PubMed · 10636289
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G Barletta. 2000. Does flow reserve match contractility?. https://doi.org/10.1016/s0735-1097(99)00519-7
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AIMS: We hypothesized that real-time color encoding of contrast-enhanced images would allow objective detection of stress-induced wall motion abnormalities (WMA). METHODS: We studied 117 patients with poorly visualized endocardium undergoing dobutamine stress tests. Color-encoded images (Philips, color kinesis) were obtained at rest and peak stress in four standard views during i.v. infusion of Definity. Images were reviewed without color overlays by two expert readers, who graded regional wall motion as normal or abnormal. In 101/117 patients (86%), in whom contrast enhancement allowed endocardial tracking, regional fractional area changes were calculated from the color overlays, and thresholds for calling a stress-induced WMA were optimized in a randomly selected subgroup of 34 patients (ROC analysis) to achieve maximum agreement with expert grades. This computerized detection of stress-induced WMA was then tested prospectively in the remaining 67 patients, using the expert grades as a "gold standard". RESULTS: 20/67 patients had resting WMA and 13/67 patients developed WMA at peak stress. The automated technique detected stress-induced WMA in at least one vascular territory with a sensitivity, specificity and accuracy of 0.80, 0.65 and 0.69, while the level of agreement between the two experts was 0.62, 0.91 and 0.85, respectively. CONCLUSION: Analysis of color-encoded, contrast-enhanced images allows objective, accurate, automated detection of stress-induced WMA in patients with poor acoustic windows.
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BACKGROUND: Cardiogenic shock is a condition associated with high mortality. The evidence base for choice of treatment is insufficient, but new therapeutic options and new understanding have lead to some improvement in the prognosis. A new class of heart failure medication is now approved in Norway (calcium sensitizers). METHODS: We present a case history that illustrates new options in the treatment of cardiogenic shock complicating acute myocardial infarction. We have searched available literature and give a review of the treatment of cardiogenic shock with special emphasis on the role of inotropic drug therapy. RESULTS AND INTERPRETATION: A 46-year-old man with cardiogenic shock complicating myocardial infarction because of occlusion of the left-main coronary artery was treated with acute revascularization, intra-aortic balloon counterpulsation (IABP) and levosimendan. Early revascularization is a key factor in the treatment of cardiogenic shock; rapid transfer of patients to a revascularization centre is recommended. IABP should be considered after successful revascularization because of post-ischaemic dysfunction that persists despite restoration of epicardial blood flow. Beta-adrenergic stimulation of the heart should, if possible, be avoided, because of increased myocardial oxygen requirement, calcium overload of the cardiomyocytes, and increased mortality. Drug therapy using calcium sensitizers is promising, but more controlled clinical trials are needed.