Symptoms Of Exertional Dyspnea Research Articles

Diagnostic value of expired gas analysis in heart failure with preserved ejection fraction

Cardiopulmonary exercise testing (CPET) may potentially differentiate heart failure (HF) with preserved ejection fraction (HFpEF) from noncardiac causes of dyspnea (NCD). While contemporary guidelines for HF recommend using CPET for identifying causes of unexplained dyspnea, data supporting this practice are limited. This study aimed to determine the diagnostic value of expired gas analysis to distinguish HFpEF from NCD. Exercise stress echocardiography with simultaneous expired gas analysis was performed in patients with HFpEF (n = 116) and those with NCD (n = 112). Participants without dyspnea symptoms were also enrolled as controls (n = 26). Exercise capacity was impaired in patients with HFpEF than in controls and those with NCD, evidenced by lower oxygen consumption (VO2), but there was a substantial overlap between HFpEF and NCD. Receiver operating characteristic curve analyses showed modest diagnostic abilities of expired gas analysis data in differentiating individuals with HFpEF from the controls; however, none of these variables clearly differentiated between HFpEF and NCD (all areas under the curve < 0.61). Expired gas analysis provided objective assessments of exercise capacity; however, its diagnostic value in identifying HFpEF among patients with symptoms of exertional dyspnea was modest.

Coexistent Chronic Obstructive Pulmonary Disease-Heart Failure: Mechanisms, Diagnostic and Therapeutic Dilemmas

Mortality in chronic obstructive pulmonary disease (COPD) is more often due to cardiac rather than respiratory causes. The coexistence of heart failure (HF) and COPD is frequent but remains under-diagnosed. Both conditions share several similarities including the age of the population affected, a common risk factor in smoking and symptoms of exertional dyspnoea. There is also a strong possibility of COPD promoting atherosclerotic vascular disease through systemic inflammation. Both the conditions are punctuated by episodes of acute exacerbations of symptoms from time to time where differentiation between these two can be especially challenging. Although coexistence of the two is common, more often, only one of the two is diagnosed resulting in under-treatment and unsatisfactory response. Awareness of co-occurrence is essential among both pulmonologists and cardiologists and a high index of suspicion should be maintained. The coexistence of the COPD and HF also poses several challenges in management. Active search for the second disease using clinical examination supplemented with specialised investigations including plasma natriuretic peptides, lung function testing and echocardiography should be carried out followed by appropriate management. Issues such as adverse effects of drugs on cardiac or pulmonary function need to be sorted out by studies in coexistent COPD-HF patients. Caution is advised with use of beta2-agonists in COPD when HF is also present, more so in acute exacerbations. On current evidence, the beneficial effects of selective beta1-blockers should not be denied in stable patients who have coexistent COPD-HF. The prognosis of coexistent COPD and HF is poorer than that in either disease alone. A favourable response in the patient with coexistent COPD and HF depends on proper evaluation of the severity of each of the two and appropriate management with judicious use of medication.

Myocardial Bridge or Something Else?

In this E-Challenge, the authors report on a patient with symptoms of exertional dyspnea and angina, scheduled to have surgical unroofing of an identified myocardial bridge (MB). An MB is very common in patients with hypertrophic cardiomyopathy (HCM). Intraoperative transesophageal echocardiography with provocative maneuvers revealed the patient had a systolic anterior motion of the mitral valve with septal contact and resulting outflow tract obstruction despite the notable absence of significant basal septal hypertrophy. HCM has many phenotypic variants that can make the identification of patients with latent left ventricular outflow tract obstruction difficult in the absence of a high index of suspicion. In this report, the authors discuss the association between MBs and HCM and the importance of recognizing phenotypic variants of HCM.

Prevalence of cardiovascular diseases in patients hospitalized for acute exacerbation of COPD: prospective observational study

Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has considerable cardiovascular risk. Various cardiovascular diseases are common during exacerbations. Both diseases share several similarities such as older age of the patient, smoking as a common risk factor and symptoms of exertional dyspnea. Knowledge regarding the magnitude of underlying cardiovascular diseases during AECOPD is limited. Authors performed this study to assess the presence of different associated cardiovascular diseases (CVDs) in patients hospitalized for AECOPD and its effect on the outcome.Methods: It was a prospective observational study involving 436 patients of AECOPD divided to Group 1 (AECOPD with CVD- 137 (31.4%) patients) and Group 2 (AECOPD without CVD 299 (68.6%) patients). All the patients were subjected to full history taking, clinical examination, chest X-ray, spirometry, ECG and echocardiography.Results: COPD patients in exacerbation with CVD, were significantly more likely to have longer duration of hospital stay (p &lt; 0.0001), high CRP level (p&lt;0.001), more frequent mechanical ventilations (p &lt; 0.001), two or more exacerbations per year (p &lt;0.0001) and the mortality was (p&lt;0.0001). Also, they have GOLD grade III/IV severe (43.5%) and very severe (19.5%) air flow limitation. The high percentage of them had (64.8%) pulmonary hypertension, (37.3%) systemic arterial hypertension, (31.5%) arrhythmia, (27.8%) ischemic heart diseases and (21.3%) heart failure.Conclusions: The prevalence of cardiovascular diseases (CVD) in patients hospitalized for COPD was high. Age, sex and CVD trends, as well as life style changes, should be considered when prevention and control strategies are formulated.

Imatinib-Induced Congestive Heart Failure: A Case Report

Imatinib has been approved by the FDA as an oral drug for the treatment of Chronic Myeloid Leukemia (CML), gastrointestinal stromal tumors (GISTs) and hyper eosinophilic syndrome. Although imatinib is well tolerated, the incidence of edema and dyspnea are reported to be as high as 66 and 16%, respectively. Imatinib-induced cardiotoxicity is a very uncommon adverse event <1%. A 53-year-old male with history of Chronic Myeloid Leukemia (CML) on Imatinib for the past 5 years. He presented with symptoms of exertional dyspnea, poor exercise performance, fatigue, and leg swellings. Chest X-ray revealed cardiomegaly, and pulmonary edema. Electrocardiogram showed normal sinus rhythm, no ischemic changes. Cardiac enzymes were normal. 2D Echocardiogram showed ejection fraction EF of 35%, normal pulmonary systolic pressure, no wall motion abnormality, with normal valvular function. In our case report, we discuss the association between Imatinib use and congestive heart failure, which may need discontinuing the medication and prompt treatment of congestive heart failure.

Study of cardiovascular diseases in hospitalized AECOPD patients

BackgroundChronic obstructive pulmonary disease patients in exacerbation (AECOPD) have considerable cardiovascular risk, and different cardiovascular diseases are common during exacerbations. Both diseases share several similarities such as, age of the patients, a common risk factor which is smoking and symptoms of exertional dyspnea. Little is known about the magnitude of underlying cardiovascular insult during COPD exacerbations. ObjectivesTo assess the presence of different associated cardiovascular diseases (CVDs) in subjects hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and its effect on the outcome. Settings and designProspective, observational study conducted in Chest and Cardiology Departments, Zagazig University Hospitals. Patients and methodsThere were total 252 patients included in our study after fulfilling the inclusion criteria, patients were subjected to, full history taking, clinical examination, plain chest X-ray, PFTs (post bronchodilators FEV1 <0.7), ECG, echocardiograghy. ResultsCOPD patients in exacerbation with CVD, were significantly more likely to have longer duration of hospital stay (p<0.0001), high CRP level (p<0.001), more frequent mechanical ventilations (p<0.001), two or more exacerbations per year (p<0.0001) and the mortality was (p<0.01). Also, they have GOLD grade III/IV severe (43.5%) and very severe (19.5%) air flow limitation. The high percentage of them had (64.8%) pulmonary hypertension, (37.3%) systemic arterial hypertension, (31.5%) arrhythmia, (27.8%) ischemic heart diseases and (21.3%) heart failure. ConclusionsThe prevalence of cardiovascular diseases (CVD) in patients hospitalized for COPD in Zagazig University Hospital was high. Age, sex and CVD trends, as well as life style changes, should be considered when prevention and control strategies are formulated.

The Relationship between High Sensitive C-reaction Protein (hs-CRP) and Diastolic Heart Function in Diabetes Mellitus Type II

Among several inflammatory markers, high sensitive C-reaction protein (hs-CRP) is outstandingly observed in diabetic individuals. Serum hs-CRP is the main marker of inflammation whose levels independently predict the risk of cardiovascular events, and it has a prognostic value in heart patients. On the other hand, diabetes can lead to diastolic dysfunction of the heart. Diastolic dysfunction can cause symptoms of exertional dyspnea, which restricts the patient's activity. It is likely to predict diastolic dysfunction by screening through hs-CRP. The present investigation was a case-control study that was carried out on 52 patient diagnosed with diabetes mellitus type II. After the demographic data were recorded, and following the collection of data on the patients' history, physical examination, and para-clinical measures, individuals who had factors interfering with level of serum hs-CRP (kidney and liver diseases, inflammatory and infectious diseases, peripheral vascular disease, cerebrovascular disease, connective tissue disease, malignant tumor, trauma, consumption of statins, aspirin, ACEI, and fibrates) and diastolic dysfunction (ischemic heart disease, cardiomyopathies, pericardial disease, arrhythmias and valvular disease) were crossed out of the study. Serum hs-CRP was measured by nephelometry method. According to the results of tissue Doppler echocardiography, these patients are divided into two groups: one with diastolic dysfunction and the other without diastolic dysfunction. The serum hs-CRP levels of these patients were compared with each other. Among the participants, 30.8% were men and 69.2% were women, 36 individuals (69.2%) had diastolic dysfunction while 16 (30.8%) did not. There was a high level of correlation between the level of serumhs-CRP and diastolic dysfunction (p = 0.02, t = 2.36). The results of the present study indicated that there is a correlation between level of serum hs-CRP and diastolic dysfunction, such that the more the level of hs-CRP, the higher probability of diastolic dysfunction existence will be.

The Relationship between High Sensitive C-reaction Protein (hs-CRP) and Diastolic Heart Function in Diabetes Mellitus Type II

Among several inflammatory markers, high sensitive C-reaction protein (hs-CRP) is outstandingly observed in diabetic individuals. Serum hs-CRP is the main marker of inflammation whose levels independently predict the risk of cardiovascular events, and it has a prognostic value in heart patients. On the other hand, diabetes can lead to diastolic dysfunction of the heart. Diastolic dysfunction can cause symptoms of exertional dyspnea, which restricts the patient's activity. It is likely to predict diastolic dysfunction by screening through hs-CRP. The present investigation was a case-control study that was carried out on 52 patient diagnosed with diabetes mellitus type II. After the demographic data were recorded, and following the collection of data on the patients' history, physical examination, and para-clinical measures, individuals who had factors interfering with level of serum hs-CRP (kidney and liver diseases, inflammatory and infectious diseases, peripheral vascular disease, cerebrovascular disease, connective tissue disease, malignant tumor, trauma, consumption of statins, aspirin, ACEI, and fibrates) and diastolic dysfunction (ischemic heart disease, cardiomyopathies, pericardial disease, arrhythmias and valvular disease) were crossed out of the study. Serum hs-CRP was measured by nephelometry method. According to the results of tissue Doppler echocardiography, these patients are divided into two groups: one with diastolic dysfunction and the other without diastolic dysfunction. The serum hs-CRP levels of these patients were compared with each other. Among the participants, 30.8% were men and 69.2% were women, 36 individuals (69.2%) had diastolic dysfunction while 16 (30.8%) did not. There was a high level of correlation between the level of serumhs-CRP and diastolic dysfunction (p = 0.02, t = 2.36). The results of the present study indicated that there is a correlation between level of serum hs-CRP and diastolic dysfunction, such that the more the level of hs-CRP, the higher probability of diastolic dysfunction existence will be.

The Relationship between High Sensitive C-reaction Protein (hs-CRP) and Diastolic Heart Function in Diabetes Mellitus Type II

Among several inflammatory markers, high sensitive C-reaction protein (hs-CRP) is outstandingly observed in diabetic individuals. Serum hs-CRP is the main marker of inflammation whose levels independently predict the risk of cardiovascular events, and it has a prognostic value in heart patients. On the other hand, diabetes can lead to diastolic dysfunction of the heart. Diastolic dysfunction can cause symptoms of exertional dyspnea, which restricts the patient's activity. It is likely to predict diastolic dysfunction by screening through hs-CRP. The present investigation was a case-control study that was carried out on 52 patient diagnosed with diabetes mellitus type II. After the demographic data were recorded, and following the collection of data on the patients' history, physical examination, and para-clinical measures, individuals who had factors interfering with level of serum hs-CRP (kidney and liver diseases, inflammatory and infectious diseases, peripheral vascular disease, cerebrovascular disease, connective tissue disease, malignant tumor, trauma, consumption of statins, aspirin, ACEI, and fibrates) and diastolic dysfunction (ischemic heart disease, cardiomyopathies, pericardial disease, arrhythmias and valvular disease) were crossed out of the study. Serum hs-CRP was measured by nephelometry method. According to the results of tissue Doppler echocardiography, these patients are divided into two groups: one with diastolic dysfunction and the other without diastolic dysfunction. The serum hs-CRP levels of these patients were compared with each other. Among the participants, 30.8% were men and 69.2% were women, 36 individuals (69.2%) had diastolic dysfunction while 16 (30.8%) did not. There was a high level of correlation between the level of serumhs-CRP and diastolic dysfunction (p = 0.02, t = 2.36). The results of the present study indicated that there is a correlation between level of serum hs-CRP and diastolic dysfunction, such that the more the level of hs-CRP, the higher probability of diastolic dysfunction existence will be.

Diagnostic Evaluation of Chronic Thromboembolic Pulmonary Hypertension.

Pulmonary hypertension is defined by a mean pulmonary artery pressure greater than 25 mm Hg. Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as pulmonary hypertension in the presence of an organized thrombus within the pulmonary vascular bed that persists at least 3 months after the onset of anticoagulant therapy. Because CTEPH is potentially curable by surgical endarterectomy, correct identification of patients with this form of pulmonary hypertension and an accurate assessment of surgical candidacy are essential to provide optimal care. Patients most commonly present with symptoms of exertional dyspnea and otherwise unexplained decline in exercise capacity. Atypical chest pain, a nonproductive cough, and episodic hemoptysis are observed less frequently. With more advanced disease, patients often develop symptoms suggestive of right ventricular compromise. Physical examination findings are minimal early in the course of this disease, but as pulmonary hypertension progresses, may include nonspecific finding of right ventricular failure, such as a tricuspid regurgitation murmur, pedal edema, and jugular venous distention. Chest radiographs may suggest pulmonary hypertension, but are neither sensitive nor specific for the diagnosis. Radioisotopic ventilation-perfusion scanning is sensitive for detecting CTEPH, making it a valuable screening study. Conventional catheter-based pulmonary angiography retains an important role in establishing the presence and extent of chronic thromboembolic disease. However, computed tomographic and magnetic resonance imaging are playing a growing diagnostic role. Innovative technologies such as dual-energy computed tomography, dynamic contrast-enhanced magnetic resonance imaging, and optical coherence tomography show promise for contributing diagnostic information and assisting in the preoperative characterization of patients with CTEPH.

Postoperative radiotherapy to stabilize a tumor embolus in clear cell renal cell carcinoma: A case report.

Superior vena cava (SVC) syndrome results from clear cell renal cell carcinoma and is a challenge in clinical practice due to its pathological complexity and a lack of research data. The current study presents a 49-year-old female with symptoms of exertional dyspnea and increased fatigue, which had persisted for 15 months, as well as bilateral edema in the lower limbs for two days. A transesophageal echocardiogram demonstrated a right atrial mass originating from the inferior vena cava (IVC; size, 14×8 cm) that caused a tricuspid inflow obstruction. Following a partial resection of the thrombus, a clear cell renal cell carcinoma was identified by histological examination. The patient received intensity-modulated radiation therapy following refusal of other therapeutic methods. The eleven-month follow-up indicated that the tumor on the kidney and IVC was stable. Intensity-modulated radiation therapy may be beneficial to patients with clear cell renal cell carcinoma and SVC syndrome. However, additional studies are required to obtain further data regarding the treatment of this syndrome.

Laparoscopic Diaphragmatic Plication in Patients with Unilateral Diaphragm Paralysis with Thoracoscopic Verification

Diaphragm eventration or paralysis causes elevation of the ipsilateral diaphragm. Some patients have symptoms. The most common symptom is dyspnea. In symptomatic patients with unilateral diaphragm paralysis and dyspnea disproportionate to the degree of physical activity, diaphragm plication is the treatment of choice to relieve dyspnea. We report on our experience with laparoscopic plication of a paralysed hemidiaphragm. The laparoscopic approach is an attractive surgical alternative for the treatment of phrenic nerve palsy. This technique combines the advantage of an excellent field of vision during surgery with a fast postoperative recovery and early discharge from hospital. In accordance to recent literature, we have successfully applied the laparoscopic approach to treat our patients who suffered from a unilateral paralysis of the diaphragm. Preoperative symptoms of exertional dyspnea and orthopnea were significantly reduced.

33-Year-Old Man With Syncope

33-Year-Old Man With Syncope

Short term effects of exercise training on exercise capacity and quality of life in patients with pulmonary arterial hypertension: protocol for a randomised controlled trial.

BackgroundAdvances in the understanding and management of pulmonary arterial hypertension have enabled earlier diagnosis and improved prognosis. However, despite best available therapy, symptoms of exertional dyspnoea and fatigue are commonly reported and result in a reduced capacity to perform daily activities and impaired quality of life. Exercise training has demonstrated efficacy in individuals with other respiratory and cardiovascular diseases. Historically, however, exercise training has not been utilised as a form of therapy in pulmonary arterial hypertension due to the perceived risk of sudden cardiac death and the theoretical possibility that exercise would lead to worsening pulmonary vascular haemodynamics and deterioration in right heart function. Now, with the advances in pharmaceutical management, determining the safety and benefits of exercise training in this population has become more relevant. Only three studies of supervised exercise training in pulmonary arterial hypertension have been published. These studies demonstrated improvements in exercise capacity and quality of life, in the absence of adverse events or clinical deterioration. However, these studies have not utilised an outpatient-based, whole body exercise training program, the most common format for exercise programs within Australia. It is uncertain whether this form of training is beneficial and capable of producing sustained benefits in exercise capacity and quality of life in this population.Design/MethodsThis randomised controlled trial will determine whether a 12 week, outpatient-based, supervised, whole body exercise training program, followed by a home-based exercise program, is safe and improves exercise capacity and quality of life in individuals with pulmonary arterial hypertension. This study aims to recruit 34 subjects who will be randomly allocated to the exercise group (supervised exercise training 3 times a week for 12 weeks, followed by 3 sessions per week of home exercise for 12 weeks) or the control group (usual medical care). Subjects will be assessed at baseline, 12 weeks and 24 weeks.DiscussionThis study will determine whether outpatient-based, whole body exercise training is beneficial and safe in individuals with pulmonary arterial hypertension. Additionally, this study will contribute to clinical practice guidelines for this patient population.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000502235

Pericarditis Constrictiva in a 10-Year-Old Boy After Influenza A Virus Infection

Pericarditis constrictiva is caused by fibrotic degeneration of the pericardium and leads to impaired diastolic ventricular filling. The diagnosis of constrictive pericarditis in children remains challenging and often requires a multimodal approach. We present a case of a pericarditis constrictiva in a 10-year old boy after influenza A virus infection. Clinicians should be aware of this complication, especially in patients with symptoms of exertional dyspnea and congestive heart failure.

Rapid Progression of a Urinary Bladder Leiomyosarcoma: Report of a Case

The case we report shows rapid progression and a very poor prognosis only for a month that differs from the clinical course reported in the literature. An 83-year-old man was referred to our hospital for macroscopic hematuria. Computed tomography (CT) revealed a large bladder tumor measuring 4 cm × 3 cm and magnetic resonance imaging revealed extravesical invasion and pelvic wall invasion of the tumors. Chest CT and bone scintigraphy revealed no evidence of distant visceral metastases, and a clinical diagnosis of T4N0M0 was made. Transurethral resection of the bladder tumor (TUR-BT) was performed for histopathological diagnosis 18 days after admission, and no further adjuvant treatment was given. At 15 days after TUR-BT, the patient's clinical status worsened with symptoms of exertional dyspnea. CT showed multiple metastatic lesions in the lung, liver, and retroperitoneal lymphadenopathy. The patient died 2 days later and underwent autopsy. A final histopathological diagnosis of leiomyosarcoma was made based on immunohistochemical staining.

ASYMPTOMATIC LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND RISK OF DEATH IN THE COMMUNITY

LV to untwist in diastole is dependent on systolic twist. We hypothesise that patients with heart failure and normal ejection fraction (HFNEF) have reduced LV untwist to facilitate rapid early diastolic filling particularly during exercise thus symptoms of exertional dyspnoea. Methods: 34 clinically diagnosed HFNEF patients with proven cardiac limitation (72± 7 years, 23 females, LVEF 60± 7%, VO2max 17.9± 3.0ml/(min kg)) and 23 agematched healthy controls (70± 8 years, 15 females, LVEF 63± 8%, VO2max 30.9± 4.6ml/(min kg)) were recruited. Rest and submaximal supine exercise echocardiography were performed to comparable heart rate and blood pressure. Apical rotation and untwist were studied by speckle tracking. The mitral flow propagation velocity (Vp) was derived from colour M-mode Doppler. Results: LV apical systolic rotation and early diastolic untwist are significantly less at rest and on exercise in patients. Vp at rest is comparable between the two groups. However, the increase in Vp on exercise is significantly less in patients hence Vp is significantly lower than controls. LV early untwist correlates significantly with the increase in Vp (r= 0.43, p= 0.005) and VO2max (r= 0.526, p= 0.007). Exercise Vp also correlates with VO2max (r= 0.347, p= 0.03). Patients Controls p-Value Rotation rest (◦) 10.7 ± 4.1 13.9 ± 3.2 0.002 Rotation exercise (◦) 13.5 ± 4.8 17.6 ± 4.0 0.006 Untwist rest (◦) 24.3 ± 9.4 30.9 ± 9.7 0.013 Untwist exercise (◦) 22.1 ± 8.9 29.5 ± 7.8 0.008 Vp rest (m/s) 40.2 ± 10.8 39.8 ± 7.3 0.875 Vp exercise (m/s) 52.6 ± 12.0 62.4 ± 13.8 0.012 Conclusion: LV rotation and untwist mechanics are impaired in HFNEF. This is associated with reduced LV suction in early diastole and reduced exercise tolerance. The efficiency of LV rotation and untwist is crucial to aid rapid early diastolic filling particularly on exercise when heart rate is increased and diastole shortens. doi:10.1016/j.hlc.2009.03.042 Tuesday Young Investigators ASYMPTOMATIC LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AND RISK OF DEATH IN THE COMMUNITY Walter Abhayaratna, Katrina Hayes, Christine O’Reilly, Satoru Sakuragi, Niels Becker Australian National University, Canberra, ACT, Australia Background: There is limited information regarding the risk of death in asymptomatic individuals with left ventricular (LV) diastolic dysfunction (LVDD) and ejection fraction (EF) >50%. In this population-based study, we assessed mortality rates of subjects with LVDD without a history or clinical evidence of congestive heart failure. Methods and results:Weassessed diastolic function using comprehensive Doppler echocardiography in 1275 Canberra Heart Study participants (mean age 69 years; 50% men). Diastolic dysfunction was classified as mild or advanced (with elevated LV filling pressure). Prevalence rates of mild and advanced preclinical LVDD were 26% and 7.5% in women, respectively; and 24% and 6.9% in men, respectively. During a mean follow-up of 4.8 years, there were 61 deaths in preclinical subjects with EF> 50%. Death rates among individuals with normal LV diastolic function and mild LVDD were similar (0.8 vs. 1.1 per 100 person-years, respectively; p= 0.24). However, the rate of death among those with advanced LVDD (3.0 per 100 person-years)was higherwhen compared to subjectswith normal diastolic function and mild LVDD (p< 0.01 for both). After adjustment for age, sex, EF and cardiovascular risk factors, preclinical advanced LVDDwas associated with an increased mortality risk (adjusted Hazards Ratio 2.2, CI 1.1–4.2). Conclusion: Community-based adults with preclinical LVDD are at increased risk of death only when the condition is advanced and is associatedwith increased LVfilling pressures. doi:10.1016/j.hlc.2009.03.043 LEFT VENTRICULAR DYSSYNCHRONY EARLY AFTER NON-ST ELEVATION MYOCARDIAL INFARCTION INDEPENDENTLY PREDICTED LONG-TERM LEFT VENTRICULAR REMODELLING A. Ng, J. Vidiac, D.Y. Leung Liverpool Hospital, Sydney, NSW, Australia We evaluated the prognostic significance of LV dyssynchrony early after non-ST elevation myocardial infarction (NSTEMI). Methods: LV dyssynchrony was measured as standard deviation of times to 12 regional peak Smvelocities (SDTs) in 100 NSTEMI patients (age 60.0± 11.8 years, 71 men) prior to angiography, at 6 and 12 months. Significant dyssynchrony was defined as SDTs≥ 32.6ms. Results: LV end-diastolic volume (EDV) index decreased with time (47.1± 14.2mL/m2 vs. 46.4± 13.6mL/m2 vs. 43.1± 12.8mL/m2, p< 0.001) and was independently predicted by lower number of diseased vessels (p= 0.001) and revascularization (p= 0.041). LV end-systolic volume (ESV)

Vocal Cord Dysfunction in Patients With Exertional Dyspnea

To evaluate patients for vocal cord dysfunction (VCD) in a military population presenting with symptoms of exertional dyspnea. Cross-sectional, controlled study. Pulmonary disease clinic at an army tertiary care center. Forty military patients with complaints of exertional dyspnea and 12 military asymptomatic control subjects. Patients underwent direct visualization of vocal cords with flexible laryngoscopy before and after exercise to evaluate for presence of inspiratory vocal cord adduction. Complete evaluation for all patients consisted of spirometry with flow-volume loops, lung volumes, diffusing capacity, and maximum voluntary ventilation at rest; chest radiograph; methacholine bronchoprovocation testing; and a maximal cardiopulmonary exercise test with expiratory gas analysis. Fifteen percent of patients studied prospectively were found to have VCD, whereas all control subjects were negative for VCD. There was minimal difference in pulmonary function testing between VCD-positive and VCD-negative patients, whereas control subjects had higher spirometric values. Twenty percent of VCD-positive patients had abnormal flow-volume loops compared with 14% of patients without VCD, but after methacholine, 60% of VCD-positive patients developed abnormal flow-volume loops. In the VCD-positive group, 60% had a positive methacholine response, but there was less decrease in FEV(1)/FVC ratio compared with either VCD-negative patients or control subjects. Paradoxical inspiratory vocal cord closure is a frequent occurrence in patients with symptoms of exertional dyspnea and should be strongly considered in their evaluation.

Stress echocardiography for evaluation of hemodynamics: Valvular heart disease, prosthetic valve function, and pulmonary hypertension

A broad variety of diseases can affect dynamic cardiac function and contribute to exertional symptoms. Although hemodynamic data at rest may be sufficient to guide therapy in some patients with cardiovascular disease, medical and surgical decisions may be impacted by the cardiac response to stress and the ability to associate exertional symptoms with cardiac hemodynamic response. Stress echocardiography/ Doppler provides a unique noninvasive means to evaluate cardiovascular function and ehmodynamic responses during increased cardiac work. Specifically, stress echocardiographic/Doppler imaging allows assessment of the response to exercise of left and right ventricular function, transvalvular and prosthetic valve gradients, and right ventricular systolic pressure. It has substantial clinical use in the evaluation of patients with equivocal evidence of mitral stenosis, suspicion of dynamic mitral insufficiency or prosthetic valve dysfunction, aortic stenosis and impaired left ventricular systolic function, diseases associated with pulmonary hypertension or cor pulmonale, and among patients with dyspnea of unknown origin. The dynamic nature of cardiovascular disease and the broad spectrum of diseases that affect cardiac function make exercise echocardiography/Doppler an ideal tool ideal for the noninvasive assessment of patients with symptoms of exertional dyspnea.

Sudden Death in Young Patients With Congenital Aortic Stenosis

Four patients with congenital valvular and subvalvular aortic stenosis who died suddenly are presented in detail. Each had evidence of severe obstruction and left ventricular "strain" pattern on the electrocardiogram. Symptoms were present in three cases. Survey of the literature was done with particular reference to the usefulness of standard scalar electrocardiography and patient symptomatology in estimating the severity and the progression of the aortic obstruction. Of those who died suddenly with isolated aortic stenosis, 70% had left ventricular strain pattern, 21% had left ventricular hypertrophy alone, and 9% had an apparently normal electrocardiogram. Symptoms of exertional dyspnea, syncope, chest pain, and fatigue were present in almost all cases. Sudden death in the absence of severe ECG abnormalities and/or symptoms is very uncommon.