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The introduction of digital echocardiography has significantly enhanced our ability to select the best set of frames for analysis. However, despite the beneficial attributes of transthoracic dobutamine stress echocardiography, poor quality 2-dimensional images continue to be a significant limiting factor in patients with chest deformities, severe chronic obstructive lung disease, marked obesity, and previous chest surgery. Transesophageal echocardiography provides a new window to monitor left ventricular contractility without the interference of bone and air-filled structures of the thoracic cage. The transesophageal dobutamine stress test is a logical but poorly explored modality to image/stress the heart in certain patients with known or suspected myocardial ischemia. Overall sensitivity (< or = 85%) and specificity (< or = 95-100%) of transesophageal dobutamine stress echocardiography appear to be similar to that of previous transthoracic studies, although no direct comparison has been accomplished between transthoracic and transesophageal stress images. False negative transesophageal dobutamine stress echocardiography results have been described in patients with single-vessel disease in whom ischemic regions may not have been visualized throughout the entire study. False positive study results may be present in patients with hypertension and myocardial hypertrophy that may have signs and symptoms of myocardial ischemia in absence of obstructive disease of the epicardial coronary arteries, presumably related to either microvascular disease or impaired vasodilatory reserve. The proportion of patients with coronary artery disease who need a transesophageal examination for reliable assessment of echocardiographic response to stress varies depending on the operators' skills, the interpreters' experience, and the use of videotape or digitizing systems for image analysis. Although clinically useful in its present transthoracic and transesophageal form, a major limitation of dobutamine stress echocardiographic study is the subjective visual interpretation of endocardial motion and wall thickening, which is only semiquantitative. Color kinesis and tissue Doppler imaging (TDI) are 2 novel echocardiographic techniques that color code endocardial motion and myocardial velocity online and have the potential to objectively quantify regional left ventricular function. Quantitative standardization of transthoracic and transesophageal data interpretation, such as establishing endocardial motion by color kinesis or velocity thresholds by TDI for an abnormal segmental response to stress, has the potential to decrease interobserver variability and increase interinstitutional agreement.

The clinical arena in which we must consider the role of echocardiography is characterized by 2 fundamental findings: (1) most patients with chest pain and suspected acute myocardial infarction (MI) do not present diagnostic electrocardiograms; and (2) an early and correct diagnosis is necessary to match the patient with the most adequate treatment. Echocardiography may be very useful in the coronary care unit, allowing a correct diagnosis of ischemic heart disease when electrocardiography is unclear, even before the rise of cardiac enzymes is detected. It may also play a role in decision-making for thrombolytic therapy. In addition, echocardiography provides useful information for early risk stratification. In fact, although high-risk patients are well identified by simple clinical or instrumental variables (i.e., Killip classification, enzymatic data, blood-gas analysis, electrocardiogram, etc.), most patients (>60%) are identified as low risk, and several subjects classified into the low-risk groups have a poor prognosis and are not detected using a single variable. In our experience, 2-dimensional echocardiography was able to further stratify between patients of low-risk classes. Therefore, echocardiography plays an important role in the early stratification of acute MI patients, especially in those without signs or symptoms of heart failure.

The available data suggest that digitalis improves symptoms of a failing heart in the presence of sinus rhythm as well as supraventricular arrhythmias. Intravenous digitalis administration in patients with chronic heart failure and baseline hemodynamic deterioration increases cardiac index and reduces heart rate. These beneficial effects are maintained with long-term oral therapy and are comparable with those obtained using dobutamine in patients with chronic severe heart failure. The addition of digoxin to therapy with vasodilators and diuretics confers clinical benefit in patients with moderate to severe heart failure symptoms because of systolic ventricular dysfunction. Digoxin effects on diastolic function appear to be different in patients with preserved systolic function in comparison to patients with overt heart failure and systodiastolic dysfunction. In patients with right ventricular dysfunction digoxin does not appear to influence hemodynamic measurements unless concomitant left ventricular dysfunction is present.

The efficacy of a new slow release (SR) diltiazem preparation was assessed in 10 patients with stable effort angina. A double-blind, placebo controlled, randomized, crossover protocol was carried out comparing the effects of diltiazem 60 mg tid and diltiazem SR 120 mg bid on clinical and ergometric parameters. Exercise test was carried out 3 and 12 hours after the last dose of diltiazem or diltiazem SR respectively. Both drug preparations reduced the incidence of positive test, increased the exercise time and the time of onset of ischemic ST depression. The beneficial effects of the drugs appeared to be due to a reduction in myocardial oxygen consumption at the same workload as shown by the lesser value of pressure rate product at submaximal exercise. In conclusion, diltiazem SR at 12 hours after the last administration has the same effectiveness of diltiazem 60 mg at 3 hours.

To assess the significance of ST segment shift during the acute phase of non-Q myocardial infarction we studied the clinic echocardiographic, ergometric and coronarographic findings of 46 patients with a first non-Q wave myocardial infarction. The study population was subdivided in 2 subgroups on the basis of acute electrocardiographic change (Group I with ST elevation, Group II with ST depression). Patients with ST elevation had little myocardial infarction with enzymatic (early CPK peak) and coronarographic (low prevalence of coronary occlusion) signs of early spontaneous fibrinolysis. The second group had more diffuse myocardial infraction, higher prevalence of multivessel coronary disease and positive stress test. The ECG changes in this subgroup an probably due to subendocardial necrosis for the presence of collateral flow. The worse intrahospital prognosis of patients with ST segment depression may be related to cardiac function and age.

To assess the relation between the extent of myocardial necrosis and the presence of myocardium at risk in myocardial infarction without Q waves (NQMI) we studied by echocardiography the prevalence of jeopardized myocardium in a group of NQMI stratified on the basis of left ventricular wall motion (akinesis, hypokinesis, normal kinesis). We have studied 60 consecutive patients with non-Q myocardial infarction. Patients were examined by 2D echo at rest (V-VI day from the acute episode) and during symptoms limited bicycle ergometric test (ExT) (XX-XXX day). Regional left ventricular wall motion was evaluated as normal or asynergic (severe hypokinetic, akinetic) and the ExT was considered positive in case of new asynergic areas or ECG criteria. 2D echo at rest was technically satisfactory in 56 patients, 19 showed almost an akinetic segment (Aci) 17 had hypokinetic areas (Ipo) and 20 had normal left ventricle kinesis (Norc). Wall motion abnormalities were localized more frequently in the apex and lateral areas. During exercise 2D echo was performed in 46 patients (82%) with 23 positive tests (50%). Stratifying the population on the basis of left ventricle wall motion we observed a major number of positive tests in the group of patients with normal wall motion in comparison with those with asynergic areas at rest (Norc 66.6%, Ipo 35.7%, Aci 42.6% p less than 0.05 Nore vs Ipo and Nore vs Aci) despite the same CAD extension. These data show the heterogeneity of the NQMI that likely includes patients with transmural (asynergy group) and subendocardial MI (normal kinesis group), the latter with a higher degree of myocardium at risk.

The feasibility of echocardiography in detecting left ventricle wall motion abnormalities, their location and their spontaneous or therapeutic regression, was assessed performing monodimensional and two-dimensional echocardiography in 35 patients with stable effort angina, without previous AMI. A control group of 10 normal subjects was also studied. The Authors evaluated echocardiographic findings on subjects at rest, during supine bicycle exercise and after sublingual nitroglycerin administration, defining the quality of wall motion as normal, hypokinetic, akinetic or dyskinetic in M-mode, and normal or asynergic in 2-D. They also analyzed, in M-mode, some echocardiographic indices of regional left ventricle function (IVSE, PWE, VIVS, VPW, delta TS, delta TP), and, in 2-D, the percent of systo-diastolic endocardial outline changes versus standard references in 7 sectors of left ventricle (anterior, lateral, inferior, septal in short-axis, septal, postero-lateral in long-axis, and apical) by means of a HP 9845B Computer, interfaced to a Digitizer. The percentage of feasibility of exercise echocardiography has been 60% in M-Mode, and 70% in 2-D. Mono and two-dimensional findings were normal in all patients at rest, whereas, during exercise, 57% of them, in M-mode, and 88% in 2-D, showed segmental contraction abnormalities. The Authors conclude that exercise echocardiography, though technically difficult, is feasible, Both M-mode and 2-D involve peculiar advantages or disadvantages. They provide, however, a valuable tool in detecting the mechanical consequences of exercise-induced regional myocardial ischemia and may be applicable in patients with equivocal exercise test.

9 patients with persistent truncus arteriosus, 11 patients with pseudotruncus and 2 patients with hemitruncus, ranging in age from 6 months to 29 years, have been studied by M-mode and two-dimensional echocardiography (2-D echo). In all patients the diagnosis was confirmed by cardiac catheterization and angiocardiography; in 10 of them surgical or autopsy documentation was available. Peripheral contrast echocardiography was performed in 13 patients. A variable degree of truncal or aortic override was observed in 7 of 9 patients with truncus arteriosus and in all patients with pseudotruncus by M-mode or two-dimensional echocardiography. By 2-D echo the truncal origin of the right and left pulmonary arteries was visualized in 7 of 9 of the patients with truncus arteriosus. Visualization of one aberrant pulmonary artery from the aortic wall was assessed retrospectively in 2 patients with hemitruncus. A pulmonary atretic valve region was recorded in 10 of 11 of the patients with pseudotruncus. Peripheral contrast echocardiography enabled to distinguish patients with complete obstruction to pulmonary flow from patients with unobstructed right ventricular outflow tract. By showing no direct connection between the pulmonary arteries and the ascending aorta or direct continuity between one or both pulmonary arteries and truncal or aortic root, differentiation of pseudotruncus arteriosus from truncus or hemitruncus may be achieved by 2-D echo.