Left ventricular systolic function does not correlate well with functional class in patients with dilated cardiomyopathy. To determine whether the correlation is better with Doppler indexes of left ventricular diastolic function, 34 patients with dilated cardiomyopathy (M-mode echocardiographic end-diastolic dimension greater than 60 mm, fractional shortening less than 25%, increased E point-septal separation) were studied. Patients were classified into two groups according to functional class. Group 1 consisted of 16 patients in New York Heart Association functional class I or II; group 2 included 18 patients in functional class III or IV. Left ventricular dimensions, fractional shortening, left ventricular mass, meridional end-systolic wall stress, peak early and late transmitral filling velocities and their ratio, isovolumetric relaxation period and time to peak filling rate were computed from pulsed wave Doppler and M-mode echocardiograms and calibrated carotid pulse tracings. Right heart catheterization was performed in 20 of 34 patients. No differences were observed between groups with regard to age, gender distribution, heart rate, blood pressure and M-mode echocardiographic-derived indexes of systolic function. Peak early filling velocity (72 +/- 13 versus 40 +/- 10 cm/s, p less than 0.001) was higher and atrial filling fraction (27 +/- 4% versus 46 +/- 8%, p less than 0.001) was lower in group 2 than in group 1. The ratio of early to late transmitral filling velocities was higher in group 2 patients (2.3 +/- 0.5 versus 0.7 +/- 0.2, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Previous studies have established that most of the heterogeneity in exercise capacity seen with sedentariness, aging, or physical training can be accounted for by individual differences in the maximal rate of total body oxygen consumption (VO2 max) during dynamic exercise. However, the factors that limit VO2 max in normal subjects remain disputed. To test the hypothesis that differences in left ventricular diastolic performance contribute to the heterogeneity of VO2 max seen in healthy subjects, 57 normal sedentary volunteers (36 +/- 13 yr, range 20-76 yr) and 9 endurance athletes (37 +/- 8 yr, range 26-51 yr) were studied. Aerobic capacity was estimated as VO2 max during a multistage dynamic cycle exercise protocol, whereas resting left ventricular systolic and diastolic function was assessed by two-dimensional and Doppler echocardiography. The relationship of the left ventricular functional indexes with VO2 max was investigated by stepwise multiple regression analysis. VO2 max ranged from 25 to 58 ml.kg-1 x min-1 in sedentary subjects and from 44 to 60 ml.kg-1 x min-1 in athletes. With univariate analysis, significant correlations were observed between VO2 max and age (r = -0.60), maximal heart rate (r = 0.48), maximal work load (r = 0.80), left ventricular volumes at both end diastole (r = 0.51) and end systole (r = 0.62), peak early transmitral filling velocities (r = 0.80), and the ratio of early to late transmitral filling velocities (r = 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the effects of a moderately prolonged exercise on left ventricular systolic performance, 23 healthy male subjects, aged 18 to 51 yr (mean 37 yr) were studied. The subjects exercised first on a treadmill (brief exercise) and completed, on a separate day, a 20-km run. M-mode, two-dimensional, and Doppler echocardiography, as well as calibrated carotid pulse tracings, were obtained at rest and immediately on completion of both brief and prolonged exercise. Left ventricular systolic function was assessed by end-systolic stress-shortening relationships. Heart rate increased similarly after brief and prolonged exercise (+30%). Mean arterial pressure decreased from 99 +/- 7 to 92 +/- 8 mmHg (P less than 0.001) after prolonged exercise, but it remained unchanged after brief exercise. Left ventricular end-diastolic volume was decreased after prolonged exercise (130 +/- 23 vs. 147 +/- 18 ml at rest, P less than 0.01). Both ejection fraction and rate-adjusted mean velocity of fiber shortening decreased after prolonged exercise [from 67 +/- 5 to 60 +/- 6% (P less than 0.001) and from 1.12 +/- 0.2 to 0.91 +/- 0.2 cm/s (P less than 0.001), respectively] despite a lower circumferential end-systolic wall stress (133 +/- 23 vs. 152 +/- 20 g/cm2). The relationship between ejection fraction (or mean velocity of fiber shortening adjusted for heart rate) and end-systolic wall stress was displaced downward on race finish (P less than 0.05). These changes were independent of the changes in left ventricular end-diastolic volume and hence those in preload. The data suggest that moderately prolonged exercise may result in depressed left ventricular performance in healthy normal subjects.

Coronary arteriographic data have been compared in 278 patients (231 males and 47 females) with the ECG response to a maximal exercise test and with the history (myocardial infarction -MI, typical or atypical angina pectoris -AP). The sensitivity and specificity of exercise ECG were similar in males and females. False negative ECG responses were frequent in males (40%) and false positive ECG responses were frequent in females (38%). This difference between sexes was essentially due in our patients to the higher prevalence of CHD in males (80%) than in females (43%).In the absence of a previous MI, a history of typical AP was associated with coronary heart disease (CHD) in 94% of males and 62% of females. Atypical AP was rarely associated with CHD (18% EXERCISE ELECTROCARDIOGRAPHY (ECG) is a well-established method for the diagnosis of coronary heart disease (CHD). Its value has been differently assessed from correlative studies with arteriographic data' and the validity of exercise ECG has more recently been questioned especially in women.10-14 Clinically, however, the results of an exercise test are never interpreted without taking into account the patient's history and complaints. The purpose of the present study was to estimate the actual contribution of exercise ECG to the overall diagnosis of CHD and thus to define its advantages and limitations. The patient's history and the ECG recorded during a test of maximally tolerated exercise were compared with the angiographic findings in a group of 278 patients. MaterialOf the 278 patients that were studied, 231 were males (mean age 48 years, range 27-65) and 47 were females (mean age 49 years; range 33-64). This group included a series of patients from January 1971 to November 1975 who had a coronary arteriographic study and within one month prior to the arteriography underwent a maximal exercise test. The majority of the exercise tests were performed one to five days before the coronary arteriography. Those patients with bundle branch block, valvular heart disease and those receiving digitalis less than three weeks before the exercise test were excluded.The reasons for having these patients undergo exercise tests and coronary arteriography were: 1) the diagnosis of CHD in patients with complaints of typical or atypical angina pectoris (AP); 2) the presence of typical or atypical in males; 11% in females). When typical AP was associated with an abnormal exercise ECG, CHD was highly probable in males (98%) and present in 75% of females. In presence of atypical AP with a normal exercise ECG, CHD was unlikely in males (11%) and in females (8%).We conclude that exercise ECG has limited value for the diagnosis of CHD. In men with typical AP, exercise ECG often confirms the diagnosis but a negative ECG exercise does not rule out CHD because of the high incidence of fales negative responses. In males and females with atypical AP, an abnormal response to exercise is difficult to interpret owing to a high incidence of false positive responses. AP in patients with a previou...

SUMMARY The clinical value of combining exertional ECG and postexertional thallium (201T1) scintigraphy was assessed in 160 patients (130 men and 30 women) suspected of having coronary artery disease (CAD) who underwent a coronary arteriography. Based on sex and history, the patients were subdivided in two groups with different prevalences of CAD: Group 1 (high prevalence of CAD = 90%) included 98 men with typical angina pectoris (AP) and group 2 (low prevalence of CAD = 18%) included 32 men and 30 women with atypical AP.Compared with the exertional ECG, myocardial scintigraphy was more sensitive (87% vs 74%) and more specific (89% vs 70%) for the diagnosis of CAD. The combination of the ECG and scintigraphic data was useful if both tests gave concordant results: 100% of true positives (n = 67) and 84% of true negatives (n = 43). In case of discordant results (n = 50), no firm diagnostic conclusion could be made due to the many false-positive (27%) and false-negative (25%) scintigrams.These results are easier to interpret when the prevalence of CAD is taken into account. According to Bayes' theorem, abnormal exercise results confirm CAD when the prevalence is high and normal results rule out CAD when the prevalence is low; also, a normal response to exercise has no predictive value when the prevalence is high. When the prevalence is low, an abnormal ECG or thallium has low predictive value but concordant abnormal responses are highly predictive for CAD (100% of true positives).EXERCISE myocardial perfusion scintigraphy with thallium-201 is useful for detecting myocardial ischemia due to coronary artery disease (CAD) and seems more reliable than the exertional ECG. '-5 In symptomatic patients, the characteristics of the complaints are important and, from a well-taken history, one can evaluate the likelihood of CAD.8 12 Several reports on exertional ECG have indicated that the diagnostic information provided by the test was largely determined by the prevalence of the disease within the population.9" [13][14][15][16][17] This study was undertaken to assess the diagnostic value of exercise thallium scintigraphy and its combination with exertional ECG; in order to analyze the influence of the prevalence of CAD, the patients were subdivided in groups according to the information provided by the history. The prevalence of CAD is almost 100% after an acute myocardial infarction, so patients with a history of infarction were excluded. Material One hundred sixty patients, 130 men and 30 women, suspected of CAD but without evidence of a previous myocardial infarction, were studied. They underwent a multistage maximal exercise test 1 to several days before the arteriographic study. These patients were studied because of the presence of chest pain. Before the exercise test, the patients were carefully questioned by the same physician. From the clinical history, the complaints were subjectively judged to be typical or atypical of angina pectoris (AP). As in a previous study,9 this judgment was based on the location, qualit...