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Hypertrophic cardiomyopathy (HC) may transition to a phase characterized by systolic impairment resembling dilated cardiomyopathy. This study retrospectively assessed the incidence of left ventricular (LV) systolic impairment at initial clinical evaluation in 248 consecutive patients with HC (mean age 53 +/- 16 years). HC with systolic impairment was diagnosed if the LV ejection fraction was <50%, calculated by echocardiography. Twenty patients (8%) had HC with LV systolic impairment at initial evaluation. Patients with systolic impairment had a greater incidence of family histories of sudden cardiac death (SCD) than patients with preserved systolic function (25% vs 5.3%, p = 0.006) and more severe functional limitations (New York Heart Association class >or=III, p <0.001). All-cause mortality and cardiovascular mortality did not differ between the 2 groups. The incidence of SCD was 1.7% in patients with normal LV ejection fractions, and no SCD was observed in patients with systolic impairment. The latter group had more frequent major cardiac events (SCD, ventricular fibrillation, aborted cardiac arrest, and first implantable cardioverter-defibrillator discharge; p = 0.03). During follow-up, 2 patients progressed to HC with systolic impairment (annual incidence 0.85%). In conclusion, systolic impairment is not exceptional in patients with HC at initial evaluation and is associated with functional deterioration and major cardiac events.

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BACKGROUND: As a clinical analogue of ischemic preconditioning (IP), preinfarction angina (PA) shares a well-documented protective effect in the setting of acute myocardial infarction (AMI) by reducing infarct size, preserving left ventricular function and improving prognosis. In the experimental setting, multiple cycles of IP may induce the loss of this protection. OBJECTIVE: To evaluate the effect of repeated cycles of PA on clinical outcomes in patients exhibiting a first AMI. METHODS: Seventy-four consecutive patients with AMI, in whom PA was the surrogate of experimental IP, were studied prospectively. All patients had poor or no collaterals. The patients were divided into three groups: group 1 (n=32) comprised patients without PA (control subjects); groups 2 (n=24) and 3 (n=18) comprised patients reporting one to four and more than four episodes of new-onset PA, respectively (preconditioned groups). Both of the preconditioned groups were compared with the control subjects with regard to creatine kinase-MB release, corrected Q-T interval (QTc) at discharge and major in-hospital complications. RESULTS: Compared with the control subjects, groups 2 and 3 exhibited reduced creatine kinase-MB release (75+/-26 IU/L and 85+/-22 IU/L versus 172+/-13 IU/L, P=0.004 and P=0.024, respectively), lower discharge QTc values (418+/-15 ms and 422+/-19 ms versus 443+/-38 ms, P=0.004 and P=0.031, respectively), and a reduced incidence of postinfarction angina (25% and 11% versus 44%, P<0.05), arrhythmias (0% and 0% versus 22%, P<0.05) and pulmonary edema (4% and 0% versus 28%, P<0.05). CONCLUSIONS: Regardless of the number of recurrences, IP seems to be a powerful intervention to reduce infarct size, limit QTc at discharge and improve the outcome in patients with AMI.

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Right ventricular (RV) infarction (RVI) is usually associated with severe RV global dysfunction representing predominantly stunned myocardium that may respond favorably to reperfusion. We assessed the efficacy of low-dose dobutamine stress echocardiography (DSE), performed early in the course of a reperfused RVI, to predict the recovery of RV systolic and diastolic function in 3 months, documenting the recovery of stunned myocardium. In all, 27 patients with acute, successfully thrombolyzed RVI comprised the study population. All patients underwent standard echocardiography at baseline and 3 months later for evaluation of RV systolic and diastolic function. At day 5 DSE was performed for evaluation of RV contractile reserve. Of the total number of segments analyzed, 69% were detected as stunned. At baseline, RV systolic and diastolic indices were seriously impaired showing significant improvement at follow-up. RV wall-motion score index during DSE was positively correlated with the same index at follow-up. DSE is a safe and precise modality to predict recovery of stunned myocardium in the setting of RVI.

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Diabetic cardiomyopathy is a distinct entity in diabetic patients with congestive heart failure, who have no angiographic evidence of significant coronary artery stenosis. The aim of this study was to evaluate left ventricular (LV) function in 24 elderly patients (mean age 67 +/- 2 years) with type 2 diabetes, who were asymptomatic and had no history of hypertension, or coronary or valvular heart disease. LV systolic indices (ejection fraction [EF] and fractional shortening [FS]), diastolic indices (E wave, A wave, E/A ratio, isovolumic relaxation time [IVRT] and deceleration time [DT]) and the myocardial performance index (MPI) were evaluated with echocardiography. Compared to controls (24 age- and gender-matched normal subjects), the E wave was reduced (0.60 +/- 0.10 m/sec vs 0.72 +/- 0.08 m/sec, p < 0.05), the A wave was increased (0.77 +/- 0.07 m/sec vs 0.68 +/- 0.06 m/sec, p < 0.05), the E/A ratio was decreased (0.78 +/- 0.20 vs 1.06 +/- 0.18, p < 0.001) and both IVRT and DT were prolonged (0.115 +/- 0.01 sec vs 0.09 +/- 0.01 sec, p < 0.001 and 0.240 +/- 0.04 sec vs 0.180 +/- 0.03 sec, p < 0.001, respectively). The MPI was significantly increased (0.640 +/- 0.170 vs 0.368 +/- 0.098, p < 0.001). LV diastolic function and the MPI are markedly impaired in asymptomatic elderly patients with type 2 diabetes.

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We evaluated right ventricular (RV) systolic and diastolic function in 30 patients with acute RV myocardial infarction on echocardiography. Systolic and diastolic function were impaired early in the setting of RV myocardial infarction, but improved significantly at 3 months.

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OBJECTIVE: Elevated plasma total homocysteine (tHcy) levels constitute a risk factor for coronary artery disease (CAD). We prospectively examined the association of fasting tHcy levels in patients in Northern Greece who had established CAD. PATIENTS AND METHODS: Plasma fasting tHcy levels were measured in 42 patients with angiographically documented CAD and compared to 42 age-, sex-, BMI- and smoking habit-matched control subjects. We also determined the plasma vitamin B(12), folic acid and lipoprotein levels in all patients and controls. Conventional risk factors for CAD were also estimated. RESULTS: In a univariate analysis, tHcy (micromol/l) levels were higher in patients compared to controls almost reaching statistical significance (13 (7-41) vs 11.3 (4-39); p= 0.07). Multivariate analysis of conventional risk factors showed that tHcy levels were not an independent risk factor for CAD. However, tHcy levels were significantly higher in patients with a previous history of myocardial infarction compared to patients without such a history and to controls (15 (8.8-29) vs 11.7 (7-41); p = 0.007 and 15 (8.8-29) vs 11.3 (4-39); p = 0.002, respectively). Hyperhomocysteinaemia (> 15 micromol/l) was detected in 35.7% of patients and 11.9% of controls (p < 0.05). CONCLUSIONS: In Northern Greece, plasma tHcy levels may not be an independent risk factor for CAD in patients with angiographically documented CAD. However, patients with CAD have a trend towards higher tHcy levels. Additionally, plasma tHcy levels may be associated with the development of myocardial infarction.

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BACKGROUND: Several studies have demonstrated the protective effects of preinfarction angina in Q wave myocardial infarction, implicating the role of ischemic preconditioning but this role remains uncertain in patients with a NSTEMI. Subendocardial viability in NSTEMI patients, is thought to be less dependent on collateral circulation and thus more likely to be protected by other mechanisms such as preconditioning. METHODS: We have studied prospectively 40 patients with first NSTEMI and with angiographically proven poor or no collateral development and compared two groups; those with versus those without preinfarction angina. All in-hospital events, such as recurrent angina, congestive heart failure, arrhythmias and reinfarction were recorded. Serum markers of myocardial necrosis (CPK, CPK-MB, AST) and discharge QTc values were estimated. RESULTS: Preconditioned patients suffered less recurrent angina (18 vs. 55% P=0.014), congestive heart failure (0 vs. 22%, P=0.02), arrhythmic events (0 vs. 27%, P=0.008) and had significant smaller values of mean peak CPK (381 +/- 152 vs. 859 +/- 496 I.U./l, P=0.0008), mean peak CPK-MB (45.5 +/- 24.6 vs. 105.2 +/- 87 I.U./l, P=0.01), mean peak AST (59.8 +/- 23.1 vs. 112.4 +/- 64.3 I.U./l, P=0.003) and QTc value at discharge (0.42 +/- 0.03 vs. 0.46 +/- 0.05 s, P=0.005) than patients without preconditioning. Multiple logistic regression analysis confirmed that the absence of preinfarction angina (relative risk 9.10, 95% CI 2.08-40.00, P=0.003) was a significant predictor of in-hospital complications. CONCLUSIONS: Preinfarction angina constitutes a strong clinical correlate to ischemic preconditioning in patients with first NSTEMI, offering serious protection, by improving in-hospital outcome and reducing infarct size.

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BACKGROUND: Preinfarction angina (PA) consists a strong clinical correlate to ischemic preconditioning (PC) and seems to occur in a bimodal time course. The aim of the study is to evaluate the impact of both forms of PC on QTc value representing myocardial electric stability, in patients with a first NSTEMI. METHODS: Forty-eight patients, with first NSTEMI and poor or no collateral development were enrolled in the study. QTc at admission and discharge were recorded. All patients had comparable admission QTc values and were divided into three groups according to the absence or presence and exact timing of preinfarction angina. The first group consisted of 20 patients who did not report PA (PA-, representing no PC effect); the second group of 12 patients with reported PA within 12 hours prior to admission (12h PA+, representing the classic form of PC); and the third group of 16 patients reporting PA within 12 to 48 hours prior to admission (48-hour PA+, representing the delayed form of PC). The primary outcome was determined as the effect of PA on QTc value at discharge. RESULTS: Discharge QTc values were significantly reduced in both (PA+) groups compared to (PA-) group (412 +/- 50 vs. 455 +/- 53 ms, p = 0.015 and 417 +/- 29 vs. 455 +/- 53 ms, P = 0.033, respectively). Both groups of (PA+) patients compared to (PA-) patients suffered no arrhythmic events during their hospitalization (0/12 vs. 6/20, P = 0.04 and 0/16 vs. 6/20, P = 0.02). CONCLUSIONS: Both forms of preconditioning, similarly and significantly reduce QTc value at discharge in patients experiencing a first NSTEMI, suggesting possible protection from future arrhythmic events.

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