Download Transmitral Flow Changes during DipyridamoleInduced lschemia*

Transmitral Flow Changes during
DipyridamoleInduced
lschemia*
A Doppler-Echocardiographic
Fabio L.attanzi,
MD;
Francesco
De Prisco,
Antonio
L’Abbate,
Study
Eugenio
Picano,
M. D. ; Alessandro
M.D.;
Michele
Masini,
Distante,
M. D. ; and
M.D.
in altered
left ventricular
(LV)
by an abnormal
mitral inflow
pattern
on Doppler
echocardiography.
To investigate
the
relationship
of Doppler
echocardiography
and
regional
myocardial
systolic function
during dipyridamole
infusion,
we evaluated
transmitral
flow changes
detected
by pulsed
Doppler
technique
during a high-dose
dipyridamole
echocardiography
test (DET, two-dimensional
echo monitoring
with dipyridamole
infusion,
up to 0.84 mg/kg
over
10 mm).
The DET response
produced
two
groups:
group
1 (34
Myocardial
diastolic
ischemia
results
compliance,
patients)
with
reflected
negative
and
DET,
group
2 (35
patients)
with
positive
DET, defined as the development
of a newly onset
LV regional
asynergy.
The E/A values overlapped
at baseline
(1.07 ± .32 vs .92 ± .22; p NS) but differed at peak changes
(.92±
.26 vs .75±
.25; p<.Ol).
Heart
rate
changes
could not
A
transient
regional
ofmyocardial
of the dipyndamole
This
regional
sensitive
tion
and
asynergy
owing
to the induction
ischemia
is the diagnostic
end point
echocardiography
test (DET).’2
systolic
marker
energy;
seems
dysfunction
of the
relaxation
ischemic
are
is
an
event.
active
early
Both
processes
and
contracrequiring
however,
compared
with the former,
relaxation
to be more
sensitive
to small
changes
in
energetics.3
Recently,
clinical
studies
have
shown
that
mitral
inflow
velocity
curve,
observed
noninvasively
in man
by Doppler
technique,
is an index
of left
ventricular
(LV) diastolic
function
in resting
conditions.4#{176}Alterations
are associated
with
ation
owing
in the mitral
inflow
an acute
impairment
to myocardial
hemodynamic
sion has shown
velocity
curve
in LV relax-
ischemia.79
Biventricular
monitoring
during
dipyridamole
infuthat the dP/dt ofrelaxation,
an invasive
but
*From
also
the
Pisa, Pisa,
Manuscript
velocity
is not
on heart
Istituto
Italy.
received
rate,
di
curve,
dependent
Fisiologia
July
although
easy to obtain
on only relaxation,
myocardial
contractility,
Clinica
13; revision
del
accepted
Reprint requests:
Dr Lattanzi,
Institute
ofClinical
(library),
Via P Savi 8, Piza, Italy 56100
CNR,
blood
Universit#{224} di
November,
Physiology
account
of R-R
for the observed
Doppler
changes,
since the values
interval
were
similar
in the groups,
both basally
(.927±.226
vs .867±.143
5;
pNS)
and at peak dipyridamole (.754±
.100
vs.681±
.112; pNS).
Transient
myocardial ischemia
induced
by dipyridamole
adminisfration
is
accompanied
by changes
in transmitral
flow which consist
of an increase
in the relative
atrial contribution
to LV
filling,
possibly
owing
to an acute
impairment
in
LV
relaxation.
(Chest 1989; 95:1037-42)
DETdipyridamole
Accacceleration
deceleration
pendent
of the
The aim
and clinical
detected
CNR
test;
WMSwaII
mo-
rapid inflow
due to atrial
diastolic
inflow
topeaklate
velocity;
of early diastolic rapid inflow (cm/se); Dec=
of early diastolic rapid inflow (cm/s’)
pressure,
preload,
values
may change
and passive
compliance.
during
dipyridamole
possible
induction
of this work
significance
by pulsed
of
was to evaluate
of transmitral
Doppler
These
inde-
“s
stress
the presence
flow changes
technique
during
Doppler
monitoring
dipyri-
damole-induced
ischemia.
transmitral
flow,
echocardiographic
combined
with
two-dimensional
(2D echo)
monitoring,
was
tempted
in 94 patients
undergoing
MATERIAL
Ninety-four
patients
with a
years)
characterized
images
by
of
undergo
Exclusion
nosed
had
were
basis
21 women;
typical
for
in
the
resting
range, 36 to 71
artery
disease
or atypical
study.
chest
had
All
conditions
pain,
2D
and
echo
had
to
purposes.
were
the
of echo
presence
criteria),
treatment
of LV
valvular
fibrillation,
since these
mitral
inflow
velocity
discontinued
age
of coronary
of either
for diagnostic
at-
METHODS
enrolled
quality
of
DET
diagnosis
a history
criteria
on the
and atrial
Doppler
(73 men,
acceptable
DET
AND
presumptive
or at rest,
conditions
are
rv”
Patients
with
antianginal
hypertrophy
(diag-
or pericardial
known
entering
disease,
to affect
the
the study
medications
for at least
48h.
Dipyridamole
Echocardlography
Two-dimensional
were
performed
mg/kg
over
in 2 mm.
8.
echocardiography
peak velocity
of early
velocity
of late diastolic
E/A
ratioofpeakearly
tion
ScOre;
E
(cm/s);
A=peak
contraction(cm/s);
on effort
index
of LV diastolic
function,
provides
a sensitive
marker
of dipyndamole-induced
0 It seems
appealing
to monitor
noninvasively
myocardial
diastolic function
by Doppler
techniques.
Unfortunately,
the mitral
valve
and to analyze,
M.D.;
lest
echocardiographicand
in combination
4 mm,
followed
The cumulative
12-lead
with
by 4 mm
dose,
a dipyridamole
of no dose,
therefore,
was 0.84
ECC
monitoring
infusion:’
then
0.28
mg/kg
0.56
mg/kg
over
10
mm.
Aminophyllmne
(240
mg),
which
promptly
reverses
CHEST/95/5/MAV,1989
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the
effects
of
1037
dipyridamole,
pressure
and
sional
was
readily
the
ECG
at hand.
were
echocardiograms
to 20 mm after
cially
model
needed
to obtain
2.5-
a wall
and
motion
the
minute.
imaging
3.5-MHz
waveforms
blood
system
(WMS)
we relied
views).
and
thickening
of the
of
the
left
segment
for
the apex and
(septal,
was
into
A WMS
diastolic
rapid
inflow
diastolic
rapid
inflow
WMS
0 (akmnetic),
left
ventricle
The
test
vs
negativity),
the
subsequent
WMS
was
ofthe
segments
for
each
of
inferoposterior),
middle
third,
adding
the
mg)
wall
average
to
each
by
linked
two
was
ofa
through
ofa
Angiographic
binding
a consensus
the
before
results
and
all
cases,
the
ofthe
end
ofthe
Doppler
The
of the
and
maximal
was
positioned
received
was
oriented
that
three
excursion
of the
through
valve
diastolic
blood
and
(cursor),
this
patient.
left
flow
angle
The
peaks
volume
usually
position
of diastolic
flow
was
as steady
as possible
velocity
1 mm
For
each
changes
occurred
at
positive
tests,
dipyridamole
For
each
the
time
state
points
and
were
peak
in transmitral
Doppler
peak
and
dose
time
ischemia
(just
before
at 1 to 6 mm
in negative
point
after
each
test,
E
ofA
made
the
Acc
=
more
with
flow
in
full
the
left
or
were
observers,
angiograms.
A vessel
if its diameter
respect
to the
ventricular
with
fraction
value
for
was
prestenotic
was
end-diastolic
a fluid-filled
calculated
frames
the
mean
and
by
paired
significance
data
by
x’
and
coronary
test.
A p value
SD
the
are
given.
pres-
Left
catheter.
on
with
and
artery
of Doppler
Doppler
end-diastolic
Dodge
and
method.
Differences
unpaired
<0.05
(CAD)
was
were
Student’s
disease
extent
considered
test.
t
were
statistically
Study
study
was attempted
for DET.
Four patients
ofa poor apical window,
Doppler
examination
patients
cardia
had to be
in baseline
could
velocity
and interobserver
during
be
Variability
Dec
obtained
in the
ofDoppler
study;
two
because
of resting
which
precluded
remaining
more
tachythe
Dec
=
Transmitral
rate
Aow Changes
The
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/10/2017
Dec
9.9±4.9
of E wave;
durin9
%
Acc
5.0±2.7
deceleration
69 patients.
Variability,
A
4.8±2.1
E wave;
94 patients
Parameters*
E
9.0±5.3
ofthe
in the
had to be excluded
which
precluded
the
2D echo
excluded
conditions,
Interobserver
rate
artery
independent
obstruction
measured
%
acceleration
coronary
Judkins
acquisition
of readable
resting
Doppler
tracings.
Another
19 patients,
with dipyridamole-induced
tachycardia,
were excluded
for the same reason.
Interpretable Doppler
tracings
during
control
and during
DET
usually
of the
8.9±4.9
wave;
Two
selective
the
Analysis
each
enrolled
because
every
when
Acc
3.3±2.2
velocity
was
ventriculographic
The
kept
injection)
diastolic
and
either
coronary
significant
examination,
end-systolic
Feasibility
quantifiable
This
1-lntraobserver
A
4.2±3.6
for
administration
Variability,
difference
observation
RESULTS
diastolic
effect,
recorded.
LV
the
first
The
significant.
tests.
in
as
of each
the
or
ejection
Doppler
was
were
ammnophylline
the
first
evaluation.
ofthe
using
views.
analyzed
of the
and
recordings
considered
were
again
the
highest
the
conditions
dipyridamole
flow
Intraobserver
peak
and
The
All
first
ventriculography
views
craniocaudal
ventricular
evaluated
of
annulus,
the
volume
test.
challenge.
area
sample
in resting
was
after
beam
valve
until
recorded,
recorded
cycles
calculated
value
sets)
20#{176}
in each
inflow
mitral
the
Feasibility
to achieve
direction
than
Multiple
70 percent
(LVEDP)
tested
from
ultrasound
adjusted
ofthe
Table
=
the
left
arteriography,
to have
by
For
apnea.
two
basal
maximal
taken
in the
was
were
throughout
was
was
to the
line
position
dipyridamole
test,
evaluation:
cursor
The
waveform
during
positioned
inferior
velocity
optimal.
expiratory
during
sure
line
ventricle
to be 0#{176}
or less
was
the
of
was
(ten
To determine
month
of his
by the
biplane
data,
considered
Statistical
cursor
the presumed
orientation
1 to 2 cm
along
waveform
flow
to 240
LV cavity
The
left
care
sets).
of cardiac
one
independ-
at rest
tract.
foui’chamber
of the
the
Great
estimated
apical
leaflets.
traversing
between
the
an
valve
annulus.
angle
was
sample
ventricle,
and its
(50
visualization
mitral
a plane
the apex to the mitral
the smallest possible
obtain
good
set
least
divided
technique.
narrowed
interpretation
IV aminophylline
to
provided
at
observers
cycles
(ten
knowledge
coronary
to clinical
was
Examination
heart
two
of cardiac
same
the
values
including
blind
test.
transducer
view
Sones
During
patients
of early
administration
underwent
left
obtained,
study,
None
findings
(5) deceleration
Studj
and
the
the
in
decision.
right
asynergy
about
reviewed
was
to angiographic
observers.
transient
a disagreement
judgment
and
1).
(Table
normokinetic
independent
observer
sets
of difference
two
of the
of early
+ 1 (hypoki-
score
to detection
a third
majority
required,
PuLsed
the
diastolic
ratio
(4) acceleration
variability,
same
without
percentage
oflate
(3) the
in cm/s’).
observer
and
between
assigned
one
velocity
in cmls);
the
of early
Measurements
variability,
interpretation
apex.
score
the
tracing,
velocity
(E/A);
in cm/s’);
(Dec,
interobserver
by
(A,
characterized
each
(1) peak
(2) peak
ratio
were
For
obtained:
velocity
(Acc,
cycles
averaged.
in can’s);
dipyridamole
Patients
there
had access
at the
1038
LV
each
during
evaluated
videotapes.
When
*A
so that
and
The
four
late
interpreted
intraobserver
one
the
+ 2 (normokinetic),
1 (dyskinetic).
was
assigned
observers
two
and
of
the
cardiac
contraction
ofDoppler
To assess
motion
segments,
analyzed
When
(positively
of wall
to peak
Reproducibility
18.
were
ofthe
purpose
degree
nine
graded
-
thus
videotapes
of contraction.
the
the
into
by
was
and
was
Positivity
For
and
divided
third,
derived
The
ventricle
early
(E,
atrial
2D
was
lateral,
basilar
was
segment.
netic),
ventricle
anterior,
divided
left
myocardium.
analysis,
walls
the
values
inflow
to the
on the apical
and
center
due
peak
echo
three
the
were
we
ently
the
rapid
inflow
to combine
least
measurements
diastolic
approach
Wall motion
abnormalities
were
evaluated
both
at rest and at
peak dipyridamole
dose in each patient.
The evaluation
was based
on the subjective
impression
ofthe
inward
motion
ofthe
endocardial
toward
at
and
following
(HewlettBecause
primarily
from
quantitatively
Two-dimen-
tranducers).
score
monitoring,
two-chamber
procedure,
recorded
during
and up
We used a commer-
administration.
phased-array
77020;
Doppler
(four- and
the
each
continuously
wide-angle,
Packard
echo with
were
dipyridainole
available
During
recorded
E
Dipyridamole
peak
8.5±5.0
velocity
IndUCed
of E wave.
schemia
(Lattanzi eta!)
Table
4-Variation
in Doppkr
E
1
Dip
64.9
2
55.1
3
57.1
62.1
±15.6
*A
=
peak
after
velocity
of A wave
(cmls);
Acc
or peak
diastolic
filling are notably
rates,
which
progressively
altered
increase
=
acceleration
changes);
rate
E
velocity
754
688
.75t
(cmls2);
367
7851
(cmls);
=
Dec
E/A
ratio;
.887
388
306
.959
3844
deceleration
.7711±098
.734t
±269
±103
.867
±142
R-R
Dip
±155
±180
±106
= basal;
Bas
403
±227
±318
Bas
±140
366
828
644
Dip
±129
±221
±256
of E wave
Groups*
R-R
Bas
±205
±263
±25
of E wave
peak
Dip
737
.88
±22
in the Three
Dec
±207
±21
.92
±20.1
(ischemia
=
dipyridamole
83.51-
±18.5
.95
±36
DET
Bas
±29
1.03
±13.9
62.6
±17.0
Dip
±28
7.28t
±7.0
During
Acc
1.10
±21.8
53.3
±14.7
Bas
74.9t
±13.7
66.1
±18.1
Dip
59.3
±14.9
Rate
E/A
Bas
69.6
±17.7
Heart
and
A
Bas
Group
Parameters
.681t
±143
rate
±112
of E wave
(cmls2);
on ECC
R to R interval
Dip
(S).
1-= p<O.OOl.
:
p<0.Ol.
=
contribution
of the normal
infusion,
even
However,
heart
rate
between
as E/A
ratio)
in the
R-R
negative
cannot
and
difference
administration
positive
of Doppler
be directly
correlated
s
and
‘
in CAD
the
since
damole
(such
to variations
patients
reported
with the impairment
in spite of the increased
n’
recording
of
at over
dial
stress
ischemia
the
can
of
,
atrial
contribution
several
models
without
dipyridani
:
,p
.
?jS,
#{149}5!
interpretable
evidence
development
provoke
that
of
dipyrimyocar-
of the
LV dP/dt
the increase
of the
filling recognized
in
This
mechanism
is
_______
.
.
during
a decrease
can explain
in ventricular
of ischemia.69”7
I
Doppler
a fusion
of significant
This
LV
infusion.1016
the limiting
90 to 95 beats/mm,
E and A waves
occurs.
There
is some
direct
interval.
normal
for
tracings,
in
DETs.
indices
previously
relaxation
rate induced
by dipyridamole
The
stress-induced
tachycardia
is also
factor
no significant
dipyridamole
differences
those
mimic
of LV diastolic
tests.’2
was
after
with
intergroup
heart
atrial
Mild tachycardia
is a part
response
to dipyridamole
in negative
there
increase
patients
Thus,
In
to LV filling.”
hemodynamic
by increasing
the relative
“I
‘
-
C
.,
h4_.k
!
-,
-I
J.5W#{149}W
-U..,
z’;,
Ic
.-
.
t
!
I:
a
-‘S
S
.‘4:’
‘
j
‘
BASAL
1. Two-dimensional
FIGURE
(lower
panels)
shows
tracings,
an
in resting
akinesia
the E/A
in the A wave-during
1040
.,
_
.‘
kk
-
.1
.
I
.
.4, 4:1 4
DIPYR
end-systolic
conditions
involving
the
ratio is balanced
panels) and transmitral
inflow
velocity
ischemia
during
dipyridamole.
Two-dimensional
distal
septum
during
dipyridamole
infusion.
In the
conditions
(BASAL),
hut it decreases-mostly
for the
ischemia (DIPYR).
frames
(upper
(left) and at peak
apex
and
in resting
dipyridamole-induced
Transmitral
Flow
Changes
during
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/10/2017
Dipyridamole
profiles
echo
Doppler
increase
Induced
Ischemia
(Lattanzi
at a!)
BASAL
DIPYRIDAMOLE
I
I
I
18
E/A
WMS
14
10
6
2
E/A
0
U
4. E/A and
tests (group
FIGURE
ography
able
in patients
nounced
with
in the
wall
3).
motion
DET,
score
were
E/A
<
reduction
WMS
=
with
reduction
WMS
=
negative
group
WMS
>
(WMS)
more
documented
5
*
5
**
variations
a feasible
it remains
triggered
very
well
virtually
buried
by dipyridamole
mimic
on transmitral
or mask
flow
We
for secretarial
measuretest
is
diagnostic
function,
curves,
individual
effect
E,
L’Abbate
very
to
Ms.
gina
pectoris.
2 Picano
E,
A,
Am
J Cardiol
dipyridamole-echocardiography
toris.
J Am Coll Cardiol
WH,
1985;
F, Masini
dose
3 Gaash
Morales
Dipyridamole-echocardiography
Lattanzi
12
and
left
Doppler
1042
ventricle
technique.
Asao
blood
in
M,
flow
health
Jpn
Circ
during
E,
in man
[Abstract].
Picano
E, Simonetti
MG,
test
in effort
in effort
F,
velocity
patterns
Herzog
and
1982;
diastolic
disease-a
46:92-96
study
behaviour
of
pulsed
CY,
function
DA,
of
Hintze
J
Cardiol
M,
function
1989;
(in press)
of transmitral
1988;
flow
function:
and
Doppler
new
echocar-
12:426-40
which
affect
the
diastolic
MA,
Asinger
42:171-80
M,
left
MA.
ischemia
F, Macarata
Murakami
ventricular
diastolic
echocardiography
MC,
filling
J
[Abstract].
Weyman
Vatner
arteries
AE,
Fifer
indexes
of
J Am Coil Cardiol
in humans.
Hutha
1986;
TH,
Morales
diastolic
Manoles
Doppler-derived
JC,
approaches
coronary
by
2):230
Relation
1978;
Doppler
Herrmann
Danford
M,
biventricular
Am
RL.
on
V.
diastolic
1987; 9:197A
of
diography
T, Abe
KJ,
pacing
pulsed
diastolic
graphic
Left
implications.
Masuyama
Elsperger
dependence
pec-
JK.
Choong
global
Res
Deligonal
and
myocardial
74(suppl
Factors
Circ
K.
produced
C, Lattanzi
J Am Coll Cardiol
of atrial
by
Lombardi
venticular
WW.
M,
ischemia
hemodynamic
curve.
CA,
Effect
left
Parmley
Am Coil Cardiol
an-
16
J,
Tanouchi
reflecting
J
Mexander
clinical
to
a combined
SA,
D,
and
Popp
Kato
myocardial
echocardiography
by transient
testing.
LK,
J
10:748-55
1986;
stress
study.
Glantz
1987;
Regional
Hatle
from
measured
A. High
angina
al.
in
systolic
myocardial
induced
H,
filling
Vandormel
I, Carpeggiani
dipyridamole
CP,
M,
Circulation
et
Appleton
T, Watanabe
ventricular
A, Rovai
flow
of left
of Doppler
techniques.
Doppler
Kern
Cardiol
Distante
in mitral
cine-
5:1155-60
ofleft
Coil
assessment
analysis
ventricular
transient
Am
pressure-volume
15
MA,
the
Lattanzi
A, L’Abbate
Qumnones
H, et al. Transmitral
MK,
filling
with
angiographic
1985;
Evaluation
J
insights
14
Distante
test
M,
AJ, Lewen
MA.
diastolic
Noninvasive
comparative
dimensional
Cardiol
angioplasty.
during
1986; 8:848-54
HJ,
A, Inoue
MA,
RO.
right
Coil
9 Moscarelli
11
99:452-56
M,
ventricular
compliance:
mechanisms
Am J Cardiol 1976; 38:845-50
4 Kitabatake
Levine
Am
HL.
Triveila
and
Quinones
comparison
radionuclide
a two
with
J
MC,
ventricular
71:543-50
function:
of left
dysfunction
R.
M,
1982;
and
Assessment
13
Masini
Limacher
ofleft
Am Coll Cardiol 1986; 7:518-26
7 Fuji J, Yazaki Y, Sawada
H, Aizawa
10
Antonella
WA,
BJ, Bonow
echocardiographic
of LV ischemia
grateful
echocardi-
echocardiography:
diastolic
Changes
assistance.
Distante
A.
P. Maron
diography
are
Zoghibi
Circulation
Kennedy
by hemodynamic
infusion,
which
the
LC,
Doppler
ventricular
REFERENCES
1 Picano
pulsed
angiography.
6 Spirito
dipyridamole
of parameters
8 Labovitz
pattern.
ACKNOWLEDGMENT:
Distante
R, Kuo
method.
dipyridamole
interest.
How-
severely
limited
by the poor feasibility
and
accuracy.
The
information
on LV diastolic
which
is present
in transmitral
flow-velocity
requires
a large
sample
population.
In the
may
with
noninva-
the clinical
appeal
of Doppler-derived
during
dipyridamole-echocardiography
positive
Determination
infarction
representing
sive window
on diastolic
events
during
stress,
is of potential
pathophysiologic
patient,
changes
p<O.OO1
with
5 Rockey
pro-
the presence
of more
pronounced
ischemia,
as independently
assessed
by the evaluation
(through
the
WMS) of the entity
and extent
of systolic
ischemic
ever,
ments
p<O.05
in patients
systolic
dysfunction
provoked
by dipyridamole-induced
ischemia; and (2) in patients
with
positive
DET,
a more
marked
alteration
in Doppler
indexes
was found
in
dysfunction.
This information,
WMS
Murphy
to ventricular
DJ.
MA.
left
1987;
Doppler
diastolic
Preload
ventricular
10:800-08
echocardio-
function.
Echocar-
3:33-40
SF.
Adenosine
in the
and
conscious
dipyridamole
dilate
dog.
Circulation
function
in
large
1983;
68:
1321-27
17 Grbic
M,
ischemic
Transmftrai
Sigwart
U.
[Abstract].
Flow
Changes
Left
atrial
Circulation
during
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/10/2017
Dipyridamole
1986;
74(suppl
Induced
acute
transient
2):360
Ischemia
(Lattanzi
et a!)
160
140
% E/A
von
120
oti on
‘a
.
100
J
80
::
60
2. Perceptual
variation
of E/A
ratio in the three
groups
after
dipyridamole
infusion.
If one takes
a 25 percent
reduction
of E/A as a criterion
of myocardial
ischemia
(horizontal
dashed line),
the sensitivity
for prediction
of angiographically
assessed
CAD
is 36 percent,
FIGURE
S S
S
40
S
____________
20
-
Groupi
Table
5-Variation
During
DET
Group
Group2
in E/A Doppler
Value
and Heart Rate
in Patients with Negative
and Positive Test*
E/A
tion,
increase
activity
Group
1 and
(n
Bas
2 (DET-)
=
1.07
*Bas
=
=
.92
±
.26
.927
±
LVEDP
Dip
.754
.226
.100
±
.75t±.25
.92±.22
.867±143
=
(5);
dipyridamole;
Dip
=
+
positive;
-
E/A
=
E, A ratio;
R-R
From
R to R
diastolic
markers
negative.
p<0.01.
and
also the
nounced
positive
In fact,
most
likely
explanation
decrease
in E/A
value
DET
than in patients
the heart
rate changes
with
different
dipyridamole-induced
responses
rate,
and
of69
atrial
compensatory
may
contribution
effects
that is secondary
percent.
hyper-
synergistically
in LV filling.
override
the
to ischemia
and,
afterload,
should
to LV filling.
increased
through
increase
the
a
relative
.681±112
Clinical
basal;
a specificity
contraction”7
combined
rise in left atrial
atrial contribution
35)
interval
t
.32
Bas
34)
3(DET+)
(n
±
Dip
atrial
relative
These
with
in heart
ofleft
increase
R-R
3
of the more
in patients
prowith
theoretical
viewpoint,
indices
might
of myocardial
Doppler-derived
have a clinical
appeal
as useful
ischemia.
They
proved
early
indicators
models,
coronary
myocardial
of acute
such
as
ischemia
coronary
BASAL
D I PYR
in other
angioplasty9
vasospasm.’#{176} Also, with dipyridamole
ischemia
can contribute
to the
changes
in Doppler
indices
of diastolic
function.
Two lines of evidence
support
sion: (1) significant
E/A changes,
although
to DET
In patients
with
ischemia,
impaired
LV relaxa-
I
the
sensitive
clinical
with a negative
DET
are similar
in patients
Implications
or
stress,
recorded
myocardial
this conclualso detect-
I DAMOLE
I
I
1200
I 000
900
800
R-R
700
ma
600
500
400
300
200
100
0
E/A
0
=
DET
U
=
DET positive
negative
3. E/A and R-R interval
variations
2) and positive
(group
3) DET.
FIGURE
and
R-R
*
during
=
p<O.O1
dipyriclainole
test
in patients
with
negative
(groups
CHEST/95/5/MAV,1989
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/10/2017
1
1041
BASAL
DIPYRIDAMOLE
I
I
I
18
E/A
WMS
14
10
6
2
E/A
0
U
4. E/A and
tests (group
FIGURE
ography
able
in patients
nounced
with
in the
wall
3).
motion
DET,
score
were
E/A
<
reduction
WMS
=
with
reduction
WMS
=
negative
group
WMS
>
(WMS)
more
documented
5
*
5
**
variations
a feasible
it remains
triggered
very
well
virtually
buried
by dipyridamole
mimic
on transmitral
or mask
flow
We
for secretarial
measuretest
is
diagnostic
function,
curves,
individual
effect
E,
L’Abbate
very
to
Ms.
gina
pectoris.
2 Picano
E,
A,
Am
J Cardiol
dipyridamole-echocardiography
toris.
J Am Coll Cardiol
WH,
1985;
F, Masini
dose
3 Gaash
Morales
Dipyridamole-echocardiography
Lattanzi
12
and
left
Doppler
1042
ventricle
technique.
Asao
blood
in
M,
flow
health
Jpn
Circ
during
E,
in man
[Abstract].
Picano
E, Simonetti
MG,
test
in effort
in effort
F,
velocity
patterns
Herzog
and
1982;
diastolic
disease-a
46:92-96
study
behaviour
of
pulsed
CY,
function
DA,
of
Hintze
J
Cardiol
M,
function
1989;
(in press)
of transmitral
1988;
flow
function:
and
Doppler
new
echocar-
12:426-40
which
affect
the
diastolic
MA,
Asinger
42:171-80
M,
left
MA.
ischemia
F, Macarata
Murakami
ventricular
diastolic
echocardiography
MC,
filling
J
[Abstract].
Weyman
Vatner
arteries
AE,
Fifer
indexes
of
J Am Coil Cardiol
in humans.
Hutha
1986;
TH,
Morales
diastolic
Manoles
Doppler-derived
JC,
approaches
coronary
by
2):230
Relation
1978;
Doppler
Herrmann
Danford
M,
biventricular
Am
RL.
on
V.
diastolic
1987; 9:197A
of
diography
T, Abe
KJ,
pacing
pulsed
diastolic
graphic
Left
implications.
Masuyama
Elsperger
dependence
pec-
JK.
Choong
global
Res
Deligonal
and
myocardial
74(suppl
Factors
Circ
K.
produced
C, Lattanzi
J Am Coll Cardiol
of atrial
by
Lombardi
venticular
WW.
M,
ischemia
hemodynamic
curve.
CA,
Effect
left
Parmley
Am Coil Cardiol
an-
16
J,
Tanouchi
reflecting
J
Mexander
clinical
to
a combined
SA,
D,
and
Popp
Kato
myocardial
echocardiography
by transient
testing.
LK,
J
10:748-55
1986;
stress
study.
Glantz
1987;
Regional
Hatle
from
measured
A. High
angina
al.
in
systolic
myocardial
induced
H,
filling
Vandormel
I, Carpeggiani
dipyridamole
CP,
M,
Circulation
et
Appleton
T, Watanabe
ventricular
A, Rovai
flow
of left
of Doppler
techniques.
Doppler
Kern
Cardiol
Distante
in mitral
cine-
5:1155-60
ofleft
Coil
assessment
analysis
ventricular
transient
Am
pressure-volume
15
MA,
the
Lattanzi
A, L’Abbate
Qumnones
H, et al. Transmitral
MK,
filling
with
angiographic
1985;
Evaluation
J
insights
14
Distante
test
M,
AJ, Lewen
MA.
diastolic
Noninvasive
comparative
dimensional
Cardiol
angioplasty.
during
1986; 8:848-54
HJ,
A, Inoue
MA,
RO.
right
Coil
9 Moscarelli
11
99:452-56
M,
ventricular
compliance:
mechanisms
Am J Cardiol 1976; 38:845-50
4 Kitabatake
Levine
Am
HL.
Triveila
and
Quinones
comparison
radionuclide
a two
with
J
MC,
ventricular
71:543-50
function:
of left
dysfunction
R.
M,
1982;
and
Assessment
13
Masini
Limacher
ofleft
Am Coll Cardiol 1986; 7:518-26
7 Fuji J, Yazaki Y, Sawada
H, Aizawa
10
Antonella
WA,
BJ, Bonow
echocardiographic
of LV ischemia
grateful
echocardi-
echocardiography:
diastolic
Changes
assistance.
Distante
A.
P. Maron
diography
are
Zoghibi
Circulation
Kennedy
by hemodynamic
infusion,
which
the
LC,
Doppler
ventricular
REFERENCES
1 Picano
pulsed
angiography.
6 Spirito
dipyridamole
of parameters
8 Labovitz
pattern.
ACKNOWLEDGMENT:
Distante
R, Kuo
method.
dipyridamole
interest.
How-
severely
limited
by the poor feasibility
and
accuracy.
The
information
on LV diastolic
which
is present
in transmitral
flow-velocity
requires
a large
sample
population.
In the
may
with
noninva-
the clinical
appeal
of Doppler-derived
during
dipyridamole-echocardiography
positive
Determination
infarction
representing
sive window
on diastolic
events
during
stress,
is of potential
pathophysiologic
patient,
changes
p<O.OO1
with
5 Rockey
pro-
the presence
of more
pronounced
ischemia,
as independently
assessed
by the evaluation
(through
the
WMS) of the entity
and extent
of systolic
ischemic
ever,
ments
p<O.05
in patients
systolic
dysfunction
provoked
by dipyridamole-induced
ischemia; and (2) in patients
with
positive
DET,
a more
marked
alteration
in Doppler
indexes
was found
in
dysfunction.
This information,
WMS
Murphy
to ventricular
DJ.
MA.
left
1987;
Doppler
diastolic
Preload
ventricular
10:800-08
echocardio-
function.
Echocar-
3:33-40
SF.
Adenosine
in the
and
conscious
dipyridamole
dilate
dog.
Circulation
function
in
large
1983;
68:
1321-27
17 Grbic
M,
ischemic
Transmftrai
Sigwart
U.
[Abstract].
Flow
Changes
Left
atrial
Circulation
during
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21593/ on 05/10/2017
Dipyridamole
1986;
74(suppl
Induced
acute
transient
2):360
Ischemia
(Lattanzi
et a!)