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Background We hypothesized that the severity of resting perfusion abnormalities assessed by the summed rest score (SRS) would be associated with a higher rate of adverse outcomes in patients with heart failure (HF) and reduced left ventricular (LV) ejection fraction (EF). Methods A subset of 240 subjects from HF-ACTION underwent resting technetium-99m tetrofosmin-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). Images were evaluated using a 17-segment model to derive the SRS and additional nuclear variables. Results After adjusting for prespecified covariates, SRS was significantly associated with the primary end point (hazard ratio 0.98, 95% confidence interval [CI] 0.97-1.00, P = .04), with a higher SRS corresponding to lower risk of an event. This association was not present in the unadjusted analysis. The relationship between SRS and the primary outcome was likely due to a higher event ratein patients with ischemic HF and a low SRS. The LV phase SD was not predictive of the primary outcome (hazard ratio 1.00, 95% confidence interval 0.99-1.01, P = .49). In a post hoc analysis, nuclear variables provided incremental prognostic information when added to clinical information ( P = .006). Conclusions Gated SPECT MPI provides important information in patients with HF and reduced LVEF. In the adjusted analysis, SRS has an unexpected relationship with the primary end point. Phase SD was not associated with the primary end point. Rest-gated SPECT MPI provides incrementally greater prognostic information than clinical information alone.

Background Randomized trials have demonstrated benefits of biventricular (BiV) pacing in patients with advanced heart failure, intraventricular conduction delay, and atrial fibrillation (AF) postatrioventricular (AV) node ablation. The AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial (AVAIL CLS/CRT) was designed to demonstrate superiority of BiV pacing in patients with AF after AV node ablation, to evaluate its effects on cardiac structure and function, and to investigate additional benefits of Closed Loop Stimulation ® (CLS) (BIOTRONIK, Berlin, Germany). Methods Patients with refractory AF underwent AV node ablation and were randomized (2:2:1) to BiV pacing with CLS, BiV pacing with accelerometer, or right ventricular (RV) pacing. Echocardiography was performed at baseline and 6 months, with paired data available for 108 patients. Results The RV pacing contributed to significant increase in left atrial volume, left ventricular (LV) end-systolic volume, and LV mass compared to BiV pacing. Ejection fraction decreased insignificantly with RV pacing compared to significant increase with BiV pacing. Interventricular dyssynchrony significantly decreased with BiV compared with RV pacing. Closed Loop Stimulation ® did not result in additional echocardiographic changes; heart rate distribution was significantly wider with CLS. All groups showed significant improvement in 6-minute walk distance, quality-of-life score, and New York Heart Association class. Conclusion In conclusion, RV pacing results in significant increase in left atrial volume, LV mass, and worsening of LV contractility compared to patients receiving BiV pacing post-AV node ablation for refractory AF. Closed Loop Stimulation ® was not associated with additional structural changes but resulted in significantly wider heart rate distribution.

To describe the epidemiology of echocardiographic mitral valve prolapse (MVP) and its anthropometric, physiologic, and psychobehavioral correlates with a cross-sectional analysis at 4 urban clinical centers.A biethnic, community-based sample of 4136 young (aged 23 to 35 years) adult participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study who had echocardiograms during their third examination between 1990 and 1991.Echocardiographic mitral valve prolapse, Doppler mitral regurgitation, blood pressure, anthropometry, and 4 psychobehavioral scales.Definite echocardiographic MVP prevalence was 0.6% overall and was similar across the 4 ethnicity/sex groups. Most participants (21 of 26, 80%) with definite echocardiographic MVP were unaware of their condition. Relative to persons with normal echocardiograms, those with echocardiographic MVP were taller (174.6 cm vs 171.0 cm, P.01), leaner (26.7 mm vs 37.4 mm sum of triceps and subscapular skinfolds, P.01), had lower body mass index (22.0 kg/m(2) vs 26.2 kg/m(2), P.01), and more often has Doppler mitral regurgitation (34.8% vs 11. 8%, P.01). Women with echocardiographic MVP had higher ethnicity-adjusted hostility scores (19.9 vs 16.1, P.05) than women with no MVP. Among 111 (2.7%) of 4136 participants reporting prior physician diagnosis of MVP, only 5 (0.45%) of 111 had definite echocardiographic MVP.These data document a low prevalence of definite echocardiographic MVP and suggest a constellation of anthropometric, physiologic, and psychobehavioral characteristics in young adults with echocardiographic MVP. Most definite echocardiographic MVP diagnoses were discordant with self-reported MVP status, and false-positive diagnoses of echocardiographic MVP were made more often in women and whites.

This report describes the relation among diabetes, blood pressure, and prevalent cardiovascular disease, and echocardiographically measured left ventricular mass and filling (transmitral valve flow) velocities in the Cardiovascular Health Study, a cohort of 5201 men and women > or = 65 years of age. Ventricular septal and left posterior wall thicknesses were greater in diabetic than in nondiabetic subjects, showing a significant linear trend (p = 0.025 for ventricular septal thickness in both sexes combined, p = 0.002 for posterior wall thickness) with increased duration of diabetes. Increased wall thickness of the ventricular septum or the left posterior wall was not associated with prevalent coronary heart disease (CHD) in the cohort. Increased left ventricular mass was associated with diabetic persons not reporting CHD and with all subjects with CHD regardless of glucose tolerance status. After adjusting for body weight, blood pressure, heart rate, and prevalent coronary or cerebrovascular disease, diabetes (as measured by glucose level, insulin use, oral hypoglycemic use, and a positive history of diabetes before baseline examination) remained an independent predictor of increased left ventricular mass among men and women (174.2 gm in diabetic men vs 169.8 gm in normal men, 138.2 gm in diabetic women vs 134.0 gm in normal women, p = 0.043 for both sexes combined). Both early and late diastolic transmitral peak flow velocities were higher with increased duration of diabetes, but the calculated ratio of the early peak flow velocity to the late velocity (E/A ratio) did not differ significantly between subjects with historical diabetes and those with normal fasting glucose (both genders combined, p = 0.190). Glucose level, insulin use, oral hypoglycemic use, and a positive history of diabetes before baseline examination were significant independent predictors of the late transmitral peak flow velocity and its integrated flow-velocity curve but not for the integral of the early peak flow velocity or the E/A ratio. Diabetes is associated with abnormal left ventricular structure and function in elderly persons. This association persists after adjustment for body weight, blood pressure, heart rate, and reported coronary or cerebrovascular disease.

Prior history of heart failure (HF) has been shown to be a predictor of poor outcomes after percutaneous coronary intervention (PCI). Clinical predictors of the development of inhospital HF and its prognostic significance after PCI have yet to be defined. In this study, we sought to identify the incidence, risk factors, and prognosis of inhospital HF after PCI.Using a contemporary registry of consecutive PCIs, the incidence of HF after PCI was identified. Multivariate logistic regression analysis was used to determine predictors of the development of HF after PCI as well as the impact of HF on inhospital mortality.The incidence of HF after PCI in the overall patient population was 1.4%. Independent predictors of HF were female sex, ageor = 60 years, exceeding a maximum weight- and creatinine-adjusted contrast dose, diabetes, prior HF, prior gastrointestinal bleeding, prior chronic obstructive pulmonary disease, history of atrial fibrillation, American College of Cardiology type B2 or C vessel, emergency PCI, ejection fraction50%, myocardial infarction with or without cardiogenic shock, and repeat angiography. After adjustment for comorbidities, the development of HF was independently associated with an increased risk of inhospital death (adjusted OR 2.48, 95% CI 1.77-3.48).The development of HF is a relatively uncommon occurrence after PCI and is associated with a poor prognosis. The identification of risk factors for HF could foster the development of interventions aimed toward its prevention in high-risk patients.

Background Treadmill stress testing (TMST) is a valuable diagnostic test for ischemic heart disease. However, the inability to achieve the target heart rate because of either chronotropic incompetence or poor exercise capacity is a major limitation to its utility. We evaluated the usefulness of atropine in decreasing the number of tests with inconclusive results in patients with a poor chronotropic response or exercise capacity during TMST. Methods The study comprised 126 patients undergoing TMST. In subjects experiencing fatigue at submaximal exercise, atropine was administered in doses of 0.5 mg per minute until the test conclusion (positive test results or target heart rate achieved) or until a maximum dose of 2 mg was administered. Results Thirty-three of the 126 patients (26%) required atropine (mean dose, 1 mg) during the study; 23 of the 33 patients (70%) proceeded to achieve their target heart rate (n = 17) or positive test results (n = 6). The mean increase in heart rate after atropine administration was 25 beats/min (range 3-53 beats/min). Atropine was required in 39% of patients receiving β-blockers, versus 21% of patients not receiving β-blockers ( P = .02). Among patients receiving atropine, a conclusive test was achieved significantly more often in patients not receiving β-blockers (94% vs 46%, P = .01). No adverse events were associated with the use of atropine. Atropine administration resulted in conclusive tests more often in subjects with poor chronotropic response than in subjects with poor exercise capacity (78% vs33%, P = Conclusion The use of atropine as an adjunct to standard TMST can help decrease the number of inconclusive tests, even in patients taking β-blockers. Larger studies are warranted to further define the role of atropine in diagnostic TMST.

To determine the unbiased relative strength of the association of static (systolic and diastolic) and pulsatile (pulse pressure) blood pressure components with left ventricular mass and function.Blood pressure is correlated with left ventricular mass; however, the unbiased relative strength of static and pulsatile blood pressure components with left ventricular mass and function is unknown in young adults.Cross-sectional analyses of 3918 young adult participants at 4 community-based CARDIA clinical centers during 1990 and 1991.Left ventricular mass positively correlated (P.01) with systolic, diastolic, and pulse pressure in all ethnicity-sex groups except for diastolic blood pressure in white men (P =.19). The association rank ordered as systolic blood pressurepulse pressurediastolic blood pressure except in white men, in whom pulse pressure and systolic blood pressure reversed positions in this hierarchy. Systolic blood pressure was the third and fourth strongest independent correlate of left ventricular mass in men and women, respectively. Body mass index, followed by height, was the strongest correlate of left ventricular mass in both sexes. Left ventricular wall thickness/chamber radius ratio positively correlated with diastolic and systolic blood pressure (women only) (P.05) but not with pulse pressure. In all groups, stroke volume positively correlated (P.05) with pulse pressure but was unrelated to static blood pressure measures, except for systolic blood pressure in black men. Left ventricular mass and the ventricular wall thickness/chamber radius ratio were greater in blacks compared with whites.Although systolic blood pressure was consistently the strongest unbiased blood pressure correlate of left ventricular mass, this relation varied by ethnicity and sex. Pulse pressure correlated with favorable left ventricular function and geometry, suggesting an opposite meaning to the ominous prognosis of wide pulse pressure in hypertensive, older adults.

Low left ventricular ejection fraction (LVEF), a measure of global systolic left ventricular dysfunction, is associated with an increased risk of recurrent coronary events or death in persons with cardiac disease. There are few data on the distribution of resting LVEF and component volumes in healthy young adults or on any association of LVEF with coronary risk factors. LVEF and left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV, respectively) were measured by two-dimensional echocardiography in 1782 men and women 23 to 35 years old without self-reported heart disease (other than mitral valve prolapse, n = 53) who were participants in the multicenter Coronary Artery Risk Development in Young Adults study. Factors analyzed as potential contributors to LVEF, LVEDV, and LVESV included age, gender, race, blood pressure, alcohol use, current smoking, family history of myocardial infarction, total and high-density lipoprotein cholesterol concentrations, obesity, reported physical activity, and fitness as assessed by treadmill exercise testing. LVEF was lower in men (mean 62.6% SD 5.7%) than in women (mean 63.9%, SD 5.7%) (p0.01) but did not differ significantly between black and white subjects. Ninety percent of subjects had an LVEF between 53% and 71%. LVEDV and LVESV were25% greater in men than in women. From multivariate analysis, male gender, history of hypertension, and current smoking were each positively and independently associated with an approximately 1% lower LVEF. Body surface area, a family history of premature myocardial infarction, and treadmill workload 150 time were positively related, whereas total skinfold thickness was negatively related to LVEDV and LVESV.(ABSTRACT TRUNCATED AT 250 WORDS)

Whether acute doses of cocaine can induce left ventricular (LV) regional wall motion abnormalities in animals with otherwise normal coronary arteries is unknown. We studied rabbits receiving constant cocaine infusions (group I: 0.025 to 1.5 mg/kg/min, n = 10), multiple cocaine boluses (group II: 3-5 mg/kg each bolus, n = 10), or saline (group III; n = 8). In group I rabbits, short-axis LV area and diameter increased by 15% to 40% at 60 minutes compared to baseline and to controls (p0.01), but percentage of global area fractional shortening was unchanged. Eight rabbits in each of groups I and II, but no controls, developed LV regional wall motion abnormalities as detected by echocardiography: 15 (7 hypokinesis and 8 akinesis or dyskinesis) in the anteroseptal and 2 (hypokinesis) in the posterior LV wall. Among rabbits showing LV wall motion abnormalities, anteroseptal fractional shortening and % area reduction averaged20% less (p = 0.03 for area reduction) at 30 minutes versus controls. Only 50% of group I or II rabbits with LV anteroseptal wall motion abnormalities had intraventricular conduction disturbances. Radioactive microsphere flow studies (n = 6) 1 minute after a 4 mg/kg cocaine bolus revealed an equivalent decrease (10% to 20%, average) in septal and LV free wall perfusion (p value not significant). Electron microscopy revealed myocardial cell contraction band necrosis in 3 and sarcoplasmic reticular edema in 7 of 10 cocaine rabbits (unrelated to dose). We conclude that acute cocaine administration in rabbits frequently produces LV anteroseptal wall motion abnormalities even in the absence of differentially decreased perfusion or intraventricular conduction disturbances and produces ultrastructural abnormalities of the myocytes. These findings suggest a direct, nonuniform effect of cocaine on the LV myocardium.

Visual estimates of the intensity of the continuous wave (CW) Doppler regurgitant jet signal have been used to estimate the severity of valvular regurgitation. Theoretically, the strength of the reflected Doppler signal is a function of the number of scatterers. To test this approach quantitatively, free jets were produced in 27 experiments using a power injector and cornstarch suspension varying in concentration from 1% to 3%. Flow volume was varied from 5 to 15 ml, and orifice diameter varied from 2.5 to 10 mm. Machine settings were kept constant. Also, 22 patients with mitral regurgitation (MR)--5 mild, 11 moderate, and 6 severe by angiography--were studied. Average signal intensity under the CW Doppler flow curve was calculated using a computer image processor. In MR patients, average regurgitant flow (RF) intensity was compared with average mitral forward flow (FF) signal intensity. (1) The intensity under the CW flow signal in the free jet experiments correlated well with injection volume (r greater than 0.98). (2) RF average signal intensity did not correlate with angiographic MR severity (r = 0.21), but the ratio of RF to FF average signal intensity did correlate with MR severity (r = 0.73). (3) The sensitivity and the specificity of an RF/FF ratio greater than 0.65 for angiographically severe mitral regurgitation were both 83%. (4) The sensitivity and specificity of an RF/FF ratio less than 0.50 for angiographic mild mitral regurgitation were both 80%. The ratio of regurgitant to forward mitral flow CW Doppler signal intensity appears to be an accurate and clinically applicable method for estimating the severity of mitral regurgitation.

In color Doppler flow studies, "variance" is an important display modality for diagnosing stenotic, regurgitant, and shunt lesions. Variance, a mathematical calculation based on the variation in the Doppler signal frequencies, has been reported to reflect the degree of flow disturbance. A wide-band pulsed Doppler spectrum results in a larger degree of variance. It has been suggested that variance area (green color or mosaic area) might provide useful quantitative information regarding the severity of stenotic, regurgitant, and shunt lesions. Since ultrasound machine settings may affect the color Doppler variance image, we evaluated in 101 free jet experiments the effect of packet size (eight versus four samples per line), pulse repetition frequency (3.9 versus 5.2 kHz), frame rate (11 versus 22 frames per second), system gain (+15 dB versus -15 dB), transmit power (high versus low), and moving target indicator (MTI) filter setting (high versus low) on variance display. The variance area was planimetered using an image analysis computer. The following machine parameters were inversely correlated with variance area: (1) packet size (p less than 0.01), (2) pulse repetition frequency (p less than 0.001), and (3) frame rate (p less than 0.05). Both system gain (p less than 0.001) and wall filter setting (p less than 0.01) showed a direct correlation with variance area. We conclude that machine factors must be standardized in evaluating stenotic, regurgitant, and shunt lesions by color Doppler variance display imaging.

Previous studies have demonstrated a relationship between both age and body surface area (BSA) and M-mode echocardiographic measurements of left ventricular, left atrial, and aortic root dimensions and left ventricular wall thickness. We evaluated the relationships between age, BSA, gender and blood pressure, and Doppler aortic and pulmonary artery (PA) flow velocity measurements in 97 adults, aged 21 to 78 years, without clinical evidence of cardiac disease. No significant relationship was found between gender or blood pressure and aortic or PA flow velocity measurements. Aortic peak flow velocity, flow velocity integral, and average acceleration decreased with increasing age (all p less than 0.001), whereas ejection time (corrected for heart rate) increased, and acceleration time did not change. In contrast, there was no relationship between age and Doppler PA flow velocity measurements. Although there was no relationship between BSA and Doppler aortic flow measurements, PA peak flow velocity and average acceleration increased, while acceleration time decreased with increasing BSA (all p less than 0.02). Decreases in aortic peak flow velocity and flow velocity integral may be partly related to known increases in aortic root diameter with aging. The relationship between PA flow velocity measurements and BSA is not readily explained.

Blood flow velocity measurements were made in the ascending aorta and proximal main pulmonary artery of 20 adult normal subjects (12 men and eight women, age range 21 to 46 years) with the use of a commercial prototype ultrasound instrument combining a spectrum analyzer-based, pulsed Doppler velocimeter with a two-dimensional sector scanner. The sector scanner was used to produce two-dimensional images of the main pulmonary artery so that the Doppler sample volume could be placed parallel to the flow stream. A 2.25 MHz right-angle M-mode ultrasound transducer was positioned in the suprasternal notch and was used to measure blood flow velocity in the ascending aorta. There were significant differences (p less than 0.001) between the ascending aorta and main pulmonary artery (PA) in the following blood flow parameters: peak flow velocity (aorta = 92 cm/sec, PA = 63 cm/sec), average acceleration (aorta = 940 cm/sec2, PA = 396 cm/sec2), acceleration time (aorta = 98 msec, PA = 159 msec), deceleration time (aorta = 197 msec, PA = 172 msec), average deceleration (aorta = 473 cm/sec2, PA = 356 cm/sec2), and ejection time (aorta = 294 msec, PA = 331 msec). These data indicate that despite a four to five times higher arterial resistance in the systemic circuit compared to the pulmonary circuit, blood is accelerated two to three times more rapidly in the ascending aorta than in the main pulmonary artery. Also, the peak flow velocity is higher in the aorta and is achieved earlier in systole than in the pulmonary artery.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the prevalence and significance of aortic valve early systolic partial closure (notching) in congestive cardiomyopathy by reviewing clinical and M-mode echocardiographic findings in 33 patients. We also compared their echocardiographic aortic root and valve findings to those in 17 aortic regurgitation patients and 24 normal subjects. Thirteen cardiomyopathy patients (39%) exhibited aortic valve partial closure—similar to the prevalence in the aortic regurgitation (41%) and normal (33%) groups. However, patients with dilated cardiomyopathy and aortic valve notching exhibited a higher mean percentage of partial closure (18% ± 10) than those with notching in either the aortic regurgitation (8% ± 9) or normal (5% ± 2) group. There was no significant difference in age, body surface area, left ventricular dimension, systolic function, or presence of mitral regurgitation between cardiomyopathy patients with and without aortic valve notching, but the former had slightly greater aortic root dimensions and maximal aortic leaflet separation. Although the reason for this difference is unknown, a wider aortic root may result in low-pressure areas bordering the aortic flow stream during early systole, which may favor partial aortic valve closure.

The ability of pulsed Doppler echocardiography to identify patients with left ventricular systolic dysfunction was evaluated in 12 patients with dilated (congestive) cardiomyopathy. A range-gated, spectrum analyzer-based Doppler velocimeter was used to record blood flow velocity in the ascending aorta and main pulmonary artery. The following blood flow velocity parameters were measured or derived: peak flow velocity, acceleration time, average acceleration, deceleration time, average deceleration, ejection time, and aortic flow velocity integral. Doppler blood flow velocity data in the cardiomyopathy patients were compared to data from 20 normal subjects. Measurements from the ascending aorta revealed that peak aortic flow velocity discriminated between cardiomyopathy patients (mean 47 cm/sec, range 35 to 62) and normal subjects (mean 92 cm/sec, range 72 to 120) with no overlap in data (p < 0.001). Aortic flow velocity integral was also able to separate the patients with dilated cardiomyopathy (mean 6.7 cm, range 3.5 to 9.1) from normal subjects (mean 15.7 cm, range 12.6 to 22.5) with no overlap in data (p < 0.001). Although mean values for average aortic acceleration and aortic ejection time were also significantly different (both p < 0.005), there was some overlap between the two groups. Pulmonary artery blood flow studies demonstrated significantly increased average acceleration, as well as decreased ejection time (both p < 0.05), but no difference in average deceleration or peak flow velocity in cardiomyopathy patients compared to normals. Compared to pulmonary flow measurements, aortic Doppler flow velocity measurements allowed better separation of cardiomyopathy and normal groups. In addition, aortic peak flow velocity appeared to correlate well (r = 0.83) with M-mode echocardiographic measurement of left ventricular percent fractional shortening; both parameters were equally useful in discriminating patients with normal left ventricular function from those with global dysfunction (dilated cardiomyopathy). Thus pulsed Doppler echocardiography appears to be a useful addition to M-mode and two-dimensional echocardiography in the quantitative noninvasive assessment of left ventricular systolic function. © 1983.

Postnatal circulatory adaptations were studied with Doppler echocardiographic measures of flow velocity in the main pulmonary artery (PA) and ascending aorta (Ao) in 45 normal full-term neonates at 5 hours and at 27 hours after birth. PA flow velocity integral (FVI) was measured as the area under the systolic flow velocity curve and reflected total systemic flow in the presence of a left-to-right shunt through the ductus arteriosus. This index increased from 5 and 27 hours age, while Ao FVI, reflecting total pulmonary flow, remained unchanged. Evidence of a left-to-right ductal shunt demonstrated as diastolic retrograde flow in the main PA was detected in 42 neonates at 5 hours and in only four subjects after 27 hours of age, indicating a patent ductus arteriosus at 5 hours of age and its subsequent closure. In the PA, acceleration time (AT) increased while pre-ejection period to ejection time ratio (PEP/ET) decreased from 5 to 27 hours of age, reflecting the physiologic fall in PA pressure. In the Ao, FVI, AT, and PEP/ET remained unchanged, suggesting little change in left ventricular function.