Endomyocardial fibrosis is a rare cardiomyopathy characterized by thickening of the endocardium, which leads to a restrictive phenotype. Differential diagnosis with other forms of cardiomyopathy may ...not always be straightforward and various imaging modalities are frequently necessary. In the present case, we report a patient with heart failure of uncertain origin, in whom, after an in-depth instrumental evaluation, a rare variant of endomyocardial fibrosis was diagnosed.
Cardiovascular risk factors are classically associated with coronary atherosclerosis. We sought to investigate whether risk factors are also associated with left ventricular (LV) dilatation, ...contractile impairment and reduced myocardial blood flow (MBF) in patients with non-ischemic LV dysfunction.
We studied 81 patients (59 males, age 60 ± 9 years) with mild-to-severe LV dysfunction (mean ejection fraction 37%, range 19%-50%), no history of diabetes and normal coronary arteries. Absolute MBF was measured by positron emission tomography and 13N-ammonia at rest and after dipyridamole (0.56 mg/kg I.V. over 4 min).
Overt LV dysfunction (LV end-diastolic diameter >60 mm associated with LV ejection fraction <45%) was present in 42 patients (52%); severely depressed hyperemic MBF (<1.09 mL · min−1 · g−1) was present in 41 patients (51%). Using multivariate logistic regression analysis, low high-density lipoprotein cholesterol (HDL-C, P < .036), newly diagnosed non-insulin-dependent diabetes or insulin-resistance (NIDD/IR, P < .019) and the use of diuretics (P = .001) were independently associated with overt LV dysfunction. Low HDL-C (P = .015) and NIDD/IR (P = .048) were also independently associated with severely depressed hyperemic MBF.
Low HDL-C and NIDD/IR are associated with more severe LV impairment and reduced hyperemic MBF in non-ischemic LV dysfunction.
Acute coronary syndromes can substantially disrupt the lives of our patients. However, patients' view of their illness is usually scarcely considered in routine medical practice. We aimed to ...investigate the psycho-emotional impact of acute coronary syndromes.
We studied 30 patients with acute coronary syndrome, aged <70 years. Before discharge, each patient was interviewed by a psychologist using a semi-structured interview; data were collected in the form of verbal reports.
After learning that they had had a heart attack, 16 patients (53%) reported a feeling of fear linked to the idea of death, sometimes real despair; 7 patients (23%) showed a weak emotional response, 4 (13%) reacted with denial, and 3 responded evasively. During the interview, 17 patients (57%) reported events relating to family life and 9 (30%) to work; all these events were negative and related to suffering, conflict, and stress. When compared to pre-admission status, 30% of patients experienced negative psychological changes, such as a sense of fragility, uncertainty and a redefinition of self-image, while 50% reported no change. Surprisingly, 6 patients (20%) referred positive psychological changes. This positive restructuring was related to the patients' ability/need to change their lifestyle. This process entails a different vision of the past and the future, and is associated with a feeling of rebirth and physical wellbeing.
The psycho-emotional effects of acute coronary syndromes may be immense, and may radically change the way the patient relates to himself and to the world. We often remain detached from these changes, and are sometimes even unaware of them.
Despite the useful information provided by myocardial contrast echocardiography, the meaning of myocardial contrast intensity remains elusive. This review is meant to define the contribution of ...physical and biologic factors in producing myocardial contrast and to elucidate the relative roles of coronary blood flow and intramyocardial blood volume in determining contrast effect. The main physical factors influencing the contrast echo effect include the properties of microbubbles as scattering elements (mainly their radius, compressibility, stability and concentration), electronic signal processing, instrument setting and contrast-induced signal attenuation. The effect of these factors can be limited by an appropriate experimental or clinical setup. Biologic factors are less easily controllable, and changes in coronary blood flow and alterations in myocardial blood volume appear to be the main determinants of myocardial contrast intensity. Moreover, these factors influence contrast intensity in opposite directions. Both the area under the time-intensity curve and the mean transit time of myocardial contrast are inversely related to coronary blood flow but directly related to myocardial vascularity and blood volume. Therefore, an increase in coronary flow not accompanied by an increase in myocardial vascularity and volume is accompanied by a decrease in the area under the curve and mean transit time of contrast. Conversely, an increase in coronary flow mediated by augmented myocardial vascularity and volume will produce an increase in the area under the curve and mean transit time. A better understanding of the physical and biologic determinants of contrast echo intensity will be fundamental in the clinical application of new agents and technologies.
We assessed the contribution of difference in duration of pulmonary venous and mitral flow at atrial contraction (ARd-Ad) for prognostic stratification of patients with left ventricular (LV) systolic ...dysfunction.
Although pulmonary venous flow (PVF) variables may supplement mitral flow patterns in evaluating left ventricular (LV) diastolic function, their value to the prognostic stratification of patients has not been investigated.
Pulsed wave Doppler mitral and PVF velocity curves were recorded in 145 patients (mean age: 70 years) with LV systolic dysfunction secondary to ischemic or nonischemic cardiomyopathy who were followed for 15 +/- 8 months. In 38% of patients, PVF signal was enhanced by the intravenous (IV) administration of a galactose-based echo-contrast agent. Based on E-wave deceleration time < or = or >130 ms and ARd-Ad, patients were grouped into restrictive (group 1, n = 40), nonrestrictive with ARd-Ad > or =30 ms (group 2, n = 55) and nonrestrictive with ARd-Ad <30 ms (group 3, n = 50).
During follow-up, 29 patients died from cardiac causes and 28 were hospitalized for worsening heart failure (HF). On multivariate Cox model, ARd-Ad > or =30 ms provided important prognostic information with regard to cardiac mortality and emerged as the single best predictor of cardiac events (cardiac mortality, hospitalization). The 24-month cardiac event-free survival was best (86.3%) for group 3; it was intermediate (37.9%) for group 2; and it was worst (22.9%) for group 1 (p < 0.0002 group 1 vs. 3; p < 0.0005 group 2 vs. 3; p < 0.0003 group 1 vs. group 2).
Assessment of ARd-Ad exhibited an independent value in the prognostic evaluation of patients with LV systolic dysfunction. Moreover, it contributed to identify patients at low, intermediate and high risk of cardiac events.
The development of technologically advanced, expensive techniques has progressively reduced the value of chest X-ray in clinical practice for the assessment of left ventricular (LV) dilatation and ...dysfunction. Although controversial data are reported on the role of this widely available technique in cardiac assessment, it is known that the cardio-thoracic ratio is predictive of risk of progression in the NYHA Class, hospitalization, and outcome in patients with LV dysfunction. This study aimed to evaluate the reliability of the transverse diameter of heart shadow TDH by chest X-ray for detecting LV dilatation and dysfunction as compared to Magnetic Resonance Imaging (MRI) performed for different clinical reasons.
In 101 patients, TDH was measured in digital chest X-ray and LV volumes and ejection fraction (EF) by MRI, both exams performed within 2 days.
A direct correlation between TDH and end-diastolic volumes (r = .75, P<0.0001) was reported. TDH cut-off values of 14.5 mm in females identified LV end-diastolic volumes >150 mL (sensitivity: 82%, specificity: 69%); in males a cut-off value of 15.5 mm identified LV end-diastolic volumes >210 mL (sensitivity: 84%; specificity: 72%). A negative relation was found between TDH and LVEF (r = -.54, P<0.0001). The above cut-off values of TDH discriminated patients with LV systolic dysfunction - LVEF <35% (sensitivity and specificity: 67% and 57% in females; 76% and 59% in males, respectively).
Chest X-ray may still be considered a reliable technique in predicting LV dilatation by the accurate measurement of TDH as compared to cardiac MRI. Technologically advanced, expensive, and less available imaging techniques should be performed on the basis of sound clinical requests.
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