SUMMARY Left ventricular (LV) performance at rest and during multilevel exercise in the supine and upright positions was studied in seven normal subjects with equilibrium radionuclide ventriculography. The mean left ventricular end-diastolic volume (LVEDV) during supine rest was 107 4 10 ml (± SEM) and 85 ± 6 ml (p < 0.02) in the upright position; the mean resting left ventricular end-systolic volumes (LVESV) were not diSferent in the upright and supine positions. The Changes in posture at rest are associated with significant changes in LV filling and stroke volume. A transition from the supine to the upright position produces a decrease in LV end-diastolic pressure1-3 and volume4-6 and in stroke volume.' -4 6-10 The results of previous studies of the alterations in LV enddiastolic volume during exercise in the supine position have varied.5, 6, 11-15 There is general agreement that end-systolic volume is smaller during exercise than at rest;6 11, 12, 14,15 most investigators3' 6, 12, 13 have reported an exercise-induced increase in stroke volume, although others have not.1 4These data are generally consistent with an enhanced contractile state From the Departments of Medicine

Diastolic and systolic parameters of left ventricular performance were characterized from high-frequency time-activity curves obtained in 10 normal volunteers (mean age 29 4 yr), in 25 patients with normal coronary arteries, and in 50 patients with coronary artery disease (CAD) at rest and during three stages of exercise radionuclide angiography. In the normal volunteers ejection fraction was 65 + 5% (SD) at rest and 78 + 5% with exercise (p < .001). In patients with normal coronary arteries ejection fraction was 64 + 5% at rest and 72 + 8% with exercise (p < .0001). In patients with CAD resting ejection fraction was 60 ± 10% and that during exercise was 61 ± 13% (p = NS). Peak diastolic filling rate in the first half of diastole, peak systolic ejection rate, and times to peak rates and to end-systole were measured. In the normal subjects resting peak distolic filling rate was 3.1 ± 0.6 enddiastolic counts/sec and it increased in all subjects with exercise to 3.6 + 0.7 (p < .05). In patients with normal arteries and those with CAD peak diastolic filling rate was 2.3 ± 0.8 at rest and with exercise this parameter increased to 3.2 + 1.1 (p < .001) in patients with normal arteries and fell to 1.7 ± 0.6 in those with CAD (p < .001). Peak systolic ejection rate decreased from 2.5 0.8 to 1.9 ± 0.8 with exercise in patients with CAD (p < .001). The sensitivity of wall motion and ejection fraction response to exercise for detection of CAD in patients was 62% (80% excluding those with one-vessel disease), with no false-positive results. Sensitivity and specificity of peak systolic ejection rate were 66% and 67%, respectively. Peak diastolic filling rate exercise/rest ratio was greater than 1 for patients with normal and 1 or less for patients with diseased arteries, with sensitivity of 98% and specificity of 94%. Thus, alteration of peak diastolic filling rate during exercise is a very sensitive and specific indicator of ischemic heart disease. Circulation 70, No. 6, 942-950, 1984.

SUMMARY Two-dimensional echocardiography (2-D echo) was performed in 73 patients evaluated for coronary artery disease (CAD) and in four normal volunteers before and immediately after a maximal treadmill exercise test. Diagnostic images were obtained from the apical and parasternal windows. In 17 patients with normal coronary arteriograms, ejection fraction (EF) increased from 66 9 % (±4 SD) at rest to 73 8% after exercise (p < 0.001), while in 56 patients with proved CAD, EF fell from 56 13% at rest to 53 16% after exercise (p < 0.01). The sensitivity of postexercise 2-D echo for detecting CAD (based on abnormal EF response and/or regional dyssynergy) was 91% (51 of 56 patients) and the specificity was 88% (15 of 17). Sensitivity for one-, two-and three-vessel disease was 64% (seven of 11), 95% (20 of 21) and 100%, respectively. Patients with multivessel disease showed a significant fall in a wall motion score index, from 0.79 0.25 to 0.63 0.26. Exercise radionuclide ventriculography (RNV) was also performed in 41 of the subjects (17 normals and 24 CAD patients) on a bicycle ergometer. The overall sensitivity of 2-D echo in this subgroup was 92%, compared with 71% for RNV. The sensitivity of 2-D echo for one-vessel disease (n = 4) was 50%, that for two-vessel disease (n = 12) was 100% and that for three-vessel disease (n = 12) was 100%. Respective values for RNV were 0%, 80% and 90%. The specificity of 2-D echo was 88% and that of RNV was 82%. A significantly higher peak heart rate response was observed on the treadmill than on the bicycle ergometer in both CAD patients and normal subjects. MethodsThe study population consisted of 73 patients (63 males and 10 females, mean age 54 years, range 28-75 years) with suspected CAD and four normal volunteers (two males and two females, mean age 46 years, range 34-54 years). Sixty-nine patients were evaluated for chest pain, two for dyspnea and two for ventricular arrhythmias. Patients with unstable angina, recent myocardial infarction or valvular heart disease were excluded. Cardiac medications were not discontinued before exercise. Twenty-five patients were taking propranolol and five digoxin at the time of study. All 73 patients underwent coronary angiography within 1 week of the exercise study. Echocardiographic MethodThe 2-D echoes were obtained in all 77 subjects before exercise without previous echo screening. The studies were performed using a commercially available 900 mechanical sector scanner (Advanced Technology Laboratories Mark III). With the patient in the supine left lateral position, the transducer was handheld.on the patient's chest and multiple views were obtained through the left parasternal and apical windows. The acoustic windows providing the best images were marked on the patient's chest using a washable felt-tip marker for reference during the postexercise study. Twelve-lead ECG recordings were obtained at rest and at each 3-minute level of exercise with leads V4 monitored continuously during exercise. The chest electrodes were positioned so as...

Two-dimensional echocardiography and gated radionuclide ventriculography were performed in 93 patients (66 men, 27 women; mean age 61 years) with 95 episodes of acute myocardial infarction within 48 hours and at 10 days after infarction. Electrocardiographic sites of infarction were: 35 anterior, 49 inferoposterior and 11 nonlocalized. Abnormal motion of the anterior wall, septum or apex was seen in 97 and 100% of anterior infarctions by radionuclide ventriculography and echocardiography, respectively. Abnormal motion of an inferior or posterior wall segment was seen in 91% of inferoposterior infarctions by echocardiography versus 61% seen by radionuclide ventriculography. Ejection fractions determined by echocardiography and radionuclide ventriculography correlated well (r = 0.82) and did not change from the first 48 hours to 10 days after infarction (0.48 +/- 0.14). Similarly, wall motion score showed minimal change from the first 48 hours to 10 days. In-hospital mortality was 37 and 42% in patients with an ejection fraction of 0.35 or less by echocardiography and radionuclide ventriculography, respectively. No mortality was seen in patients with an ejection fraction above 0.40 by either test. The echocardiographic wall motion score was also predictive of mortality (40 versus 2%; score less than or equal to 0.50 versus greater than 0.50). The 1 year mortality rate in the 81 short-term survivors was 17%. Mortality was lowest in patients with an ejection fraction above 0.49 or wall motion score above (0.79 (2 to 5%) and worse in those with an ejection fraction below 0.36 or wall motion score below 0.51 (36 to 63%) by either technique. Thus in acute myocardial infarction, echocardiography and radionuclide ventriculography provide a comparable assessment of left ventricular function and wall motion in anterior infarction. Echocardiography appears more sensitive in detecting inferoposterior wall motion abnormalities. Both techniques are capable of identifying subgroups of patients with a high risk of death during the acute event and with an equally high mortality rate over a 1 year follow-up period.

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