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Aim: We sought to assess the reliability of some basic echocardiographic data obtained by trained sonographers using a hand-held ultrasound device., Methods: One hundred and twelve consecutive patients (mean age 61, 64 males) referred for in-hospital or ambulatory routine echocardiography were considered. All patients underwent two-dimensional and colour Doppler examination performed by a trained sonographer equipped with a hand-held ultrasound device and by a certified cardiologist equipped with a standard platform, in random order. Indexed left ventricular end-diastolic and end-systolic transverse diameters, aortic root, end-systolic left atrium transverse diameter, end-diastolic interventricular septum and posterior wall thickness were calculated by two-dimensional left parasternal long-axis view in blind conditions. Mitral and aortic valve regurgitation were investigated by colour-Doppler imaging on parasternal and apical views and compared using a 0 to 4 semi-quantitative score., Results: Overall feasibility was high for both settings (sonographers: 93%; cardiologists: 95%; P not significant). Excellent concordance of end-diastolic diameter (kappa 0.75), left atrium (kappa 0.76) and interventricular septum thickness (kappa 0.77) results was found. Good concordance was observed for end-systolic diameter (kappa 0.66), aortic root (kappa 0.64) and posterior wall thickness (kappa 0.67) results. A high linear correlation between the couples of results was present for all parameters. A good agreement of the mitral (kappa 0.66) and aortic (kappa 0.84) regurgitation scores was also found, with a low prevalence of discordant results (mitral regurgitation: 22%, aortic regurgitation: 9%) and no > or =2-point discrepancies., Conclusion: In a general population referred for Doppler echocardiography, basic cardiac linear dimensions and valvular regurgitation severity assessment by trained sonographers using hand-held ultrasound devices appear accurate and reliable for routine clinical use.

Exercise electrocardiography (ECG) is of limited usefulness in hypertensive patients, whereas pharmacologic stress echocardiography can provide diagnostic and prognostic information. The aim of this study was to compare the prognostic value of clinical data, exercise ECG, and pharmacologic stress echocardiography in hypertensive patients with chest pain and to identify the best strategy for their risk stratification. Three hundred sixty-seven hypertensive patients (189 men, age 61 +/- 9 years) with chest pain of unknown origin underwent exercise ECG and pharmacologic stress echocardiography (237 with dipyridamole and 130 with dobutamine) and were followed up for 31 +/- 24 months. Positive exercise ECG (ST-segment shift of > or =1 mm at 80 ms after the J point) and stress echocardiography (new wall motion abnormalities) were found in 130 (35%) and 86 (23%) patients, respectively. During follow-up, there were 13 deaths and 16 myocardial infarctions. Additionally, 43 patients underwent coronary revascularization and were censored accordingly. Of 12 clinical, electrocardiographic, and echocardiographic variables analyzed, a positive result of stress echocardiography was the only multivariate predictor of either death (hazard ratio [HR] 4.7, 95% confidence interval [CI] 1.5 to 14.5, p = 0.007) or hard events (death, myocardial infarction) (HR 4.1, 95% CI 1.8 to 9.3, p = 0.0009). Using an interactive stepwise procedure, stress echocardiography provided additional prognostic information to clinical evaluation and exercise ECG. However, the negative predictive value of the 2 tests was similarly (p = NS) high in assessing 4-year event-free survival. In conclusion, a negative exercise electrocardiographic test identifies low-risk hypertensive patients with chest pain and should be the first-line approach for risk stratification. In contrast, positive exercise ECG is unable to distinguish between patients with different levels of risk. In this case, stress echocardiography provides strong and incremental prognostic power over clinical and exercise electrocardiographic data.

Purpose: Although coronary artery disease is a frequent cause of left bundle branch block, the prognostic value of myocardial ischemia in patients with this conduction abnormality has not been defined. We investigated the value of pharmacologic stress echocardiography in risk stratification of patients with left bundle branch block., Patients and Methods: Three hundred eighty-seven patients [230 men and 157 women, mean (+/- SD) age, 64 +/- 9 years] with complete left bundle branch block on the resting electrocardiogram underwent dobutamine (n = 217) or dipyridamole (n = 170) stress echocardiography to evaluate suspected or known coronary artery disease. A summary wall motion score (on a one to four scale) was calculated. The primary end points were cardiac death and nonfatal myocardial infarction., Results: A positive echocardiographic result (evidence of ischemia) was detected in 109 (28%) patients. During a mean follow-up of 29 +/- 26 months, there were 21 cardiac deaths and 20 myocardial infarctions, 63 patients underwent coronary revascularization, and 1 patient received a heart transplant. In a multivariate analysis, four clinical and echocardiographic variables were associated with increased risk of cardiac death: resting wall motion score index [hazard ratio (HR) = 7.5 per unit; 95% confidence interval (CI), 2.8 to 20; P = 0.001], previous myocardial infarction (HR = 2.9; 95% CI, 1.1 to 7.3; P = 0.02), diabetes (HR = 2.7; 95% CI, 1.1 to 6.6; P = 0.03), and the change in wall motion score index from rest to peak stress (HR = 3.0 per unit; 95% CI, 1.0 to 8.6; P = 0.04). The 5-year survival was 77% in the ischemic group and 92% in the nonischemic group (P = 0.02). Four variables were associated with increased risk of cardiac death or infarction: previous myocardial infarction (HR = 3.4; 95% CI, 1.7 to 6.8; P = 0.0005), diabetes (HR = 2.4; 95% CI, 1.2 to 4.6; P = 0.01), resting wall motion score index (HR = 2.2 per unit; 95% CI, 1.1 to 4.1; P = 0.02), and positive echocardiographic result (HR = 2.2; 95% CI, 1.1 to 4.5; P = 0.03). The 5-year infarction-free survival was 60% in the ischemic group and 87% in the nonischemic group (P < 0.0001). Stress echocardiography significantly improved risk stratification in patients without previous myocardial infarction (P = 0.0001), but not in those with previous myocardial infarction (P = 0.08). In particular, it provided additional value over clinical and resting echocardiographic findings in predicting cardiac events among patients without previous infarction., Conclusions: Myocardial ischemia during pharmacologic stress echocardiography is a strong prognostic predictor in patients with left bundle branch block, particularly in those without previous myocardial infarction.

Background: Residual viable myocardium identified by dobutamine stress after myocardial infarction may act as an unstable substrate for further events such as subsequent angina and reinfarction. However, in patients with severe global left ventricular dysfunction, viability might be protective rather than detrimental. The aim of this study was to assess the impact on survival of echocardiographically detected viability in medically treated patients with global left ventricular dysfunction evaluated after acute uncomplicated myocardial infarction., Methods and Results: The data bank of the large-scale, prospective, multicenter, observational Echo Dobutamine International Cooperative (EDIC) study was interrogated to select 314 medically treated patients (271 men; age, 58+/-9 years) who underwent low-dose (1.6). Patients were followed up for 9+/-7 months. Low-dose dobutamine stress echocardiography identified myocardial viability in 130 patients (52%). Dobutamine-atropine stress echocardiography was positive for ischemia in 148 patients (47%) and negative in 166 patients (53%). During the follow-up, there were 12 cardiac deaths (3.8% of the total population). With the use of Cox proportional hazards model, delta low-dose WMSI (the variation between rest WMSI and low-dose WMSI) was shown to exert a protective effect by reducing cardiac death by 0.8 for each decrease in WMSI at low-dose dobutamine (coefficient, -0.2; hazard ratio, 0.8; P<0.03); WMSI at peak stress was the best predictor of cardiac death in this set of patients (hazard ratio, 14.9; P<0.0018)., Conclusions: In medically treated patients with severe global left ventricular dysfunction early after acute uncomplicated myocardial infarction, the presence of myocardial viability identified as inotropic reserve after low-dose dobutamine is associated with a higher probability of survival. The higher the number of segments showing improvement of function, the better the impact is of myocardial viability on survival. The presence of inducible ischemia in this set of patients is the best predictor of cardiac death.

Background: Thrombolysis has reduced early and longterm mortality by about 20%; sometimes, however, there is a re-occlusion of the infarct related artery or an unsuccessful thrombolysis. In these situations, there is a possible increase in detrimental events in the follow-up., Objectives: The aim of the study was to compare the prognostic value of dobutamine echocardiography (DET) and ECG exercise test (EET) in pts submitted to thrombolysis., Methods: One hundred and fifty-one pts, with acute uncomplicated myocardial infarction, were enrolled. The pts were able to perform EET and had a sufficient echocardiographic window; 58 had anterior myocardial infarction (38%), 79 had inferior (52%), 2 had lateral (1%), 12 had non-Q (8%). EET was performed with an initial load of 25 Watt, and thereafter, 25 W every two minutes. DET was performed with step-wise infusion every three minutes (5, 10, 20, 30 and 40 mcg/kg/min.). If the target heart rate was not reached, a further dose of 40 mcg/kg/min. together with atropine 0.25-1 mg was administered, in the absence of signs and symptoms of ischemia., Results: During a mean (+/- SD) follow-up period of 8 +/- 4.5 months (range 1-23), 16 spontaneous events happened (4 deaths, 5 non-fatal re-infarctions, 7 unstable angina). One-hundred and three EET (68%) were negative for ongoing ischaemia, while 48 were positive, 79 DET (52%) were negative for ongoing ischaemia and 72 were positive (48%). Statistical results: DET and EET had a sensitivity of 41% and 54%, a specificity of 57% and 74%, a positive predictive value of 7% and 14%, a negative predictive value of 91% and 95%, an accuracy of 56% and 73%. Kaplan-Maier survival curves demonstrated that patients with Peak Wall motion > 1.8 and EET score > 3, had the higher risk of spontaneous events., Conclusion: A few spontaneous events happened in the follow-up. These data demonstrate that patients treated with thrombolysis are not at high risk of spontaneous events. DET and EET, therefore, have had a high negative predictive value. For this reason, we can conclude that pts with negative tests can be considered at low risk and do not need any further investigations.

Prevalence and prognostic significance of painful and silent ischemia detected by exercise electrocardiography (ECG) and dobutamine stress echocardiography (DSE) were evaluated in 407 consecutive patients recovering from acute myocardial infarction. Painful ischemia assessed by both tests was not associated with different clinical characteristics of patients; on the other hand, it identified a higher risk subgroup compared with silent ischemia during exercise ECG but not during DSE.

Aims: An abnormal left ventricular volume response during dobutamine echocardiography identified patients with severe coronary artery disease. The aim of the study was to assess the prognostic value of left ventricular volume changes during dobutamine stress echocardiography in 136 patients., Methods and Results: Endpoints were defined as spontaneous cardiac events at follow-up. Left ventricular end-diastolic and end-systolic volume changes (abnormal response: < 10% and < 20% decrease, respectively) were compared with other clinical and stress test variables. During 18 +/- 7 months of follow-up, 31 cardiac events occurred: 12 hard events (cardiac death [n = 6], myocardial infarction [n = 6]) and 19 soft events (unstable angina [n = 16], congestive heart failure [n = 3]). End-diastolic volume response (P = 0.006), diabetes (P = 0.008), inducible wall motion abnormalities (P = 0.024), end-systolic volume response (P = 0.039) and inducible angina (P = 0.038) were related to a greater likelihood of cardiac events. The Cox regression analysis revealed end-diastolic volume response (odds ratio: 3.0; CI 1.44-6.32) and diabetes (odds ratio: 2.7; CI 1.28-5.69) to be independent predictors of spontaneous cardiac events. Diabetes (odds ratio: 4.0; CI 1.26-12.80) and < 40% baseline ejection fraction (odds ratio: 2.21; CI1.14-4.29) were independent predictors of hard events., Conclusion: An abnormal end-diastolic volume response during dobutamine stress echocardiography identifies patients with an unfavourable outcome; they should be considered for more accurate prognostic stratification.

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.

Objectives: The aim of this multicenter, multinational, prospective, observational study was to assess the relative value of myocardial viability and induced ischemia early after uncomplicated myocardial infarction., Background: Dobutamine-atropine stress echocardiography allows evaluation of rest function (at baseline), myocardial viability (at low dose) and residual ischemia (peak dose, up to 40 micrograms with atropine up to 1 mg) in one test., Methods: Dobutamine-atropine stress echocardiography was performed 12 +/- 5 days (mean +/- SD) after a first uncomplicated acute myocardial infarction in 778 patients (677 men; mean age 58 +/- 10 years) with technically satisfactory rest echocardiographic study results. Patients were followed-up for 9 +/- 7 months., Results: Dobutamine-atropine stress echocardiographic findings were positive for myocardial ischemia in 436 of patients (56%) and negative in 342 (44%). During follow-up, there were 14 cardiac-related deaths (1.8% of the total cohort), 24 (2.9%) nonfatal myocardial infarctions and 63 (8%) hospital readmissions for unstable angina. One hundred seventy-four patients (22%) underwent coronary revascularization (bypass surgery or coronary angioplasty). Spontaneous events occurred in 61 of 436 patients with positive and 40 of 342 patients with negative findings on dobutamine-atropine stress echocardiography (14% vs. 12%, p = 0.3). When only spontaneously occurring events were considered, the most important predictor was myocardial viability (chi-square 9.7). Using the Cox proportional hazards model, only the presence of myocardial viability (hazard ratio [HR] 2.0, p < 0.002) and age (HR 1.03, p < 0.001) were predictive of spontaneously occurring events. When only hard cardiac events were considered, age was the strongest predictor (chi-square 3.6, p = 0.056), followed by wall motion score index (WMSI) at peak dose (chi-square 3.3, p = 0.06) and remote ischemia (chi-square 2.25, p = 0.1). When cardiac death was considered, WMSI at peak dose was the best predictor (HR 9.2, p < 0.0001)., Conclusions: During dobutamine stress, echocardiographic recognition of myocardial viability is more prognostically important than echocardiographic recognition of myocardial ischemia for predicting unstable angina, whereas WMSI at peak stress was the best predictor of cardiac-related death. Different events can be recognized with different efficiency by various stress echocardiographic variables.

Backgrounds: The aim of the study was to assess the relative prognostic accuracy of dobutamine echocardiography (TED) vs maximal bicycle exercise electrocardiography (TE) in patients with proven coronary artery disease., Methods: One hundred and thirty consecutive patients (70 patients with uncomplicated recent myocardial infarction, 19 asymptomatic patients with previous myocardial infarction and 41 patients with stable angina pectoris and previous myocardial infarction or previous myocardial revascularization procedure) underwent TED (incremental dobutamine infusion: 5 to 40 ncg/kg/min, continued with atropine 0.25 to 1 mg iv if necessary) and TE on different days and in random order. Criteria for positivity were: new or worsening regional dyssynergy for TED; ST segment shift > or = 1 mm from baseline for TE. End points were defined as spontaneous events (cardiac death, myocardial infarction and unstable angina) and total events (spontaneous events plus myocardial revascularization procedures)., Results: During 15.4 +/- 7.9 (range 1-33) months of follow-up, 33 events occurred: cardiac death (1), myocardial infarction (4) unstable angina (21) myocardial revascularization (7). Sensitivity, specificity, positive and negative predictive value, prognostic accuracy were similar for TED and TE (P = NS). Cumulative event-free survival curves as a function of TED and TE results were both statistically significant. A Cox stepwise regression analysis identified TED positivity obtained without atropine administration as the best predictor of spontaneous and total events (Odds ratio 5.33 and 4.38, respectively). Cumulative survival curves obtained by the combination of TED and TE results were statistically different (P < 0.05 and P < 0.001 for spontaneous and total events, respectively) and showed a poor clinical outcome in patients with both tests or only TED positive. TED correctly predicted clinical outcome in 24/39 patients in whom there was disagreement between the two tests., Conclusions: In patients with proven coronary artery disease, TED and TE have a similar accuracy for predicting clinical outcome. Where a discrepancy is seen between the two tests, TED appears to have a slightly higher prognostic value.

Background: Recent reports demonstrated an increased accuracy of dipyridamole echocardiography test with the intravenous infusion of 0.25 to 1 mg of atropine in 1-4 consecutive administrations at the end of the test. The effect of higher doses of atropine during dipyridamole echocardiography, potentially able to further increase heart rate and myocardial oxygen consumption, has not been evaluated. The aim of the study was to evaluate the effect of high doses of atropine during dipyridamole echocardiography and to investigate the possible pharmacological interference between dipyridamole and atropine., Methods: One-hundred consecutive patients (M = 81, F = 19; mean age 58 yrs) without inducible wall motion abnormalities at 14th minute of a high-dose (0.84 mg/Kg in 10') dipyridamole echocardiography test were studied. Seventy-five patients referred to the test in pharmacological wash-out were randomly divided in three groups: 25 patients (Group 1) received 10 mcg/Kg of atropine in 60"; 25 patients (Group 2) received 15 mcg/Kg of atropine in 120"; 25 patients (Group 3) received 20 mcg/Kg of atropine in 120"; moreover, 25 patients with a full-dose oral beta-blocker therapy (Group 4) received 20 mcg/Kg of atropine in 120". Atropine was infused during the 15th and 16th minute of the test. Heart rate (HR) changes and new wall motion abnormalities induced by atropine were considered and compared for each Group. In 60 patients (15 randomly selected from each Group) the effect on mean HR and R-R interval (msec) of the same dose of atropine infused during dipyridamole echocardiography was evaluated in resting conditions 24 hours apart., Results: The dipyridamole-atropine test was well tolerated and accomplished in all patients. HR increased significantly in all Groups of patients in comparison with pre-atropine HR values (Group 1: +14 +/- 8 b/m', p < 0.0001; Group 2: +19 +/- 8 b/m', p < 0.0001; Group 3: +22 +/- 9 b/m', p < 0.0001; Group 4: +19 +/- 8 b/m', p < 0.0001; Groups 2, 4 vs Group 1: p = 0.03, Group 3 vs Group 1: p = 0.002). No patients in Group 1 (0%), 3 patients in Groups 2 and 3 (12%), and 5 patients in Group 4 (20%) showed new wall motion abnormalities after atropine infusion (Group 4 vs Group 1: p = 0.06). Effects of atropine on HR and mean R-R interval were significantly more pronounced in resting conditions than during dipyridamole test (HR: +25 +/- 11 vs +18 +/- 9 b/m', p < 0.001; R-R: -256 +/- 122 vs -127 +/- 68 msec, p < 0.0001)., Conclusions: High doses of atropine during dipyridamole echocardiography test are safe and more effective for induction of new wall motion abnormalities than usual doses, particularly in patients tacking beta-blockers. The likelihood of an antagonistic mechanism between atropine and endogenous, dipyridamole-induced adenosine on sinus node is supported from our results.

Objectives: The prognostic value of dipyridamole echocardiography was assessed in patients with chronic coronary artery disease and preserved left ventricular function., Background: Few data are available on the prognostic value of dipyridamole echocardiography in patients with a low risk of cardiac events., Methods: Two hundred sixty-eight consecutive patients with stable, proven or suspected coronary artery disease and ejection fraction > or = 0.40 underwent high dose (up to 0.84 mg/kg body weight) dipyridamole echocardiography. In 204 patients definite exercise electrocardiographic (ECG) results were also available., Results: During a mean (+/- SD) follow-up period of 16 +/- 8 months (range 6 to 36), 33 spontaneous events occurred: 15 "hard" events (cardiac death [n = 6], myocardial infarction [n = 9]) and 18 "soft" events (unstable angina). Events occurred more frequently in patients with positive findings on dipyridamole echocardiography (59% vs. 3%, p < 0.001; hard events 24% vs. 2%, p < 0.01). A positive response at the low dose (up to 0.56 mg/kg) identified patients with a high incidence of hard events (7 of 16 patients, sensitivity 50%, specificity 96%). In patients with an exercise ECG, a comparable sensitivity for cardiac events was found (89% vs. 93%, p = NS), but dipyridamole echocardiography was more specific (91% vs. 61%, p < 0.01). A positive response on the low work load exercise ECG (< 8 min) and a positive response to low dose dipyridamole echocardiography had similar accuracy (82% vs. 90%, p = NS). Cox analysis identified dipyridamole echocardiography as the best predictor of cardiac events (odds ratio [OR] 20.9, 95% confidence interval [CI] 10.8 to 37.9); the highest risk of hard events was found in patients with a positive response to low dose dipyridamole echocardiography (OR 25.4, 95% CI 12.2 to 54.1)., Conclusions: In patients with chronic coronary artery disease and a low incidence of cardiac events, dipyridamole echocardiography was effective in prognostic stratification, and positive low work load exercise ECG results were a reliable predictor of subsequent events. Consequently, dipyridamole echocardiography should be considered a complementary tool in the presence of high work load positivity or ambiguous exercise ECG results.

The value of pulsed Doppler echocardiography in assessing the presence and severity of tricuspid regurgitation (TR) has been studied in three groups of subjects, 12 without cardiovascular disease (Group I), 38 with TR (Group II) and 16 patients with aortic and mitral valve disease but no TR (Group III). The presence and severity of TR was also independently evaluated by clinical examination, jugular vein pulse recording and/or hemodynamic investigation. Left parasternal, sub-xyphoid and apical views were adapted for the pulsed Doppler echocardiographic examination. The sample volume was placed in the right atrium at varying distances from the tricuspid valve. We tried to quantitate the degree of TR according to: 1) the diameter and maximal distance from the tricuspid valve of the regurgitant stream, 2) the duration of reguritation through systole, and 3) the degree of turbolence as demonstrated by the time interval histograms. On the basis of above mentioned criteria, three subgroups of subjects with TR, i.e. mild, moderate and severe were recognised. These results were compared to hemodynamic and/or clinical-poligraphic evaluation. In 34 Group II subjects (89%), the Doppler study revealed the presence of TR and allowed an acceptable quantitative assessment. Falsely positive diagnoses were not made in any of the subjects of Group I. Identification of organic TR in patients with atrial fibrillation was possible only when regurgitation was moderate or severe.