Backgruond: Systemic sclerosis (SSc) is a connective disease characterized by fibrosis and vascular remodelling with poor long-term survival of patients who develop pulmonary arterial hypertension (PAH).Exercise echocardiography might improve the early diagnosis of PAH by unmasking exercise-induced PAH (ex-PAH) but is not feasible in all SSc patients.We sought therefore to investigate whether pulmonary artery enlargement and right ventricle (RV) dysfunction were parameters indicative of ex-PAH.Methods: 89 SSc patients with normal resting systolic pulmonary artery pressure (sPAP) and without severe pulmonary function abnormalities underwent exercise echocardiography and multislice computed tomography (MSCT).They were divided into two groups according to the presence of ex-PAH, defined by sPAP >45 mmHg.Right ventricular (RV) function was evaluated using 2D strain.The ratio of main pulmonary artery diameter (mPA) over the diameter of ascending aorta (Ao) was determined using MSCT.Results: As compared with non ex-PAP group, ex-PAH group was older (60 ±10 vs 50 ±13 years, p=0.001), had higher exercise sPAP (54 ±10 vs 34 ±6 mmHg, P<0.001), increased mPA diameter (33.6 ±4.5 vs 30.6 ±3.9 mm, P=0.003) and mPA/Ao ratio (1.1 ±0.1 vs 1.0 ±0.1, P=0.001).Global RV free wall strain was lower in ex-PAH group than in non ex-PAP group (24 ±5 vs 30 ±5%, P<0.001).Exercise sPAP was significantly correlated with mPa/Ao ratio.Sensitivity and specificity of mPa/Ao ratio >1 to identify ex-PAH was 80% and 81%, respectively.Multivariate analysis identified age, RV strain and mPa/Ao ratio as independent parameters indicative of ex-PAH. Conclusions:In SSc patients with normal resting sPAP, increase in mPa/Ao ratio and decreased RV strain are parameters that can indicate the presence of exercise PAH.
The aim of this study was to assess a Doppler-echocardiographic parameter which has not been previously reported for the diagnosis of acute cardiac rejection. The parameter was left ventricular isovolumic relaxation blood flow. Eighty patients who had undergone orthoptic cardiac transplantation were followed up regularly with echocardiography for a period of 2 years. In all, 495 echocardiographic studies were performed and the results compared with those of endomyocardial biopsy performed on the same day (11.4 echocardiographic studies per patient). In the absence of cardiac rejection, isovolumic relaxation Doppler signal was recorded in all patients (364/387 echo studies). This was a positive signal directed towards the apex detected by continuous mode Doppler in the apical position, arising along the interventricular septum in the mid part of the left ventricle (82% of cases) or from the basal region of the septum (18% of cases) and lasting throughout the phase of isovolumic relaxation. The maximal velocity was 0.53 +/- 0.08 m/s (range 0.32 to 0.73 m/s) : the velocity-time integral was 34 +/- 33 cm. This signal was associated with medioventricular endosystolic acceleration of blood flow in 75% of cases. The incidence of the isovolumic relaxation flow signal decreased in cardiac rejection with no significant changes in the other usual Doppler-echocardiographic parameters except for a significant decrease in the ejection fraction in the group with severe rejection. In the group with mild rejection (n = 89) an isovolumic relaxation flow signal was only observed in 52 cases (including 29 in whom immunosuppressive treatment was not increased). In patients with moderate rejection (n = 12) there were only 5 cases in which a isovolumic relaxation flow signal was recorded, and in the group with severe rejection (n = 7), the signal could only be recorded in 1 case. The authors conclude that the absence of an isovolumic relaxation blood flow signal in a cardiac transplant patient is a reliable sign of cardiac rejection with an excellent specificity (94%). The absence of this signal is a sensitive indicator of severe rejection (86%) but less so for moderate (58%) or mild rejection (42%).
BackgroundRecommended medications are under-prescribed in elderly patients with atrial fibrillation (AF), coronary artery disease (CAD), and congestive heart failure (CHF). The relationship between under-prescribing and comorbidity is unclear.
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