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AIMS: To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. METHODS AND RESULTS: We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. CONCLUSIONS: This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region

Background—The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. Methods and Results—Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with a

BACKGROUND--The purpose of this study was to assess the long-term value of dobutamine-atropine stress echocardiography (DSE) for prediction of late cardiac events in patients with proven or suspected coronary artery disease. METHODS AND RESULTS--Clinical data and DSE results were analyzed in 1734 consecutive patients undergoing DSE between 1989 and 1997. Seventy-four patients who underwent revascularization within 3 months of DSE and 1 patient lost to follow-up were excluded; the remaining 1659 (median age, 62 years; range, 14 to 99 years) were followed up for 36 months (range, 6 to 96 months). Wall motion abnormalities at rest and the presence and extent of stress-induced wall motion abnormalities (ischemia) were scored for each patient. Cardiac events were related to clinical and ECG data and DSE results. Four hundred twenty-eight cardiac events occurred in 366, documented cardiac death in 108 (total death, 247), nonfatal infarction in 128, and late revascularization in 192 patients. In a multivariable Cox proportional-hazards model, the ratio of documented cardiac death or (re)infarction was increased in the presence of stress-induced ischemia (hazard ratio, 3.3; 95% CI, 2.4 to 4.4) and extensive rest wall motion abnormalities (hazard ratio, 1.9; 95% CI, 1.3 to 2.6). The number of ischemic segments was predictive for late cardiac events. A normal DSE carried a relatively good prognosis, with

Objectives. This study evaluated the relative merits of the most frequently used techniques for predicting improvement in regional contractile function after coronary revascularization in patients with left ventricular dysfunction due to chronic coronary artery disease. Background. Several techniques have been proposed for predicting improvement in regional contractile function after revascularization, including thallium-201 (TI- 201) stress-redistribution-reinjection, T1-201 rest-redistribution, fluorine- 18 fluorodeoxyglucose with positron emission tomography, technetium-99m sestamibi imaging and low dose dobutamine echocardiography (LODE). Methods. A systematic review of all reports on prediction of functional recovery after revascularization in patients with chronic coronary artery disease (published between 1980 and March 1997) revealed 37 with sufficient details for calculating the sensitivity and specificity of each imaging morality. From the pooled data, 95% and 99% confidence intervals were also calculated. Results. Sensitivity for predicting regional functional recovery after revascularization was high for all techniques. The specificity of both T1- 201 protocols was significantly lower (p < 0.05) and LDDE significantly higher (p < 0.01) than that of the other techniques. Conclusions. Pooled analysis of 37 studies showed that although all techniques accurately identify segments with improved contractile function after revascularization, the T1-201 protocols may overestimate functional recovery. The evidence available thus far indicates that LDDE appears to have the highest predictive accuracy.

Large numbers of patients referred for evaluation of chest pain are unable to perform adequate, diagnostic exercise testing. In these patients, dobutamine stress echocardiography (DSE) represents an alternative, exercise- independent stress modality. Apart from the ~5% of patients with an inadequate acoustic window, 10% of patients referred for this test have nondiagnostic (sub-maximal negative) test results. Serious side effects during or shortly after DSE are uncommon, with ventricular fibrillation or myocardial infarction occurring in ~1 of 2,000 studies. No deaths have been reported. On the basis of a total number of 2,246 patients, reported in 28 studies, the sensitivity, specificity and accuracy of the test for the detection of coronary artery disease (CAD) were 80%, 84% and 81%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 74%, 86% and 92%, respectively. The sensitivity for detection of disease in the left circumflex coronary artery (55%) was lower, both compared with that for left anterior descending (72%) and right coronary artery disease (76%). The sensitivity of predicting multivessel disease by multiregion echocardiographic abnormalities varied widely, from 8% to 71%. In direct comparisons, DSE was superior to exercise electrocardiography and dipyridamole echocardiography and comparable to exercise echocardiography and radionuclide imaging. DSE is a useful, feasible and safe exercise-independent stress modality for assessing the presence, localization and extent of CAD.

The aim of this study was to assess the influence of the severity of coronary artery stenosis and the grade of collateral circulation on myocardial viability in patients with chronic left ventricular (LV) dysfunction undergoing coronary artery bypass grafting. Forty patients (age 59 ± 8 years) with old myocardial infarction were studied by dobutamine stress echocardiogrophy (DSE) before coronary artery bypass grafting. LV function was assessed using a 16-segment, 5-grade score model. Viability and functional recovery were respectively defined as a reduction in wall motion score ≤ 1 at low-dose DSE and at follow-up echocardiograms obtained 3 months after surgery. There were 56 stenotic coronary arteries subtending severely dyssynergic myocardial segments, of which 38 were occluded. Among 186 severely dyssynergic segments, functional recovery occurred in 42 (23%). There was no significant difference between myocardial regions with patent or occluded coronary arteries with respect to prevalence of viability or functional recovery and percentage of viable or recovered segments relative to the total number of dyssynergic segments. In patients with total occlusion, these parameters were not different between regions with different collateral grades. Sensitivity, specificity, and accuracy of low-dose DSE for prediction of regional functional recovery were 71%, 90%, and 86%, re

Objectives. We evaluated the use of fluorine-18 fluorodeoxyglucose (FDG) and single-photon emission computed tomography (SPECT) to predict improvement of left ventricular ejection fraction (LVEF) after revascularization. Background. FDG SPECT has recently been proposed for assessment of myocardial viability. However, FDG SPECT still awaits validation in terms of predicting improvement of contractile function after revascularization in patients with poor left ventricular (LV) function. Methods. Fifty-five patients with contractile dysfunction (including 22 with LVEF <30%) underwent FDG SPECT during hyperinsulinemic glucose clamping and early thallium-201 SPECT (to assess perfusion). Improvement of LV function was evaluated 3 months after revascularization with echocardiography and radionuclide ventriculography. Results. The 55 patients were arbitrarily classified into two groups: 19 with three or more viable, dysfunctional segments on FDG SPECT and 36 with less than three viable, dysfunctional segments. LVEF increased significantly in the first group, from 28 ± 8% (mean ± SD) before to 35 ± 9% (p < 0.01) after revascularization. In the second group, LVEF remained unchanged after revascularization (45 ± 14% vs. 44 ± 14%, p = NS). The 22 patients with severely depressed LV function were similarly classified into two groups: 14 with three or more viable segments on FDG SPECT in whom LVEF improved significantly (25 ± 6% vs. 32 ± 6%) and 8 with less than three viable segments in whom LVEF remained unchanged (24 ± 6% vs. 25 ± 6%). Conclusions. This study shows that FDG SPECT can identify patients in whom LV function improves after revascularization. Because SPECT is widely available, this technique may contribute to more routine use of FDG for determination of viability.

OBJECTIVE: To assess the relation between ST segment elevation during the dobutamine stress test and late improvement of function after acute Q wave myocardial infarction. PATIENTS AND DESIGN: 70 patients were studied a mean (SD) 8 (3) days after acute myocardial infarction with high dose dobutamine-atropine stress echocardiography and a follow up echocardiogram at 85 (10) days. A score model based on 16 segments and four grades was used to assess left ventricular function. Functional improvement was defined as a reduction of wall motion score > or = 1 in > or = 1 segments at follow up. INTERVENTION: Myocardial revascularisation was performed in 23 patients (33%) before follow up studies. RESULTS: ST segment elevation occurred in 40 patients (57%). Late functional improvement occurred in 35 patients (50%). Functional improvement was more common in patients with ST segment elevation (68% v 30%, P < 0.005) and they had a higher mean (SD) number of improved segments at follow up (1.9 (2.2) v 0.5 (1.1), P < 0.005). The wall motion score index decreased between baseline and follow up in patients with ST segment elevation (1.54 (0.50) v 1.48 (0.43), P < 0.05) but not in patients without ST segment elevation (1.39 (0.60) v 1.45 (0.47)). The accuracy of ST segment elevation for the prediction of functional improvement was similar to that of low dose dobutamine echocardiography in patients with anterior infarction (80% v 83%) and in patients who underwent revascularisation (78% v 83% respectively). CONCLUSION: In patients with a recent Q wave myocardial infarction, dobutamine-induced ST segment elevation is a valuable marker of myocardial viability particularly when the test is performed without or with suboptimal echocardiographic imaging.

Objectives. We compared: three techniques to predict functional recovery after revascularization. Background. Recently, fluorine-18 (F-18) fluorodeoxyglucose in combination with single-photon emission computed tomography (SPECT) has been proposed to identify viable myocardium. Thallium-201 reinjection and 'low' dose dobutamine echocardiography are used routinely for this purpose. Methods. Seventeen patients (mean [±SD] left ventricular ejection fraction 36 ± 11%) were studied. Regional and global ventricular function were evaluated before and 3 months after revascularization by echocardiography and radionuclide ventriculography, respectively. Myocardial F-18 fluorodeoxyglucose uptake (during hyperinsulinemic glucose clamping) was compared with rest perfusion assessed with early thallium-201 SPECT. Oh a separate day, low dose dobutamine echocardiography and post-stress thallium-201 reinjection SPECT were simultaneously performed. Results. The sensitivities for F18 fluorodeoxyglucose/thallium-201, thallium-301 reinjection and low dose dobutamine echocardiography to assess recovery were 89%, 93% and 85%, respectively; specificities were 77%, 43% and 63%, respectively. Stepwise logistic regression indicated that F-18 fluorodeoxyglucose/ thallium-201 was the best predictor. In hypokinetic segments, the combination of F-18 fluorodeoxyglucose/thallium-201 and low dose dobutamine echocardiography was the best predictor. Global function improved (left ventricular ejection fraction increased > 5%) in 6 patients and remained unchanged in 11. All three techniques correctly identified five of six patients with improvement. Fluorine-18 fluorodeoxyglucose/thallium-201 identified all patients without improvement; low dose dobutamine echocardiography identified 9 of 11 without improvement; and thallium-201 reinjection identified 6 of 11 patients without improvement, Conclusions. Fluorine-18 fluorodeoxyglucose/thallium-201 SPECT was superior to the other techniques in assessing funct

Spontaneous improvement of contraction and perfusion occurs after acute myocardial infarction. The relative merit of low-dose dobutamine stress echocardiography (LDDE) and rest-redistribution thallium scintigraphy (RR Tl) in this setting has not been evaluated. We studied 30 patients at 7

Dobutamine stress echocardiography is an accurate method for the diagnosis and localization of vascular compromise in patients evaluated after coronary artery bypass graft surgery. The test provides useful data for selection of patients for whom coronary angiography may be indicated.

BACKGROUND: Akinesis becoming dyskinesis at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, to our knowledge, the relationship between this pattern and myocardial viability has not been assessed. METHODS: We studied 42 patients with myocardial infarction who underwent DSE (up to 40 micrograms/kg/min) before coronary artery bypass surgery, and resting echocardiogram 3 months after surgery. Viability in akinetic segments was considered to be present if systolic thickening occurred with low-dose dobutamine (LDD). RESULTS: During high-dose DSE, dyskinesis occurred in 35 of the 164 akinetic segments (group A). The remaining 129 segments comprised group B. Segments of group B had a higher prevalence of viability pattern with LDD (18% vs 0%; p < 0.01) and a higher prevalence of functional improvement (20% vs 0%; p < 0.005) compared with group A. In absence of viability pattern with LDD, postoperative improvement occurred in 10% of segments in group B and in none of segments in group A, resulting in a higher negative predictive value of LDD in group A vs B (100% vs 90%; p < 0.05). CONCLUSION: The phenomenon of akinesis becoming dyskinesis with high-dose DSE is associated with absence of viability pattern with LDD and poor functional outcome after surgical revascularization. Observation of this pattern provides additional data to those obtained only with LDD echocardiography.

Objectives: This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography. Background: Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities. Methods: Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed. Results: The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age >70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative asses

OBJECTIVES. The purpose of this study was to determine the predictive value of quantitative coronary angiography in the assessment of the functional significance of coronary stenosis as judged from the development of left ventricular wall motion abnormalities during dobutamine-atropine stress echocardiography. BACKGROUND. Coronary angiography is the reference method for assessment of the accuracy of noninvasive diagnostic imaging techniques to detect the presence of significant coronary stenosis. However, use of arbitrary cutoff criteria for the interpretation of angiographic data may considerably influence the true diagnostic accuracy of the technique investigated. METHODS. Thirty-four patients without previous myocardial infarction and with single-vessel coronary stenosis were studied with both quantitative angiography and dobutamine-atropine stress echocardiography. Two different techniques of quantitative angiographic analysis--edge detection and videodensitometry--were used for measurement of minimal lumen diameter, percent diameter stenosis and percent area stenosis. Two-dimensional echocardiographic images were collected during incremental doses of intravenous dobutamine and later analyzed using a 16-segment left ventricular model. Angiographic cutoff criteria were derived from receiver-operating curves to define the functional significance of coronary stenosis on the basis of dobutamine-atropine stress echocardiography. RESULTS. The angiographic cutoff values with the best predictive value for the development of left ventricular wall motion abnormalities during dobutamine-atropine stress echocardiography were minimal lumen diameter of 1.07 mm, percent diameter stenosis of 52% and percent area stenosis of 75%. Minimal lumen diameter was found to have the best predictive value for a positive dobutamine stress test (odds ratio 51, sensitivity 94%, specificity 75%). CONCLUSIONS. Automated quantitative angiographic measurement of minimal lumen diameter is a pract

To compare the diagnostic value of exercise echocardiography and perfusion single photon emission computed tomography (SPECT) in the detection of the presence and the severity of coronary artery disease, we studied 21 patients with isolated stenosis of different degree of the left anterior descending artery. Both echocardiography and SPECT were performed in conjunction with the same symptom-limited bicycle exercise test. Positivity of the test was based on the presence of exercise-induced wall motion abnormalities and transient perfusion defects, respectively. For both tests, an 'ischemic' score was derived, as index of extent and severity of myocardial ischemia. Coronary arteriography was evaluated by caliper. The agreement between exercise echocardiography and SPECT for the presence of coronary artery disease was 90%; the discordance was due to two patients with positive echocardiography and negative SPECT. A good correlation between ischemic wall motion and perfusion score indices was found (r=0.78, p<0.0001. Moreover, the percent diameter stenosis was well correlated with both ischemic indices (r= 0.75, p<0.0001; r=67, p<0.001, respectively). In patients with a positive test, the mean value of ischemic wall motion score index was higher in patients with a diameter stenosis ≥ 70% than in patients with a diameter stenosis <70% (0.59 ± 0.19 vs 0.29 ± 0.12, p < 0.01); a similar trend was found for ischemic perfusion score index (0.51 ± 0.35 vs 0.27± 0.12, ns). The results of this study indicate that in patients with single vessel disease of left anterior descending artery exercise echocardiography and SPECT give the same information on the presence, the extent and the severity of myocardial ischemia.

The aim of this study was to evaluate the results of predischarge stress testing in the elderly, and to assess the prognostic value of the test during one-year follow-up. The database consisted of 48 patients older than 64 years of age and 109 patients 55-64 years of age, who survived acute myocardial infarction, out of 532 consecutive patients admitted for myocardial infarction. Stress-test results were not different in the two groups. During one-year follow-up mortality was 6% in the younger patients and 4% in the older group, and the incidence of non-fatal reinfarctions was 8% in both groups. Mortality was best predicted by the extent of blood pressure rise (43 +/- 26 mmHg in survivors vs 19 +/- 15 mmHg in non-survivors, P less than 0.001). Stress-test results were no more predictive when non-fatal reinfarction was added to mortality as an end-point. We conclude that for patients in whom the stress test is not contraindicated, age does not affect stress test results, the extent of blood pressure rise during a stress test is the best single predictor of mortality, stress tests are not predictive of reinfarctions.

The extent to which patients with low peak serum creatine kinase (CK) at their first myocardial infarction differ from patients with high CK levels in terms of risk for subsequent ischaemic events was investigated in 266 patients who survived the first 48 h from the onset of infarction. All patients were followed up for one year. Four groups were formed based on peak CK less than or equal to 200, 201-400, 401-800 and greater than 800 IU l-1. During follow-up the incidence of mortality was 15% (N = 39), non-fatal re-infarction 9% (N = 23), and angina 53% (N = 140). Hospital mortality was significantly higher (P less than 0.02) in the highest CK-group (16%), but the incidence of non-fatal re-infarction, angina pectoris and late mortality was similar in the four groups. In hospital survivors, ischaemic ST-changes during pre-discharge symptom limited bicycle stress test and multiple vessel disease were equally distributed in all four groups. We conclude that while hospital mortality is directly related to peak CK, there is no relationship between peak CK and late mortality, non-fatal re-infarctions, or recurrent angina. Accordingly, diagnostic and therapeutic procedures in the individual patients are not influenced by the amount of serum CK released during acute infarction.

The aim of this study was to assess whether data related to predischarge clinical examinations, resting radionuclide ventriculography and symptom-limited bicycle ergometry can predict the achievement of a normal exercise capacity after a rehabilitation program in patients with a recent myocardial infarction. The study population consists of 141 consecutive patients who completed a 3-month training program. Patients with heart failure and/or severe angina were excluded. The rehabilitation program included two training sessions weekly during the 3 months. Wo

The relative value of predischarge clinical variables, bicycle ergometry, radionuclide ventriculography and 24 hour ambulatory electrocardiographic monitoring for predicting survival during the first year in 351 hospital survivors of acute myocardial infarction was assessed. Discriminant function analysis showed that in patients eligible for stress testing the extent of blood pressure increase during exercise slightly improved the predictive accuracy beyond that of simple clinical variables (history of previous myocardial infarction, persistent heart failure after the acute phase of infarction and use of digitalis at discharge), whereas radionuclide ventriculography and 24 hour electrocardiographic monitoring did not. The predictive value for mortality was 12% with clinical variables alone and 15% with the stress test added. Radionuclide ventriculography and 24 hour electrocardiographic monitoring were slightly additive to clinical information in the whole group of patients independent of the eligibility for stress testing (predictive value for mortality 24% with clinical variables alone and 26% with radionuclide ejection fraction and 24 hour electrocardiographic monitoring added). It is concluded that the appropriate use of simple clinical variables and stress testing is sufficient for risk stratification in postinfarction patients, whereas radionuclide ventriculography and 24 hour electrocardiographic monitoring should be limited to patients not eligible for stress testing.