Comparison of myocardial performance index versus ratio of isovolumic contraction time/ejection time in left ventricular systolic dysfunction

Myocardial performance index (MPI) has been regarded as an important parameter in the evaluation of ventricular systolic function in congestive heart failure. This study was designed to investigate the relationship between the ratio of isovolumic contraction time/left ventricular ejection time (IVCT/LVET), MPI, and LV systolic function. A total of 43 patients (patient group) with LV ejection fractions (LVEFs) <55% were compared with 43 patients (control group) with LVEF values ≥55%. LVEF was measured in all cases by 2-dimensional echocardiography via the modified Simpson method. Isovolumic relaxation time (IVRT), IVCT, LVET, ratio of IVCT/LVET, and MPI ([IVRT+IVCT]/LVET) were measured via Doppler echocardiography. The mean value for IVCT was found to be significantly higher (P<.001) and concomitant mean LVET value significantly lower (P=.027) in the patient group. Similarly, the mean value of MPI and the ratio of IVCT/LVET were found to be significantly higher (P<.001 for both) in the patient group. The value of the ratio of IVCT/LVET was found to have a significant negative correlation with the value of LVEF (r=-.947; P<.001) and a significant positive correlation with the value of MPI (r=.796; P<.001). The study reported here clearly demonstrates the noninferiority of the ratio of IVCT/LVET to MPI and the possibility of its substitution for MPI in the evaluation of LV systolic function.     

Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction.

We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.     

Cardiac time intervals and the association with 2D-speckle-tracking,tissue Doppler and conventional echocardiography: the Thousand&amp;1 Study

Cardiac time intervals (CTI) are prognostic above and beyond conventional echocardiographic measures. The explanation may be that CTI contain information about both systolic and diastolic measures; this is, however, unknown. The relationship between the CTI and systolic and diastolic function assessed by conventional, tissue Doppler (TDI) and speckle-tracking echocardiography (STE) was investigated. CTI and echocardiographic measurements, including conventional, STE, and TDI echocardiography, were studied in 1088 type 1 diabetes patients without known heart disease randomly selected from the out-patient clinic at Steno Diabetes Center. The CTI were obtained by TDI M-mode through the mitral leaflet and included the isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and the myocardial performance index (MPI = (IVRT + IVCT)/ejection time). Standardized beta-values were assessed. Both systolic and diastolic measures associated with CTI. Conventional measures: left ventricular ejection fraction (stand. beta): MPI ?0.34, IVRT 0.24, and IVCT ?0.21, all p < 0.001. For the TDI measures, the most significant association was found with e′: MPI (stand. beta: ?0.30, p < 0.001) and IVRT (?0.35, p < 0.001) but no association with IVCT ?0.05, p = 0.1). Speckle-tracking derived measures were in general strongly associated with the cardiac time intervals. Thus, global longitudinal strain and MPI (?0.38, p < 0.001), IVRT (?0.23, p < 0.001), and IVCT (?0.10, p < 0.001); and global longitudinal strain rate e and MPI (?0.40, p < 0.001), IVRT (?0.42, p < 0.001), and IVCT (?0.04, p = 0.11). CTI, in particular MPI and IVRT, associate with both systolic and diastolic myocardial function assessed by conventional and newer echocardiographic measures. This may possibly help to explain the prognostic significance of CTI.     

Effect of the isolated left bundle branch block on systolic and diastolic functions of left ventricle.

BACKGROUND: We planned this study to evaluate the effects of left bundle branch block (LBBB) on systolic and diastolic functions of left ventricle (LV) that have not previously been investigated in detail. MATERIAL AND METHODS: Forty-five cases diagnosed as isolated LBBB according to the standard electrocardiographic criteria (group I, mean age: 60 +/- 12 years) were taken as the case group and 65 cases with normal conduction system (group II, mean age 58 +/- 14 years) were taken as the control group. Echocardiography was performed to all patients and coronary angiography was performed to 21 patients in group I and 35 patients in group II. In addition to standard systolic and diastolic function parameters, isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and ejection time (ET) were measured by echocardiography, and the myocardial performance index (MPI) [(IRT+ICT)/ET] was calculated. LV end-diastolic pressure was calculated for the patients undergoing coronary angiography. RESULTS: In group I, LV end-systolic diameter was greater (3.1 +/- 0.4 cm vs 2.8 +/- 0.4 cm, P <.001) and ejection fraction was lower (64% +/- 6% vs 68% +/- 6%, P <.001) than those of group II. Rapid filling deceleration time and rate was markedly different in group I (respectively, 133 +/- 50 ms vs 166 +/- 24 ms, P <.001; 608 +/- 291 cm/s(2) vs 383 +/- 116 cm/s(2), P <.001). In addition, it was found that LBBB caused shortening of LV diastolic period and ET markedly (respectively, 347 +/- 116 ms vs 394 +/- 106 ms, P =.03; 255 +/- 40 ms vs 294 +/- 21 ms, P <.001) and prolongation of IRT and ICT (respectively; 124 +/- 36 ms vs 91 +/- 16 ms, 96 +/- 35 ms vs 38 +/- 9 ms, P <.001). The MPI was predominantly higher in group I (0.89 +/- 0.29 vs 0.40 +/- 0.06, P <.001). Invasively determined LV end-diastolic pressure was found higher in group I (14 +/- 3 mm Hg vs 10 +/- 3 mm Hg, P <.001). CONCLUSION: A marked elevation of the LV MPI and end-diastolic pressure, parallel to changes of conventional echocardiographic parameters, in patients with isolated LBBB points out that LBBB causes marked deterioration on LV systolic and diastolic functions.     

Tissue doppler myocardial performance index in patients with heart failure and its relationship with haemodynamic parameters

The myocardial performance index (MPI) reflects both the systolic and diastolic function of the heart, and is easily applied in practice. In this study, we aimed to determine the relationship between MPI and invasive haemodynamic parameters in heart failure patients. A total of 126 patients with heart failure were selected, all of whom were referred for diagnostic cardiac catheterisation, and were divided into two groups. Group I consisted of 59 patients (32 men and 27 women, mean age 61 ± 10; functional capacity New York Heart Association (NYHA) Class I; and left ventricular end-diastolic pressure (LVEDP) <16 mmHg). Group II included 67 patients (34 men and 33 women, mean age 60 ± 9; NYHA Class ≥ II; LVEDP ≥ 16 mmHg). The following parameters were measured in all patients: ejection fraction with Simpson method, the peak mitral early (E) and late (A) diastolic velocities, E/A ratio, deceleration time (DT) and tissue Doppler from four different areas of the mitral annulus (septum, lateral, inferior and anterior). In order to measure MPI with two methods (standard Doppler and tissue Doppler), isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT) and ejection time (ET) were measured from four areas and mean values of MPI were calculated. There was no difference between the two groups in E/A ratios, DT and IVRT (p > 0.05). Group II patients had longer IVCT and ET, when compared with group I patients (p < 0.05). MPI, measured by both standard pulsed wave Doppler and tissue Doppler methods, was significantly higher in group II patients, when compared with the values obtained from group I patients (Group I: 0.50 ± 0.2 and 0.50 ± 0.14; group II: 0.98 ± 0.3 and 1.2 ± 0.32; p < 0.001). According to receiver operating characteristics curve analysis, the cut-off value for MPI measured by tissue Doppler was 0.74. The sensitivity and specificity of this value were measured as 92.5 and 91.5 %, respectively. MPI measured by standard Doppler method was 0.67, and its sensitivity and specificity were 85.1 and 83.1 %, respectively. We found a strong relationship between MPI and LVEDP (r = 0.83, p < 0.001; r = 0.96, p < 0.001), especially when measured by tissue Doppler. In addition, we observed a significant relationship between the MPI values measured by tissue Doppler and those measured by standard traditional methods (r = 0.85, p < 0.001). We showed that MPI was reliable for the evaluation of global cardiac functions in patients with heart failure, as measured with both pulsed-wave Doppler and tissue Doppler. We assert that, in order to differentiate between those patients with symptomatic heart failure from the asymptomatic cases, MPI as measured with the tissue Doppler method is an improvement on MPI as measured using traditional methods.     

A perspective on atrioventricular delay optimization in patients with a dual chamber pacemaker

Atrioventricular delay (AVD) is critical in patients with DDD pacemakers (PM). Echo/Doppler evaluation of AVD providing the longest left ventricular filling time (FT) or the highest cardiac output (CO) is used for AVD optimization. Recently myocardial performance index (MPI) has been shown to improve by optimizing AVD. The aim was to compare the CO, FT, MPI derived optimal AVD, and to analyze systolic and diastolic performance at every optimal AVD. Twenty-five patients, 16 men 68 +/- 11 years, ejection fraction >or= 50%, with a DDD PM for third-degree AV block, without other major cardiomyopathies, underwent echo/Doppler AVD optimization. CO, FT, and MPI derived optimal AVDs were identified as the AVDs providing the highest CO, the longest FT, and the minimum MPI, respectively. Isovolumic contraction and relaxation time (ICT, IRT), ejection time (ET), ICT/ET, and IRT/ET ratios were also evaluated at every optimal AVD. CO, FT, and MPI derived optimal AVDs were significantly different (148 +/- 36 ms, 116 +/- 34 ms, and 127 +/- 33 ms, respectively). ICT/ET was similar at CO, FT, and MPI derived optimal AVD (0.22 +/- 0.10, 0.23 +/- 0.11, and 0.21 +/- 0.10, respectively). IRT/ET ratio was similar at FT and MPI derived optimal AVDs (0.34 +/- 0.15 and 0.33 +/- 0.15, respectively) and significantly shorter (P < 0.02) than at CO derived optimal AVD (0.40 +/- 0.15). Different methods indicate different optimal AVDs. However analysis of systolic and diastolic performance shows that different AVDs result in similar systolic or diastolic performance. At MPI optimized AVD, a high CO combined with the most advantageous conditions of both isovolumic contraction and relaxation phases is achieved.     

The myocardial performance index during low-dose dobutamine echocardiography in control subjects and patients with a recent myocardial infarction: a new index of left ventricular functional reserve?

BACKGROUND: Wall-motion analysis during low-dose dobutamine echocardiography (LDDE) is a semiquantitative measure of left ventricular contractile reserve after myocardial infarction (MI). The Doppler echocardiographic myocardial performance index (MPI) is a quantitative measure of combined left ventricular systolic and diastolic function. We sought to characterize the changes in MPI during LDDE in control subjects and patients with MI, and to describe the relation of these changes to changes in regional systolic function. METHODS: MPI was obtained at rest and during LDDE (10 microg/kg/min) in 25 healthy volunteers (group 1) and 50 patients with a recent MI. Patients were divided into two subsets; those with (n = 23; group 2A) and those without (n = 27; group 2B) a contractile reserve defined as an improvement of wall motion in more than two contiguous infarct-zone segments during LDDE. DeltaMPI was defined as the change from rest to LDDE. RESULTS: MPI decreased significantly during LDDE in groups 1 and 2A, whereas MPI increased in group 2B (DeltaMPI = 0.12 +/- 0.04 and 0.10 +/- 0.08 vs -0.03 +/- 0.08, P <.0001). On multivariate analysis, Deltawall-motion score index predicted DeltaMPI (beta = 0.65, P <.0001) independently of age, sex, and the dobutamine-induced change in heart rate and systolic blood pressure. CONCLUSIONS: Data suggest that the change in MPI during LDDE may provide a simple and quantitative measure of overall left ventricular functional reserve in patients with a recent MI.     

真性红细胞增多症患者骨髓CD34阳性细胞凋亡及增殖特征研究

目的　了解真性红细胞增多症 (PV)患者骨髓CD34 阳性细胞的凋亡、增殖情况。方法　应用双色流式细胞仪检测 2 0例PV患者及 10例原发性血小板增多症 (ET)患者和 12名正常人骨髓CD34 阳性细胞AnnexinⅤ以及细胞增殖相关抗原Ki6 7的表达情况并分析其与PV临床表现的相关性。结果　PVCD34 阳性细胞AnnexinⅤ表达率为 (15 .96± 1.4 5 ) % ,ET为 (15 .5 3± 1.76 ) % ,明显低于正常对照组的 (2 3.6 1± 3.89) % (P <0 .0 5 ) ;CD34 阳性细胞Ki6 7表达率PV为 (4 8.79± 11.6 8) % ,ET为 (4 9.6 0±9.98) % ,明显高于正常对照组的 (33.87± 6 .82 ) % (P <0 .0 1) ;凋亡增殖比PV为 0 .33± 0 .10 ,ET为 0 .32± 0 .0 2 ,明显低于正常对照组的 0 .72± 0 .11(P <0 .0 1) ;CD34 阳性细胞凋亡与血红蛋白、白细胞计数、内源性红系集落呈负相关 (分别r=- 0 .4 81,P =0 .0 37;r=- 0 .5 38,P =0 .0 2 6 ;r=- 0 .6 32 ,P =0 5 0 )。凋亡增殖比与血红蛋白、白细胞计数呈负相关 (分别r=- 0 .5 37,P =0 .0 18;r=- 0 .6 6 7,P =0 0 0 3)。结论　PV患者骨髓CD34 阳性细胞有低凋亡及高增殖特点 ,低凋亡与疾病严重度相关。     

Clinically useful estimates of insulin sensitivity during pregnancy: validation studies in women with normal glucose tolerance and gestational diabetes mellitus

OBJECTIVE: We examined whether selected indexes of insulin sensitivity derived from an oral glucose tolerance test (IS(OGTT)) or fasting glucose/insulin levels (IS(QUICKI) and IS(HOMA)) can be used to predict insulin sensitivity in women before and during pregnancy. RESEARCH DESIGN AND METHODS: A 2-h euglycemic-hyperinsulinemic clamp (5 mmol/l glucose, 40 mU. m(-2). min(-1) insulin) and a 120-min oral glucose tolerance test (75 g load pregravid, 100 g pregnant) were repeated on 15 women (10 with normal glucose tolerance [NGT] and 5 with gestational diabetes mellitus [GDM]) pregravid and during both early (12-14 weeks) and late (34-36 weeks) pregnancy. An index of insulin sensitivity derived from the clamp (IS(CLAMP)) was obtained from glucose infusion rates adjusted for change in fat-free mass and endogenous glucose production measured using [6,6(-2)H(2)]glucose. RESULTS: Univariate analysis using combined groups and periods of pregnancy resulted in significant correlations between IS(CLAMP) and IS(OGTT) (r(2) = 0.74, P < 0.0001), IS(QUICKI) (r(2) = 0.64, P < 0.0001), and IS(HOMA) (r(2) = 0.53, P < 0.0001). The IS(OGTT) provided a significantly better correlation (P < 0.0001) than either IS(QUICKI) or IS(HOMA.) Multivariate analysis showed a significant group effect (P < 0.0003) on the prediction model, and separate equations were developed for the NGT (r(2) = 0.64, P < 0.0001) and GDM (r(2) = 0.85, P < 0.0001) groups. When subdivided by period of pregnancy, the correlation between IS(CLAMP) and IS(OGTT) pregravid was r(2) = 0.63 (P = 0.0002), during early pregnancy was r(2) = 0.80 (P < 0.0001), and during late pregnancy was r(2) = 0.64 (P = 0.0002). CONCLUSIONS: Estimates of insulin sensitivity from the IS(OGTT) during pregnancy were significantly better than from fasting glucose and insulin values. However, separate prediction equations are necessary for pregnant women with NGT and women with GDM.     

Serum levels of advanced glycation end products are associated with left ventricular diastolic function in patients with type 1 diabetes.

OBJECTIVE: Impairment of left ventricular diastolic function, possibly caused by increased collagen cross-linking of the cardiac muscle, is common in patients with type 1 diabetes even without coronary artery disease. Advanced glycation end products (AGEs) cross-link tissue collagen and are found within myocardial fibers. The aim of this study was to examine for a possible association between circulating AGEs and left ventricular cardiac function. RESEARCH DESIGN AND METHODS: Left ventricular diastolic and systolic function were assessed by M-mode and Doppler echocardiography in 52 patients with type 1 diabetes, age 40 +/- 13 (mean +/- SD) years, diabetes duration 17 +/- 13 years, and HbA1c 8.3 +/- 1.1%. Serum levels of AGEs and N epsilon-(carboxymethyl)lysine (CML) were measured by newly developed competitive immunoassays. RESULTS: A positive correlation was found between serum levels of AGEs and isovolumetric relaxation time (IVRT), r = 0.46 (P < 0.0008), and left ventricular diameter during diastole, r = 0.37 (P < 0.008). The systolic parameters did not correlate with serum levels of AGEs. Stepwise regression analysis showed that 21% of the IVRT variation could be explained by serum levels of AGEs (F = 11.4, P < 0.002), whereas serum levels of CML, HbA1c, albumin excretion rate, diabetes duration, and mean arterial blood pressure were of no importance. AGE levels were significantly increased in men compared with women (P < 0.03) and present or former smokers (P < 0.04). CONCLUSIONS: Increased serum levels of AGEs, unlike serum levels of CML, are associated with heart stiffness in patients with type 1 diabetes, possibly mediated by the cross-linking properties of AGEs.     

Maternal cardiac systolic and diastolic function: relationship with uteroplacental resistances. A Doppler and echocardiographic longitudinal study.

OBJECTIVE: To test the hypothesis of the existence of a relationship between central and peripheral hemodynamic parameters by the longitudinal evaluation of maternal echocardiographic and uteroplacental resistance modifications during normal pregnancy. METHODS: Forty-three healthy normotensive primigravidae were evaluated at 12 +/- 1, 21 +/- 1, and 33 +/- 1 weeks of gestation with uterine artery color Doppler and maternal echocardiographic examinations to identify morphologic, systolic, and diastolic variables. RESULTS: Cardiac output and stroke volume significantly increased during pregnancy. Uterine resistance index (RI) decreased from the first to the second trimesters (0.72 +/- 0.10 versus 0.54 +/- 0.09, P < 0.001). Left atrial dimensions increased during pregnancy (33.8 +/- 1.9 cm, 38.1 +/- 1.8 cm, 39.3 +/- 2.1 cm, P < 0.001). Left atrial function also increased. Left ventricular mass increased (132 +/- 18 g, 162 +/- 16 g, 174 +/- 27 g, P < 0.001). Diastolic function parameters showed significant modifications: E wave velocity and E/A ratio decreased; A wave velocity and deceleration time of the E wave (DtE) increased; the left ventricular isovolumetric relaxation time (IVRT) decreased significantly (88.7 +/- 6.7 ms, 75.6 +/- 7.7 ms, 71.1 +/- 5.0 ms, P < 0.001) showing a correlation with left atrial dimensions and RI (r = -0.38, r = 0.47, respectively; P < 0.001). CONCLUSIONS: Diastolic cardiac function varies during pregnancy. A relationship between preload (left atrial enlargement), afterload (RI reduction), morphologic, and diastolic function modifications (IVRT reduction, DtE prolongation) appears to exist as a consequence of the hemodynamic modifications which occur during physiologic pregnancy. Diastolic function analysis maybe useful to identify women who fully adapt to pregnancy, and to understand the mechanisms that might be involved in women who show abnormal uterine artery Doppler waveforms.     

Effect of Preload Alternations on a New Doppler Echocardiographic Index of Combined Systolic and Diastolic Performance

The objective of the study was to assess the effect of preload alternations on a nongeometric Doppler index of combined systolic and diastolic myocardial performance (MPI). Doppler echocardiography was performed during Valsalva maneuver, passive leg lifting, and after sublingual administration of nitroglycerin in 50 healthy volunteers (group 1) and 25 patients (group 2) with previous myocardial infarction. MPI was significantly lower in group 1 (0.34 +/- 0.04) compared with group 2 (0.52 +/- 0.14), P <.0005. In group 1 MPI was significantly increased during preload manipulations (P =. 001). The largest change in MPI was induced by nitroglycerin (0.034 +/- 0.05). In group 2 no significant changes in MPI were found. In both groups peak E-wave velocity (P <.0005), E/A-ratio (P <.0005), and E-wave deceleration time (P <.0005) were found to change during preload alternations. In conclusion, we found in normal subjects and to a lesser extent in patients with previous myocardial infarction that MPI is influenced by preload.     

Reduction in hepatic endothelin-1 clearance in cirrhosis

Circulating endothelin-1 (ET-1) levels are increased in cirrhosis. The liver is an important site for circulating ET-1 clearance through the ET(B) receptor. We evaluated ET-1 kinetics in cirrhosis to determine if a reduced liver clearance contributes to this process. Cirrhosis was induced by carbon tetrachloride in rats. Hepatic ET-1 clearance was measured in isolated perfused livers using the single bolus multiple indicator-dilution technique. Plasma ET-1 levels doubled in cirrhosis from 0.49+/-0.04 fmol/ml (mean+/-S.E.M.) to 1.0+/-0.18 fmol/ml ( P <0.01). Liver ET-1 extraction was reduced from 81+/-1% (mean+/-S.E.M.) in controls to 50+/-6% in cirrhosis ( P <0.01). Kinetic modelling revealed a major irreversible binding site for ET-1 that is blocked by the selective ET(B) receptor antagonist BQ788 and a minor non-specific reversible binding site that cannot be blocked with BQ788 or the selective ET(A) antagonist BQ123. Reduced hepatic clearance correlated with the biochemical markers of cirrhosis, portal vein perfusion pressure ( r =-0.457; P <0.001) and the increase in ET-1 levels ( r =-0.462; P =0.002). Immunohistofluorescence with specific anti-(ET(B) receptor) antibodies revealed a preponderant distribution of ET(B) receptors on hepatic stellate cells, which was increased in cirrhosis. We conclude that cirrhosis reduces ET-1 clearance probably by capillarization of hepatic sinusoids and reduced access to ET(B) receptors. This relates to the severity of cirrhosis and may contribute to the increase in circulating ET-1 levels.     

Noninvasive monitoring of carbon dioxide in infants and children with congenital heart disease: end-tidal versus transcutaneous techniques

End-tidal CO2 (ET(CO2)) monitoring and transcutaneous (TC) CO2 monitoring were prospectively compared in 53 patients, 1 month to 16 years of age, with congenital heart disease (CHD). There were 32 patients with cyanotic CHD and 21 with acyanotic CHD. The TC-Pa(CO2) difference was 2 +/- 1 mm Hg and the ET-Pa(CO2) difference was 5 +/- 3 mm Hg (P < .0001). The TC-Pa(CO2) difference was < or = 2 mm Hg in 30 of 53 patients and < or = 5 mm Hg in 53 of 53 patients. The ET-Pa(CO2) difference was < or = 2 mm Hg in 9 of 53 patients and < or = 5 mm Hg in 30 of 53 patients (P < .001). No variation in the TC-Pa(CO2) difference was noted based on the type of CHD (acyanotic vs cyanotic) or age. The ET-Pa(CO2) difference was greater in patients with cyanotic versus acyanotic CHD (7 +/- 3 mm Hg vs 4 +/- 2 mm Hg, P < .0001) and in patients < or = 1 year of age versus patients > or = 1 year of age (6 +/- 3 mm Hg vs 4 +/- 2, P = .008). In infants and children with CHD, TC monitoring provides a more accurate estimation of Pa(CO2) than ET monitoring.     

Factors associated with myocardial infarction after emergency endoscopy for upper gastrointestinal bleeding in high-risk patients: a prospective observational study

BACKGROUND: Because myocardial infarction (MI) after emergency endoscopy for upper gastrointestinal bleeding carries high mortality, we investigated factors associated with procedure-related MI in high-risk patients. METHODS: Consecutive patients with coronary artery disease or age-based risk for coronary artery disease (men, age >45 years; women, >55 years) who underwent emergency endoscopy were enrolled at a single ED. Demographic, laboratory, and outcome data were recorded. Patients fit 1 of 3 groups: MI before endoscopy (pre-panendoscopy [PES] MI), MI after endoscopy (post-PES MI), or non-MI. RESULTS: We enrolled 108 high-risk patients, including 5 (4.6%) with MI diagnosed preendoscopy. Five patients (4.6%) had MIs postendoscopy. Compared with non-MI patients, significantly more post-PES MI patients had heart disease (60.0% vs 12.2%; P = .021), lower systolic pressure on arrival (86.2 +/- 16.6 vs 128.0 +/- 27.2 mm Hg; P = .002), lower diastolic pressure on arrival (50.0 +/- 6.3 vs 69.5 +/- 15.8 mm Hg; P = .003), lower hemoglobin on arrival (6.7 +/- 1.1 vs 9.1 +/- 2.4 g/dL; P = .021), and more persistent shock status preendoscopy (80.0% vs 13.3%; P = .002). There was no significant difference in factors including duration of procedure and rates of recurrent bleeding, postprocedure complication, and mortality. CONCLUSIONS: Heart disease, lower blood pressure or hemoglobin level on arrival, and persistent shock before endoscopy are associated with increased risk for procedure-related MI.     

Comparison of myocardial tissue Doppler with transmitral flow Doppler in left ventricular hypertrophy

We sought to determine the most useful echocardiographic measurements for assessment of diastolic function in patients with left ventricular hypertrophy (LVH) and normal systolic function. We compared myocardial Doppler velocities of the basal inferoposterior wall with mitral inflow pulsed wave Doppler velocities in 11 healthy volunteers (age, 36 +/- 6 years), 25 patients (age, 64 +/- 14 years) without LVH, and 37 patients (age, 67 +/- 14 years) with LVH and otherwise normal echocardiograms. The discriminatory measurements were myocardial A-wave duration (120 +/- 18 versus 98 +/- 20 and 92 +/- 12 ms, P <.0001), myocardial isovolumetric relaxation time (124 +/- 45 versus 95 +/- 48 and 78 +/- 25 ms, P =.0035), mitral A-wave velocity (0.98 +/- 0.37 versus 0.73 +/- 0.28 m/s and 0.61 +/- 0.22 m/s, P =.009), and mitral E-wave deceleration time (257 +/- 93 versus 201 +/- 85 ms and 184 +/- 83 ms, P =.015), which were significantly increased, and myocardial E-wave velocity (0.84 +/- 0.04 m/s versus 0.13 +/- 0.03 m/s and 0.14 +/- 0.03 m/s, P <.0001), which was significantly decreased, in patients with LVH compared with patients without LVH and normal volunteers, respectively. Left ventricular posterior wall thickness correlated with myocardial isovolumetric relaxation time (r = 0.52, P <.0001) and myocardial A-wave duration (r = 0.59, P <.0001), negatively with myocardial E wave (r = -0.43, P <.0001), and showed no correlation with mitral inflow parameters except mitral inflow A wave (r = 0.43, P =.002). On multivariate analysis using these variables, myocardial isovolumetric relaxation time (P =.0014) and A-wave duration (P =.001) were the only 2 variables that correlated with posterior wall thickness (multiple R = 0.71). In the presence of LVH and preserved left ventricular systolic function, myocardial relaxation time and velocities are more sensitive than mitral Doppler inflow parameters in detecting abnormal left ventricular relaxation.     

Inhibition of ischemia-induced phospholipase activation by quinacrine protects jeopardized myocardium in rats with coronary artery occlusion

Phospholipase activation has been proposed as one relevant biochemical step toward irreversible myocardial injury during ischemia. Accordingly, after coronary artery occlusion, the time course of myocardial phospholipid degradation was studied in 83 control rats and 84 rats treated with quinacrine (75 mg/kg s.c. every 8 hr), a phospholipase inhibitor. Animals were sacrificed at different times ranging from 2 to 48 hr postocclusion. In controls a rapid fall in left ventricular phospholipid concentration (from 1.33 +/- 0.12 to 0.67 +/- 0.05 micrograms of P/mg of protein) and creatinkinase (CK) activity (from 9.84 +/- 0.49 to 6.93 +/- 0.60 I.U./mg of protein) was observed within 4 hr postocclusion. In quinacrine-treated animals phospholipids and CK also fell initially; however, 24 and 48 hr after occlusion they were higher than in controls (phospholipids: 0.99 +/- 0.05 vs. 0.62 +/- 0.04 micrograms of P/mg of protein, P less than .001; CK: 7.76 +/- 0.54 vs. 4.99 +/- 0.37 I.U./mg of protein, P less than .001, at 48 hr). Additional rats surviving coronary occlusion were divided randomly into a control (n = 14) and three treated groups receiving quinacrine every 8 hr at the dose of 5 (n = 13), 20 (n = 13) or 75 mg/kg (n = 15); 13 rats were sham-operated. Forty-eight hours postocclusion myocardial phospholipids were measured and infarct size calculated by CK depletion. Infarct size was significantly smaller in high dose quinacrine-treated than in control rats (16.6 +/- 5.7 vs. 42.1 +/- 4.4% of left ventricle, P less than .001). In treated animals, myocardial phospholipid concentration was also significantly higher.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic evaluation of ventricular remodeling in a mouse model of myocardial infarction.

Gene-targeting in mice is a powerful tool to define molecular mechanisms of ischemic heart disease that determine infarct size, postinfarct left ventricular (LV) remodeling, and arrhythmogenesis. Coronary ligation in mice is becoming a widely used model of myocardial infarction (MI), but the pathophysiologic consequences of MI in mice and its relevance to human MI have not been fully elucidated. To characterize structural and functional changes during evolving MI, we analyzed 2-dimensional-based reconstruction of the left ventricle by noninvasive echocardiography obtained 1 day and 1 week after surgical ligation of the left anterior descending coronary artery in mice. Sequential 2-dimensional short-axis cineloops of the left ventricle were used to measure LV mass, and LV volumes at end-diastole and end-systole. Echocardiographic infarct size was estimated by measuring the volume of akinetic LV segments. Histologic infarct size was measured by planimetry of 9 transverse sections of each heart. There was close correlation between the 2 methods (31% +/- 20% of LV mass and 34% +/- 17% of LV area, respectively; y =.83x + 7.9, r = 0.96, P <.01). LV volumes at end diastole increased significantly between 1 day and 1 week (51 +/- 17 microL vs 78 +/- 46 microL, respectively, P <.05). The relative change in LV volumes at end diastole varied as a function of infarct size (r = 0.93, P <.01). LV mass and the extent of hypertrophy of noninfarcted segments also varied with infarct size (r = 0.92, P <.01; r = 0.90, P <.01, respectively). Thus, echocardiography is an accurate noninvasive tool for determination of infarct size and quantitative characterization of postinfarct remodeling in the mouse model of MI. Alterations in cardiac structure and function after coronary ligation in mice closely resemble pathophysiologic changes in human ischemic heart disease.     

Myocardial global performance index as a predictor of in-hospital cardiac events in patients with first myocardial infarction.

OBJECTIVE: We sought to assess the ability of a Doppler index of global myocardial performance (MPI), measured at entry, to predict inhospital cardiac events in a series of patients with first acute myocardial infarction (AMI). METHODS: A complete 2-dimensional and Doppler echocardiographic examination was performed within 24 hours of arrival at the coronary care department in 96 patients (81 men and 15 women; mean age 58 +/- 9 years) with first AMI. Patients were divided a posteriori into 2 groups according to their inhospital course: group 1 comprised 75 patients with an uneventful course and group 2 comprised 21 patients with a complicated inhospital course (death, heart failure, arrhythmias, or post-AMI angina). RESULTS: There were no significant differences between the 2 groups with regard to history of hypertension, diabetes mellitus, hypercholesterolemia, site and size of infarction, and conventional parameters of diastolic function. However, patients with complications were significantly older (63 +/- 10 vs 55 +/- 8 years, P =.005) and had higher wall-motion score index and left ventricular end-systolic volume compared with patients without events (1.84 +/- 0.27 vs 1.52 +/- 0.30, P =.001; and 66 +/- 29 vs 47 +/- 21 mL, P =.009, respectively), whereas the ejection fraction was reduced (40 +/- 10% vs 52 +/- 10%, P =.0001). The mean value of the MPI was significantly higher in patients with cardiac events than in those without events (0.65 +/- 0.20 vs 0.43 +/- 0.16, P =.0001). A MPI >/= 0.47 showed a sensitivity of 90% and specificity of 68% for identifying patients with events, on the basis of the receiver operator curve. In a multivariable model, the MPI at admission remained independently predictive of inhospital cardiac events (odds ratio 15.6, 95% confidence interval 2.4-99, P =.003). CONCLUSION: These data suggest that in the acute phase of AMI, the MPI measured at entry may be useful to predict which patients are at high risk for inhospital cardiac events.     

Stress echocardiography using transesophageal atrial pacing in rats.

BACKGROUND: Echocardiography is increasingly used for noninvasive evaluation of cardiac function and morphology in small animal models of cardiovascular diseases. The aims of this study were to develop a simple method for stress echocardiography in rats and to evaluate left ventricular function of the postinfarct remodeling heart during stress induced by rapid atrial pacing. METHODS: Myocardial infarction (MI) was induced in rats by ligation of left coronary artery. Rats with 3 week-old MI (n = 9) and sham operation (n = 7) were examined with transthoracic echocardiography during stress induced by transesophageal pacing. The stress protocol consisted of examinations at baseline; during 2 different pacing rates, at 360 and 600 bpm; and during recovery. Systolic blood pressure was measured at each step. RESULTS: Stroke volume decreased at pacing with 600 bpm in both groups compared with baseline and to pacing at 360 bpm (sham group, 0.15 +/- 0.01 vs 0.24 +/- 0.02 mL; MI group, 0.13 +/- 0.01 vs 0.31 +/- 0.02 mL, P <.05). Cardiac index increased at 360 bpm pacing compared with baseline and remained constant at the higher pacing rate in the sham-operated rats (246 +/- 34 vs 192 +/- 25 mL/kg, P <.05). In the MI rats, cardiac index decreased at 600 bpm pacing compared with baseline (195 +/- 9 vs 235 +/- 15 mL/kg, P <.01). Systolic blood pressure did not change during the stress protocol in the groups. CONCLUSION: Stress echocardiography induced by transesophageal pacing in rats is a feasible and simple method for evaluation of left ventricular function. This method may be useful for noninvasive evaluation of left ventricular function under stress conditions in small animal models of heart diseases.