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PubMed1991

Prevalence of unsuspected mitral regurgitation and left ventricular diastolic dysfunction in patients with coronary artery disease and acute pulmonary edema associated with normal or depressed left ventricular systolic function.

To define the prevalence and role of left ventricular (LV) systolic dysfunction, LV diastolic dysfunction and mitral regurgitation (MR) in patients with acute pulmonary edema, 40 patients with coronary artery disease and acute pulmonary edema were prospectively evaluated within 36 hours of presentation. LV ejection fraction and 3 parameters of LV diastolic function were measured with radionuclide ventriculography, whereas MR was assessed with Doppler echocardiography. LV ejection fraction was normal in 11 (27%) and depressed in 29 (73%) patients. Moderate or severe MR without LV diastolic dysfunction was common and equally prevalent in patients with and without LV systolic dysfunction (33 vs 38%; difference not significant). Diastolic dysfunction without MR was less frequent but equally prevalent in patients with and without systolic dysfunction (17 vs 27%; difference not significant). Two (18%) of 11 patients without and 12 (33%) of 36 patients with LV systolic dysfunction had both MR and LV diastolic dysfunction. Furthermore, MR was clinically silent and unsuspected in two-thirds of all patients with MR, regardless of a normal or depressed systolic function. These data show that there is a high prevalence of unrecognized moderate to severe MR in patients with acute pulmonary edema, regardless of the presence or absence of LV systolic dysfunction. Furthermore, the prevalence of LV diastolic dysfunction without MR is relatively low even in patients with normal LV systolic function and pulmonary edema. Thus, unrecognized MR may be an important contributor to the syndrome of acute pulmonary edema in patients with normal or depressed LV systolic function.

Aged↗
PubMed1978

Mid-systolic click and mitral valve prolapse following mitral commissurotomy.

Five patients with rheumatic mitral stenosis were observed to have mid-systolic clicks with murmurs of mitral regurgitation at various intervals after mitral commissurotomy. In two patients echocardiography showed an unusually rapid posterior deflection of the mitral valve coinciding exactly with a systolic nonejection click. It is speculated that the shortened, fused chordae tendineae, compromised by mitral commissurotomy, rigidly hold the valve leaflets fixed at the onset of systole. During systole, ventricular conformational changes, in the face of marginal coaptation of thickened and fibrotic mitral leaflets, allow the mitral valve to be forced abruptly towards the left atrium with great velocity. This is manifested by a loud systolic click and, in some patients, a near vertical posterior systolic deflection of the mitral valve on the echocardiogram. The systolic click may occur without echocardiographic or angiographic evidence of mitral valve prolapse. Unusually loud mid-systolic clicks can be heard in patients with rheumatic heart disease after mitral commissurotomy and may be accompanied by a distinctive echocardiographic appearance of the mitral valve.

Adult↗
PubMed1984

Comparison of the effects of diuretic therapy and low sodium intake in isolated systolic hypertension.

Of 103 patients with isolated systolic hypertension, 71 were treated with diuretics and another 32 with low-sodium diet. In the 71 who were treated with diuretics, body weight decreased from 69.48 +/- 1.47 to 68.60 +/- 1.45 kg (p less than 0.0005) and systolic blood pressure from 178 +/- to 152 +/- 2 mm Hg (p less than 0.0005). Plasma renin activity increased from 1.78 +/- 0.30 to 7.32 +/- 1.78 ng/ml per hour (p less than 0.005) and urinary aldosterone from 10 +/- 1 to 23 +/- 4 micrograms per 24 hours (p less than 0.005). The greatest decrease in systolic blood pressure occurred in patients in the low-renin group (-32 +/- 2 mm Hg), whereas it decreased by 24 +/- 2 mm Hg (p less than 0.04) in the normal-renin group; however, blood pressure did not change significantly in the high-renin group. In the 32 patients who were treated with low-sodium diet, the 24-hour urinary sodium excretion decreased from 143 +/- 10 to 48 +/- 5 meq (p less than 0.005), body weight decreased from 71.18 +/- 2.50 to 70.17 +/- 2.47 kg (p less than 0.005), systolic blood pressure decreased from 174 +/- 2 to 156 +/- 3 mm Hg (p less than 0.0005), and diastolic blood pressure decreased from 90 +/- 1 to 87 +/- 1 mm Hg (p less than 0.01). Plasma renin activity increased from 2.25 +/- 0.33 to 4.27 +/- 0.43 ng/ml per hour (p less than 0.005) and urinary aldosterone from 9 +/- 1 to 15 +/- 2 micrograms per 24 hours (p less than 0.005). The decrease in the systolic blood pressure was related to the pretreatment 24-hour urinary sodium excretion (r = 0.40, p less than 0.05). The smallest decrease in systolic blood pressure occurred in the patients with high renin values (-1 +/- 9 mm Hg, n = 5), whereas the decrease in systolic blood pressure in the low-renin (n = 12) and normal-renin groups (n = 15) was similar, -22 +/- 2 mm Hg and -21 +/- 3 mm Hg, respectively (p less than 0.005 compared with the high-renin group). These results indicate that both diuretic therapy and low-sodium diet are effective antihypertensive means in most patients with isolated systolic hypertension and low or normal plasma renin activity.

Adult↗
PubMed2004

Electrocardiogram and B-type natriuretic peptide as screening tools for left ventricular systolic dysfunction in a population-based sample of 75-year-old men and women.

BACKGROUND: Plasma concentration of B-type natriuretic peptide (BNP) has been suggested as a powerful screening tool for left ventricular systolic dysfunction. However, there are reports indicating that the 12-lead electrocardiogram (ECG) could be just as powerful. We aimed to evaluate the 12-lead ECG and BNP as screening tools for left ventricular systolic dysfunction in an elderly, unselected population. METHODS: In a randomly selected population-based sample of 75-year-old men and women (n = 407), diagnostic characteristics were evaluated for the ECG and plasma concentration of BNP to detect left ventricular systolic dysfunction. RESULTS: Sensitivity, specificity, and negative and positive predictive values for the ECG to detect left ventricular systolic dysfunction were 96%, 79%, 100%, and 26%, respectively. The corresponding values for the BNP (cut-off value 28 pg/mL) were 93%, 55%, 99%, and 13%. In participants without major abnormalities in the ECG, left ventricular systolic dysfunction was found in <1% (1/302), irrespective of BNP concentrations. In participants with abnormal ECGs, systolic dysfunction was more prevalent in persons with abnormal BNP concentrations than in those with normal concentrations (35% vs 3%, difference 32%, 95%CI for the difference 16%-44%) CONCLUSIONS: In 75-year-old subjects both the ECG and the plasma concentration of BNP are highly efficient in excluding left ventricular systolic dysfunction. However, compared with the BNP, the ECG yields a lower number of false positive cases. In screening for left ventricular systolic dysfunction, the BNP has a diagnostic value in addition to the ECG, but only in individuals with abnormal ECGs.

Aged↗
PubMed2004

Is B-type natriuretic peptide a useful screening test for systolic or diastolic dysfunction in patients with coronary disease? Data from the Heart and Soul Study.

BACKGROUND: Whether B-type natriuretic peptide (BNP) levels can be used to screen for ventricular dysfunction in patients at risk of heart failure but without overt symptoms is not known. We examined the characteristics of a BNP test for identifying systolic and diastolic dysfunction in outpatients with stable coronary disease. METHODS: In a cross-sectional study of 293 outpatients who had stable coronary disease and no history of heart failure, we compared elevations in plasma BNP levels with echocardiography for the diagnosis of systolic dysfunction (ejection fraction <55%) and diastolic dysfunction (diastolic dominant pulmonary vein flow with ejection fraction > or =55%). RESULTS: A total of 48 patients (16%) had systolic dysfunction, and among the remaining 245 with preserved systolic function, 31 (13%) had diastolic dysfunction. At the standard cutpoint of >100 pg/mL, an elevated BNP level was 38% sensitive (80% specific) for systolic dysfunction and 55% sensitive (85% specific) for diastolic dysfunction. Negative likelihood ratios were 0.8 (95% confidence interval [CI]: 0.6 to 1.0) for systolic dysfunction and 0.5 (95% CI: 0.4 to 0.8) for diastolic dysfunction. Positive likelihood ratios were 1.9 (95% CI: 1.2 to 2.9) for systolic dysfunction and 3.8 (95% CI: 2.4 to 5.9) for diastolic dysfunction. Areas under the receiver operating characteristic curves were 0.59 (95% CI: 0.49 to 0.69) for systolic dysfunction and 0.79 (95% CI: 0.71 to 0.87) for diastolic dysfunction. CONCLUSION: These data suggest that BNP is not a useful screening test for asymptomatic ventricular dysfunction in patients with stable coronary disease.

Aged↗
PubMed2001

Pulse pressure and risk of cardiovascular events in the systolic hypertension in the elderly program.

Pulse pressure has been related to higher risk of cardiovascular events in older persons. Isolated systolic hypertension is common among the elderly and is accompanied by elevated pulse pressure. Treatment of isolated systolic hypertension may further increase pulse pressure if diastolic pressure is lowered to a greater extent than systolic pressure. Little is known regarding pulse pressure as a predictor of cardiovascular outcomes in elderly persons with isolated systolic hypertension, and the influence of treatment on the pulse pressure effect. We assessed the relation between pulse pressure, measured throughout the follow-up period, and the incidence of coronary heart disease (CHD), heart failure (HF), and stroke in 4,632 participants in the Systolic Hypertension in the Elderly Program, a 5-year randomized, placebo-controlled clinical trial of treatment of isolated systolic hypertension in older adults. In the treatment group, a 10-mm Hg increase in pulse pressure was associated with a statistically significant 32% increase in risk of HF and a 24% increase in risk of stroke after controlling for systolic blood pressure and other known risk factors, as well as with a 23% increase in risk of HF and a 19% increase in risk of stroke after controlling for diastolic blood pressure and other risk factors. Pulse pressure was not significantly associated with HF or stroke in the placebo group, nor with incidence of CHD in either the placebo or treatment group. These results suggest that pulse pressure is a useful marker of risk for HF and stroke among older adults being treated for isolated systolic hypertension.

Aged↗
PubMed1997

Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population.

BACKGROUND: In most previous epidemiological studies on the prevalence of chronic heart failure (CHF) the disorder has been defined on clinical criteria. In a cross-sectional survey of 2000 men and women aged 25-74, randomly sampled from one geographical area, we assessed left-ventricular systolic function by echocardiography. METHODS: 1640 (83%) of those invited took part. They completed a questionnaire on current medication, history, and symptoms of breathlessness. Blood pressure was measured and electrocardiography (ECG) and echocardiography were done. Left-ventricular ejection fraction was measurable in 1467 (89.5%) participants by the biplane Simpson's rate method. FINDINGS: The mean left-ventricular ejection fraction was 47.3%. The prevalence of definite left-ventricular systolic dysfunction (defined as a left-ventricular ejection fraction < or = 30%) was 2.9% overall (43 participants); it increased with age and was higher in men than in women (4.0 vs 2.0%). The left-ventricular systolic dysfunction was symptomatic in 1.5% of participants and asymptomatic in 1.4%, 83% of participants with left-ventricular systolic dysfunction had evidence of ischaemic heart disease (IHD) from history or ECG criteria compared with 21% of those without this abnormality (p < 0.001). Hypertension was also more common in those with left-ventricular systolic dysfunction (72 vs 38%, p < 0.001), but there was no difference between those with and without left-ventricular systolic dysfunction in the rate of hypertension without IHD. INTERPRETATION: Left-ventricular systolic dysfunction was at least twice as common as symptomatic heart failure defined by clinical criteria. The main risk factors are IHD and hypertension in the presence of IHD; screening of such high-risk groups for left-ventricular systolic dysfunction should be considered.

Adult↗
PubMed1998

Assessment of left ventricular systolic wall motion velocity with pulsed tissue Doppler imaging: comparison with peak dP/dt of the left ventricular pressure curve.

To assess the usefulness of the tissue Doppler imaging variables for the evaluation of left ventricular (LV) systolic function, we compared variables obtained by the pulsed Doppler method with the LV ejection fraction (%EF) and the maximum value for the first derivative of LV pressure (peak dP/dt). We examined 65 patients, including 15 patients with noncardiac chest pain, 15 with ischemic heart disease, 15 with dilated cardiomyopathy, 10 with hypertensive heart disease, and 10 with asymmetric septal hypertrophic cardiomyopathy. The subendocardial systolic wall motion velocity patterns were recorded for LV posterior wall and ventricular septum in the parasternal LV long-axis view. The peak dP/dt was significantly lower in the hypertensive heart disease, hypertrophic cardiomyopathy, and dilated cardiomyopathy groups. The peak systolic velocity was lower and the time from the electrocardiographic Q wave to the peak of the systolic wave for the posterior wall was longer in the hypertensive heart disease (5.9 +/- 0.5 cm/sec and 215 +/- 21 msec, respectively), hypertrophic cardiomyopathy (6.2 +/- 0.9 cm/sec and 217 +/- 17 msec, respectively), and dilated cardiomyopathy (5.2 +/- 0.8 cm/sec and 235 +/- 26 msec, respectively) groups than in the noncardiac chest pain (7.7 +/- 0.9 cm/sec and 187 +/- 24 msec, respectively) and the ischemic heart disease (7.6 +/- 0.8 cm/sec and 184 +/- 22 msec, respectively) groups. In all groups, the peak systolic velocity and the time from the electrocardiographic Q wave to the peak of the systolic wave for the posterior wall correlated directly and inversely, respectively, with the %EF (r = 0.59, p < 0.0001; r = -0.59, p < 0.0001) and the peak dP/dt (r = 0.75, p < 0.0001; r = -0.68, p < 0.0001). Both tissue Doppler variables for the ventricular septum did not correlate with the %EF but roughly correlated with peak dP/dt. We conclude that the systolic LV wall motion velocity parameters obtained by pulsed tissue Doppler imaging may be useful for noninvasive evaluation of global LV systolic function in patients with no regional asynergy.

Cardiac Catheterization↗
PubMed1999

Overview of the outcome trials in older patients with isolated systolic hypertension.

AIMS: Isolated systolic hypertension affects over 8 to 15% of all subjects older than 60 years. In the elderly, systolic hypertension is the major modifiable cardiovascular risk factor. Three placebo-controlled outcome trials on antihypertensive drug treatment of this disorder have been published. The aim of this article was to shortly review each of these three trials and to present the pooled estimates of benefit of antihypertensive drug treatment in isolated systolic hypertension in the elderly. METHODS AND RESULTS: The Systolic Hypertension in the Elderly Program (SHEP) in the United States, the Systolic Hypertension in Europe (Syst-Eur) trial and the Systolic Hypertension in China (Syst-China) trial published their main findings in 1991, 1997 and 1998, respectively. The outcome results of these trials were pooled by calculating the common odds ratio for active versus placebo treatment for five major end-points. Zelen's exact test for homogeneity did not reach statistical significance for any of the end-points considered. Thus, the hypothesis of a common underlying treatment effect across the three trials was not rejected. Overall, active treatment compared with placebo, reduced all-cause mortality by 17%, cardiovascular mortality by 25%, all cardiovascular end-points by 32%, total stroke by 37% and myocardial infarction including sudden death by 25%. CONCLUSIONS: The pooled results of the outcome trials in older patients with isolated systolic hypertension prove that antihypertensive drug treatment must be prescribed, if on repeated measurement systolic blood pressure is 160 mm Hg or higher.

Aged↗
PubMed2002

Noncompressibility of myocardium during systole with freehand three-dimensional echocardiography.

BACKGROUND: Measures of ventricular performance, such as the ejection fraction, assume that myocardium is noncompressible and does not change volume significantly from end diastole to end systole. Although this principle is widely accepted as true, little data exist in the literature to support it. Freehand 3-dimensional (3D) echocardiography has previously been shown to be highly accurate for measurement of myocardial mass and volume. Therefore, we hypothesized that it has sufficient accuracy to test the validity of this assumption. We measured myocardial volume at end diastole and end systole in 2 groups of subjects with hypertrophy. METHODS: Forty-one healthy young adult athletes and 17 adult patients with hypertension, hypertrophy, normal ejection fraction, and heart failure symptoms underwent examination with freehand 3D echocardiography. Endocardial and epicardial surfaces at end diastole and end systole were reconstructed, and their volumes were computed. From these surface volumes, myocardial volume at end diastole and end systole and epicardial stroke volume and endocardial stroke volume were calculated. These volumes were compared with the 2 sample paired t test. RESULTS: Myocardial volume was constant from diastole to systole (174.7 +/- 45.3 mL versus 174.6 +/- 45.8 mL; P = not significant), and endocardial and epicardial stroke volumes were identical (76.0 +/- 17.4 mL versus 76.0 +/- 17.1 mL; P = not significant). The average absolute difference between the end-diastolic and end-systolic myocardial volumes was 1.9 mL, or less than 1.1% of end-diastolic volume. CONCLUSION: Myocardial volume measured with freehand 3D echocardiography does not change significantly during systole. Myocardial volume may be considered noncompressible for purposes of measurement of ventricular function with freehand 3D echocardiography. Comparison of end-diastolic and end-systolic myocardial volumes may be used for quality assurance in performing 3D reconstructions.

Adult↗
PubMed2001

Significant changes in systolic blood pressure post vectored upper cervical adjustment vs resting control groups: a possible effect of the cervicosympathetic and/or pressor reflex.

OBJECTIVE: To determine whether a vectored adjustment of the atlas in patients identified as demonstrating signs of upper cervical joint dysfunction would cause lowering of blood pressure in comparison with resting controls. DESIGN: Test 1: controlled clinical trial with a treatment (adjustment) group and a control (resting) group. Test 2: controlled clinical trial with subjects serving as their own controls. SETTING: Private chiropractic practice. PARTICIPANTS: Test 1: Forty established patients demonstrating signs of upper cervical subluxation/joint dysfunction and 40 established patients without such signs. Test 2: Thirty established patients demonstrating signs of upper cervical subluxation/joint dysfunction. INTERVENTION: Specific, vectored upper cervical (atlas) adjustment or similarly positioned resting. MAIN OUTCOME MEASURES: Prerest, postrest, and postadjustment systolic, diastolic, and pulse rates as recorded through use of a digital oscillometric sphygmomanometer. RESULTS: In test 1, subjects receiving adjustment had a significant (P <.001) decrease in systolic blood pressure whereas resting subjects did not. Intergroup comparison of the treatment (adjustment) and control (resting) groups demonstrated a significant difference (P <.001). A greater pre/post drop in systolic pressure was associated with greater age and higher initial systolic pressure. In test 2, the pre/postrest change in systolic blood pressure was not significant. The systolic blood pressure changed significantly (P <.001) from postrest readings to postadjustment readings. CONCLUSION: The results indicate that palpation and vectored atlas adjustment causes a significant decrease in systolic blood pressure in patients with putative upper cervical subluxation/joint dysfunction in comparison with resting controls. Similar results were also demonstrated when subjects acted as their own controls. The lack of randomization, blinding, and a manipulated control group are factors that weaken these findings. The sudden drop in systolic pressure is proposed to be due to stimulation of the cervicosympathetic reflex or moderation of muscle tone and elimination of the effects of the pressor reflex.

Adult↗
PubMed1998

Effects of isolated systolic hypertension and essential hypertension on large and middle-sized artery compliance.

BACKGROUND: Systolic hypertension of the elderly is characterized by a reduction in arterial compliance. Whether and to what extent this involves arteries of various structure and size is not well known. OBJECTIVE: To study carotid and radial artery compliance in systolic hypertension of the elderly, compared to essential hypertension and normotension. METHODS: We investigated 28 elderly patients with systolic hypertension (age 68.6 +/- 1.4 years, mean +/- SE; systolic blood pressure > 160 mmHg and diastolic blood pressure < 90 mmHg) plus 17 age-matched patients with essential hypertension and 15 age-matched healthy normotensive subjects. Radial and carotid artery compliance were evaluated using echotracking techniques. In both arteries compliance was assessed statistically and dynamically, i.e. as compliance values throughout the diasto-systolic pressure range. Measurements included intima-media wall thickness of the radial artery. RESULTS: Compared to normotensive subjects, carotid artery compliance was reduced in essential hypertension and more so in systolic hypertension. However, although in both groups radial artery wall thickness was markedly greater than in the normotensive group, radial artery compliance was markedly reduced in systolic hypertension, but unchanged in essential hypertension. CONCLUSIONS: In systolic hypertension of the elderly the reduction of arterial compliance is marked in both muscular and large elastic arteries, while in elderly essential hypertensives changes in arterial compliance are more heterogeneous, i.e. only carotid artery compliance is reduced. The different effects of these two types of hypertension on arterial mechanics are visible throughout the physiological range of blood pressure and probably accounted for by different alterations in vessel wall structure.

Aged↗
PubMed1989

Isolated systolic hypertension in Dutch middle aged and all-cause mortality: a 25-year prospective study.

In the early 1950s, the blood pressure of 3901 Dutch civil servants and their spouses aged 40-65 years was measured in a general health survey. Isolated systolic hypertension (systolic pressure greater than 160 mmHg, diastolic pressure less than 90 mmHg) was observed in 6.3% of the women and 3.0% of the men. The prevalence increased with age and it was more common in women in all age groups. Using logistic regression, with adjustment for potential confounders (age, smoking, serum cholesterol, Quetelet index, alcohol consumption, haemoglobin level, pulse rate and diastolic blood pressure) the association of 15- and 25-year total mortality with isolated systolic hypertension was determined. Compared to normotensive people (systolic pressure less than or equal to 135 mmHg, diastolic pressure less than 90 mmHg), the risk of death from all causes was significantly higher for men with isolated systolic hypertension after 15 and 25 years of follow-up (odds ratio OR = 2.4, 95% confidence interval (CI) 1.2-4.8 and OR = 3.2, 95% CI 1.3-8.0). For women 15-years mortality risk was strongly associated with isolated systolic hypertension (OR = 3.7, 95% CI 1.4-9.7). The increased risk was less pronounced after 25 years of follow-up (OR = 1.7, 95% CI 0.96-3.0). Our results support those of other studies and indicate that isolated systolic hypertension is an important independent risk factor for all-cause mortality. Since isolated systolic hypertension may be an indicator for the early onset of ageing, it is important to study its determinants and to pay more attention to its diagnosis and treatment in middle-aged populations.

Adult↗
PubMed2002

The impact of hypercapnia on systolic cerebrospinal fluid peak velocity in the aqueduct of sylvius.

UNLABELLED: Phase-contrast magnetic resonance imaging measurements of systolic cerebrospinal fluid peak velocity (CSFVPeak) in the aqueduct of Sylvius have been shown to be sensitive enough to detect even minor changes in cerebral compliance. Clinically relevant changes in cerebral compliance can be caused by changes in cerebral blood volume (CBV). Changes in arterial carbon dioxide partial pressure, which correlate well with end-tidal carbon dioxide concentration (ETCO(2)), cause changes in CBV. In this study, we investigated the effect of hypercapnia-induced changes in CBV on systolic CSFVPeak in anesthetized patients (n = 8). Hypercapnia (ETCO(2) = 60 mm Hg) increased systolic CSFVPeak in the aqueduct of Sylvius as compared with normocapnia (ETCO(2) = 40 mm Hg) (hypercapnia: -5.67 +/- 0.74 cm/s versus normocapnia: -3.54 +/- 0.98 cm/s). In addition to the already known decrease in systolic CSFVPeak, changes in cerebral compliance can also prompt an increase in systolic CSFVPeak. IMPLICATIONS: Magnetic resonance imaging measurements of systolic cerebrospinal fluid peak velocity (CSFVPeak) in the aqueduct of Sylvius are sensitive enough to detect even minor changes in cerebral compliance. We investigated the effect of hypercapnia-induced changes in cerebral blood volume on systolic CSFVPeak in anesthetized patients. Hypercapnia (end-tidal carbon dioxide concentration = 60 mm Hg) increased systolic CSFVPeak.

Adult↗
PubMed1998

The end-systolic pressure-volume relationship and ventriculoarterial coupling in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: The end-systolic pressure-volume relationship and analysis of ventriculoarterial coupling have been established as a useful tool to determine the left ventricular performance and arterial loading conditions. The purpose of this study was to evaluate the end-systolic pressure-volume relationship and ventriculoarterial coupling in anesthetized patients with either a normal heart or coronary artery disease (CAD) using a transesophageal echocardiography (TEE) monitor. METHODS: Sixteen patients with CAD and 4 patients without ischemic disease were studied. The end-systolic volume of the left ventricle was obtained by TEE, and the end-systolic pressure was obtained from the brachial arterial dicrotic pressure. In order to obtain the end-systolic pressure-volume relationship, we plotted 7 different left ventricular end-systolic pressures against the corresponding left ventricular end-systolic volumes during the pressure manipulation. The linear regression obtained by this method was designated as the end-systolic elastance (Ees). Furthermore, we calculated the effective arterial elastance (Ea) using the pressure-volume framework. RESULTS: We divided the patients with CAD into 3 groups: Group A: left ventricular ejection fraction (LVEF) > 50%, Group B: LVEF 35-50%, Group C: LVEF < 35%. We also studied a control group (Group D) who did not suffer from an ischemic heart condition. Ees in group C (1.4 +/- 0.2) was lower than in the other 3 groups (P < 0.05). Ea/Ees in group C (1.9 +/- 0.1) was greater than in group A (0.7 +/- 0.1), group B (1.0 +/- 0.06) and group D (0.6 +/- 0.1)(P < 0.05). There were no significant differences in Ees and Ea/Ees between group A and group D. CONCLUSIONS: We found that patients with CAD and a normal LVEF had a physiological Ea/Ees identical to the control subjects. We also demonstrated that patients with CAD and a reduced LVEF showed a deterioration in Ea/Ees.

Aged↗
PubMed2003

Exercise systolic blood pressures are of questionable value in the assessment of the adult with a previous coarctation repair.

BACKGROUND: The role of exercise testing in the follow up of adults with a coarctation repair is unclear. Exercise induced systolic hypertension has been advocated as an indication for further investigation; however, the value of exercise testing in this role has been questioned, especially in paediatric populations. OBJECTIVE: To assess the value of resting and exercise blood pressure measurements in a cohort of adults with repaired coarctation. SETTING: Tertiary referral centre for adult congenital cardiac disease. PATIENTS: 56 patients (33 male, 23 female) with a previous coarctation repair, and 33 age matched controls. MAIN OUTCOME MEASURES: Resting and exercise blood pressures, including arm-leg systolic blood pressure gradients; standard echocardiographic measurements of left ventricular mass, aortic root diameter, and repair site gradient. RESULTS: The coarctation cohort had higher resting upper limb blood pressures than the controls (systolic: 129.7 v 120.7 mm Hg, p = 0.014; diastolic: 76.8 v 72.2 mm Hg, p = 0.02). Mean resting arm-leg systolic blood pressure gradient was also higher, at 3.6 v -2.2 mm Hg, p = 0.027. However, there were no differences between the peak exercise systolic blood pressures of the two groups. Peak exercise systolic blood pressure did not correlate with resting arm-leg blood pressure gradient (r = 0.24, p = 0.13) or with repair site gradient (r = 0.14, p = 0.39). Resting upper limb systolic blood pressure and resting arm-leg systolic blood pressure gradient were related to repair site gradient (r = 0.33, p = 0.03, and r = 0.47, p = 0.002). CONCLUSIONS: Measurements of upper limb blood pressure during exercise are of limited value in the assessment of the post-repair coarctation patient. If routine exercise testing is to be advocated in this population it must be for another indication.

Adult↗
PubMed1975

Value of systolic time intervals in assessing severity of congenital aortic stenosis in children.

Simultaneous recordings have been made of electrocardiogram, phonocardiogram, carotid pulse tracing, left ventricular pressure, and aortic pressure in 27 children with aortic valve stenosis and 3 children with membranous subaortic stenosis. Peak systolic pressure difference ranged from 10 to 110 mmHg (1.3 to 14.6 kPa). None of the patients had congestive heart failure and cardiac output was in the normal range in all. Total electromechanical systole, left ventricular ejection time, and pre-ejection time were corrected for heart rate, age, and sex. Mild stenosis (peak systolic pressure difference less than or equal to 50 mmHg (6.7 kPa)) was present in 18, severe stenosis (peak systolic pressure difference greater than 50 mmHg) in 12 patients. The externally measured pre-ejection time and ejection time proved to be nearly equal to the corresponding intervals measured internally; from these data it is concluded that pre-ejection time and ejection time in children with aortic stenosis can be measured reliably by non-invasive methods. Mean values for corrected total electromechanical systole and ejection time were prolonged, but the corrected pre-ejection time did not differ from the normal value. When corrected time intervals were plotted against severity of the aortic stenosis as expressed by the peak systolic pressure difference or the aortic valve orifice index, a wide scatter was found. It is concluded that a normal ejection time is strong evidence against a peak systolic pressure difference of more than 50 mmHg (6.7 kPa) or an aortic valve orifice index less than 0.70 cm2 per m2 BSA. A prolonged ejection time, however, may occur in mild as well as in severe stenosis. Total electromechanical systole and pre-ejection time have no value in predicting the severity of aortic stenosis in children.

Adolescent↗
PubMed1977

Contractile state of the left ventricle in man as evaluated from end-systolic pressure-volume relations.

End-systolic pressure (PES), volume (VES), wall tension (TES) and circumference (CES) of the human left ventricle were studied at cardiac catheterization in 24 subjects with varying degrees of left ventricular dysfunction. Acute alterations in systolic load consistently resulted in changes in VES and CES, with a smaller volume and circumference characterizing the lower systolic load in each subject. End systolic pressure-volume lines were constructed by plotting PES against VES at the higher and lower systolic load in each subject. The slope of the resultant lines was considerably steeper for normal than for poorly contractile left ventricles. Vo, the volume axis intercept of the line (i.e., the theoretical VES at PES = O) was significantly smaller for normal than for poorly contractile ventricles. Similar findings were noted for Co, the theoretic end-systolic circumference at zero end-systolic ventricular wall tension. Post-extrasystolic potentiation resulted in decreased VES and CES with no change in PES and only a slight fall in TES. In conclusion, end-systolic pressure-volume and tension-circumference relations reflect the contractile state of left ventricular myocardium. Quantitation of these relationships may provide a useful new approach to the assessment of myocardial function in man.

Blood Pressure↗