Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography

Stress echocardiography today has matured into a robust and reliable technique not only for the diagnosis of suspected coronary artery disease (CAD) but also for the accurate risk stratification of patients with suspected and established CAD. This is mainly because of rapid advances in image acquisition, digital display, and the development of harmonic and contrast imaging. Stress echocardiography today is also utilised in patients with heart failure both for assessing the cause of heart failure and determining the extent of hibernating myocardium. With advances in myocardial perfusion imaging, stress echocardiography now allows simultaneous assessment of myocardial function and perfusion. Tissue Doppler imaging allows quantitation of wall motion. Ready availability and reliability makes stress echocardiography a cost effective technique for the assessment of CAD.     

Zur funktionellen Anatomie der menschlichen Stimmlippe

Ohne Zusammenfassung     

First-in-man evidence of the mechanistic effects of biventricular pacing on coronary physiology

BackgroundNormal coronary blood flow is principally determined by a diastolic backward travelling decompression (suction) wave. Dyssynchronous heart failure may attenuate suction. We hypothesised that biventricular pacing, by restoring left ventricular (LV) synchronisation and improving LV relaxation, might increase this suction wave and coronary flow.MethodsTen patients with congestive heart failure (nine men; mean age 65 years [SD 12]; mean ejection fraction 26% [SD 7] with left bundle branch block (LBBB, mean QRS duration 174 ms [SD 18]) underwent atriobiventricular pacing at 100 beats per min. LV pressure was measured and wave intensity calculated from invasive coronary flow velocity and pressure, with native conduction (LBBB) and during biventricular pacing at atrioventricular (AV) delays of 40 ms (BiV-40), 120 ms (BiV-120), and separately pre-identified haemodynamically optimal AV delay (BiV-Opt). Data are given as median (IQR).FindingsCompared with LBBB, BiV-Opt enhanced coronary flow velocity time integral (VTI) by 15% (7–25, p=0·007), LV dP/dt_max by 17% (9–22, p=0·005), and _negdP/dt_max by 17% (9–22, p=0·005). The cumulative intensity of the diastolic backward decompression (suction) wave increased by 26% (18–54, p=0·005). Much of the increase in coronary flow VTI occurred in diastole (69% [41–84], p=0·047). The systolic compression waves also increased: forward by 36% (6–49; p=0·022) and backward by 38% (20–55, p=0·022). BiV-120 generated a smaller LV dP/dt_max (by 12% [5–23], p=0·013) and _negdP/dt_max (by 15% [8–40], p=0·009) increase than did BiV-OPT, with LBBB as reference; BiV-Opt and BiV-120 were not significantly different in coronary flow VTI or waves. BiV-40 was no different from LBBB.InterpretationWhen biventricular pacing improves left ventricular contraction and relaxation, it increases coronary blood flow velocity, predominantly by increasing the dominant diastolic backward decompression wave.FundingBritish Heart Foundation.     

Predictive factors of intensive care unit admission in patients with haematological malignancies and pneumonia

Objective To describe early signs at the onset of pneumonia occurring in the haematology ward which could be associated with a transfer to the ICU.Design A 13-month preliminary prospective observational cohort study.Setting Department of haematology and (32-bed) medical intensive care unit (ICU).Patients Fifty-three of 302 patients hospitalised in the haematology ward who developed presumptive clinical evidence of pneumonia were enrolled.Measurements and results At the onset of the clinical evidence of pneumonia (day 1), we compared variables between patients requiring an ICU admission and those who did not. Twenty-four patients (45%) required a transfer to the ICU. Factors associated with ICU admission were: numbers of involved quadrants: 2.3 vs 1, P=0.001 and oxygenation parameters (initial level of O₂ supplementation: 3.5 vs 0.9 l/min, P<0.05), the presence of hepatic failure (58% vs 10%, P<0.01), Gram-negative bacilli isolated in blood culture (7 vs 1, P=0.01). In the multivariate analysis, a decrease of 10% in the SaO₂ and the requirement of nasal supplementary O₂ at the onset of acute respiratory failure increased the risk of admission to MICU, respectively, by 18 and by 14. The overall 6-month mortality rate of the 53 patients was 28%.Conclusion Parameters of oxygenation and radiological score could be associated with this transfer on day 1 of the onset of pneumonia occurrence. A further study should evaluate an earlier selection of this type of patient, followed by an early admission to the MICU, in order to improve ICU outcome.