary angioplasty

Background: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited. Hypothesis: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty. Methods: A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow-up. Results: During a mean follow-up of 30 ± 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction <40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction ≥ 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris or ST-segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI. Conclusion: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.     

The prevalence and prognosis of ventricular dyskinesis after myocardial infarction using radionuclide ventriculography

To assess the prevalence and prognosis of ventricular dyskinesis,radionuclide ventriculography was performed on 100 consecutivepatients just before discharge from hospital following theirfirst myocardial infarction; thereafter follow-up studies wereperformed after one and four months. Dyskinesis of the leftventricle was seen in 25 patients who had sustained transmuralinfarction which was anterior in 19 and inferolateral in six.Clinical examination poorly predicted dyskinesis; 20 patientsexhibited persisting ST segment elevation on the electrocardiogram,but only 10 had radiological cardiomegaly at the time of discharge.Mean left ventricular ejection fraction (LVEF) was significantlyreduced at discharge (0.23 ± 0.07, mean ± 1 S.D)and for the group failed to improve four months after infarction.However, 10 patients remained free from cardiac failure duringfollow-up and could be distinguished by otherwise good leftventricular regional wall movement.     

Myocardial systolic function in systemic lupus erythematosus: a study based on radionuclide ventriculography.

We assessed left ventricular systolic function by means of radionuclide ventriculography in 20 consecutive unselected patients with systemic lupus erythematosus. All patients had normal left ventricular systolic function (defined as ejection fraction greater than 45%) in a resting state. Regional wall motion abnormalities were, however, seen in 4 patients (20%). Of these 20 patients, 8 were able to exercise on a bicycle ergometer. These patients were subjected to exercise radionuclide ventriculography. Of these 8 patients, 3 (37.5%) had an abnormal ventriculographic response to exercise (as evidenced by a subnormal rise in ejection fraction or a fall, appearance of a new regional wall motion abnormality or worsening of a pre-existing one). This probably reflects subclinical left ventricular dysfunction unmasked by the stress of exercise. The clinical significance of these abnormalities on long-term myocardial function and their possible reversibility with remission of the disease needs to be assessed in future studies.     

Predictive value of dobutamine radionuclide ventriculography in detection of functional improvement after acute anterior wall infarction and thrombolytic therapy

Background: Prolonged postischemic ventricular dysfunction (stunned myocardium) may prevent the assessment of myocardial salvage early after thrombolysis. Dobutamine in conjunction with radionuclide ventriculography has been proposed for the early assessment of myocardial viability and prediction of functional recovery. Hypothesis: This study was designed to investigate the effects of low-dose dobutamine infusion on early global and regional function of reperfused myocardium after acute anterior wall myocardial infarction (MI). In particular, our purpose was to examine whether this response can predict late recovery of left ventricular function and correlate with the reperfused status (patency of infarct-related artery). Methods: In all, 29 consecutive patients with first uncomplicated anterior wall MI, and who had received thrombolytic therapy, underwent radionuclide ventriculography at rest and 2 min after each dose increment of dobutamine infusion (5–15 m?g/kg/min) on the third day after the infarction, at discharge, and at 3 months' follow-up. Global and regional ejection fraction were calculated at each stage. Four patients with complications were dropped from the study. A significant response to dobutamine was defined as an increase of at least ≥7% in global or regional ejection fraction at the infarct zones. Results: Of the 25 patients, 18 (72%) fulfilled these criteria. Of these, 10 patients (56%) had a significant improvement in global or regional ejection fraction at discharge and 13 patients (72%) at 3-month follow-up. The overall sensitivity of the dobutamine test in predicting left ventricular improvement was 100% at discharge and 93% at 3-month follow-up. However, the positive and negative predictive values were 56 and 100% at discharge and 72 and 86%, respectively, at 3-month follow-up. Conclusion: Low-dose dobutamine radionuclide ventriculography is a safe and useful test for assessing myocardial viability and may predict late functional improvement in patients with anterior wall MI.     

Prognostic value of supine scintigraphic heart function and simultaneous conventional exercise response in patients after myocardial infarction

A total of 240 survivors of one or more myocardial infarctions were consecutively admitted to perform supine exercise radionuclide ventriculography. Within 3 years after the test, 22 died; this group was compared to an age-matched control group of 22 survivors for left and right ventricular function during rest, exercise, and simultaneously assessed exercise performance as well as ECG variables. Evaluation of 3-year survival by linear discriminant analysis revealed an accuracy of 82% for discriminant models using ECG and exercise performance variables. Implementation of resting left ventricular ejection fraction and change of right ventricular ejection fraction during exercise, as well as scintigraphic presence or absence of dyskinesia, improved the accuracy of the model to 91% of correctly classified patients.     

小剂量多巴酚丁胺核素心室造影与201铊再注射心肌显像对存活心肌评估的比较

采用小剂量多巴酚丁胺（Ｄｏｂ）负荷试验与核素心室造影（ＲＮＶ）相结合的方法（ＤｏｂＲＮＶ）对２０例陈旧性心肌梗塞（ＯＭＩ）患者进行存活心肌的评估并与２０１铊（Ｔｌ）再注射心肌断层显像（ＳＰＥＣＴ）相比较。结果显示：静态ＲＮＶ明显地低估存活心肌的程度，ＤｏｂＲＮＶ将静态ＲＮＶ对存活心肌的检出率增加６１．５％。以２０１Ｔ１再注射心肌ＳＰＥＣＴ为标准，ＤｏｂＲＮＶ检测存活心肌的阳性预测率为９３．８％，阴性预测率为８０％，预测准确率为８８．５％。     

The efficacy of nifedipine and acebutolol in coronary artery disease assessed by radionuclide ventriculography

The efficacy of a fixed combination of 10 mg nifedipine and 100 mg acebutolol was tested in 21 patients with angiographically proven coronary artery disease (CAD). Ejection fraction (EF), emptying and filling rate (VS and VD), and end-systolic volume (ESV) were assessed by means of radionuclide ventriculography at rest and during exercise prior to as well as 1 hour and 5 hours following oral drug application. Whereas exercise-induced worsening of cardiac function had been documented in all the patients prior to medication, EF and ESV improved significantly after drug administration.     

Early exercise test for evaluation of long-term prognosis after uncomplicated myocardial infarction

The prognostic value of early load-limited exercise testinghas been assessed in 200 men younger than 66 years three weeksafter uncomplicated myocardial infarction. Positive criteriaof the test were: typical angina, ischemic ST depression 0.1mV, increase in heart rdte of 35 beats/min or more above theresting heart rate, poor systolic blood pressure rise (<5 mm Hg) and malignant ventricular premature beats. No complicationsof exercise testing were noted.The prognostic value of the positivetest and of the different positive criteria independently predictingcardiac mortality was studied during a follow-up of three monthsto six years (mean three years and one month). The positivetest was predictive of cardiac mortality (P <0.005). Exerciseangina (P <0.05), ischemic ST depression (P < 0.005) andexcessive increase in heart rate (P < 0.01) were also predictiveof mortality, whereas a poor systolic blood pressure rise andmalignant premature beats were not. We conclude that patients without complications three weeksafter acute myocardial infarction can safely perform load-limitedexercise testing and that the prognostic value of this testduring the succeeding years is considerable.     

Comparison of radionuclide ventriculography and 2D echocardiography for the measurement of left ventricular ejection fraction following acute myocardial infarction

To compare the measurement of left ventricular ejection fractionobtained by two-dimensional echocardiography and by radionuclideventriculography in patients following acute myocardial infarction,49 consecutive patients with acute myocardial infarction underwentechocardiography and radionuclide ventriculography on the sameday, pre-discharge. Left ventricular ejection fraction was assessedby two blinded observers for each method and reproducibilitywas also assessed for each technique. The limits of agreementfor the differences in ejection fraction (%) between the twomethods was –11.4, 12.2; the mean difference 0.4 was notsignificantly different from zero. The limits of agreement forthe intra- and inter-observer differences in ejection fractionby radionuclide ventriculography were –9.4, 7.6 and –86,11.0, respectively; the mean differences –0.9 and 1.2were not significantly different from zero. The limits of agreementfor the intra- and inter-observer differences by echocardiographywere –5.8, 6.6 and –8.9, 9.5 respectively; the meandifferences 0.4 and 0.3 were not significantly different fromzero. Thus, two-dimensional echocardiography compares well withradionuclide ventriculography for the assessment of ejectionfraction without the disadvantage of radiation.     

Prognostic value of submaximal exercise radionuclide ventriculography after myocardial infarction

Submaximal exercise testing with radionuclide ventriculography (RVG) was performed in 117 patients before hospital discharge 17 +/- 7 days (+/- standard deviation) after an acute myocardial infarction (MI). The hypothesis tested in these studies was that submaximal exercise testing coupled to RVG allows the identification of patients at risk for future ischemic events in the subsequent 6 months, irrespective of MI location and type. The sites of MI were characterized as anterior transmural in 33, inferior transmural in 39, limited nontransmural in 18, extensive nontransmural in 24 and indeterminant in 3. During 6 months of follow-up, 9 patients died, 14 had recurrent MI, 18 had refractory angina pectoris, 16 had limiting angina and 17 had congestive heart failure. Discriminant function analysis ranked exercise changes in left ventricular (LV) ejection fraction and end-systolic volume the most important of all clinical, exercise and scintigraphic variables for predicting future cardiac events. The predictive accuracy of changes in LV ejection fraction and end-systolic volume were 93 and 91%, respectively, for the entire group, and were significantly more sensitive than any degree of ST-segment depression or elevation (p less than 0.001). These findings were generally independent of MI location and type. Thus, submaximal exercise RVG after MI is an accurate means of identifying patients at risk for major cardiac events in the 6 months after hospital discharge.     

Evaluation of three methods for quantifying valvular regurgitation using gated equilibrium radionuclide ventriculography

The non-invasive quantification of mitral and aortic regurgitationusing the left-to-right stroke count ratio (SCR) calculatedwith gated equilibrium radionuclide ventriculography (RNV),is affected by the overlap of atria and ventricles and the consequentdifficult definition of the ventricular regions of interest(ROI). Various solutions of the problem have been proposed.In this study we evaluated the results obtained with a techniquebased on visual inspection of the RNV images (variable ROI method—VRI)and those of two approaches which utilize functional images(stroke volume image method—SVI—and Fourier amplituderatio—FAR), by comparing them with the invasive quantificationof valvular regurgitation according to Sandier et al.^[1] (strokevolume ratio — SVR). Forty patients (15 controls and 25valvular patients) were studied.In the control group the rangeof the SVR wasO.81±1.11 (mean±lSD=1.01±0.08).The SCR was O.83–1.28 (1.03±0.15) with VRI, 1.10–1.15(1.30±0.14) with SVI and 1.11–1.58 (1.35±0.17)with FAR. The correlations between SVR and SCR were r=0.47 (P<0.05),r=0.62 (P<0.001) and r=0.55 (P<0.01) respectively withVRI, SVI and FAR. The SCR of valvular patients fell in the rangeof controls in 11/25 using VRI, 6/25 using SVI and in 4/25 usingFAR. This overlap was present in 2/25 with the invasive quantification.Irrespective of the method used, a reliable assessment of thevalvular regurgitation was not possible in two patients withseverely depressed left ventricular function. We conclude thatthe use of techniques based on functional images clearly improvesthe effectiveness of the non-invasive quantification of valvularregurgitation with the SCR even if this cannot be regarded asa substitute for invasive quantification and has a limited reliabilityin particular groups of patients.     

Gold 195m in the assessment of the cold pressor test by first pass radionuclide ventriculography

First pass radionuclide ventriculography was performed withgold 195m in a sequential evaluation of left ventricular ejectionfraction during cold pressor stimulation. We studied 10 normalcontrols, 10 patients with angina pectoris who had proven coronaryartery disease and normal left ventricular function during contrastangiography and 10 patients with dilated cardiomyopathy withnormal coronary arteries and impaired left ventricular functionat contrast angiography. Mean resting ejection fraction was similar in controls and patientswith coronary heart disease (57 ± 2 vs 58 ± 3)but was significantly lower in the cardiomyopathic subjects(27 ± 4, P < 0.001). After 30 seconds cold pressorstimulation, mean left ventricular ejection fraction fell inthe normal controls (57 ± 2 to 52 ± 2, P <0.05)but was unchanged in those with coronary heart disease and dilatedcardiomyopathy (58 ± 3 to 55 ± 3 and 27 ±4 to 24 ± 4, both NS). No further significant changeoccurred after 2.5 minutes stimulation (53 ± 1, 58 ±3 and 23 ± 3, respectively). There was no differencein the pattern of left ventricular ejection fraction responsebetween the groups. Six controls, 4 patients with coronary heartdisease and 4 patients with dilated cardiomyopathy had a significantfall in left ventricular ejection fraction and 4, 5 and 6, respectively,developed a new or further deterioration in regional wall motion.Thus neither changes in regional wall motion nor left ventricularejection fraction response distinguished either patient groupfrom the normal controls. We do not recommend cold pressor stimulationas a diagnostic test for coronary heart disease.     

Diagnostic accuracy of radionuclide techniques in patients with equivocal electrocardiographic exercise testing

The aim of the present study was to evaluate the yield of radionuclide studies for the diagnosis of coronary artery disease (coronary artery narrowing greater than 50%) in a prospective series of 73 patients with thoracic pain and equivocal electrocardiographic stress testing. In the study population, the prevalence of coronary artery disease was 51%. The sensitivity, specificity, diagnostic accuracy and the post-test probability difference curves according to the Bayes' theorem were calculated for 201-thallium exercise testing and radionuclide exercise equilibrium ventriculography. For the latter study the following criteria were considered: (1) increase in left ventricular ejection fraction less than 5%; (2) the criterion proposed by Rozanski; (3) decrease in regional ejection fraction; and (4) abnormalities in phase and amplitude analysis (Fourier). 201-thallium exercise testing was the most sensitive (97%) and accurate (86%) study. Radionuclide ventriculography sensitivity was always lower for any criterion, although its best result was for evaluation of regional ejection fraction (85%). The most specific study was Fourier analysis (97%), although its sensitivity was low (42%). The application of Bayes' theorem to these results shows that the highest post-test probability difference values were achieved with 201-thallium exercise testing for prevalences higher than 40% and with Fourier analysis for lower prevalences.     

Evaluation of three methods for quantifying valvular regurgitation using gated equilibrium radionuclide ventriculography

The non-invasive quantification of mitral and aortic regurgitationusing the left-to-right stroke count ratio (SCR) calculatedwith gated equilibrium radionuclide ventriculography (RNV),is affected by the overlap of atria and ventricles and the consequentdifficult definition of the ventricular regions of interest(ROI). Various solutions of the problem have been proposed.In this study we evaluated the results obtained with a techniquebased on visual inspection of the RNV images (variable ROI method—VRI)and those of two approaches which utilize functional images(stroke volume image method—SVI—and Fourier amplituderatio—FAR), by comparing them with the invasive quantificationof valvular regurgitation according to Sandier et al.^[1] (strokevolume ratio — SVR). Forty patients (15 controls and 25valvular patients) were studied.In the control group the rangeof the SVR wasO.81±1.11 (mean±lSD=1.01±0.08).The SCR was O.83–1.28 (1.03±0.15) with VRI, 1.10–1.15(1.30±0.14) with SVI and 1.11–1.58 (1.35±0.17)with FAR. The correlations between SVR and SCR were r=0.47 (P<0.05),r=0.62 (P<0.001) and r=0.55 (P<0.01) respectively withVRI, SVI and FAR. The SCR of valvular patients fell in the rangeof controls in 11/25 using VRI, 6/25 using SVI and in 4/25 usingFAR. This overlap was present in 2/25 with the invasive quantification.Irrespective of the method used, a reliable assessment of thevalvular regurgitation was not possible in two patients withseverely depressed left ventricular function. We conclude thatthe use of techniques based on functional images clearly improvesthe effectiveness of the non-invasive quantification of valvularregurgitation with the SCR even if this cannot be regarded asa substitute for invasive quantification and has a limited reliabilityin particular groups of patients.     

Left Ventricular Response to Exercise after Transmural Anterior Myocardial Infarction*

Abstract: Left ventricular response to exercise after transmural anterior myocardial infarction. A. T. H. Tan, N. Sadick, P. J. Harris, J. Morris and D. T. Kelly. Aust. N.Z. J. Med., 1982, 12 , pp. 489–494. The purpose of this study was to determine the effect of a previous myocardial infarction on the left ventricular response to exercise and to see how this response is modified by the presence of multivessel versus single vessel coronary artery disease. Twenty-seven patients with a past history of transmural anterior myocardial infarction underwent rest and exercise gated equilibrium blood pool imaging. All 27 patients had a total occlusion of the left anterior descending coronary artery and akinesis of the anterior wall of the left ventricle. Sixteen patients had isolated, left anterior descending artery occlusion (Group A). Eleven patients had multivessel disease with 70% or greater stenosis of one or more major coronary arteries in addition to the total left anterior descending artery occlusion (Group B). Seventeen subjects with atypical chest pain and normal exercise test were selected as controls. Seven Group B patients but no Group A patients developed angina and/or ischaemic ST changes with exercise. Control subjects achieved an average 94±2% (mean) of their predicted work capacity whereas the post-infarct patients had a diminished work capacity (Group A 73±6%, P <0.001; Group B 65±5%, p< 0.001). Control subjects showed an increase in ejection fraction (EF) from rest (0.53 ±0.02) to peak exercise (0.63±0.02). This increase was primarily due to a 33±6% decrease in end systolic volume since the end diastolic volume did not change significantly from rest to peak exercise (-1.4±4%). In Group A patients, EF did not change from rest (0.32±0.03) to peak exercise (0.30±0.03) because there was a similar increase in end-diastolic volume (76±4%) and end-systolic volume (19±4%). However, in Group B patients EF decreased from 0.32±0.03 to 0.23±0.02 (p<0.01) because of a disproportionate increase in endsystolic volume (45 ± 13%) compared to enddiastolic volume (27± 7%). When patients with abnormal resting left ventricular function due to previous myocardial infarction exercise there is little change in the ejection fraction and the increase in cardiac output is heart rate dependent. If additional myocardial ischaemia develops the ejection fraction and stroke volume decrease due to a disproportionate increase in endsystolic volume.     

Right and left cardiac function in HIV-infected patients investigated using radionuclide ventriculography and brain natriuretic peptide: a 5-year follow-up study

OBJECTIVE: The aim of the study was to determine the incidence of myocardial dysfunction in an HIV-infected population receiving state-of-the-art treatment. METHODS: Between April 2001 and July 2002, 91 HIV-infected patients had a radionuclide ventriculography performed with determination of right ventricular ejection fraction (RVEF) and left ventricular ejection fraction (LVEF), as well as measurement of brain natriuretic peptide (BNP). Between July 2005 and January 2007, 63 patients (69%) agreed to participate in a follow-up study with a mean follow-up of 4.5 years. RESULTS: All patients had normal LVEF at both examinations. A minimal increase in mean LVEF of 0.02 was observed at follow-up (P=0.01). At the initial visit, four patients [6%; 95% confidence interval (CI) 2-15%] had a reduced RVEF, and at follow-up two patients (3%; 95% CI 0-11%) had slightly reduced RVEF. No significant change in mean RVEF was found. No patients had increased BNP and no change in mean plasma BNP was found. CONCLUSIONS: HIV-related cardiomyopathy appears not to constitute a problem in closely monitored, well-treated HIV-infected patients. Compared with pre-highly active antiretroviral therapy (HAART) studies, it seems that the improvement in immunocompetency and viral load has removed the problem of HIV-related cardiomyopathy. Although HAART has been suggested as a possible new cause of cardiomyopathy, we did not find any evidence of this.