Value of left ventricular ejection fraction during exercise in predicting the extent of coronary artery disease
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An investigation was conducted to assess whether an algorithm based on simple clinical information would suffice to classify patients with acute myocardial infarction, with respect to indication for angiotensin-converting-enzyme inhibitor treatment. One hundred consecutive patients with myocardial infarction were prospectively studied. Based on clinical, radiological, electrocardiographic and biochemical information, the patients were classified as having (a) significantly depressed left ventricular function (ejection fraction < or = 40%) justifying treatment with angiotensin-converting-enzyme inhibitors (ACEI), (b) preserved ventricular function (ejection fraction > 40%) making ACEI unnecessary, or (c) indeterminate ventricular function, requiring further examination. Using a blinded design, ejection fraction was determined by echocardiography and radionuclide ventriculography. A clinical assumption of reduced left ventricular function had a predictive value of an echocardiographically determined ejection fraction < or = 40% of 83% (n = 23). Clinical criteria of good ventricular function had a predictive value of ejection fraction > 40% of 96% (n = 24). In these two groups clinical misclassification occurred in five patients with ejection fraction within the range of 39-45%. Left ventricular function was found to be clinically indeterminate in 53 of the 100 patients. Ejection fraction values assessed by radionuclide ventriculography (n = 44) were on average 9.3%-points lower than echocardiographic values. The indication for ACEI can apparently be determined on the basis of readily available clinical information in approximately 50% of patients with acute myocardial infarction.
Ventricular Function
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To assess the usefulness of a step by step evaluation of exercise left ventricular ejection fraction (LVEF), 219 consecutive patients with recent uncomplicated myocardial infarction and 30 normal subjects underwent a symptom-limited cycloergometer test followed by exercise radionuclide ventriculography (ExRNV). LVEF was monitored throughout the whole test. 49 patients underwent coronary arteriography for clinical reasons. 5 patterns of exercise LVEF could be observed: progressive increase: 55 patients (25%) and 27 normal subjects (90%); progressive decrease: 37 patients (17%); initial increase followed by significant decrease: 54 patients (25%); lack of initial modification and terminal decrease: 35 patients (16%); no modification: 38 patients (17%) and 3 normal subjects (10%). Grouping the patients in this fashion allowed us to increase the specificity of ExRNV from 70% to 100%, without loss of sensitivity (95%). As for the patients in subgroup C, 32/54 showed unequivocal ECG ischaemic changes, occurring simultaneously with LVEF decrease; in 33/54 LVEF dropped during the last workload; in 25/54 the last stage LVEF was equal to or higher than the basal LVEF. The statistical analysis showed that ischaemic ECG changes (P less than 0.0001), exercise-induced wall-motion abnormalities (P less than 0.0001), and the presence of multivessel coronary artery disease (P less than 0.0001) were significantly more frequent in patients showing patterns (b)-(d), which should be considered as ischaemic. Our method allowed the unequivocal identification of ischaemic patterns in LVEF during exercise, which might be missed if only its basal and final values are considered.
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Using equilibrium radionuclide ventriculography, the authors investigated left ventricular ejection fraction in 10 healthy men and in 57 men who had undergone their first transmural myocardial infarction (MI) 4 to 7 months earlier, were below 65 years of age and did not present signs of heart failure at the time of examination. Resting ejection fraction in healthy men amounted to 63 +/- 5%, in patients with uncomplicated MI to 54 +/- 7%, and in patients with clinical manifestations of heart failure in the acute phase to 37 +/- 8%. Patients with anteroseptal MI showed a negative correlation between the ejection fraction, on the one hand, and the sum of Q wave voltages in the precordial ECG map and the maximum value of serum creatine kinase in the acute phase of MI, on the other hand. The ejection fraction correlated with the degree of pulmonary hypertension during exercise. At work load of 50 W the ejection fraction measured in 31 patients was not significantly different shortly before discharge from hospital and 6 months after the onset of MI.
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The prognostic significance of changes in resting left ventricular ejection fraction was examined in 102 patients who underwent successful coronary artery bypass grafting. Between preoperative and early postoperative radionuclide ventriculography, mean resting left ventricular ejection fraction improved from 47.2% to 53.9% (p less than 0.01). Left ventricular ejection fraction increased by 5% or greater in 64 patients (63%), remained unchanged (within 4%) in 31 (30%), and decreased by at least 5% in 7 (7%). During 14 to 39 months (mean 27 months) of clinical follow-up, patients with normal preoperative left ventricular ejection fraction had a lower prevalence of recurrent angina, congestive heart failure, and mortality resulting from cardiovascular disease. Cardiovascular morbidity and mortality occurred with equal frequency for patients who did and did not show early postoperative improvement in left ventricular ejection fraction (36% versus 39%). Among 69 patients who had a third radionuclide ventriculography at late follow-up, left ventricular ejection fraction was less than the early postoperative value in 69% and less than the preoperative result in 36%. Patients with early postoperative improvement in left ventricular ejection fraction were more likely to retain resting left ventricular contractile function, at least at the preoperative level (71% versus 46%).
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Abstract The purpose of this study was to evaluate the effect of intra‐aortic balloon pumping (IABP) on left ventricular (LV) performance in ten patients (group I) with pump failure and in ten patients (group II) with angina pectoris. Left ventricular ejection fraction, regional ejection fraction, systolic chordal shortening and volumes were measured by first‐pass radionuclide ventriculography using a computerized multicrystal gamma camera. Patients in group I had significantly lower ejection fractions, regional ejection fractions and systolic chordal shortening and larger end‐diastolic and end‐systolic volumes than patients in group II, both on (p>0.0001) and off (p<0.004) IABP. With IABP, the ejection fraction increased by 0±0.5% in group I and 5.8±1.7% in group II (p=0.004); the regional ejection fraction increased by 0.1 ±0.9% in group I and 10.3±2.1% in group II (p=0.0004); the systolic chordal shortening increased by 1.1 ±0.6% in group I and 6.5 ±1.1% in group II (p=0.0006); the end‐diastolic volume decreased by ‐0.4±6% in group I and 14±4% in group II (p=0.07); and the end‐systolic volume decreased by ‐1±6% in group I and ‐21 ±5% in group II (p=0.02). Thus, IABP results in improvement in left ventricular performance in patients with angina pectoris but not in patients with pump failure.
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Thirty patients were prospectively studied to assess the value of radionuclide ventriculography (RNV) during step-wise dobutamine infusion for the detection of coronary artery disease (CAD). Radionuclide ventriculography was performed under basal conditions and during dobutamine infusion at each 10 μg kg-1 min-1 dose increment from 10 to a maximum of 40 μg kg-1 min-1. The test response was considered positive if the ejection fraction (EF) decreased by more than 5% or if segmental contraction abnormalities developed. Dobutamine stress testing was well tolerated, no complications and no significant arrhythmia were observed. In nine of 11 patients without CAD, EF increased more than 5% of the rest value and the left ventricular wall motion was normal in 10 of them during dobutamine infusion (specificity 91%). In 18 of 19 patients with CAD, new wall motion abnormalities (WMA) were identified in segments corresponding to the arterial lesions diagnosed by angiography (sensitivity 94%). Ejection fraction response was significantly different in normal subjects and in patients with CAD: 11 ± 5.9% versus 1.9 ± 9.5% (P < 0.01). However, abnormal EF response was found in seven of 19 CAD patients and development of new WMA was found to be a more sensitive and specific parameter than EF response for dobutamine RNV. It is concluded that dobutamine RNV is an accurate, widely available and cost-effective test for detecting CAD, especially in patients unable to exercise.
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