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The high sensitivity and specificity of echocardiography in the diagnosis of infective endocarditis have been well established for a number of years. However, little is known yet about the incremental value of this technique over the clinical and serological findings already available in subsets of patients presenting different initial probabilities in infective endocarditis. In this report, sensitivity and specificity of echocardiography were calculated in 173 consecutive patients with suspected infective endocarditis who underwent echocardiography within 5 days following admission. The echocardiogram was considered positive when Duke major criteria were fulfilled. Infective endocarditis was diagnosed in 88 patients, while other illnesses in the remaining 85. The diagnoses were confirmed retrospectively with a follow-up done after at least 3 months, at surgery or during autopsy. Sensitivity and specificity of the echocardiography in this population were 85 and 97% respectively. The initial probabilities of infective endocarditis in patients with different clinical presentations were taken from a thorough review of the literature available in English and from personal research. The positive predictive value of echocardiography is already high or very high even at low or very low levels of initial probability, and this has a strong impact on clinical decisions. In these situations and with intermediate probabilities, a negative echocardiogram would theoretically rule out the disease. However, this result, if considered alone, calls for a careful reassessment of the entire clinical context. As with any other test, when the initial probabilities of infective endocarditis are highest, the incremental value of echocardiography is poor.

Unlabelled: Cardiological involvement in HIV infection is relatively rare but it presents important clinical aspects that are still open questions. We report our experience with HIV patients who underwent cardiological evaluation, Doppler echocardiography and follow-up., Material and Method: We selected 127 patients (9%) on the basis of clinical suspicion of heart disease, taking them from the 1398 admitted for HIV infection between 1992 and 1995. Ninety-six patients had AIDS (group A) and 31 were in pre-AIDS phase (group B). The age was 21-52 years: 83 were males, 44 were females and 91% of the patients had been drug addicts. Echocardiography was executed with Hp Sonos 1000 and Sonos 2500 devices. Follow-up was 6-36 months., Results: Ninety-two patients (6.5% on total admitted patients) had heart disease. Thirty-five patients were normal on echocardiography. Other diseases were: pericardial effusion in 38 cases (30%), with CD4+ number significantly lower (p < 0.005); dilated cardiomyopathy in 20 patients (16%), with a low CD4+ number (p < 0.005); reversible segmental or diffuse hypokinesia compatible with clinical myocarditis was seen in 11 patients (9%), especially in group A (p < 0.005); infective endocarditis in 17 patients (13%), especially group B (p < 0.005); right ventricular dilatation in 7; discrete right ventricular mass in 3 patients. Sixty-five patients (51%) died during follow-up (group A only). There were 19 cardiac deaths (15%), which represents 1.3% of the total number of patients. Nine of these (47%) were in patients with cardiomyopathy. Total mortality was 85% in patients with dilated cardiomyopathy, 73% in myocarditis cases, 71% in pericarditis cases (especially extracardiac), 66% in right ventricular dilatation cases, 18% in endocarditis cases, 34% in normal cases., Conclusions: Cardiac complications assume clinical importance, especially in the AIDS phase of HIV infection, but early diagnosis in the pre-AIDS phase is important for treatment. Clinical evaluation and echocardiography are corner-stones of the diagnosis. Prognosis depends especially on the clinical stage of HIV infection and myocardial involvement.

Background: Isolated alterations of the left ventricular diastolic function have been described in diabetic insulin-dependent patients (IDDM), even in the absence of old age, hypertension, ischemic heart disease, left ventricular hypertrophy. Such alterations have been associated with microangiopathy but it is not known whether it is reversible or if there is a relation with the way the therapy is given., Methods: Fifty-five subjects have been studied, of which 15 were healthy, 30 recently diagnosed IDDM without microangiopathy and 10 IDDM with microangiopathy. All the patients were under 35 years old and did not present risk factors for coronary artery disease, hypertension or autonomic neuropathy. The maximal exercise stress test proved negative. The diastolic function was studied using the results of Doppler echocardiography of the mitral flow and of isovolumetric relaxation time, with continuous and discrete parameters., Results: The velocity of wave A and E, the relationship between them and their integrals are significantly greater in diabetics with microangiopathy than in those without it and in healthy subjects. There are no significant differences between healthy and diabetic subjects without microangiopathy using continuous parameters. Using discrete parameters diastolic damage is absent in the healthy subjects and is present in 48% of diabetics without microangiopathy and in 90% of those with it., Conclusions: Slight preclinical diastolic dysfunction is present in young recently diagnosed IDDM without microangiopathy. More severe dysfunction is present when there is also microangiopathy.

Two women suffered from aortic dissection during the third term of pregnancy. The first one, 37 years old, died from a sudden and intractable cardiovascular shock at the end of pregnancy, but the fetus was saved by cesarean. The diagnosis was made post mortem. In the second case a faster diagnosis and a slower development of the aortic dissection allowed, during the 29th week of pregnancy, a surgical treatment after cesarean saving both the mother's and newborn's life. The histological examination in both cases showed only non specific alterations of the collagenous and the elastic fibres.

Thirty-two patients with non acute myocardial infarction (inferior in twenty, anterior in ten, anterior and inferior in two) were studied with contrast left ventriculography, two-dimensional echocardiography and radionuclide angiography to assess left ventricular wall motion. We adopted the CASS criteria for the standard left ventriculography, and the Mayo Clinic classification for the echocardiographic study. Radionuclide angiography studies were obtained in left anterior oblique view; the images were evaluated with the use of Walsh-Hadamard transform; the left ventricle was divided in basal and apical septal, apical, posterolateral, posterobasal and two central segments. We tried to correlate the findings of the three techniques both for single segments and larger regions made of contiguous segments. Left ventricular angiography and two-dimensional echocardiography showed a fair concordance for both anterobasal and posterolateral left ventricular wall, whereas for the septal, apical and posterolateral regions contrast and radionuclide angiography had the best correlation. Compared to left ventricular angiography two-dimensional echocardiography shows better sensitivity than radionuclide angiography; the latter is more specific in defining left ventricular wall motion. The two non invasive techniques are therefore helpful in the evaluation of wall motion and their role is complementary.

One hundred and twenty asymptomatic patients underwent a submaximal treadmill exercise 2-3 weeks after an acute myocardial infarction. These patients were subsequently followed from 15 to 54 months (average 2 years). Coronary events (cardiac death or angina) occurred in 14% of the patients with normal response, in 55% of those with ischemic response and in 12% of those with abnormal but non-ischemic response. The incidence of coronary events in patients with ischemic response is significantly higher than in the other two groups. However, among the patients who had a normal response, one out of seven suffered from a coronary event during the follow-up period. More than 25% of our patients with an ischemic response to the early exercise testing showed a non-ischemic response during a second one. On the other hand, more than 25% of our patients with normal early exercise test had an ischemic response when the test was performed at the end the follow-up period. Submaximal exercise testing of asymptomatic patients early after an acute myocardial infarction does not seem to be predictive of future coronary events and its long-term reproducibility is poor.