Estimation of cardiac output and pulmonary vascular resistance by contrast echocardiography transit time measurement: a prospective pilot study

Background Studies with other imaging modalities have demonstrated a relationship between contrast transit and cardiac output (CO) and pulmonary vascular resistance (PVR). We tested the hypothesis that the transit time during contrast echocardiography could accurately estimate both CO and PVR compared to right heart catheterization (RHC). Methods 27 patients scheduled for RHC had 2D-echocardiogram immediately prior to RHC. 3 ml of DEFINITY contrast followed by a 10 ml saline flush was injected, and a multi-cycle echo clip was acquired from the beginning of injection to opacification of the left ventricle. 2D-echo based calculations of CO and PVR along with the DEFINITY-based transit time calculations were subsequently correlated with the RHC-determined CO and PVR. Results The transit time from full opacification of the right ventricle to full opacification of the left ventricle inversely correlated with CO (r = -0.61, p \u3c 0.001). The transit time from peak opacification of the right ventricle to first appearance in the left ventricle moderately correlated with PVR (r = 0.46, p \u3c 0.01). Previously described echocardiographic methods for the determination of CO (Huntsman method) and PVR (Abbas and Haddad methods) did not correlate with RHC-determined values (p = 0.20 for CO, p = 0.18 and p = 0.22 for PVR, respectively). The contrast transit time method demonstrated reliable intra- (p \u3c 0.0001) and inter-observer correlation (p \u3c 0.001). Conclusions We describe a novel method for the quantification of CO and estimation of PVR using contrast echocardiography transit time. This technique adds to the methodologies used for noninvasive hemodynamic assessment, but requires further validation to determine overall applicability

Genomic profiling reveals the potential role of TCL1A and MDR1 Deficiency in chemotherapy-induced cardiotoxicity

Background: Anthracyclines, such as doxorubicin (Adriamycin), are highly effective chemotherapeutic agents, but are well known to cause myocardial dysfunction and life-threatening congestive heart failure (CHF) in some patients. Methods: To generate new hypotheses about its etiology, genome-wide transcript analysis was performed on whole blood RNA from women that received doxorubicin-based chemotherapy and either did, or did not develop CHF, as defined by ejection fractions (EF)≤40%. Women with non-ischemic cardiomyopathy unrelated to chemotherapy were compared to breast cancer patients prior to chemo with normal EF to identify heart failure-related transcripts in women not receiving chemotherapy. Byproducts of oxidative stress in plasma were measured in a subset of patients. Results: The results indicate that patients treated with doxorubicin showed sustained elevations in oxidative byproducts in plasma. At the RNA level, women who exhibited low EFs after chemotherapy had 260 transcripts that differed \u3e2-fold (pIn vitro studies confirmed that inhibition of MDR1 by verapamil in rat H9C2 cardiomyocytes increased their susceptibility to doxorubicin-induced toxicity. Conclusions: It is proposed that chemo-induced cardiomyopathy may be due to a reduction in TCL1A levels, thereby causing increased apoptotic sensitivity, and leading to reduced cardiac MDR1 levels, causing higher cardiac levels of doxorubicin and intracellular free radicals. If so, screening for TCL1A and MDR1 SNPs or expression level in blood, might identify women at greatest risk of chemo-induced heart failure

Current status of stress echocardiography

Stress echocardiography is a widely applied technique for the evaluation of individuals with known or suspected coronary artery disease. The technique combines echocardiographic imaging with exercise testing or pharmacologic stress. Advances in digital image acquisition and harmonic imaging have substantially improved the quality of echocardiographic images, and have therefore increased general applicability of stress echocardiography

Antihypertensive treatment to lower cardiovascular risk among post-menopausal women on estrogen replacement therapy

The project investigates the optimal antihypertensive therapy for elderly women on hormone replacement therapy. Hypertension is a major public health challenge in the United States. The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) trial established that among available hypertensive therapies, hydrochlorothiazide (HCTZ) diuretics are superior to calcium-channel blockers and angiotensin-converting enzyme inhibitors in preventing 1 or more major forms of cardiovascular disease (CVD). Postmenopausal women on hormonal replacement therapy are generally at increased cardiovascular risks. There have been several studies that suggest lower of tolerance of HCTZ compared to other hypertensive medications in this population. The goal of the study is to give healthcare providers with more liberty to select initial anti-hypertensive medication for postmenopausal women on estrogen replacement therapy, taking into account individual patient\u27s side effect profile and other comorbidities

Clinical relevance of chest pain during dobutamine stress echocardiography in women

Background: Dobutamine stress echocardiography (DSE) is commonly used for diagnosis and management of patients with known or suspected coronary artery disease. Chest pain occurring during DSE potentially provides additional diagnostic accuracy. Our experience suggests that chest pain occurs frequently in women undergoing DSE. Hypothesis: It was the purpose of this study to determine the frequency with which chest pain occurs in women undergoing DSE and the relation to inducible ischemia or coronary artery stenosis. Methods: To determine the prevalence and clinical significance of chest pain during DSE, we reviewed the records of 154 consecutive women undergoing DSE in our laboratory. Of these, 59 patients (37.5%) also underwent coronary angiography. The presence or absence of chest pain was correlated with ECG changes, left ventricular wall motion abnormalities during DSE, and coronary stenosis by angiography. Results: Forty-one women (26%) developed chest pain during DSE. Patients experiencing chest pain were older (58.5 ± 9.3 vs. 54.9 ± 12.6; p = 0.05), and had lower resting heart rates (71 ± 12.2 vs. 77.9 ±14.9; p = 0.008), but received similar maximum doses of dobutamine and reached comparable peak heart rates (131.1 ± 17.4 v s. 133.5 ± 21.7; p = NS). Patients with chest pain more commonly exhibited ST-segment depression ≥1 mm during dobutamine infusion (13/41, 32%, vs. 17/113, 15%; p = 0.02), but chest pain showed no statistically significant correlation with abnormal DSE or with coronary stenosis. Conclusions: In women undergoing DSE, chest pain occurs in 26% and does not appear to be related to inducible myocardial ischemia. Electrocardiographic changes occur more frequently in patients who experience chest pain, but are also often unrelated to inducible myocardial ischemia

Clinical and morphologic expression of hypertrophic cardiomyopathy in patients ≥ 65 years of age

Hypertrophic cardiomyopathy (HC) is most often identified in patients in the second through fifth decades of life, but has been increasingly recognized in older patients. The present report characterizes morphologic and clinical features of HC in 134 consecutively studied patients aged ≥ 65 years referred to a tertiary center. Echocardiographic or clinical evaluation, or both, was performed in 134 patients aged 65 to 85 years (mean 72) at most recent evaluation. Selected findings were compared with those in 64 youthful patients with HC aged 15 to 35 years (mean 25). Most elderly patients (120 of 134, 90%) developed marked symptoms that usually became evident after age 55 years; 94 of 120 experienced sustained improvement with medical treatment or operation. Elderly patients had relatively mild left ventricular (LV) wall thickening (20 ± 3 mm), generally confined to the septum. In most (i.e., 68%), septal hypertrophy was uniformly distributed with parallel right and left borders and associated with elliptical LV cavity shape; however, in 32%, an inhomogeneously hypertrophied septum bulged into the left ventricle, disrupting normal cavity shape. Dynamic subaortic obstruction was present under basal or provocable conditions in a particularly small LV outflow tract in 103 of 134 patients (77%), and was usually produced by relatively restricted excursion of the anteriorly displaced mitral leaflets and posterior septal motion. HC is characterized by age-related differences in both clinical and morphologic expression. Elderly patients with HC characteristically demonstrate onset of cardiac symptoms late in life, as well as distinctive LV morphology and dynamics of outflow obstruction. © 1994

Diversity of patterns of hypertrophy in patients with systemic hypertension and marked left ventricular wall thickening

In selected patients with systemic hypertension it may be difficult to ascertain whether left ventricular (LV) hypertrophy is a secondary end-organ consequence of long-term elevations in blood pressure or, alternatively, a manifestation of a coexistent primary hypertrophic cardiomyopathy. To address this issue and better characterize LV hypertrophy in systemic hypertension, 2-dimensional echocardiography was used to define the patterns of LV hypertrophy in 102 patients with sustained systemic hypertension and marked degrees of wall thickening. Patients ranged in age from 31 to 88 years (mean 61) and were predominantly female (58%); all were black. By selection, each patient had a maximal LV wall thickness of \u3e15 mm (range 16 to 29). Distribution of hypertrophy was judged to be symmetric (i.e., concentric) in most patients (67 of 102, 66%). However, a substantial proportion (35 patients, 34%) demonstrated nonuniform, asymmetric patterns of hypertrophy in which at least 1 segment of the LV wall was at least 1.5 times the thickness of any other. In these 35 patients, the distribution of hypertrophy was similar to that characteristic of the morphologic spectrum of hypertrophic cardiomyopathy, with thickening of portions of both the ventricular septum and free wall in 16 patients, anterior and posterior ventricular septum alone in 11 patients and segmental involvement of only the anterior ventricular septum in 8. Patients with asymmetric patterns of wall thickening did not differ from the patients with symmetric hypertrophy with regard to age, sex or clinical findings. Asymmetric LV hypertrophy appears to represent an important feature of the morphologic spectrum of severe hypertensive heart disease. Moreover, the diverse patterns of hypertrophy observed in hypertensive patients with marked LV wall thickening often cannot be distinguished definitively, on a morphologic basis alone, from those characteristic of hypertrophic cardiomyopathy. © 1990