Ultrasound imaging versus morphopathology in cardiovascular diseases. Myocardial cell damage

This review article summarizes the results of histopathological and clinical imaging studies to assess myocardial necrosis in humans. Different histopathological features of myocardial cell necrosis are reviewed. In addition, the present role of echocardiographic techniques in assessing irreversible myocardial damage is briefly summarized

Stress echocardiography for the risk stratification of patients following coronary bypass surgery

Objectives: The aim of the study was to assess the prognostic value of stress echocardiography after surgical revascularization. Methods: We evaluated 500 (100 women) patients who had undergone exercise or pharmacological SE after a median of 69 months after coronary artery by-pass grafting (CABG). Of these, 351 (70%) complained of symptoms suggestive of ischemic origin while 149 (30%) were tested for asymptomatic progression of the disease. Results: SE was positive for ischemia in 196 (39%) patients. During a median follow-up of 25 months, 61 patients died, 33 had a nonfatal myocardial infarction, and 112 underwent late (N3 months) revascularization. Multivariable Cox\u27 regression analysis indicated age (HR=1.04; 95% CI 1.01-1.06; pb0.003), and peak WMSI (HR=3.07; 95% CI 1.96-4.81; p=0.0001) as independent predictors of hard (total mortality and myocardial infarction) events. SE information provided a significant improvement in predictive power of the statistical model (chi-square increase 34%, pb0.0001 for hard and 91%, pb0.0001 for major events, respectively). Survival analysis showed ischemia at SE to be associated with significantly higher hard and major event rate in both symptomatic and asymptomatic patients. Discussion: SE represents an effective tool for the risk stratification of patients with previous CABG independently of the presence of symptoms suggestive of ischemic origin

Additive Prognostic Value of Coronary Flow Reserve in Patients With Chest Pain Syndrome and Normal or Near-Normal Coronary Arteries

In patients with angiographically normal coronary arteries and chest pain, pharmacologic stress echocardiography can identify a subgroup of patients with a less benign prognosis. Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can currently be combined with wall motion analysis during vasodilator stress echocardiography. The aim of this study was to assess the prognostic value of CFR response in patients with normal coronary arteries and normal wall motion during stress. We selected 394 patients (171 men, 61 11 years of age) who underwent dipyridamole stress echocardiography (0.84 mg/kg over 6 minutes) with 2-dimensional echocardiography and CFR evaluation of the LAD by Doppler. All had angiographically nonsignificant (<50% quantitatively assessed) stenosis in any major vessel, normal left ventricular function (wall motion score index 1), and test negativity for conventional wall motion criteria. Images were independently read by a core laboratory for wall motion and a core laboratory for CFR. Mean CFR was 2.5 0.6 and 87 patients (22%) had an abnormal CFR <2. During a median follow-up of 51 months, 31 events occurred, namely 4 deaths and 27 nonfatal myocardial infarctions (3 ST-elevated myocardial infarctions and 24 non-ST-elevated myocardial infarctions). Kaplan-Meier survival estimates for hard events showed a better outcome for those patients with a normal CFR compared with those with an abnormal CFR (96% vs 55%, p 0.001, at 48 months of follow-up). In conclusion, in patients with angiographically normal or near-normal coronary arteries and preserved at-rest regional and global left ventricular function at baseline and during stress, CFR adds incremental value to the prognostic stratification achieved with clinical and angiographic data

Stress echocardiography for risk stratification of patients following percutaneous coronary intervention

Objectives: To assess the prognostic value of stress echocardiography following percutaneous coronary intervention. Materials and methods: The study group was made by 904 patients (682 men; age 64?10 years) who underwent stress echocardiography with exercise (n=66), dipyridamole (n=677) or dobutamine (n=161) after a median of 7 months from percutaneous coronary intervention. Patients were followed-up for the occurence of hard (death, infarction) and major events [death, infarction, late (>3 months) revascularization]. Results: Ischemia at stress echo was assessed in 272 (30 %) patients. During a median follow-up of 18 months, there were 182 events (43 deaths, 51 myocardial infarctions, and 88 late revascularizations). Additionally 131 patients underwent early (<3 months) revascularization and were censored. Independent predictors of hard events were ischemia at stress echo (HR=2.55; 95 % CI=1.68-3.87; p<0.0001), rest wall motion score index (HR=2.83; 95 % CI=1.66-4.82; p<0.0001), and age (HR=1.02; 95 % CI=1.00-1.04; p=0.04). 4-year hard event rate was 34 % in patients with and 10 % in those without ischemia (p<0.0001) (Figure). Independent predictors of major events were ischemia at stress echo (HR=2.82; 95 % CI=2.10-3.81; p<0.0001), diabetes (HR=1.87; 95 % CI=1.35-2.59; p<0.0001), rest wall motion score index (HR=1.93; 95 % CI=1.27-2.93; p=0.002), and antianginal therapy at the time of test (HR=1.44; 95 % CI=1.07-1.93; p=0.02). 4-year major event rate was 53 % in patients with and 21 % in those without ischemia (p<0.0001) (Figure). Conclusion: Stress echocardiography is effective for risk stratification of patients following percutaneous coronary intervention. In particular, inducible ischemia is a strong and independent predictor of both hard and major events

Prognostic Correlates of Combined Coronary Flow Reserve Assessment on Left Anterior Descending and Right Coronary Artery in Patients with Negative Stress Echocardiography by Wall Motion Criteria.

Aims: To assess the prognostic correlates of Doppler echocardiographically derived coronary flow reserve (CFR) on two coronaries in patients with negative stress echo. Vasodilator stress echocardiography allows dual imaging of regional wall motion and CFR both on left anterior descending (LAD) and right coronary artery (RCA). Methods: The study group comprised 460 patients with known or suspected coronary artery disease and negative stress echo by wall motion criteria. All underwent dipyridamole (up to 0.84 mg/kg over 6 minutes) stress echo with CFR evaluation of either LAD or RCA by Doppler, and were followed up for a median of 32 months. A CFR value of(2.0 was taken as abnormal. Results: CFR was abnormal in 174 patients (38%) (57 in LAD only, 48 in RCA only, and 69 in both LAD and RCA) and normal in 286 patients (62%). During follow-up, there were 77 cardiac events: 5 deaths, 44 acute coronary syndromes (6 STEMI, and 38 NSTEMI) and 28 late (.6 months from stress echo) revascularisations. CFR of (2.0 on LAD was the strongest multivariable predictor of either definite (death, acute coronary syndrome) and major (death, acute coronary syndrome, late revascularisation) events, followed by diabetes mellitus. Antiischaemic therapy at the time of testing and resting wall motion abnormality were also independently associated with major events. Preserved CFR in both LAD and RCA was associated with better (p,0.0001) definite and major event-free survival compared to abnormal CFR in one or both coronary vessels. Conclusion: CFR evaluation of either LAD or RCA allows the identification of distinct prognostic patterns. In particular, preserved CFR in both coronary vessels is highly predictive of a very favourable outcome, while reduced CFR in either coronary vessel, and especially on LAD, is a strong predictor of future cardiac events

Stress echocardiography for risk stratification of patients following coronary bypass surgery

Objectives: To assess the prognostic value of stress echocardiography following coronary bypass surgery. Methods: We evaluated 451 patients (360 men; age 65?10 years) who underwent stress echocardiography with exercise (n=33), dipyridamole (n=319) or dobutamine (n=99) after a median of 69 months from coronary bypass surgery. Patients were followed-up for the occurence of hard (death, infarction) and major events (death, infarction, late [>3 months] revascularization). Results: Ischemia at stress echo was assessed in 185 (41%) patients. During a median follow-up of 25 months, there were 119 events (56 deaths, 17 myocardial infarctions, and 46 late revascularizations). Additionally 55 patients underwent early [<3 months] revascularization and were censored. Independent predictors of hard events were age (HR=1.06; 95% CI=1.03-1.10; p<0.0001), and peak wall motion score index (HR=3.36; 95% CI=1.85-6.11; p<0.0001). 4-year major event rate was 26% in patients with and 17% in those without ischemia (p=0.44) (Figure). Independent predictors of major events were age (HR=1.03; 95% CI=1,01-1.06; p=0.002), ischemia at stress echo (HR=1.73; 95% CI=1.20-2.49; p=0.004), and resting wall motion score index (HR=1.82; 95% CI=1.20-2.77; p=0.005). 4-year major event rate was 40% in patients with and 26% in those without ischemia (p=0.02) (Figure). Conclusion: In patients with previous coronary bypass surgery, ischemia at stress echo is a multivariable indicator of future major events. However, it is unable to predict hard events

Prognostic value of pharmacologic stress echocardiography in diabetic and nondiabetic chest pain patients with intermediate-to-high threshold positive exercise electrocardiography

Aims: To compare the prognostic value of pharmacologic stress echocardiography in diabetic and nondiabetic patients with chest pain and intermediate-to-high threshold positive exercise electrocardiography. Materials and methods: 935 chest pain patients (131 diabetics) with ST-segment depression &#8805;1 mm on exercise electrocardiography at >75 watt workload underwent dipyridamole (n=786) or dobutamine (n=149) stress echocardiography and were followed-up for the occurence of hard (death, infarction) and major events (death, infarction, late revascularization). Results: During a median follow-up of 26 months, 158 events (51 deaths, 28 myocardial infarctions, and 79 late revascularizations) occurred: 34 in diabetics and 124 in nondiabetics (see Figure). Independent predictors of hard events were age, diabetes, and ischemia at stress echo. 5-year hard event rate was 24 % in patients with and 4 % in those without ischemia (p<0.0001). Independent predictors of major events were age, diabetes, hypercholesterolemia, smoking habit, antianginal therapy at the time of testing, and ischemia at stress echo. 5-year major event rate was 46 % in patients with and 7 % in those without ischemia (p<0.0001). Conclusions: Stress echocardiography is effective in risk stratifying diabetics and nondiabetics with intermediate-to-high threshold ischemic exercise electrocardiography. However, major event rate associated with a non ischemic test is similar in diabetics and nondiabetics during the first year of follow-up, and markedly increased in the former thereafter

Stress echocardiography for the risk stratification of patients following coronary bypass surgery

OBJECTIVES: The aim of the study was to assess the prognostic value of stress echocardiography after CABG. METHODS: We evaluated 500 (100 women) patients who had undergone exercise or pharmacological SE after a median of 69 months after CABG. Of these, 351 (70%) complained of symptoms suggestive of ischemic origin while 149 (30%) were tested for asymptomatic progression of the disease. RESULTS: SE was positive for ischemia in 196 (39%) patients. During a median follow-up of 25 months, 61 patients died, 33 had a nonfatal myocardial infarction, and 112 underwent late (>3 months) revascularization. Multivariable Cox\u27 regression analysis indicated age (HR=1.04; 95% CI 1.01-1.06; p<0.003), and peak WMSI (HR=3.07; 95% CI 1.96-4.81; p=0.0001) as independent predictors of hard (total mortality and myocardial infarction) events. SE information provided a significant improvement in predictive power of the statistical model (chi-square increase 34%, p<0.0001 for hard and 91%, p<0.0001 for major events, respectively). Survival analysis showed ischemia at SE to be associated with significantly higher hard and major event rate in both symptomatic and asymptomatic patients. DISCUSSION: SE represents an effective tool for the risk stratification of patients with previous CABG independently of the presence of symptoms suggestive of ischemic origin

Coronary Flow Reserve During Dipyridamole Stress Echocardiography Predicts Mortality

ObjectivesThe goal of this study was to evaluate the ability of coronary flow reserve (CFR) over regional wall motion to predict mortality in patients with known or suspected coronary artery disease (CAD).BackgroundCFR evaluated using pulsed Doppler echocardiography testing on left anterior descending artery is the state-of-the-art method during vasodilatory stress echocardiography.MethodsIn a prospective, multicenter, observational study, we evaluated 4,313 patients (2,532 men; mean age 65 ± 11 years) with known (n = 1,547) or suspected (n = 2,766) CAD who underwent high-dose dipyridamole (0.84 mg/kg over 6 min) stress echocardiography with CFR evaluation of left coronary descending artery (LAD) by Doppler. Overall mortality was the only endpoint analyzed.ResultsStress echocardiography was positive for ischemia in 765 (18%) patients. Mean CFR was 2.35 ± 0.68. At individual patient analysis, 1,419 (33%) individuals had CFR ≤2. During a median follow-up of 19 months (1st quartile 8; 3rd quartile 36), 146 patients died. The 4-year mortality was markedly higher in subjects with CFR ≤2 than in those with CFR >2, both considering the group with ischemia (39% vs. 7%; p < 0.0001) and the group without ischemia at stress echocardiography (12% vs. 3%; p < 0.0001). At multivariable analysis, CFR on LAD ≤2 (hazard ratio [HR]: 3.31; 95% confidence interval [CI]: 2.29 to 4.78; p < 0.0001), ischemia at stress echocardiography (HR: 2.40, 95% CI: 1.65 to 3.48, p < 0.0001), left bundle branch block (HR: 2.26, 95% CI: 1.50 to 3.41; p < 0.0001), age (HR: 1.08, 95% CI: 1.06–1.10; p < 0.0001), resting wall motion score index (HR: 3.52, 95% CI: 2.38 to 5.21; p < 0.0001), male sex (HR: 1.74, 95% CI: 1.12 to 2.52; p = 0.003), and diabetes mellitus (HR: 1.47, 95% CI: 1.03 to 2.08; p = 0.03) were independent predictors of mortality.ConclusionsCFR on LAD is a strong and independent indicator of mortality, conferring additional prognostic value over wall motion analysis in patients with known or suspected CAD. A negative result on stress echocardiography with a normal CFR confers an annual risk of death <1% in both patient groups

Prognostic implication of coronary flow reserve in diabetic and nondiabetic patients with negative dipyridamole stress echo by wall motion criteria

Objectives: Aim of this prospective, multicenter, observational study was to assess the prognostic value of Doppler echocardiographic derived coronary flow reserve (CFR) in diabetic and nondiabetic patients with known or suspected coronary artery disease (CAD) and negative dipyridamole stress echo. Methods: The study group consisted of 1130 patients (207 diabetics) with known (n=418) or suspected (n=712) CAD and negative stress echo by wall motion criteria. All underwent dipyridamole (up to 0.84 mg/kg over 6\u27) echo with CFR evaluation of left anterior descending artery by Doppler. A value of CFR <2.0 was considered abnormal. Results: CFR was normal in 821 (63%) and abnormal in 309 (27%) patients. During a median follow-up of 16 months, 98 events (8 deaths, 24 STEMI, and 66 NSTEMI) occurred. In addition, 89 patients underwent revascularization and were censored. Multivariable prognostic indicators were abnormal CFR (HR=4.95; 95% CI=3.26-7.50; p<0.0001), antianginal therapy at the time of testing (HR=1.96; 95% CI=1.29-2.98; p=0.002), age (HR=1.02; 95% CI=1.00-1.04; p=0.02), and resting wall motion abnormalities (HR=1.50; 95% CI=1.00-2.25; p=0.05). The 36-month event rate was lower (p<0.0001) for either diabetics and nondiabetics with normal CFR as compard to diabetics and nondiabetics with abnormal CFR (Figure). Conclusion: CFR provides effective prognostic information in diabetic and nondiabetic patients with known or suspected CAD and negative dipyridamole stress echo. In particular, a reduced CFR is associated with worse outcome in both populations