Stress echocardiography with dobutamine infusion for detection of coronary artery disease is a potential alternative to exercise stress testing with some theoretic advantages. Fifty patients who were not receiving cardioactive medication were prospectively studied with two-dimensional echocardiography and 12-lead electrocardiography (ECG) during incremental dobutamine infusion (5, 10, 15 and 20 micrograms/kg body weight per min, each dose for 8 min). Images were analyzed by using an 11-segment left ventricular model. All patients underwent correlative exercise ECG and coronary angiography, which revealed normal coronary arteries in 14 and significant disease (greater than or equal to 70% diameter stenosis) in 36. Peak rate-pressure product during dobutamine infusion was 18,845 +/- 4,156 versus 23,740 +/- 6,158 mm Hg/min on exercise (p less than 0.01). Interobserver concordance for wall motion analysis was good (kappa coefficient = 0.77). The use of baseline (n = 14) or reversible (n = 24) regional asynergy to define an abnormal dobutamine echocardiogram resulted in a sensitivity for detecting coronary artery disease of 78% and a specificity of 93%. Corresponding data for the dobutamine ECG were 47% and 71% and for the exercise ECG were 72% and 71%, respectively. The development of new mitral regurgitation on Doppler color flow imaging (n = 4) improved sensitivity to 81% without loss of specificity. Inducible asynergy or new mitral regurgitation was observed in 6 (50%) of 12 patients with single-, 6 (60%) of 10 with double- and 12 (86%) of 14 with triple-vessel disease. The site of transient asynergy provided additional localizing information. Exercise duration and time to diagnostic ST segment shift were shorter in patients with coronary artery disease with versus those without echocardiographic evidence of ischemia (both p less than 0.05). Side effects during dobutamine infusion were mild and short-lived. Dobutamine stress echocardiography is well tolerated, is useful for detection and assessment of coronary artery disease and is applicable to patients unable to exercise.

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The incidence of stroke on cranial computed tomography (CT) and change in echocardiographic vegetation area was prospectively compared in a preliminary observational study involving nine patients with infective endocarditis randomized to either low-dose aspirin (75 mg d-1, Group I, n = 4) or no aspirin (Group II, n = 5). Two symptomatic cerebral infarcts and one myocardial infarct occurred in the controls, compared to no events in patients on aspirin during a total observation period of 343 d (range 28-49 d). The mean vegetation area decreased in the aspirin group (mean change = -0.24 cm2), compared to an increase in controls (mean change = +0.35 cm2). The platelet half-life (normal range 5-6 d), which was measured using Indium-111 radiolabelling, tended to be lower in Group II (4.6 +/- 0.2 vs. 3.9 +/- 0.5 d). No side-effects or complications attributable to aspirin were observed. A possible role for adjunctive aspirin therapy in the prevention of embolic complications in infective endocarditis is suggested, and warrants further study.

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Despite heightened awareness, pulmonary embolism remains a major cause of maternal mortality in the antenatal period and one which has not decreased in incidence over the four triennia since 1976. We report a patient who suffered massive pulmonary embolism with circulatory collapse in the second trimester and who was treated with intravenous streptokinase followed by percutaneous mechanical dispersion of thrombus using a catheter and guide wire. She made an excellent recovery despite complicating antepartum haemorrhage. In life-threatening circumstances pharmacological thrombolysis is mandatory particularly for hospitals without a cardiac catheterization laboratory on site.