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Objectives: The Radiation Protection of Patients Unit of the International Atomic Energy Agency (IAEA) is concerned about the effectiveness of justification of diagnostic medical exposures. Recent published work and the report of an initial IAEA consultation in the area gave grounds for such concerns. There is a significant level of inappropriate usage, and, in some cases, a poor level of awareness of dose and risk among some key groups involved. This article aims to address this. Methods: The IAEA convened a second group of experts in November 2008 to review practical and achievable actions that might lead to more effective justification. Results: This report summarises the matters that this group considered and the outcome of their deliberations. There is a need for improved communication, both within professions and between professionals on one hand, and between professionals and the patients/public on the other. Coupled with this, the issue of consent to imaging procedures was revisited. The need for good evidence-based referral guidelines or criteria of acceptability was emphasised, as was the need for their global adaptation and dissemination. Conclusion: Clinical audit was regarded as a key tool in ensuring that justification becomes an effective, transparent and accountable part of normal radiological practice. In summary, justification would be facilitated by the "3 As": awareness, appropriateness and audit. [ABSTRACT FROM AUTHOR]

Medical radiation from X-rays and nuclear medicine is the largest non-natural (man-made) source of radiation exposure in Western countries. The aim of this study was to assess the individual cumulative effective dose in patients admitted to our cardiology ward. We collected a cumulative radiological history from a structured questionnaire and access to hospital records in 50 consecutive adult patients (36 males; age, 66.7±10.8 years) admitted to the Institute of Clinical Physiology in Pisa. The cumulative effective dose was assessed as an indicator of stochastic risk of cancer. We derived the effective dose for each individual examination from the Medical Imaging Guidelines of the European Commission (2001). On average, each patient underwent a median of 36 examinations (interquartile range, 23-46). The median cumulative effective dose was 60.6 mSv. Three types of procedures were responsible for ∼86% of the total collective effective dose: (i) arteriography and interventional cardiology (12% of examinations, 48% of average dose per patient); (ii) nuclear medicine (5% of examinations, 21% of average dose per patient); and (iii) CT (4% of examinations, 17% of average dose per patient). The median estimated extra risk of cancer was approximately 1 in 200 exposed subjects. In conclusion, the average contemporary cardiological patient is exposed to a significant cumulative effective dose from diagnostic and therapeutic interventions. It is important to log cumulative dose for each patient at the time of each examination. Every effort should be made to justify the indications and to optimize the doses. [ABSTRACT FROM AUTHOR]

Background In the stress imaging era, ECG positivity is regarded as a frequent source of false-positive responses. However, it is known that normal coronary arteries frequently coexist with abnormal endothelial function in patients with chest pain.Aim To evaluate the anatomical coronary epicardial, and functional systemic endothelial determinants of wall motion and electrocardiographic responses during stress testing.Method Sixty-eight in-hospital patients with chest pain syndrome, no previous myocardial infarction, and off nitrate therapy at the time of testing underwent, on different days, in random order and within 1 month: (1) stress ECG echo testing (with dipyridamole in 43, dobutamine in 3, and exercise in 22 patients); (2) coronary angiography; (3) endothelium-dependent, flow-mediated dilation of the brachial artery during reactive hyperaemia using high-resolution ultrasound. Criteria of positivity were: ST segment depression >0·1mm in the stress ECG; regional dysfunction >2 segments demonstrated by stress–echo; diameter reduction >50% on coronary angiography; and <5% flow-mediated dilation as revealed by endothelial function.Results Significant coronary artery disease was present in 39 patients, and was predicted on multivariate analysis by stress-induced wall motion abnormalities (OR=108.8; 95% CI=8·5–1389·4, P=0·0003), but not by either ST segment depression (P=0·13; OR=0·47; 95% CI=0·7–1·3) or reduced flow-mediated dilation (P=0·81; OR=0·87; 95% CI=0·27–2·8). Abnormal flow-mediated dilation was present in 53 patients (78%), and was predicted by stress-induced ST segment depression (P=0·023; OR=6·2; 95% CI=1·3–30·5), but not by either stress echo positivity (P=0·66; OR=0·77; 95% CI=0·23 to 2·5) or angiographically assessed coronary artery disease. There was no correlation between flow-mediated dilation and extent of coronary artery disease as assessed by the angiographic Duke score (from 0=normal to 100=most severe disease): r=−0·13, P=0·91.Conclusion Epicardial coronary artery anatomy affects wall motion abnormalities, and systemic endothelial dysfunction affects ST segment depression during stress. However, echocardiographic positivity is unrelated to endothelial dysfunction, and electrocardiographic positivity is an inaccurate predictor of coronary stenosis. An integration of ECG and functional markers is warranted in the stress testing lab. [ABSTRACT FROM PUBLISHER]

Aims The aim of the present study was to assess the relative prognostic value of clinical variables, the exercise electrocardiography test and the pharmacological stress echocardiography test either with dipyridamole or dobutamine early after a first uncomplicated acute myocardial infarction in a large, multicentre, prospective study.Methods and Results Seven hundred and fifty-nine in-hospital patients (age=56±10 years) with a recent and first clinical uncomplicated myocardial infarction, with baseline echocardiographic findings of satisfactory quality, an interpretable ECG and able to exercise underwent a resting 2D echocardiogram, a pharmacological stress test with either dipyridamole or dobutamine and an exercise electrocardiography test at a mean of 10 days from the infarction; they were followed-up for a median of 10 months. During the follow-up, there were 13 deaths, 23 non-fatal myocardial infarctions and 59 re-hospitalizations for unstable angina. When all spontaneous events were considered, with multivariate analysis, the difference between the wall motion score index at rest and peak stress (delta wall motion score index), and exercise duration were independent predictors of future spontaneous events (relative risk 7·2; 95% CI=2·73–19·1; P=0·000; relative risk 1·1, 95% CI=1·02–1·18; P=0·008, respectively). Kaplan–Meier survival estimates showed a better outcome for those patients with a negative pharmacological stress echocardiography test compared to patients with low dose positivity (94·7 vs 74·8%,P =0·000).Conclusion Stress echocardiography tests provide stronger information than historical and exercise electrocardiography test variables. Pharmacological echocardiography as well as the exercise ECG is able to predict all spontaneously occurring events when the presence as well as the timing, severity, and extension of stress-induced wall motion abnormalities are considered. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Background Echocardiographic parameters for predicting cardioversion outcome in patients with non-valvular atrial fibrillation are not accurately defined.Objective To evaluate the role of left atrial appendage flow velocity detected by transoesophageal echocardiography for prediction of cardioversion outcome in patients with non-valvular atrial fibrillation enrolled in a prospective, multicentre, international study.Methods Four hundred and eight patients (257 males, mean age: 66±10 years) with non-valvular atrial fibrillation lasting more than 48h but less than 1 year underwent transthoracic echocardiography and transoesophageal echocardiography before either electrical (n=324) or pharmacological (n=84) cardioversion.Results Cardioversion was successful in restoring sinus rhythm in 328 (80%) and unsuccessful in 80 patients (20%). Mean left atrial appendage peak emptying flow velocity was significantly higher in patients with successful than in those with unsuccessful cardioversion (32·4±17·7 vs 23·5±13·6cm.s−1;P<0·0001). At multivariate logistic regression analysis, three parameters proved to be independent predictors of cardioversion success: the atrial fibrillation duration <2 weeks (P=0·011, OR=4·9, CI 95%= 1·9–12·7), the mean left atrial appendage flow velocity >31cm.s−1(P=0·0013, OR=2·8, CI 95%=1·5–5·4) and the left atrial diameter <47mm (P=0·093, OR=2·0, CI 95%=1·2–3·4). These independent predictors of cardioversion success outperformed other univariate predictors such as left ventricular end-diastolic diameter <58mm, ejection fraction >56% and the absence of left atrial spontaneous echo contrast.Conclusion In patients with non-valvular atrial fibrillation, measurement of the left atrial appendage flow velocity profile by transoesophageal echocardiography before cardioversion provides valuable information for prediction of cardioversion outcome. [ABSTRACT FROM PUBLISHER]

Aims The aim of this study was to assess the prognostic value of myocardial viability recognized as a contractile response to vasodilator stimulation in patients with left ventricular dysfunction in a large scale, prospective, multicentre, observational study.Methods and Results Three hundred and seven patients (mean age 60±10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction and severe left ventricular dysfunction (ejection fraction <35%; mean ejection fraction: 28±7%) were enrolled in the study. Each patient underwent low dose dipyridamole echo (0·28mg.kg−1in 4min). Myocardial viability was identified as an improvement of ≥0·20 in the wall motion score index. By selection, all patients were followed up for a median of 36 months. One-hundred and twenty-four were revascularized either by coronary artery bypass grafting (n=83) or coronary angioplasty (n=41). The only end-point analysed was cardiac death. In the revascularized group, cardiac death occurred in one of the 41 patients with and in 16 of the 83 patients without a viable myocardium (2·4% vs 19·3%,P <0·01). Outcome, as estimated by Kaplan–Meier survival, was better for patients with, compared to patients without, a viable myocardium, who underwent coronary revascularization (97·6 vs 77·4%,P =0·01). Using a Cox proportional hazards model, the presence of myocardial viability was shown to exert a protective effect on survival (chi-square 4·6, hazard ratio 0·1, 95% CI 0·01–0·8,P <0·03). The survival rate in medically treated patients was lower than in revascularized patients irrespective of the presence of a viable myocardium (79·7% vs 86·2,P =ns).Conclusion In severe left ventricular ischaemic dysfunction, myocardial viability, as assessed by low dose dipyridamole echo, is associated with improved survival in revascularized patients. [ABSTRACT FROM PUBLISHER]

Aim To assess whether ‘eye education’ through short-term, high-intensity joint reading sessions may improve diagnostic accuracy and inter-observer agreement among beginners.Methods and Results Seventeen cardiologists with absent to minimal (<100 studies performed) previous stress echo experience independently and blindly read 18 stress echo studies, nine at the beginning (‘pre-training’ set) and nine at the end (‘post-training’ set) of a 2 day stress echo school which included a joint reading session of 50 tapes. The two sets were balanced as far as type of stress and image quality. The 17 observers had an average accuracy score of 51±16·4 before and 64·3±8·7% after the training (P<0·005). Concordant (i.e. >14 readers giving the same response) interpretation occurred in three out of nine studies before and in eight out of nine studies after the training (33% vs 88%,P<0·01). Kappa values went from 0·14 (poor) before to 0·39 (fair, close to moderate) after the training.Conclusion Short-term, high-intensity dedicated training in stress echo, with joint reading sessions and consensus development of reading criteria significantly increased accuracy and markedly reduced the inter-observer variability in the reading of stress echos by beginners. If there is a Shakespearean madness in stress echo reading, ‘yet there is a method in’t’ (Hamlet, II, II, 205–206). [ABSTRACT FROM PUBLISHER]

Dipyridamole echocardiography test (DET) has gained acceptance due to its safety, feasibility, diagnostic accuracy and prognostic power. The main limitation of the test is a less than ideal sensitivity in some patient subsets, such as those with limited coronary artery disease. Atropine with dipyridamole might theoretically combine to become a synergistic ischaemic stress test, by increasing myocardial oxygen demand through chronotropic stress and by reducing flow supply through a shortening of the diastolic interval under maximal coronary vasodilation. The aim of this study was to assess the effects of the addition of atropine to DET. Three hundred and twenty-one patients (age=58±9 years), referred for testing in the echo lab, were initially studied by DET. Of these, 151 were stopped during or within the 2 min following dipyridamole infusion because of achievement of a predetermined end-point: obvious echocardiographic positivity (n = 137), severe chest pain (n = 3), diagnostic ST segment changes (n = 7) or limited side effects (n = 4). In another three cases, atropine was not given due to a history of glaucoma or severe prostatic hypertrophy. In the remaining 167 patients with a negative DET test, atropine (0.25 mg intravenously, repeated every min up to a maximum of 1 mg, if necessary) was added, starting 3 min after the end of the dipyridamole infusion. The dipyridamole-atropine echo test (DETA) was positive in 32 and negative in 135 patients, and no major side effects occurred in any patient. The peak heart rate was significantly higher during DETA than with DET alone (108±16 vs 86±14 beats . min; <0.0001). In the subset of 178 patients who were studied while not taking antianginal therapy, who had no prior myocardial infarction or revascularization procedure and who underwent coronary catheterization, independently of the test results, coronary angiography showed normal coronary arteries in 48 patients and significant coronary artery disease (CAD) (≥ 50% luminal reduction in at least one major coronary vessel by quantitative coronary arteriography) in 130 patients—with single-, double- and triple-vessel disease in 56, 47 and 27 patients, respectively. The sensitivity was 96/130 for DET and 110/130 for DETA (72 vs 85%, <0.01) while the specflcity was 96% and 92% (P=ns), respectively. The addition of atropine to dipyridamole, which causes further chronotropic stress to the myocardium already challenged by flow maldistribution, is well tolerated and safe, and increases the sensitivity of the test for the detection of coronary artery disease with no loss in specificity. [ABSTRACT FROM PUBLISHER]

Young elite athletes often show left ventricular hypertrophy, but normal values of quantitatively evaluated myocardial wall reflectivity. The aim of this study is to assess the acoustic pattern of ventricular wall reflectivity, as well as of systolic and diastolic function, in older endurance runners with increased left ventricular mass. For this purpose, 12 elite, senior isotonic athletes in full training and 11 normal, age-matched controls with sedentary life styles were studied. The following parameters were measured with a commercially available 2D echo-Doppler machine: end-diastolic diameter, diastolic septum thickness, left ventricular mass index, ejection fraction (by Teicholtz rule); peak E, peak A, E/A ratio, acceleration and deceleration time of mitral inflow velocity and isovolumic relaxation time. On-line radio frequency analysis was also performed to obtain quantitative operator-independent measurements of the integrated backscatter signal of the ventricular septum and the posterior wall. The integrated values of the radiofrequency signals were normalized for the pericardial interface and expressed in percent (% 2D-1B). In spite of the greater left ventricular mass in athletes versus normal controls (319±81 vs 225±63 g. m−2, <0.0005), there were no significant intergroup differences as regards end-diastolic diameter (50.7±5.1 vs 48.1±5.2 mm, = ns), ejection fraction (75.5±9.3 vs 71.8±9.1%, = ns), and 2D-1B of septum (22.2±6.9 vs 22.4±7.0, = ns) and posterior wall (12.5 ±5.6 vs 13.1 ±2.8, P=ns). Endurance athletes when compared with age-matched controls show an increase in left ventricular mass but no significant impairment of systolic and diastolic function detectable by 2D-echo and Doppler indexes. Furthermore, in the athlete group, the quantitatively assessed ultrasonic backscatter of myocardial walls (septum and posterior wall) was found to be comparable to controls in spite of a marked increase in wall thickness suggesting that no significant pathological structural changes occur in the older athletes' heart. [ABSTRACT FROM PUBLISHER]

Twenty-four patients with a history of effort angina, a positive exercise stress test (EST) and coronary artery disease were enrolled in the study; 12 patientshada positive dipyridamole-echocardiography test (DET) and 12 had a negative DET. Each patient performed a total of 4 ESTs in the absence of therapy on two successive days; for each test the rate-pressure product (RPP), an established index of my ocardial oxygen demand, was measured at the onset of ischaemia (ST depression >0–15mV) or at the peak of maximal exercise (if a repeated EST was negative). Taking into account the lowest of the 4 RPP values ( × 1/100) in each patient, there was no significant difference between DET-negatives and DET-positives (185.2±49.3 vs 157.4±32.4). Conversely, when considering the highest of the 4 RPP values in each patient, there was a significant difference between DET-negatives and DET-positives (280.3 ± 63.9 vs 183.3 ± 37.0; p < 0.01). Thus, DET may provide a clinically useful tool for assessing in the individual the organic ’ceiling‘ of coronary reserve, by eliminating the variability in coronary tone, which may affect EST reproducibility and the correct evaluation of the impairment of organic coronary reserve. [ABSTRACT FROM PUBLISHER]

Thirty-nine patients with early post-infarction angina (all with significant, angiographically assessed coronary artery disease and a baseline asynergy on 2-D echo), performed a dipyridamole–echocardiography test (DET: 2-D echo monitoring with dipyridamole infusion, 0·14 mg kg−1 min−1 for 4 min). Twenty-nine patients had a positive DET(sensitivitv = 74%). Two mechanical patterns of DET-positivity could be identified: (1)a worsening of the asynergy in that same region showing a baseline asynergy (11 patients); (2)a ‘de novo’ asynergy in a region remote from the one showing a baseline asynergy (18 patients); The prevalence of single-vessel disease was significantly higher in patients with type 1 positivity pattern (6 single-, three double- and two triple-vessel disease), while patients with type 2 positivity always showed a multivessel coronary involvement (8 double-, 10 triple-vessel disease). In 4 of the 10 patients with 3-vessel disease and type 2 asynergy, such asynergy developed in a territory different from the one supplied by the more stenotic non-infarct-related vessel.In conclusion, DET represents a safe and feasible tool effectively to localize ischaemia, relative to the infarcted region, and to evaluate the haetnodynamic signficance of coronary lesions in patients with post-infarction angina. [ABSTRACT FROM PUBLISHER]

Resting and stress echocardiography is a ‘one-stop shop’, which enables a wide range of information to be collected on resting function, myocardial viability, and induced ischaemia, all of which are useful for prognostic stratification. Large scale, multicentre, prospectively collected data show the prognostic failure of resting function and inducible ischaemia, both independently and combined, which are especially effective in predicting cardiac death. The GISSI data show that the increment of risk as a result of reduction in ventricular function has a hyperbolic trend, with a relatively moderate increase in mortality for ejection fraction values between 50 and 30%, but with marked increases below 30%.The EPIC data show that the 1-year risk of cardiac death is as low as 2% in patients with negative dipyridamole stress echocardiography; it doubles if the test is positive at a high dose, and is almost four times higher if it is positive at a low dose. In the field of prognostic stratification, in the absence of carefully controlled studies, the choice between coronary angiography as the only essential study, or use of a non-invasive test to discriminate access to catheterization currently reflect alternate philosophical approaches rather than scientifically based decisions. In the invasive approach, stress echocardiography offers relief from the vicious circle of chest pain—coronary angiography—revascularization. In the non-invasive and physiological approach, stress echo is capable of offering, in one sitting, an insight into the main determinants of survival: function, viability, and ischaemia. [ABSTRACT FROM PUBLISHER]

Dipyridamole stress is the forerunner and prototype of pharmacological stress echo tests in the diagnosis of coronary artery disease. Among the various stress echo tests, it is probably the least technically demanding to perform and the easiest to interpret. Its accuracy is similar to dobutamine stress echocardiography but its feasibility is higher. The prognostic impact of dipyridamole stress echo has also been proven for presentation of hard end-points such as cardiac death. The safety and prognostic value of this test has been conclusively demonstrated as a result of extensive experience in large scale multicentre projects.Dipyridamole stress is many different tests in one: dipyridamole—atropine is best for diagnosis; dipyridamole—dobutamine or dipyridamole—exercise is highly sensitive for the detection of minor forms of coronary artery disease; low and high dose dipyridamole is best suited for prognostic stratification; infra-low dipyridamole with low dose dobutamine administration is probably best suited for selective myocardial viability identification. Each patient should have their own test, tailored on the basis of the clinical picture and the diagnostic issue. [ABSTRACT FROM PUBLISHER]

Background Anti-ischaemic therapy with nitrates and/or calcium channel blockers profoundly affects the results of pharmacological stress echocardiography with coronary vasodilators but the influence on catecholamine stress testing remains unsettled. Aims The present study aimed to assess the effects of non-beta-blocker antianginal therapy on dobutamine (up to 40 μg.kg−1.min−1)-atropine (up to 1 mg) stress echocardiography and to evaluate whether drug-induced changes in the dobutamine-atropine stress echocardiography response may predict variations in exercise tolerance. Methods Twenty six patients with angiographically assessed coronary artery disease (seven patients with single-, 10 with double-, and nine with triple-vessel disease) performed a dobutamine-atropine stress echocardiography and an exercise electrocardiography test in random order both off and on antianginal drugs (nitrates and calcium antagonists). In dobutamine-atropine stress echocardiography, we evaluated: dobutamine time (i.e. the time from initiation of the dobutamine infusion to obvious dyssynergy), wall motion score index (in a 16-segment model of the left ventricle, each segment ranging from 1=normal, to 4=dyskinetic), and rate-pressure product at peak stress. Results Dobutamine-atropine stress echocardiography positivity occurred in 26 out of 26 patients off and in 23 patients on therapy (100 vs 88%, P=ns). Atropine coadministration was needed to evoke echo positivity in no patient off and in five out of 26 on therapy (0 vs 19%, P<0·01). The achieved rate-pressure product during dobutamine-atropine stress echocardiography was comparable on and off therapy (17±4 vs 19±5×103 mmHg×heart rate. min−1, Pns). Therapy induced an increase in dobutamine time (on=16±3 vs off=13±3 min, P<0·01) and a decrease in peak wall motion score index (on=1·3±0·2 vs off=1·5±0·3, P<0·01). The therapy-induced changes in exercise time during the exercise electrocardiography test were not significantly correlated to dobutamine-atropine stress echocardiography variations in either dobutamine time (r=0·07, P=ns), or peak rate-pressure product (r=0·24, P=ns), or peak wall motion score index (r=0·02, P=ns). Conclusion (1) non-beta-blocker antianginal therapy only modestly reduces dobutamine-atropine stress echocardiography sensitivity, although atropine coadministration is more often required to reach stress echo positivity under therapy; (2) therapy reduces the severity of dobutamine-atropine stress echocardiography ischaemia stratified in the time and space domain, but these changes are only poorly correlated to variations in exercise tolerance. [ABSTRACT FROM PUBLISHER]

Low (0·56 mg.kg−1 over 4 min) and high (0·48 mg.kg−1 over 10 min) doses of dipyridamole can identify viable myocardium through the contractile recovery of basally dyssynergic regions; however, it also induces ischaemia in susceptible patients. The aim of this study was to assess the potential of an ‘infra-low’ dose of dipyridamole to selectively identify myocardial viability, independently evaluated by low dose dobutamine. Forty patients with resting dyssynergy and angiographically assessed coronary artery disease (1-vessel in 18, 2-vessel in 12, and 3-vessel in 10 patients) separately underwent a low dose dobutamine (5–10μg. kg−1 min for 3 min) echo test and an infra low dose (0·28 mg.kg−1 over 4 min) dipyridamole echo test. Systolic blood pressure (rest: 131±19 mmHg) changed slightly after dobutamine (137±21, P<0·05 vs rest) and remained stable after dipyridamole (130± 17, p=ns vs rest). Heart rate (rest: 68±13 beats. min−1) was also unchanged after dipyridamole (69±12, P=ns vs rest) and increased slightly after dobutamine (71±15, P<0·05 vs rest and vs dipyridamole). No patient developed echocar diographic or electrocardiographic signs of ischaemia after either dipyridamole or dobutamine. Of the 243 segments with baseline dyssynergy, 70 were responders (i.e. they showed an improvement of I grade or more, from I normalIhyperkinetic to 4=dyskinetic in a 16-segment model of the left ventricle) by both dipyndamole and dobutamine, 157 were non-responders (i.e. they showed no change) by both dipyridamole and dobutamine, and 16 showed discordant results (five responders by dipyridamole only; 11 by dobutamine only). The overall concordance of dipyridamole and dobutamine was 93%. An echocardio graphic follow-up could be obtained >6 weeks after suc cessful revascularization (achieved with angioplasty in 17, with by pass surgery in 3) in 19 patients and showed an improvement of one grade or more in 50 segments (viable) and no improvement in 50 segments (necrotic). The sensi tivity of dobutamine and dipyridamole for predicting recov ery was 76 and 78% respectively (p=ns); the specificity of both tests was 94%.In conclusion, infra-low dose dipyridamole is a haemody namically neutral stress test which does not affect either heart rate or systolic blood pressure; it allows myocardial viability to be explored selectively, without eliciting ischae mia; it shows excellent overall concordance with low dose dobutamine and has good sensitivity and excellent specifi city for predicting functional recovery following successful revascularization. [ABSTRACT FROM PUBLISHER]

Experimental and human studies have shown that a pre served cyclic (diastolic-to-systolic) echoreflectivity variation, assessed by radiofrequency sampling of backscatter signal with non-commercially available prototypes, identifies viability in a myocardial segment with a resting dyssynergy.The objective of this study was to assess whether a videodensitometric analysis of myocardial gray level variation during cardiac cycle might identify viable but dyssynergic myocardium in a clinical setting. Thirty-four patients with a resting dyssynergy (akinesis in 26, marked hypokinesis in eight) in the septum and/or infero-posterior wall were evaluated by videodensitometry. All echo studies were performed with commercially available instruments in the long axis parasternal view, with quantitative analysis of gray levels performed off-line on digitized images. Segmental wall motion was assessed with a 16 segment model of the left ventricle, each scored from I, normal, to 4, dyskinetic. A follow-up echo study was obtained in all patients > 4 weeks after successful revascularization (in 22 by angioplasty, in 12 by bypass surgery). Two groups of segments were identified: 18 viable segments (contractile improvement of I grade or more in resting function after revascularization); 16 necrotic segments (no contractile improvement in resting function after revascularization). The % cyclic variation was higher in viable vs necrotic segments (26 ± 16 vs 1 ± 13%, P<0·01), in spite of similar % systolic thickening (5 ± 5 vs 4 ± 6%, P=ns) and end-diastolic thickness (10 ± 2 vs 10 ± 2mm, P=ns). When individual patient analysis was performed, % cyclic variation was below the 95% confidence limits obtained from normal control regions (n = 34; % cyclic variation=38 ± 14) in two out of 18 viable and in 14 out of 16 necrotic segments. A cut-off of ≥9·4% cyclic variations in a dyssynergic segment yielded 89% sensitivity and 88% specificity for predicting functional recovery following successful revascularization.In conclusion, viable dyssynergic myocardial segments show a cyclic gray level variation at rest, which can be detected by simple videodensitometric analysis, much less technologically demanding than radiofrequency backscatter evaluation.(Eur Heart J 1996; 17: 472–479) [ABSTRACT FROM PUBLISHER]

Stress echocardiography has become an accepted and cost-effective method for diagnosing coronary artery disease. However, as exercise stress echocardiography is a demanding technique, difficult to reproduce, pharmacological stress echocardiography has become very popular in recent years. The two most popular tests from the pharmacological stress echocardiography arena are dipyridamole and dobutamine. They have enabled the technical limitations inherent in exercise echocardiography to be overcome, and have provided the opportunity to obtain, during stress, images of unchanged quality in comparison to baseline. However, the sensitivity of both pharmacological stresses applied separately is less than ideal in patients with milder forms of coronary artery disease and in patients under therapy. To overcome this, a new generation of pharmacological stress tests, the combined dipyridamole-dobutamine tests were introduced. A combined dipyridamole-dobutamine echocardiography stress test should suggest that the agents are natural allies rather than competitors but in some instances they are applicable only in selected patients, and each pharmacological agent may be clinically contraindicated for administration. This is the message from a large scale study of recent years. [ABSTRACT FROM PUBLISHER]

The scientific assessment of diagnostic tests should not be based upon a small series of results published by the best academic institutions, but ought to require large scale, multicentre validation founded on grass roots institutions with real doctors, real patients and real problems. To this purpose; an international network of stress echo laboratories has been organized, and within a few years has collected data from thousands of studies using pharmacological stress echocardiography, performed with either dipyridamole (EPIC: Echo Persantine International Cooperative Study) or dobutamine (EDIC: Echo Dobutamine International Cooperative Study) stresses.In a widely deregulated field, all network laboratories have agreed: to pass a quality control examination on stress echo reading before entering the study; to adopt an identical drug infusion protocol; to code similarly the LV segments; and to adopt a common scoring system for wall motion analysis. A minimum amount of historical, clinical, and—when available—stress electrocardiographic, angiographic and follow-up data have been collected on each patient, and disseminated in the various centres, facilitating the creation of an international stress echo language that will help, not only the production of high quality scientific data, but also the build up of a common stress echo lab, with a standardized way of making the studies, unifying the methods and terminology, and archiving data. To date, we have 50 echo laboratories from 15 nations across four continents (Europe; America, Asia and Africa) actively involved in this project. These data will ultimately fill the gap between the academic theory of journals and the pragmatic experience of daily life in a busy echocardiographic laboratory. [ABSTRACT FROM PUBLISHER]

An abstract of the article "The independent prognostic value of contractile and coronary flow reserve in dilated cardiomyopathy: a dipyridamole stress echo study," by F. Rigo and colleagues is presented.

An abstract of the article "Comparison of angiography, IVUS, coronary flow reserve measurement by TEE in angiographically borderline lesions," by A. Ruzsa and colleagues is presented.

An abstract of the article "The prognostic value of coronary flow reserve in patients with single vessel disease and intermediate stenosis severity: a stress echo study," by F. Rigo and colleagues is presented.

An abstract of the article "The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stess echo," by R. Sicari and colleagues is presented.

An abstract of the article "The additional prognostic value of coronary flow reserve on anterior descending artery in patients with positive stress echo by wall motion criteria. A transthoracic vasodilator stress echo study," by F. Rigo and colleagues is presented.

An abstract of the article "Lack of end-diastolic volume recruitment during exercise in patients with diastolic heart failure," by T. Bombardini and colleagues is presented.

An abstract of the article "The prognostic value of ultrasound lung comets in patients with dyspnea and/or chest pain," by F. Frassi and colleagues is presented.

An abstract of the article "Ultrasound lung comets for differential diagnosis of dyspnea: comparison with plasma cardiac peptides," by L. Gargani and colleagues is presented.

An abstract of the article "The relationship between echocardiographic calcium score index, risk factor profile and coronary atherosclerosis," by A.I. Corciu and colleagues is presented.

An abstract of the article "Ultrasound lung comets provide an early marker of acute oleic acid lung injury in pigs," by L. Gargani and colleagues is presented.

An abstract of the article "Stress-induced pulmonary edema assessed by chest ultrasound during exercise echocardiography: correlation with severity of ischemia and wedge pressure," by E. Agricola and colleagues is presented.

An abstract of the article "The diagnostic accuracy of pharmacological stress echo: a meta-analysis," by E. Pasanisi and E. Picano is presented.

An abstract of the article "Force-Frequency Relationship During Dobutamine Stress Echo: Noninvasive Exercise-Independent Assessment of Left Ventricular Contractility" by A. Grosu and colleagues is presented.

An abstract of the article "Noninvasive Assessment of Left Ventricular Contractility by Pacemaker Stress Echocardiography" by T. Bombardini and colleagues is presented.

An abstract of the article "The Prognostic Meaning of Ultrasonically Assessed Coronary Flow Reserve in Dilated Cardiomyopathy" by F. Rigo and colleagues is presented.

An abstract of the article "Prognostic Value of Noninvasive Permanent Pacemaker Stress Echocardiography" by V. Chubuchny and colleagues is presented.

An abstract of the article "The prognostic value of pharmacological stress echo is affected by concomitant anti-ischemic therapy at the time of testing," by E. Pasanisi, R. Sicari, L. Venneri, L. Cortigiani, P. Landi, and E. Picano is presented.