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Objectives: The goals of this study were to assess late clinical outcome and left ventricular ejection fraction (LVEF) after transmyocardial revascularization with CO(2) laser (TMR)., Background: During the 1990s TMR emerged as a treatment option for patients with refractory angina not eligible for conventional revascularization. Few reports exist on clinical effects and LVEF >3 years after TMR., Methods: One hundred patients with refractory angina not eligible for conventional revascularization were block-randomized 1:1 to receive continued medical treatment or medical treatment combined with TMR. The patients were evaluated at baseline and after 3, 12 and 43 (range: 32 to 60) months with end points to angina, hospitalizations due to acute myocardial infarctions or unstable angina, heart failure and LVEF. Mortality was registered and MOS 36 Short-Form Health Survey answered at baseline and after 3, 6 and 12 months., Results: Forty-three months after TMR, angina symptoms were still significantly improved, and unstable angina hospitalizations reduced by 55% (p < 0.001). Heart failure treatment (p < 0.01) increased, whereas the number of acute myocardial infarctions, LVEF and mortality was not affected. Quality of life was improved 3, 6 and 12 months after TMR., Conclusions: Forty-three months after TMR, angina symptoms and hospitalizations due to unstable angina were significantly reduced, heart failure treatment increased and LVEF and mortality were seemingly unaffected.

We correlated the new diastolic index 'delay of apical peak velocity', as measured by colour M-mode Doppler, with radionuclide ventriculographic indices of ventricular function. Thirty-seven patients with coronary artery disease participated in the prospective and blinded study, which included repeated acquisitions to determine the effect of realigning the Doppler sample beam. In multiple regression, neither peak filling rate, left ventricular phase histogram width nor ejection fraction were statistically significantly related to delay of apical peak velocity. The standard deviation of the differences between duplicate colour M-mode acquisitions corresponded to half the reference range of the index. We conclude that in this blinded investigation, the new Doppler index did not provide information about ventricular function equivalent to radionuclide ventriculography. The index may be significantly influenced by sample beam position.

201-Thallium scintigraphy and radionuclide ventriculography with 99m-Technetium are the two most important nuclear imaging techniques in clinical cardiology. The sensitivity and specificity of tomographic Thallium scintigraphy for detection of coronary heart disease is about 90%. Radionuclide ventriculography may be used to describe systolic and diastolic function of the left and right ventricles with results comparable to those of angiographic studies. Both methods are non-invasive and feasible during exercise. These methods provide important information on myocardial ischaemia and cardiac function which may be difficult to obtain by other methods. In county hospitals with no equipment for invasive studies these methods provide important diagnostic and prognostic information. In the university hospitals, however, the techniques are of a more supportive nature and may help the clinician to select appropriate treatment.

To study the pathologic and prognostic significance of--and possible underlying mechanisms for--a pathological exercise ECG in athletes, two age-matched groups were selected from a total population of 117 middle-aged and old endurance athletes: Group A: 21 with a pathological exercise-ECG, and group B: 21 with normal exercise-ECGs. Data from 201-thallium perfusion scintigraphy, 99 m-technetium multiple gated acquisition ventriculography (MUGA), resting echocardiography and 3 years follow-up are as follows: None had thallium findings indicating reversible myocardial ischaemia, but one from group A had a probable old myocardial infarction. All had normal resting MUGA, but group A men slightly more often presented a subnormal increase in ejection fraction according to exercise MUGA than group B men (9/20 vs 4/21). The former also more often had ventricular hypertrophy (LVH) (19/21 vs 14/21). However, apart from slightly longer ventricular filling time among group A men the echocardiograms revealed no group differences e.g. in cardiac dimensions or in indices of systolic or diastolic function. Regardless of exercise-ECG response, 18/42 athletes had one or more value of left ventricular dimensions or diameter exceeding the 95th percentile of the normal range. Since one patient from group A had asymmetric septal hypertrophy, one developed cardiomyopathy during the 3 years follow-up and one had a previous myocardial infarction, only 3/21 had cardiac disease which might explain the pathological exercise-ECG. Thus, pathological exercise-ECG rarely signifies heart disease in athletes, and very rarely coronary heart disease. Rather, the pathological exercise-ECG may be related to LVH and various subtle alterations in cardiac physiology following long-term endurance training.

Forty-six subjects (11 normals with no cardiac disease, 13 persons with a 'false' positive exercise ECG test, and 22 patients with coronary artery disease) were investigated with ECG-gated cardiac blood-pool imaging at rest, during cold pressor stimulation, and during supine bicycle exercise. Changes in left ventricular ejection fraction and intervention induced regional wall motion abnormalities were measured. Cold pressure stimulation did not induce anginal pain in any person, but were generally found more unpleasant than dynamic exercise. Dynamic exercise detected significantly more coronary artery disease patients (20/22, 91%) than did cold stimulation (13/22, 59%) (P less than 0.02). Specificity of dynamic exercise and cold stimulation was not significantly different. It is concluded that cold stimulation is less sensitive than dynamic exercise in the detection of patients with ischaemic heart disease with gated cardiac blood-pool imaging.

Latent coronary heart disease was suspected in 115 of 2014 apparently healthy middle-aged men after a baseline cardiovascular survey. One hundred five of these men underwent angiography and 36 were found to have normal coronary arteries (group 1). A 7 year follow-up survey revealed that: (1) three had died of sudden cardiac death, (2) four had received a diagnosis of cardiomyopathy, (3) one had developed aortic dilatation/aortic regurgitation since the baseline survey, (4) they all had a significantly more rapid decline in their physical performance and maximal heart rate levels from the time of the baseline survey to follow-up than did randomly selected normal controls (group 2), and (5) thallium study results were normal in both groups (27 and 26 patients), but technetium ventriculography revealed a subnormal increase in ejection fraction during exercise (less than 5% units) in 14 of 27 group 1 subjects and in 4 of 26 group 2 subjects. Thus, incipient heart disease may be present in subjects in whom coronary angiographic examination has removed a previous suspicion of coronary heart disease.

Myocardial scintigraphy with thallium-201 and electrocardiogram-gated left ventriculography with technetium-99m labelled red blood cells were applied in four groups of subjects: 25 with no signs or symptoms of cardiovascular disease (group 1), 28 with a "false" positive exercise electrocardiogram (group 2), 14 with angina pectoris and normal coronary angiograms (group 3), and 43 with angina pectoris and fixed coronary artery stenoses (group 4). In groups 1 and 4 the radionuclide findings were in accordance with clinical and invasive measurements. In groups 2 and 3 the most important finding was the lack of increase in left ventricular ejection fraction during exercise in about half of these subjects (even a decrease in 25%), indicating subnormal myocardial reserve. The additional finding of pathological myocardial biopsies in four of these patients suggests that asymptomatic ST depression in patients with normal coronary angiograms may in some cases represent an early, preclinical sign of cardiomyopathy.