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Early diagnosis of postinfarction left ventricular aneurysm is mandatory. We suggest that Tc 99m-albumin radionuclide angiography, Tc 99m-MIBI scintigraphy and magnetic resonance study of the heart as useful non-invasive diagnostic tools.
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In a patient with atrioventricular nodal reentrant tachycardia, during programmed stimulation, an atrial extrastimulus induced a double ventricular response due to a single atrial depolarization, with simultaneous and delayed anterograde conduction through fast and slow pathways, and induced the tachycardia. Pacing-induced type I block involving both pathways put these pathways out of phase, so that the distal conduction system and the ventricle responded to both the fast and slow pathways anterograde impulses.
In obesity, the systemic resistances (SR) are reduced while the blood volume is increased. The rise of cardiac output (CO), stress-induced, produces an increase in blood pressure (BP), as an hypertensive behavior of the stress-response. The aim of our study is to evaluate if, in obese subjects, the considerable increase of BP is more related to the rise of CO than to the rise of SR. For this reason we studied the behavior of BP through indexes derived from the ratio of SBP values at the 1st, 3rd, 5th, 10th minutes of the recovery by the SBP value at the acme of stress. These indexes are under neurovegetative control, and were shown to be impaired in hypertensive pts. The results of ergometric stress test (EST) of 37 obese subjects (Ob+) (27 males and 10 females, mean age 46.2 +/- 7.3 years), determined according to Lorentz's formula, was compared with the parameters deduced from the EST of 18 normal subjects (Ob-) (13 males and 5 females, mean age 36.7 +/- 8.5). The exercise showed an increase, more pronounced in Ob+ subjects, of SBP and DBP, and this also persisted in the recovery phase. Although BP was significantly higher in the Ob+group, the SBP indexes did not differ in the two groups. Then, from these data it can be deduced that, although during EST in obese subjects there is an absolute increase of BP and this persists in the recovery phase, the behavior of this parameter probably cannot be related to alteration of neurovegetative system as demonstrated by the normal SBP indexes.
Two cases of phase 3 intraventricular block and linking phenomenon of type 1 and type 2 (or bigeminal rhythm linking) are presented. In the first case, complexes that follow the extrasystolic blocked beat are wide, although they are associated with relative long R-R cycle:type 1 linking. In the second case, bundle branch block and normal conduction alternate in bigeminal extrasystolic beats:type 2 linking. The linking phenomenon is due to concealed retrograde penetration of the bundle branch that is blocked in anterograde direction. It delays the cycle and the refractory period of the bundle branch. Therefore, in type 1 linking, the subsequent stimulus, although occurring with a long R-R cycle, is again blocked in the same bundle branch. In type 2 linking, the R-R cycle and refractory period, occurring after bundle branch block, are shorted because comprised between retrograde activation by extrastimulus and anterograde activation by subsequent sinus stimulus. The subsequent ectopic impulse, although premature, is normally conducted.
A family history of hypertension can influence the behaviour of blood pressure during ergometric stress test (EST) in normotensive subjects, so that it is also used in the assessment of risk of hypertension. To evaluate the relationship between parental history and blood pressure values during exercise, 57 consecutive adolescents (aged 10-16 years) were studied. Out of them, 25 patients have not been considered because of the presence of organic pathologies of various nature that could interfere with the pressure behaviour. All patients underwent EST with a load increase of 25 W every 3 min until the maximal age-related heart rate. The patients were divided in 2 groups based on the presence (PH+ 13 patients, mean age 13 +/- 2 years) or on the absence (PH- 19 patients, mean age 13 +/- 2 years) of parental history of hypertension. No difference in body surface and maximum workload was observed between the 2 groups. Exercise test induced an increase in systolic blood pressure (SBP) both in PH- and PH+ patients, but no significant differences were found in any stage of the exercise in the 2 groups. Maximum heart rate (HR) was not different in the 2 groups and diastolic blood pressure (DBP) was substantially unchanged during exercise. The variation of SBP (delta SBP) between maximum stress and first, third, fifth and tenth min of the recovery phase were considered. Besides, 4 SBP indexes were deduced from the ratio of SBP values at the first, third, fifth and tenth min of the recovery by the SBP value at the acme of stress.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: ST elevation during ergometric stress test (EST) is relatively rare. Its prevalence depends upon the tested population but occurs more frequently in patients who have had myocardial infarction or variant angina. This phenomenon is very rare in patients with typical exertional angina and its pathogenesis is still unclear. MATERIAL AND METHODS: We studied a group of 75 consecutive patients with exertional angina who underwent EST and coronary angiography. A symptom limited EST was performed in the upright position on a cycloergometer with load increases of 25 watts every 3 minutes and 12 leads were monitored during all test. Coronary angiography was performed according to Judkins technique. From these patients, according to Froelicher's criteria, a group of 49 patients (age 32-68, mean 51.6 years), without myocardial infarction and/or left ventricular asynergy, was selected. RESULTS: All patients had a coronary artery disease (16 patients with 3 vessels, 11 patients with 2 vessels and 22 patients with 1 vessel disease). The EST was positive for ST depression in 31 patients (63.3%) and for ST elevation in 5 patients (10.1%), while 13 patients (26.6%) had a non diagnostic EST. The ST elevation occurs in V1-V2 and it was associated in all cases with a stenosis in the left anterior descending (LAD) artery. Therefore we divided the 19 patients with LAD stenosis into two subgroups: subgroups A (9 patients, mean age 49.6 years) with LAD stenosis > or = 90% and subgroups B with LAD stenosis between 70% and 90%. ST elevation occurs in 5 patients (55.5%) of subgroup A and in no patient of the subgroup B. Moreover, in the subgroup A ST elevation seems to be related to the anatomic localization of the stenosis: in fact it appears in 83.3% of patients with LAD stenosis located before the onset of the first diagonal branch. CONCLUSIONS: From these data it can be desumed that ST elevation in V1-V2 that occurs in patients with exertional angina and without myocardial infarction or variant angina is strongly predictive of a very important LAD stenosis.
BACKGROUND: Of the main aspects of hypertension, left ventricular hypertrophy and appearance of cardiac dysfunction seem to be the most common and to produce an early and severe cardiac deterioration. Even in the presence of normal systolic function diastolic filling abnormalities are described. The efficacy of many antihypertensive drugs to decrease blood pressure and to reduce left ventricular hypertrophy has already been demonstrated. Cilazapril is a new ACE-inhibitor that in previous studies showed a very important antihypertensive effect. To assess its capacity, in long-term treatment, to reduce left ventricular hypertrophy we performed a prospective study on patients with mild hypertension. MATERIAL AND METHODS: Nineteen patients (aged 48 +/- 15 years) with mild hypertension (mean arterial pressure automatically recorded for 24 hours with blood pressure ambulatorial monitoring) were treated with cilazapril (5 mg/day) for 1 year. Doppler echocardiography was performed: at the beginning, after 6 months and after one year of therapy. The following parameters were evaluated: interventricular septal and posterior wall thickness, LV end-diastolic diameter, LV mass index, early (E) and late (A) diastolic filling flow velocities and the ratio E/A. RESULTS: A significant decrease was observed in mean arterial pressure (from 130 +/- 14 mmHg at beginning to 102 +/- 11 mmHg at six months of therapy and to 103 +/- 9 mmHg at one year of therapy). A significant reduction in LV hypertrophy and an improved diastolic filling pattern of the left ventricle was shown after six months of therapy with cilazapril; this improvement still remained after 1 year of therapy. CONCLUSIONS: In this study antihypertensive efficacy of cilazapril has been confirmed. Moreover, in long treatment, cilazapril has been useful to reduce left ventricular hypertrophy and to improve diastolic filling without significant side effects.
Electrophysiologic studies in a patient with intermittent ventricular pre-excitation revealed several types of paroxysmal narrow-QRS tachycardia (PSVT). One type of PSVT was characterized by normal retrograde atrial sequences with P waves occurring simultaneously with QRS. This type of PSVT reflected AV nodal reentry with anterograde slow pathway and retrograde fast pathway conduction. A second PSVT reflected alternation of anterograde fast and slow AV nodal pathway conduction and retrograde anomalous pathway conduction. A third PSVT reflected anterograde slow AV nodal pathway and retrograde anomalous pathway conduction. Moreover, discontinuous AV nodal conduction curves (A1A2/H1H2), characteristic of dual AV nodal pathway conduction, were obtained with programmed atrial extra stimulation. These observations suggest that dual AV nodal pathway conduction can coexist with abnormal bypass tract and can be the cause of PSVT in patients with Wolff-Parkinson-White syndrome.
Sixty patients with type I diabetes mellitus underwent an ergometric stress test (EST) to evaluate the relationship between cardiac autonomic neuropathy (CAN) and hemodynamic changes during EST. All patients were divided into 2 groups: in the Group A were included 26 patients (mean age 43 +/- 9 years) with impairment of 2 or more autonomic tests according to Ewing (patients with CAN) and in the Group B were included 34 patients (mean age 38 +/- 13 years) without CAN. The EST was symptom-limited and performed with load increases of 25 W every 3 min. No positive EST were observed in both groups. Heart rate (HR) at rest and systolic blood pressure (SBP) at maximum common workload were significantly higher in Group A than in Group B. Moreover, a significant linear correlation was found between a CAN score and SBP x HR product at rest and at maximal workload. These findings are correlated with increased sympathetic activity due to a parasympathetic impairment. The data show the relationship between hemodynamic changes during EST and the Ewing test used in the diagnosis of CAN.
To determine whether serial quantitative two-dimensional echocardiographic analysis of left ventricular wall motion could be effective in selecting patients in whom anthracycline treatment must be stopped, 26 patients (18 M and 8 F, mean age 10 +/- 3, range 6 to 16 years) with malignancy, receiving doxorubicin or daunomycin were followed up. Left ventricular regional wall motion abnormalities were detected in 11 patients (42%), while left ventricular ejection fraction at rest (although progressively decreased from baseline value [63 +/- 2 vs 55 +/- 2%; p = 0.0001]) was still in normal range. The following distribution of left ventricular contraction abnormalities was noted: septal, anteroseptal and posteroseptal akinesis with posterior wall hypokinesis in one patient; septal, anteroseptal and posteroseptal akinesis with anterolateral free-wall hypokinesis in another; septal, anteroseptal and posteroseptal hypokinesis in four; lateral and posterolateral free-wall hypokinesis in one; septal, anteroseptal, posteroseptal and posterior hypokinesis in four. The drug was discontinued in only two patients with akinesis, since we regarded this contraction abnormality as a predictive index of more serious and extensive myocardial damage. We began to detect hypokinesis when cumulative doses of doxorubicin or daunorubicin were 155-420 mg/m2 and 270-285 mg/m2 respectively, while akinesis was seen at doses of 395 mg/m2 of body-surface area for doxorubicin and 575 mg/m2 for daunorubicin. Follow-up examination was conducted six months after the last dose of anthracycline, and improvement or recovery of left ventricular regional wall motion abnormalities was noted in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Electrovectorcardiographic features of 150 patients showing right ventricular activation delays (RVAD) has been analyzed. This analysis of RAVD, especially for type I, which is the group with the widest morphologic variability, has permitted a more detailed classification: a type I with 5 subtypes, a type II with 1 subtype, a type III and an intermediate type between type II and III. Fifty-five per cent of the patients were included in type I and its variant and most were classified, often without cardiac disease, as belonging to the classic type I. Thirty per cent of RVAD were of type II; 12% of type III and the remaining were in the intermediate group between type II and III. The various morphologies, moreover, were correlated with the clinical picture: the classic type I was never seen in subjects with cardiac disease, while the others types and subtypes were present either in subjects with cardiac disease or in elderly subjects, also without relevant pathologies (senile heart, especially, the type IA") or in otherwise healthy subjects. In a medical-social context, checking for RVAD, in the absence of cardiac disease, might usefully avoid further investigation. It is underlined the usefulness of this correlation for clinical prognostic judgement.
In order to determine the relationship among ventricular arrhythmias, left ventricular dysfunction and sudden cardiac death (SCD), 75 consecutive patients with myocardial infarction, 38 of whom resuscitated from SCD, were studied retrospectively by 48 hour Holter electrocardiographic monitoring (ECGD), cardiac catheterization and radionuclide angiography (ACRD). The patients were divided in 3 groups, related to SCD occurrence and to the interval between acute myocardial infarction (AMI) and SCD: Group I (37 patients-control group) no cardiac arrest occurred; Group II (26 patients) resuscitated less than or equal to 48 hours after AMI; Group III (12 patients) resuscitated 6-12 weeks after AMI. ECGDs were recorded with an average of 2 (ECGD 1), 16 (ECGD 2) and 36 months (ECGD 3) after AMI. In ECGD 1, there were no differences in the frequency and complexity of ventricular arrhythmias among the 3 groups, whereas in ECGD 2 and 3 the incidence of complex ventricular arrhythmias was significantly higher in Group III than in the other 2 groups (p less than 0.05). In Group III, the complexity and frequency of ventricular arrhythmias increased both in ECGD 2 and 3 compared to ECGD 1 (p less than 0.05). Furthermore, between patients of Group II and III higher grade arrhythmias and more frequent ventricular premature beats (VPB) were noted in sudden death patients than in survivors. There was no statistical difference in mean cardiac index, left ventricular end-diastolic pressure and ejection fraction among the groups. In the ACRD 1 performed an average of 8 months after AMI, a slight decrease of ejection fraction in Group III compared to the other groups was noted (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Aim of this study was to assess the role of age-related vascular response in the onset of i.v. dipyridamole effects. The results of 129 patients who underwent a dipyridamole infusion were reviewed. The patients were divided into three according to age: 47 patients of less than 50 years (group I), 54 patients aged between 50 and 60 years (group II) and 28 patients of more than 60 years (group III). For each group heart frequency (HF) and systolic blood pressure (SBP) were considered in basal conditions, at the end of infusion and at the minimum value of SBP (SBP min); moreover the time in reaching SBP min was considered (time to SBP min). At the end of the infusion no significant changes in SBP were observed in all groups while the SBP min value reached from group III were significantly lower than basal (142.6 +/- 20.4 mmHg, p less than 0.02). The HF, without significant differences among the three groups in basal conditions, increased significantly at the end of infusion only in group I and II, with a more significant increase in group I at the time of SBP min with respect to groups II and III. The group 3 showed moreover, a significant longer time to SBP min (286 +/- 208 sec) respect to the group I and II (145 +/- 130 and 160 +/- 177 sec respectively) (p less than 0.02). From these data it can resume that age could be a factor to determine hemodynamic response to intravenous dipyridamole.
The diagnosis of acute aortic pathology is decisive for the prognosis of the patient, since an effective surgical and medical therapy can improve the high rate of mortality due to this pathology. Conventional transthoracic echocardiography (TTE) fails to detect abnormalities of the descending thoracic aorta. Aim of this study was the evaluation of the actual usefulness of transesophageal echocardiography (TEE) in the diagnosis of aneurysm (AN) and/or dissection (DISS) of the aorta. Fifty-six consecutive patients with clinical suspicion of AN or DISS underwent TEE. Of these, 24 (42.8%) did not show any abnormality, while 32 (57.2%) had a severe pathology of the aorta requiring angiography (ANG) or cardiac surgery (SURG). All the patients underwent computed tomography scanning examinations (CT) even if TEE did not show any abnormality. The diagnoses obtained by TTE, TEE and CT were compared with those obtained by reference methods (ANG and/or SURG). Non-dissecting aorta aneurysms were detected in 11 patients; dissecting aorta aneurysms were found in 21 patients; 5 patients showed an isolated aortic dissection (without aneurysm). The sensitivity of TTE for detecting pathology of the aorta resulted very low (56.3%) when compared to TEE (96.8%) and CT (90.6%). The specificity for diagnosing aortic pathology was for TTE 63.1%, for TEE 96.0% and CT 88.8%; the accuracy of TTE resulted 75.0%, TEE 98.2% and CT 94.6%; the predictive value of TTE was 85.7%, TEE 96.8% and CT 93.5%. In conclusion, TEE provides a reliable non-invasive diagnosis of AN and/or DISS superior to TTE and CT; it may be considered the method of choice to detect acute aorta pathology.
Syncope in Wolff-Parkinson-White (WPW) patients might be considered a premonitory event heralding the future development of sudden death. Therefore, we reviewed the clinical and electrophysiologic data of 91 WPW patients referred for invasive evaluation of known arrhythmias, in order to assess the incidence and clinical relevance of syncope. Thirty-four patients (37%, Group I) reported the occurrence of 1 or more syncopal episodes, while 57 patients (63%, Group II) had no syncope. These 2 groups did not differ significantly with regard to age, sex, incidence and characteristics of arrhythmias, clinical history and frequency of arrhythmic events, presence of associated cardiac diseases. Eleven patients in Group I and 9 in Group II were resuscitated from a cardiac arrest. The sensitivity (40%), the specificity (64%) as well as the positive predictive value (32%) and the negative predictive value (71%) of syncope vs a cardiac arrest were not significant. There were no statistical differences in the effective refractory period of the right atrium, atrioventricular node, accessory pathway and right ventricle between the 2 groups. Furthermore, no differences were noted in the cycle length of tachycardia (327 +/- 60 ms in Group I and 335 +/- 46 ms in Group II) and in the minimum RR interval during atrial fibrillation (248 +/- 49 ms and 244 +/- 43 ms, in Group I and II, respectively) as well as in the number of patients who had a minimum RR interval during atrial fibrillation less than or equal to 250 ms (15 patients--65%--in Group I and 21 patients--62%--in Group II).(ABSTRACT TRUNCATED AT 250 WORDS)
The purpose of this study was to assess the accuracy of a quantitative two-dimensional Doppler echocardiographic method for estimating systemic and pulmonary blood flows in atrial and ventricular septal defects. Twenty-eight patients (mean age 22 +/- 14), with atrial septal defect (ADS) or ventricular septal defect (VSD) underwent Doppler-echocardiography and cardiac catheterization in order to assess pulmonary blood flow (QP), systemic blood flow (QS), the left to right shunt (SH) and the ratio of pulmonary to systemic flow (QP/QS ratio). Cardiac output was also determined by the oximetry method according to Fick principle. Pulmonary output assessed by Doppler was 7.9 +/- 0.61/min, by catheterization 9.0 +/- 3.9. Linear regression analysis showed a low correlation coefficient (r = 0.10; p = NS). Systemic output evaluated by Doppler resulted 4.6 +/- 1.4 l/m, while at catheterization 5.1 +/- 1.5 l/min (r = 0.25; p = NS). Doppler evaluation of left-to right shunt was 3.3 +/- 1.5 l/min, at catheterization 3.9 +/- 3.1 (r = 0.74; p less than 0.001). Doppler QP/QS ratio resulted 1.7 +/- 0.5, at catheterization 1.8 +/- 0.5 (r = 0.96; p less than 0.0010. The results showed that, in spite of the lack of correlation between the pulmonary and systemic outputs assessed by Doppler vs catheterization, QP/QS ratio, as well as SH, are useful noninvasive indexes in order to evaluate intracardiac shunts.
The electrocardiographic (ECG) diagnosis of delayed ventricular left superior activation (DVLSA) is often difficult and uncertain, even when all the criteria proposed in clinical literature are fulfilled. The vectorcardiography (VCG) always permits an accurate diagnostic evaluation because the contour of the QRS loop describes successively the various phases of ventricular depolarization. Sensitivity and specificity of ECG in diagnosing DVLSA have been calculated referring to VCG analysis. The QRS loop initial forces orientation in the frontal plane, a VCG highly reliable criterion, was considered especially significant for this purpose. The sensitivity and specificity of ECG were, respectively, 75% and 95%. Moreover, this study has confirmed the low performance of frontal plane QRS axis criterion and the necessity of polyparametric method for a correct ECG-VCG diagnosis of DVLSA. However, the VCG is more reliable than ECG in such diagnosis because it allows thoroughly to analyze QRS-loop initial forces.