Clinical application of exercise stress echocardiography: Supine bicycle or treadmill?

Although exercise stress echocardiography is currently used to evaluate coronary artery disease (CAD) patients, the best exercise methodology is still undefined. The objectives of the study were: (1) to compare supine bicycle stress echocardiography (SBSE) and treadmill in the evaluation of CAD; and (2) to define, in normal subjects, the different behavior of factors determining MVO2 wish treadmill and SBSE. We selected 10 male patients with CAD (group A), and 10 male control subjects (group B). Each patient underwent SBSE and tread-mill testing in random order. We studied heart sate, systolic blood pressure, heart rate x systolic blood pressure, and end-diastolic and end-systolic volume indexes. in group A, we also studied wall motion score index (according to the American Society of Echocardiography) and in group B, systolic blood pressure/end-systolic volume index. The results were as follows: Group A: SBSE resulted in significantly lower work load, heart rate, and significantly higher systolic blood pressure, heart hate x systolic blood pressure, end-diastolic volume index, end-systolic volume index, and wall motion score index. SBSE showed wall motion abnormalities in each patient, whereas treadmill did not detect wail motion abnormalities in 4 patients (3 single-vessel; 1 multivessel); of the other 6 patients, 2 showed a lower wall motion score index and 4 did not show any difference in left ventricle kinetics with the 2 methodologies of exercise. Mean acquisition time for postexercise images was 72 +/- 6 seconds. Group B: SBSE resulted in lower work load, heart rate, heart rate x systolic blood pressure, systolic blood pressure/end-systolic volume index, and higher end-diastolic volume index and end-systolic volume index. Systolic blood pressure was similar with SBSE and treadmill testing. In conclusion, our experience suggests SBSE is a highly accurate diagnostic fool for evaluating CAD compared with treadmill testing; the maximum cardiovascular performance can be achieved With lower values of heart rate, suggesting the echo test is more feasible. Treadmill testing could lose important information about the existence, extension, and location of CAD; ire contrast, SBSE detects even small, quickly reversible wall motion abnormalities. (C) 1998 by Excerpta Medica, Inc

Assessment of regional left ventricular function during exercise test with pulsed tissue Doppler imaging

To investigate whether mitral annular velocity, measured by tissue Doppler imaging (TDI), is able to get a feasible quantitative evaluation of global and regional left-ventricular function during exercise test, 29 patients with previous uncomplicated myocardial infarction were studied by exercise echocardiography. All patients underwent coronary arteriography within 10 days of stress echocardiography. All of them were in sinus rhythm and had no right or left bundle branch block or significant mitral regurgitation as observed by left ventriculography. A total of 12 patients had anteroseptal and/or posteroseptal wall asynergies and left anterior descending involvement; 9 patients had lateral and/or posteroinferior asynergies and left circumflex coronary artery involvement; 8 patients had inferior and posteroseptal wall asynergies and right coronary artery involvement. Twelve subjects of same age and sex with normal cardiovascular findings were selected as a control group. TDI sample volumes were set on the mitral annuli corresponding to anteroseptal, posterior, posteroseptal, lateral, anterior, and inferior wall in 4-chamber, 2-chamber, and long-axis views. There was a significant correlation between the left-ventricular ejection fraction (0.41 +/- 0.8) and the means of the systolic (S) values (6.1 +/- 0.9 cm/sec, r = 0.83, p < 0.01). The mean S at the sites corresponding to the infarct regions (5.5 +/- 0.4 cm/sec) was significantly lower than the control group (11 +/- 0.8 cm/sec, p < 0.001). After stress, in patients with multivessel disease, S values corresponding to remote regions were significantly lower (p < 0.01) compared with control subjects. Thus, the parameters obtained from mitral annular velocities with pulsed TDI in patients with previous myocardial infarction reflect left ventricular asynergy corresponding to the infarct regions and reversible regional dysfunction after exercise

Heart Failure and Iron Deficiency

Heart failure (HF) is a major public health problem because it is one of the most common causes of morbidity and mortality in Western countries, with a prevalence of 1–2% in the adult population, rising to ≥10% in those age >70 years. In addition to the “classic” co-morbidities, such as COPD, arterial hypertension, diabetes, renal failure, etc., there are other conditions frequently found in patients with heart failure that many times are underestimated. One example are anemia and iron deficiency (ID). ID, regardless of anemia impair exercise tolerance, symptoms and quality of life, with a strong negative prognostic impact on hospitalization and mortality rate. Despite strong evidence of high prevalence of ID in these patients and current guidelines recommendations, the diagnosis of ID and its monitoring over time still have low priority for physicians in clinical practice. Consequently ID is under-treated; furthermore current therapies, in particular i.v. iron as ferric carboxymaltose, though effective, turn out to be poorly managed by clinicians. ID should be considered more in real world HF healthcare settings to improve patients’ quality of life and outcome

Dynamic Testing in Support of the Seismic Assessment of a Century Old Masonry Building Complex

The vulnerability assessment of existing masonry buildings is a largely investigated research topic with some aspects still to be faced. In historic towns, masonry buildings are aggregated and together confined, and their final appearance is derived from interventions and additions during their lives in different times and with different masonry textures or different construction materials. Demolitions and reconstructions of some parts were frequent, with the difficulty of now understanding the effectiveness of the mutual constraints. The seismic assessment of a case study of a 175-year-old building complex in Udine (Italy) provides an opportunity to use the results of ambient vibration tests to face the problem of modelling aggregate buildings for their seismic assessment. The “Padiglione Lodi” building complex was built in 1847 and extended and renovated several times afterwards. It was built mostly using URM with limited use of reinforced concrete. It consists of a main building and three wings (western, central and eastern). The inspections, experimental survey and analysis of the available documentation are used to suitably calibrate a Finite Element Model of the whole complex. Moreover, this allows the singling out of the central wing, as the unit needs more careful investigation. Non-destructive dynamic testing is then applied to the central wing in order to further validate the model and improve the knowledge of the interaction of the unit with the rest of the building. General remarks on the effective application of non-destructive dynamic analysis in conjunction with other methods to the seismic assessment of large URM building complexes are drawn

Value of transesophageal dobutamine stress echocardiography in assessing coronary artery disease

The introduction of digital echocardiography has significantly enhanced our ability to select the best set of frames for analysis. However, despite the beneficial attributes of transthoracic dobutamine stress echocardiography, poor quality 2-dimensional images continue to be a significant limiting factor in patients with chest deformities, severe chronic obstructive lung disease, marked obesity, and previous chest surgery. Transesophageal echocardiography provides a new window to monitor left ventricular contractility without the interference of bone and air-filled structures of the thoracic cage. The transesophageal dobutamine stress test is a logical but poorly explored modality to image/stress the heart in certain patients with known or suspected myocardial ischemia. Overall sensitivity (< or = 85%) and specificity (< or = 95-100%) of transesophageal dobutamine stress echocardiography appear to be similar to that of previous transthoracic studies, although no direct comparison has been accomplished between transthoracic and transesophageal stress images. False negative transesophageal dobutamine stress echocardiography results have been described in patients with single-vessel disease in whom ischemic regions may not have been visualized throughout the entire study. False positive study results may be present in patients with hypertension and myocardial hypertrophy that may have signs and symptoms of myocardial ischemia in absence of obstructive disease of the epicardial coronary arteries, presumably related to either microvascular disease or impaired vasodilatory reserve. The proportion of patients with coronary artery disease who need a transesophageal examination for reliable assessment of echocardiographic response to stress varies depending on the operators' skills, the interpreters' experience, and the use of videotape or digitizing systems for image analysis. Although clinically useful in its present transthoracic and transesophageal form, a major limitation of dobutamine stress echocardiographic study is the subjective visual interpretation of endocardial motion and wall thickening, which is only semiquantitative. Color kinesis and tissue Doppler imaging (TDI) are 2 novel echocardiographic techniques that color code endocardial motion and myocardial velocity online and have the potential to objectively quantify regional left ventricular function. Quantitative standardization of transthoracic and transesophageal data interpretation, such as establishing endocardial motion by color kinesis or velocity thresholds by TDI for an abnormal segmental response to stress, has the potential to decrease interobserver variability and increase interinstitutional agreement

Interactive simulator for e-Learning environments: a teaching software for health care professionals

There is an established tradition of cardiovascular simulation tools, but the application of this kind of technology in the e-Learning arena is a novel approach. This paper presents an e-Learning environment aimed at teaching the interaction of cardiovascular and lung systems to health-care professionals. Heart-lung interaction must be analyzed while assisting patients with severe respiratory problems or with heart failure in intensive care unit. Such patients can be assisted by mechanical ventilatory assistance or by thoracic artificial lung. "In silico" cardiovascular simulator was experimented during a training course given to graduate students of the School of Specialization in Cardiology at \u27Sapienza\u27 University in Rome. The training course employed CARDIOSIM(C): a numerical simulator of the cardiovascular system. Such simulator is able to reproduce pathophysiological conditions of patients affected by cardiovascular and/or lung disease. In order to study the interactions among the cardiovascular system, the natural lung and the thoracic artificial lung (TAL), the numerical model of this device has been implemented. After having reproduced a patient\u27s pathological condition, TAL model was applied in parallel and hybrid model during the training course. Results obtained during the training course show that TAL parallel assistance reduces right ventricular end systolic (diastolic) volume, but increases left ventricular end systolic (diastolic) volume. The percentage changes induced by hybrid TAL assistance on haemodynamic variables are lower than those produced by parallel assistance. Only in the case of the mean pulmonary arterial pressure, there is a percentage reduction which, in case of hybrid assistance, is greater (about 40%) than in case of parallel assistance (20-30%). At the end of the course, a short questionnaire was submitted to students in order to assess the quality of the course. The feedback obtained was positive, showing good results with respect to the degree of students\u27 learning and the ease of use of the software simulator

Usefulness of echocardiography in the prognostic evaluation of non-Q-wave myocardial infarction.

Patients with non-Q-wave myocardial infarction (MI) are a heterogeneous population with a wide range of coronary disease severity and extent of myocardial necrosis, showing, therefore, different electrocardiographic findings and different outcomes. To evaluate the role of echocardiography in the management of non-Q-wave MI patients, 192 consecutive patients without previous MI were studied (78 with ST segment elevation, 56 with ST depression and 58 without ST modifications). All patients underwent 2-dimensional echocardiography (16-segment model) within 24 hours of admission to the coronary care unit. Wall-motion abnormalities, wall-motion score index, ejection fraction, and end-diastolic and end-systolic volumes were evaluated. In 35 patients, death, reinfarction, recurrent angina, or severe heart failure occurred during the in-hospital phase, whereas the remaining 157 patients had a good outcome. Patients with a poor prognosis were older (68 +/- 6 vs 59 +/- 5 years, p 3 segments 0.28 and 0.86; wall-motion score index > 1.33 = 0.28 and 0.87; end-diastolic volume > 46 mL/m2 = 0.49 and 0.91; ST segment depression and wall-motion abnormalities in > 3 segments 0.60 and 0.88. These results underline the usefulness of echocardiography in the early risk stratification of non-Q-wave MI patients, together with electrocardiographic data. Patients with ST segment depression and more extensive wall-motion abnormalities are at higher risk and their management needs a more aggressive approach

PVF velocity pattern in patients with heart failure: Transesophageal echocardiographic assessment

In order to assess the role of the pulmonary venous flow (PVF) velocity pattern in the evaluation of patients with congestive heart failure (CHF), we studied 41 CHF patients by means of transthoracic echocardiography (TTE) and multiplane transesophageal echocardiography (TEE). The etiology of CHF was idiopathic or ischemic dilated cardiomyopathy in 19 patients and hypertensive heart disease in 22. Sixteen subjects without cardiovascular disease were selected as normal controls. PVF peak systolic and peak early diastolic (D) velocities were recorded by TEE and TTE and the systolic fraction (SF) was measured (i.e., the systolic velocity-rime integral - VTI - expressed as a fraction of the sum of systolic and early diastolic VTI). TEE tracings were obtained in all patients and had more laminar-appearing spectral signals, thus were used for analysis. By TTE the mitral flow velocity patterns were also evaluated: peak early diastolic velocity (E), peak velocity at atrial contraction, E velocity normalized for VTI (E/VTI), deceleration time (DT), and left ventricular isovolumic relaxation time (LVIRT). The left ventricular ejection fraction (LVEF) was calculated by two-dimensional echocardiographic images using the modified Simpson method. The SF was lower in CHF patients as compared with normal controls (p 50 cm/s; type B: SF similar to 50%, D > 50 cm/s) were recognized in patients with a low LVEF (type A) and a nearly normal or normal LVEF (type B). Patients with LVEF 40% (33.26 +/- 10.84 vs. 51.00 +/- 4.00%, p 40%. Thus in CHF patients TEE PVF velocity patterns help in distinguishing patients with systolic dysfunction (low LVEF and SF) from patients with predominant diastolic impairment (normal or nearly normal LVEF, high D velocities)

A Survey of Telecardiology Projects in Italy.

It is estimated that in Italy there are about three million people affected by chronic heart failure. Cardiology is the health care field currently getting the largest benefits from telemedicine. Transmission, using wireless devices, makes possible to achieve virtual hospitalization: it is possible to anticipate the time of discharging and the patient can be remotely controlled by the central station in the ICU of the department of Medicine. Teleconsulting (i.e. a distance consulting between physicians) is applied in telecardiology, it allows the realization of a consulting between cardiology departments and remote services in the same hospital or among far-away hospitals. In this paper some of the most significant cardiac telemonitoring projects in Italy are described. Also reported, the projects involving the applications of implantable cardiac devices which can be controlled remotely. In conclusion, we sketch out the future prospects of telecardiology research and its applications in Italy