Evaluation and prognostic significance of left ventricular diastolic function assessed by Doppler echocardiography in the early phase of a first acute myocardial infarction

AIM: To study the prognostic significance of left ventricular diastolicfunction evaluated by transmitral and pulmonary venous flowvelocities obtained in the early phase of a first acute myocardialinfarction in relation to later development of congestive heartfailure. METHODS: Pulsed Doppler echocardiography of transmitral and pulmonaryvenous flow was assessed in 65 consecutive patients with a firstmyocardial infarction within 1 h of arrival in the coronarycare unit. RESULTS: A univariate regression analysis identified age, left ventricularejection fraction 45%, mitral E deceleration time 130 ms, E/Aratio >1·5, peak pulmonary venous atrial flow velocity30 cm . s^–1 and a difference between mitral and pulmonaryvenous atrial flow duration >0 ms as variables significantlyrelated to the development of congestive heart failure. However,in a multivariate analysis only mitral E deceleration time 130ms and age were significant independent variables related tothe development of congestive heart failure during the firstweek following a first acute myocardial infarction. CONCLUSION: Assessment of left ventricular diastolic function complementsmeasurements of systolic function in the evaluation of cardiacfunction, and mitral deceleration 130 ms best identifies patientsat risk of development of congestive heart failure followingacute myocardial infarction.     

Determination of left ventricular wall thickness and muscle mass by intravenous digital subtractionangiocardiography: validation of the method

Left ventricular (LV) wall thickness and muscle mass are importantmeasures of LV hypertrophy. In 24 patients LV end-diastolicwall thickness and muscle mass were determined (two observers)by digital subtraction angiocardiography (DSA) and conventionalLV angiocardiography (LVA). Wall thickness was determined overthe anterolateral wall of the left ventricle according to thetechnique of Rackley (method 1) or by planimetry (method 2).Seventeen patients were studied at rest and seven during dynamicexercise. Wall thickness correlated well between LVA and DSA;the best correlations were obtained by a combined subtractionmode using either method 1 or 2 (method 1, r0–80; method2,r0. 75). The standard error of estimate of the mean (SEE) wasslightly lower for method 2 ( 10%) than for method 1 ( 13%).DSA significantly overestimated wall thickness by 5–7%with method 1 and underestimated by 12–14% with method2. Muscle mass correlated well between LVA and DSA; the SEEwas 15% for method 1 and 12% for method 2. Overestimation ofmuscle mass by DSA was 7–11% with method 1 and underestimationwas 13–15% with method 2.It is concluded that LV wallthickness can be determined accurately by DSA with an SEE rangingbetween 10 and 13%. Determination of LV muscle mass is slightlyless accurate and the SEE is slightly larger ranging between13 to 17%. With method 1, wall thickness and muscle mass wereover estimated and with method 2 underestimated.     

Successful radiofrequency ablation of accessory pathways with the first energy delivery: the anatomic and electrical characteristics

Successful ablation of accessory pathways has been achievedat the first energy delivery site in some patients, but factorspermitting success at the first site are unclear. Accessorypathway location, surface and endocardial electrogram characteristicsin each location were analysed and compared between the patientswith first site block (group A, 34 patients) and those in whommultiple sites (median seven sites) were required (group B,133 patients). No patients with right free-wall pathways hadfirst site block. In group A surface electrocardiograms weremore pre-excited (QRS duration: 132±20 vs 120 ±l7ms, P<0·0l). For left free-wall and septal pathways,the interval from the onset of the earliest delta wave on surfaceelectrocardiogram to local ventricular activation (QRS-V) wasmore negative and the local atrioventricular interval (AV) wasshorter in group A; the positive predictive value of a QRS-V0 ms, an AV 30 ms and the presence of a possible accessory pathwaypotential was 67% for left free-wall and of a QRS-V -10 ms withan AV 30ms was 100% for septal pathways. During retrograde mappingof concealed left free-wall and right anteroseptal pathways(first site block was not achieved in other locations) the positivepredictive value of a local ventriculoatrial interval 30 mswas 55%. Accessory pathway location correlated strongly with the chancesof first site block, suggesting that anatomical features areimportant. Maximizing pre-excitation may be of benefit in achievingfirst site block. Delivery of energy to a site with specialendocardial electrogram features was associated with an increasedlikelihood of first site block.     

Time domain analysis of the signal averaged electrocardiogram in patients with a conduction defect or a bundle branch block

Doubts have been expressed about the clinical usefulness oftime domain analysis of the signal averaged electrocardiogramin patients with prolonged QRS complex duration. We studied147 patients using a signal averaged ECG (40–250 Hz) whoseQRS complex was longer than 100 ms. A baseline electrophysiologystudy was also performed in 128 of these patients. Seventy-sevenpatients had a minor (QRS <120 and >100 ms) conductiondefect. Thirty-seven of these 77 had either induced or spontaneoussustained ventricular tachycardia (group I) and 40 had no sustainedventricular tachycardia (group II). Seventy patients had a major(QRS120 and >100 ms) conduction defect, 44 of whom had sustainedventricular tachycardia (group A). The remaining 26 withoutthis condition formed Group B. Group I compared to group IIpatients had a longer filtered QRS duration (120·8 ±14 vs 104·5 ± 9·5 ms, P<0·001),a longer low amplitude signal duration (41 ± 12·1vs 31 ± 12·6 ms, P<0·0001) and a lowerroot mean square of the last 40 ms of the filtered QRS complex(27 ± 29·8 vs 35 ± 25·3 µV,P=ns). Group A compared to group B had a longer filtered QRSduration (157·7±20·2 vs 140·7±15·7 ms, P<0·001), a longer low amplitude signalduration (57·3 ±24·9 vs 37·8 ±20·3 ms P<0·001) and a lower root mean squareof the last 40 ms of the filtered QRS complex (14·3 ±11·2 vs 22·0 ± 10·5 1 P<0·01).Using conventional late potential criteria, the sensitivityand specificity of the signal averaged ECG for the detectionof sustained ventricular tachycardia patients with a minor conductiondefect were 89% and 75%, respectively. The same criteria appliedto patients with a major conduction defect were sensitive (sensitivity:87%) but non-specific (specificity: 50%). However, by usingmodified late potential criteria, such as the presence of twoof any of the following three signal averaged parameters: filteredQRS duration 145 ms, low amplitude signal duration 50 ms,root mean square of the last 40 ms of the filtered QRS complex17·5µV, we derived a non-optimal but still acceptablecombination of sensitivity (68%) and specificity (73%). We concludethat traditional late potential criteria can be applied in patientswith a minor conduction defect, but modification of these criteriais necessary to derive useful clinical information for riskstratification of patients with a QRS complex duration 120ms.     

Echocardiographic wall motion abnormalities and the signal averaged electrocardiogram in the acute phase of a first myocardial infarction

We studied the relationship between wall motion abnormalitiesdetermined by echocardiography and the signal-averaged electrocardiogramin 82 consecutive patients during the acute phase of a firstmyocardial infarction. An abnormal signal-averaged electrocardiogramwas defined as the presence of two of the following criteria:a QRS duration 114 ms, a root mean square voltage (RMS) ofthe last 40 ms 25 µV and an amplitude signal lower than40µV lasting 39 ms. The left ventricle was divided into13 segments and the contraction pattern divided into akinesiaalone (including dyskinesia) (group A), hypokinesia alone (groupB) and both hypokinesia and akinesia (group C). An abnormal signal-averaged electrocardiogram was found in 14/82patients (17%) and was correlated with the persistence of occlusionof the infarct-related vessel (32% vs 9%. P < 0.02). In patientswith a patent vessel, the incidence of an abnormal signal-averagedelectrocardiogram was 14% in group A, 9% in group B and 0% ingroup C (NS). In patients with an occluded vessel an abnormalsignal-averaged electrocardiogram was found in 10% of groupA patients, in 36% in group B patients and in 75% of group Cpatients (P = 0.05). Our study suggests that the presence of hypokinetic areas duringthe acute phase of a first myocardial infarction and an abnormalsignal-averaged electrocardiogram indicate an occluded infarct-relatedvessel.     

Subjective symptoms and well-being differ in women and men after myocardial infarction

The frequency of subjective cardiac and psychological complaintsamong men and women a year after a confirmed diagnosis of myocardialinfarction (MI) were compared. Among 660 survivors, 595 patientscompleted mailed questionnaires at home one year after the MI.There were 421 men, mean age 67.1±10.7 years, and 174women, mean age 72.1±10.6 years. Controlling for the significantly higher mean age among thewomen, the latter more often had a previous history of anginapectoris, 54.6% (P0.05) versus 42.9%, and heart failure, 24.7%versus 13.5% (P0.01). Despite these facts, the women were significantlyless often referred to CCU, 82.2% versus 91.7% (P0.05). Oneyear after the MI, controlling for differences in age and co-morbidity,women reported significantly higher frequencies of psychologicaland psychosomatic complaints, including sleep disturbances.These differences may have clinical implications for diagnosisand treatment of women with coronary heart disease.     

EUROASPIRE: A European Society of Cardiology survey of secondary prevention of coronary heart disease: Principal results

BACKGROUND: The three major European scientific societies in cardiovascularmedicine—the European Society of Cardiology (ESC), theEuropean Atherosclerosis Society and the European Society ofHypertension—published in October 1994 joint recommendationson prevention of coronary heart disease in clinical practice.Patients with established coronary heart disease, or other majoratherosclerotic disease, were deemed to be the top priorityfor prevention. A European survey (EUROASPIRE) was thereforeconducted under the auspices of the ESC to describe currentclinical practice in relation to secondary prevention of coronaryheart disease. AIMS: The aims of EUROASPIRE were (i) to determine whether the majorrisk factors for coronary heart disease are recorded in patientsmedical records; (ii) to measure the modifiable risk factorsand describe their current management following hospitalization,and (ii) to determine whether first degree blood relatives havebeen screened. MEHTODS: The survey was conducted in selected geographical areas andhospitals in nine European countries. Consecutive patients (70 years) were identified retrospectively with the followingdiagnoses: coronary artery bypass grafting, percutaneous transluminalcoronary angioplasty, acute myocardial infarction and acutemyocardial ischaemia without infarction. Data collection wasbased on a retrospective review of hospital medical recordsand a prospective interview and examination of the patients. RESULTS: 4863 medical records were reviewed of whom 25% were women, and3569 patients were interviewed (adjusted response rate 85%)with an average age of 61 years. Nineteen percent of patientssmoked cigarettes, 25% were overweight (BMI 30 kg. m^–2),53% had raised blood pressure (systolic BP 140 and/or diastolicBP 90 mmHg), 44% had raised total plasma cholesterol (totalcholesterol 5·5 mmol . l^–1) and 18% were diabetic.Reported medication at interview was: antiplatelet drugs 81%,beta-blockers, 54% (58% in post-infarction patients). ACE inhibitors30% (38% in post infarction patients) and lipid lowering drugs32%. Of the patients receiving blood pressure lowering drugs(not always prescribed for the treatment of hypertension) 50%had a systolic BP <140 mmHg and 21% <160 mmHg, and ofthose receiving lipid lowering drugs, 49% had plasma total cholesterol<5·5 mmol. l^–1 and 13% <6·5 mmol.l^–1. Thirty-seven percent of patients had a family historyof premature coronary heart disease in a first-degree bloodrelative, but only 21% of patients reported being advised tohave their relatives screened for coronary risk factors. CONCLUSIONS: This European survey has demonstrated a high prevalence of modifiablerisk factors in coronary heart disease patients. There is considerablepotential for cardiologists and physicians to further reducecoronary heart disease morbidity and mortality and improve patientschances of survival     

Coronary risk factors in men occupationally exposed to vibration and noise

In a group of 481 men (group A ) exposed occupationally to vibration(exceeding by four times the permissible levels in the frequencyband 32–64–125 Hz) and noise (105–116 dB),and in a group of 303 men without contact with vibration andnoise at work (reference group R) the prevalence of coronaryrisk factors was assessed, Socioeconomic status, level of occupationalphysical activity and family history of heart disease were comparablein the two groups. Mean blood pressure values and the percentage with hypertensionwere significantly higher in the exposed than in the referencegroup(P0.01). Overweight and hypertrigliceridemia occurred lessfrequently in group A than in group R(P0.01 and P0.05 respectively).The prevalence of hypercholesterolaemia and smoking habits wassimilar in both groups. The results suggest that vibration andnoise may be factors which increase the risk of coronary heartdisease.     

Coronary risk factors in men occupationally exposed to vibration and noise

In a group of 481 men (group A ) exposed occupationally to vibration(exceeding by four times the permissible levels in the frequencyband 32–64–125 Hz) and noise (105–116 dB),and in a group of 303 men without contact with vibration andnoise at work (reference group R) the prevalence of coronaryrisk factors was assessed, Socioeconomic status, level of occupationalphysical activity and family history of heart disease were comparablein the two groups. Mean blood pressure values and the percentage with hypertensionwere significantly higher in the exposed than in the referencegroup(P0.01). Overweight and hypertrigliceridemia occurred lessfrequently in group A than in group R(P0.01 and P0.05 respectively).The prevalence of hypercholesterolaemia and smoking habits wassimilar in both groups. The results suggest that vibration andnoise may be factors which increase the risk of coronary heartdisease.     

Early administration of captopril and nitroglycerin in combination after acute myocardial infarction: an invasive haemodynamic study

The combination of captopril and nitroglycerin early after acutemyocardial infarction (AMI) could lead to a dangerous decreasein blood pressure coronary perfusion. To evaluate the safetyaspects and haemodynamic effects of this combination, we studied36 first ‘Q wave’ thrombolysed anterior wall AMIpatients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusionof nitroglycerin and were submitted to pulmonary artery catheterization.Those patients with mean arterial pressure (MAP) 70 mmHg, cardiacindex 2.21. min^–1.m^–2, and wedge pressure 10 mmHgwere included and randomized to receive 6.25 mg of captoprilevery 6 h on the first day and 12.5 mg qid on the second f MAP 70mmHg (group 1). A second group (group 2) received a placebo.Haemodynamic parameters were determined after 1, 6 and thenevery 6 h up to 48 h after basal measurements. Significant differenceswere observed only for the MAP and the rate-pressure product(reduction in group 1 values, P <0.05). However, MAP wasmaintained within acceptable limits. Our data support the factthat the combination of captopril and nitroglycerin in the earlyhours of a non-complicated anterior wall AMI is safe, and couldguarantee its use in large clinical trials to determine theeffects on left ventricle remodelling and survival after AMI.     

Lipoprotein(a) as a risk predictor for cardiac mortality in patients with acute coronary syndromes

Aims Raised lipoprotein(a) concentrations are considered to be arisk factor for atherothrombotic diseases. We examined whetherbaseline concentrations were a risk factor for an adverse outcomein patients admitted with acute coronary syndromes. Methods and Results Five hundred and nineteen patients admitted with suspected acutecoronary syndromes were studied and followed prospectively fora median of 3 years. The prognostic significance of a baselinelipoprotein(a) concentration of 30mg.dl^–1or lower forsubsequent cardiac death was assessed in patients with myocardialinfarction (266) and unstable angina (197) and compared withother variables in regression models. In patients with myocardialinfarction, a baseline lipoprotein(a) concentration of 30mg.dl^–1wasassociated with a 62% increase in subsequent cardiac death comparedto the lower concentration group (29·8% vs 18·6%,Log rankP=0·04). In a multivariate regression model abaseline lipoprotein(a) concentration of 30mg.dl^–1retainedits significance as an independent predictor of cardiac death(P=0·037). In patients with unstable angina, baselineconcentrations of 7·9mg.dl^–1were found to be significantpredictors of cardiac death in univariate (P=0·021) andmultivariate (P=0·035) regression models. Conclusion Baseline lipoprotein(a) concentrations in patients admittedwith acute coronary syndromes are associated with an increasedrisk of cardiac death. For patients with myocardial infarctiona concentration of 30mg.dl^–1appears appropriate as a riskdiscriminator; for patients admitted with unstable angina, however,much lower concentrations of lipoprotein(a) appear to be prognosticallyimportant.     

Haemodynamic findings in experimental right ventricular ischaemia after right coronary arterial ligation

Acute ischaemia limited to the free wall of the right ventriclewas produced by right coronary arterial ligation (RCAL) in 20dogs. Contrast M-mode and cross-sectional echocardiography wasperformed in 7 cases to investigate the presence of tricuspidinsufficiency. The haemodynamic findings obtained with an openpericardium at 15 to 30 min showed increases in right (l.20.5to 2.70.7 mmHg, P0.01) andleft (5.0 0.8 to 6.60.9 mmHg, P005)ventricular end-diastolic pressures, and decreases in heartrate (1394.9 to 1195.1 bpm, P0.01), cardiac index (1066.6 to817.3 ml min^–1 kg^–1, P001), stroke index (79 6 to72 8 ml x 100 beat^–1 kg^–1, P0.02), right (23.8l.5to 19.41.5 mmHg, P0.01) and left (1097.2 to 958.2 mmHg, P005)ventricular systolic pressures and right ventricular strokework index (18.32.4 to 11.41.8 g m kg^–1, P0.01). In 6of 15 cases the 'y' descent became deeper than the 'x' descentin right atrial pressure (RAP). Tricuspid insufficiency gradeI–II/IV was present in 3 of 7 cases, 2 of them with a'y'>'x' in RAP. Right ventricular mechanical alternans, probablysecondary to a decrease in contractility, appeared in 10 of20 cases after RCAL. Closure of the pericardium exaggeratedthe haemodynamic alterations and a dip-plateau appeared in 2cases on the right ventricular pressure curve. We conclude thatsignificant aemodynamic alterations in right ventricular functionare produced by RCAL in dogs, and they are exaggerated afterclosing the pericardium.     

Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction

To determine whether or not ST segment deviation on admissionelectrocardiograms can identify patients with anterior acutgemyocardial infarction due to proximal left anterior descendingartery occlusion, the magnitude and location of ST segment elevationor depression were compared between patients with proximal leftanterior descending artery occlusion (group A, n=47) and thosewith distal left anterior descending artery occlusion (groupB, n =59). ST segment depression in each of the inferior leadswas significantly greater in group A than in group B. The incidenceof ST segment depression 1 mm in each of the inferior leads(II; 81% vs 27%, III; 85% vs 54%, aVF; 87% vs 47%, P<0·01)was significantly higher in group A than in group B. In addition,the incidence of ST segment depression 1 mm in all of the inferiorleads was significantly greater in group A than in group B (77%vs 22%, P<0·01). In group A, maximal ST segment elevationwas more frequent in lead V alone (43% vs 14%, P<0·01).Group A had greater ST segment elevation in lead a VL than groupB, and the incidence of ST segment elevation 1 mm in lead aVL was significantly higher in group A than in group B (66%vs 47%, P<0·05). ST segment depression 1 mm in allof the inferior leads was most valuable for identifying groupA patients (77% sensitivity and 78% specificity). In contrast,the maximal ST segment elevation in lead V₂ alone or ST segmentelevation 1 mm in lead a VL had a low diagnostic value (43%sensitivity and 86% specificity, 66% sensitivity and 53% specificity,respectively). In conclusion, this study indicates that analysisof ST segment deviation in the inferior leads is useful foridentifying patients with acute anterior myocardial infarctiondue to proximal left anterior descending occlusion.     

Exercise training in heart failure improves quality of life and exercise capacity

Aims Benefit from exercise training in heart failure has mainly beenshown in men with ischaemic disease. We aimed to examine theeffects of exercise training in heart failure patients 75 yearsold of both sexes and with various aetiology. Methods and Results Fifty-four patients with stable mild-to-moderate heart failurewere randomized to exercise or control, and 49 completed thestudy (49% 65 years; 29% women; 24% non-ischaemic aetiology;training, n=22; controls, n=27). The exercise programme consistedof bicycle training at 80% of maximal intensity over a periodof 4 months.Improvements vs controls were found regarding maximalexercise capacity (6±12 vs –4±12% [mean±SD],P<0·01)and global quality-of-life (2 [1] vs 0 [1] units [median {inter-quartilerange}],P<0·01), but not regarding maximal oxygenconsumption or the dyspnoea–fatigue index. All of thesefour variables significantly improved in men with ischaemicaetiology compared with controls (n=11). However, none of thesevariables improved in women with ischaemic aetiology (n=5),or in patients with non-ischaemic aetiology (n=6). The trainingresponse was independent of age, left ventricular systolic function,and maximal oxygen consumption. No training-related adverseeffects were reported. Conclusion Supervised exercise training was safe and beneficial in heartfailure patients 75 years, especially in men with ischaemicaetiology. The effects of exercise training in women and patientswith non-ischaemic aetiology should be further examined.     

Autonomic balance in patients with angina and a normal coronary angiogram

The pathophysiology of angina pectoris in patients with a normalcoronary angiogram is not clear. Furthermore, the pathophysiologicalimpact of ST changes in syndrome X is controversial. The purposeof this study was to investigate cardiac autonomic function,by measuring 24 h heart rate variability, in patients with andwithout electrocardiographic evidence of ischaemia during exercise. Thirty-two patients with angina pectoris, a normal coronaryangiogram, echocardiogram, hyperventilation test and gastro-oesophagealinvestigation were studied. Fourteen healthy subjects servedas controls. Fifteen patients had significant ST segment depressionduring stress testing, whereas 17 had no electrocardiographicsigns of ischaemia. Heart rate variability was calculated as(1) mean RR= mean of all normal RR intervals, (2) the differencein mean RR level between when awake and when asleep (mean RRwake-sleep)—a tentative index of sympathetic activation,(3) the standard deviation (SD)—a broad band measure ofautonomic balance, and (4) a percentage of successive RR intervaldifferences 6% (pNN6%)—an index of vagal modulation. Thecoronary vascular resistance was measured at rest and duringpacing. Mean RR and autonomic indexes did not differ between patientswith a positive exercise test and controls (831/884 m 24 h SD125/134 m pNN6% 6.715.4%, respectively). Patients with a normalexercise test had shorter mean RR (758 ms vs 844 m P<0.05)and significantly reduced 24-h SD (103 ms vs 134 m P<0.05)than controls, whereas values for vagal index (6.5% vs 5.4%)did not differ from healthy controls. Mean RR wake-sleep alsotended to be lower in patients with a normal exercise test (–125 ms vs – 173 ms) compared to controls (P<0.1). Patientswith a positive exercise test had a significantly attenuatedreduction in coronary vascular resistance during pacing in comparisonto patients with a normal exercise test (–0.131–0.26mmHg x min. ml^{– 1}; P<0.05). The findings suggest the occurrence of general elevated sympatheticactivation in angina patients with a normal exercise test. Patientswith a positive exercise test exhibited no signs of autonomicdysfunction although these patients had altered coronary vascularresistance indicating microvascular angina. This supports thesuggestion that patients with a normal exercise test constitutean independent pathophysiological entity.     

lschaemic heart disease: The QRS score: a promising new exercise score for detecting coronary artery disease based on exercise-induced changes of Q-, R- and S-waves: a relationship with myocardial ischaemia

BACKGROUND: Recently, a new exercise test criterion diagnosing coronaryartery disease was proposed, based on a composite of changesin Q-, R- and S-waves: the QRS score. We compared this new criterionwith conventional ST-segment depression and other compositionsof Q-, R and S-wave changes in patients and normals and relatedthe QRS score to reversible thallium-201 scintigraphic defectsand ST-segment depression as markers for ischaemia. The influenceof beta-blockade on the QRS score was also studied. METHODS: The study population consisted of 155 persons with 53 normals(group I) and 102 patients with documented coronary artery disease(group II). Another 20 patients (group III) with proven coronaryartery disease and a positive exercise test by ST-segment criteriawere studied for the influence of beta-blockade on the QRS score.A symptom-limited exercise protocol according to the modifiedBruce protocol was used. For the QRS score, Q-, R- and S-waveamplitudes which could be recovered immediately were subtractedfrom pretest values: Q, R, S respectively. The score was calculatedby the formula: (R – Q –S)AVF+(R –Q–S)V5. RESULTS: Using a cut-off point of >5 as normal, the QRS score resultedin a sensitivity of 88·2%, a specificity of 84·8%and a predictive accuracy of 87·1%. For ST-segment depressionthese values were 54·9% 83% and 64·5% respectively(P<0·00l compared to the QRS score.) Predictive accuraciesof changes in Q-, R- and S-waves in leads AVF and VS separately,combinations of changes and combining the two leads, resulted—withthe exception of solitary S-wave changes—in predictiveaccuracies higher than those of ST-segment depression, but allwere lower than the QRS score. We found a significant correlationbetween the QRS score, the summed ST-segment depres sion (P<0004)and the extent of reversible thallium-201 defects (P<0·004Applying Bayes' theorem, the combination of an abnormal QRSscore and ST-segment depression resulted in the highest post-testrisk for coronary artery disease and a normal QRS score withoutST-segment depression in the lowest post-test risk. The QRSscore and the maximal ST-segment depression changed significantlyunder the influence of beta-blockade (P<0·02 and P<0·001respectively). CONCLUSION: Our data suggest that an abnormal QRS score reflects myocardialischaemia. Furthermore, for the interpretation of the exercisetest, the combined analysis of ST-segments and the QRS scoreis of value for the prediction of the presence or absence ofcoronary artery disease and its follow-up.     

Age-related mortality, clinical heart failure, and ventricular fibrillation in 4259 Danish patients after acute myocardial infarction

AIMS: To evaluate the prognosis of patients 80 years old, we analyseda large, community-based population with acute myocardial infarctionwho received intensive observation and similar pharmacotherapyregardless of age. METHODS AND RESULTS: In a 12-year period, before the introduction of thrombolysis,4259 consecutive patients hospitalized with acute myocardialinfarction from the same hospital in Denmark were prospectivelyregistered. Their complications and mortality in hospital, and1 and 5 years after discharge were analysed retrospectively.Overall, in-hospital mortality was 11% for patients less than<50 years old, 22% for patients 60–69 years old and43% for patients 80 years old. Two thirds of patients 80 yearsold had heart failure, and cardiogenic shock was twice as commonin this age group than in patients 60–69 years. Heart failure was a strong independent risk, factor for post-dischargemortality, particularly in the oldest age groups. Four out ofeight patients 80 years survived one year if discharged aliveafter experiencing in-hospital ventricular fibrillation. CONCLUSION: The life-saving potential of preventing or treating heart failureseems considerable even in the oldest patient groups. Patients80 years old who survive in-hospital ventricular fibrillationhave an acceptable prognosis 1 year post-discharge.     

Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme

Aims The principal aim of the second EUROASPIRE survey was todetermine in patients with established coronary heart diseasewhether the Joint European Societies' recommendations on coronaryprevention are being followed in clinical practice. Methods This survey was undertaken in 1999–2000 in 15European countries: Belgium, Czech Republic, Finland, France,Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Poland,Slovenia, Sweden, Spain and the U.K., in selected geographicalareas and 47 centres. Consecutive patients, men and women 70years were identified retrospectively with the following diagnoses:coronary artery bypass graft, percutaneous transluminal coronaryangioplasty, acute myocardial infarction and myocardial ischaemia.Data collection was based on a review of medical records andinterview and risk assessment at least 6 months after hospitaladmission. Results 8181 medical records (25% women) were reviewed and 5556patients (adjusted participation rate 76%) interviewed. Recordingof risk factor history and risk factor measurement in hospitalnotes was incomplete, particularly for discharge documents.At interview (median time 1·4 years after hospital discharge),21% of patients smoked cigarettes, 31% were obese, 50% had raisedblood pressure (systolic blood pressure 140mmHg and/or diastolicblood pressure 90mmHg), 58% had elevated serum total cholesterol(total cholesterol 5mmol.l^–1) and 20% reported a medicalhistory of diabetes. Glucose control in these diabetic patientswas poor with 87% having plasma glucose >6·0mmol.l^–1and72% 7·0mmol.l^–1. Among the patients interviewedthe use of prophylactic drug therapies on admission, at dischargeand at interview was as follows: aspirin or other antiplateletsdrugs 47%, 90% and 86%; beta-blockers 44%, 66% and 63%; ACEinhibitors 24%, 38% and 38%; and lipid-lowering drugs 26%, 43%and 61%, respectively. With the exception of antiplatelet drugs,wide variations in the use of prophylactic drug therapies existbetween countries. Conclusions This European survey of coronary patients showsa high prevalence of unhealthy lifestyles, modifiable risk factorsand inadequate use of drug therapies to achieve blood pressureand lipid goals. There is considerable potential throughoutEurope to raise the standard of preventive cardiology throughmore effective lifestyle intervention, control of other riskfactors and optimal use of prophylactic drug therapies in orderto reduce coronary morbidity and mortality.     

Mortality and morbidity after coronary artery bypass surgery related to pre-operative left ventricular ejection fraction: a follow-up study

OBJECTIVE: To study the pre-operative level of left ventricular ejectionfraction that may be indicative of an increased risk of earlyand late mortality and of recurrent angina pectoris and latenon-fatal myocardial infarction. MATERIAL AND METHODS: A total of 934 patients with known left ventricular ejectionfraction, 80 women and 854 men, were submitted to coronary arterybypass grafting at the Cardiovascular Unit of Rikshospitalet,Oslo, between August 1982 and December 1986. The closing datewas the 1st of January 1993, with a mean follow-up of time of7·4 years. The patients were divided in to four subgroupsaccording to their level of left ventricular ejection fraction:40%, 41–60%, 61–80% and >80%. The left ventricularejection fraction varied from 13–98%. A chi-square testof linear trend was used to calculate the relative risk betweenthe different subgroups. Cumulative survival was determinedusing survival curves. RESULTS: Early mortality. Twenty-five patients (2·7%) died within30 days of operation. Patients with left ventricular ejectionfraction 40% had a relative risk of 10·2 (1·9–17·2),for left ventricular ejection fraction 41–60% the relativerisk was 0·9 (0·1–8·9) and for leftventricular ejection fraction 61-80% the relative risk was 2·8(0·6–17·2). Left ventricular ejection fraction>80% was defined as relative risk=1. Late mortality. Altogether,174 patients died in the late phase (18·6%). For patientswith left ventricular ejection fraction 40% the relative riskwas 3·6 (2·8–10·9), for left ventricularejection fraction 41–60% the relative risk was 1·8(1·1–3·6),and for left ventricular ejectionfraction 61–80% the relative risk was 1·5 (0·9–2·8).Recurrent angina pectoris. A total of 138 patients developedrecurrent angina pectoris during the follow-up period, givingan incidence of 14·8%. Here, for left ventricular ejectionfraction 40% the relative risk was 0·5(0·2–13), for left ventricular ejection fraction 41–60% therelative risk was 1·0 (0·5–1·8) andfor left ventricular ejection fraction 61–80% the relativerisk was 1·2 (0·7–2·0). Late non-fatalmyocradial infarction. Altogether, 90 patients (9·6%)experienced non-fatal myocardial infarction in the late phase.For left ventricular ejection fraction 40% the relative riskwas 0·6(1·2–1·8), for left ventricularejection fraction 41–60% the relative risk was 1·0(0·5–2·0) and for left ventricular ejectionfraction 61–80% the relative risk was 0·7 (0·41–1·3).Cumulative survival. When pooled together, the cumulative survivalfor patients with left ventricular ejection fraction >40%was 95·9, 91·9 and 79% after 1, 5 and 10 years,respectively. For the patients with left ventricular ejectionfraction 40% cumulative survival was 87·5, 73·1and 55·2%, respectively. CONCLUSION: When the left ventricular ejection fraction was 40% or lower,there was a substantial increase in the risk of early mortalityin patients submitted to coronary artery bypass grafting. Asfor the risk of late mortality, there was a practically linearincrease in risk with falling values of left ventricular ejectionfraction. We found no difference in risk of developing recurrentangina pectoris or of late non-fatal myocardial infarction relatedto values of left ventricular ejection fraction.     

Angioscopic evaluation of prolonged vs standard balloon inflations during coronary angioplasty: A randomized study

To study the immediate effects of prolonged total balloon inflationduring PTCA, 41 patients (44 lesions) with chronic-stable anginawere randomized for prolonged sequential inflations (three tofive inflations of 3 to 5 min each, for a total duration of 12 min, group 1, n=20 lesions) or ‘standard’ sequentialinflations (three to five inflations of 1 min each, for a totalduration of 3 min, group 2, n-24 lesions). The mean durationof total balloon inflation time was 958 ± 129 s in group1 vs 205 ±46 s in group 2. Results of angioplasty wereassessed on both angiography and percutaneous transluminal coronaryangioscopy performed immediately after the procedure. High qualityimaging of the coronary lumen and lesion morphology was possibleon angioscopy in all patients without any complications. Post-PTCAangiographic percent diameter stenosis was significantly lessin group 1 compared to group 2: 26 ± 10% vs 36 ±8% (P<0.05). On angioscopy, flaps were seen in 16 patientsin group 2, but in only six in group 1 (P<0.02). There wasno difference in the incidence of thrombi on angioscopy betweenthe two groups (group 1: nine cases, group 2: 10 cases). Sensitivityof angiographic detection of flaps and thrombi was poor: 10%and 12% respectively. One patient in each group developed alongitudinal dissection, detected on both angiography and angioscopy. Conclusions: (1) prolonged sequential balloon inflations leadto less residual luminal stenosis after PTCA, with a decreasedincidence of intimal flaps in comparison with standard inflations.(2) Post-PTCA transluminal coronary angioscopy is safe and offersbetter assessment of luminal effects of PTCA than angiography.