Coronary Artery Disease: Zamorano JL

Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL, Anonymous00198. · Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124 Pisa, Italy. · Eur J Echocardiogr. · Pubmed #18579481 links to  free full text

Abstract: Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, Dallongeville J, De Backer G, Ebrahim S, Gjelsvik B, Herrmann-Lingen C, Hoes A, Humphries S, Knapton M, Perk J, Priori SG, Pyorala K, Reiner Z, Ruilope L, Sans-Menendez S, Reimer WS, Weissberg P, Wood D, Yarnell J, Zamorano JL, Anonymous00206, Anonymous00207. · European Society of Cardiology · G Ital Cardiol (Rome). · Pubmed #18383763 No free full text.

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Rydén L, Standl E, Bartnik M, Van den Berghe G, Betteridge J, de Boer MJ, Cosentino F, Jönsson B, Laakso M, Malmberg K, Priori S, Ostergren J, Tuomilehto J, Thrainsdottir I, Vanhorebeek I, Stramba-Badiale M, Lindgren P, Qiao Q, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL, Deckers JW, Bertrand M, Charbonnel B, Erdmann E, Ferrannini E, Flyvbjerg A, Gohlke H, Juanatey JR, Graham I, Monteiro PF, Parhofer K, Pyörälä K, Raz I, Schernthaner G, Volpe M, Wood D, Anonymous00256, Anonymous00257. · Department of Cardiology, Karolinska University Hospital, Sweden. · Eur Heart J. · Pubmed #17220161 links to  free full text

This publication has no abstract.

Pérez de Isla L, Rodrigo JL, Almería C, Pérez Ferro M, Serra V, Zamorano JL. · Echocardiographic Unit, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain. · Eur J Echocardiogr. · Pubmed #15698555 links to  free full text

Abstract: Myocardial contrast echocardiography (MCE) allows the assessment of myocardial perfusion by imaging the coronary microcirculation. The development of new contrast agents and new diagnostic tools far assessing myocardial perfusion by means of MCE has led to a new field of applications far patients suffering from ischemic heart disease. Several studies have shown that MCE is a feasible and accurate method to evaluate patients with: a) acute coronary syndromes: MCE is useful before the epicardial reperfusion to delineate the area at risk and to assess the collateral-derived myocardial blood flow, and after the epicardial reperfusion to detect the non-reflow phenomenon; b) chronic coronary syndromes: MCE allows the detection of significant coronary stenosis by means of stress methods and methods without any stress; c) myocardial viability and hibernating myocardium: MCE helps to predict functional recovery of akinetic segments. In these settings, MCE is not only useful as a diagnostic tool but also provides prognostic information. MCE is a technique in constant development. Among the latest advances we note the development of transesophageal probes with second-harmonic image that allows assessment of myocardial perfusion in a more accurate way. This technique should introduce MCE into new clinical fields, especially the evaluation of myocardial perfusion during cardiac operations. Another recent development is in parametric imaging techniques. These consist in obtaining time curves for all the pixels in the image instead of working only with a few separate regions of interest. A parameter scan is computed far any pixel showing their value as a color overlay in the parametric image. Summarizing, we can say that MCE is crossing from the experimental laboratory to the daily clinical practice far the evaluation of ischemic heart disease. MCE provides an interesting tool that offers the potential of a complete evaluation of patients with chronic coronary artery disease. This includes both diagnostic and prognostic evaluation.

Senior R, Monaghan M, Main ML, Zamorano JL, Tiemann K, Agati L, Weissman NJ, Klein AL, Marwick TH, Ahmad M, DeMaria AN, Zabalgoitia M, Becher H, Kaul S, Udelson JE, Wackers FJ, Walovitch RC, Picard MH, Anonymous00063. · Department of Cardiovascular Medicine, Northwick Park Hospital, Watford Road, Harrow, Middlesex HAI 3UJ, UK. · Eur J Echocardiogr. · Pubmed #19131498 links to  free full text

Abstract: AIMS: To determine if perfusion stress echocardiography (PSE) with Imagify (perflubutane polymer microspheres) is comparable to stress perfusion imaging using (99m)Tc single photon emission computed tomography (SPECT) for coronary artery disease (CAD) detection. PSE is a novel technique for evaluating myocardial perfusion. RAMP (real-time assessment of myocardial perfusion)-1 and -2 were international, Phase 3 trials that evaluated the ability of PSE with Imagify, to detect CAD. METHODS AND RESULTS: Chronic, stable, chest pain patients (n=662) underwent Imagify PSE and gated SPECT imaging at rest and during dipyridamole stress. Independent blinded cardiologists [three PSE readers per trial, and four SPECT readers (one for RAMP-1, three for RAMP-2)] interpreted images. CAD was defined by quantitative coronary angiography or 90-day outcome with clinical review. Accuracy, sensitivity, and specificity were evaluated using non-inferiority analysis (one-sided alpha=0.025) compared with SPECT. SPECT results for RAMP-1 and -2 were: accuracy (70%, 67%), sensitivity (78%, 61%), and specificity (64%, 76%). Accuracy of all six PSE readers was non-inferior to SPECT (66-71%, P<or=0.004). Four demonstrated non-inferior sensitivity (68-77%, P<or=0.002), three demonstrated non-inferior specificity (72-88%, P<or=0.013). Three PSE readers (RAMP-2) were superior for sensitivity. Two PSE readers (RAMP-1) were superior for specificity. Area under the multi-reader receiver operating characteristics curve (0.72) was equal for both modalities. Majority of adverse events followed dipyridamole dosing, and were mild, transient, and required no treatment. CONCLUSIONS: Imagify PSE was well-tolerated. Its diagnostic performance in chest pain patients is comparable with SPECT perfusion imaging.

Núñez-Gil IJ, Fernández-Ortiz A, Pérez-Isla L, Luaces M, García-Rubira JC, Vivas D, Gonzalez JJ, Alonso J, Zamorano JL, Macaya C. · Cardiology Department, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain, Europe. · Coron Artery Dis. · Pubmed #18923239 No free full text.

Abstract: OBJECTIVES: Apical ballooning shares features with acute coronary syndromes. Recently, atypical forms have been reported without apical involvement. Usually, the prognostic reports have compared them with ST-segment elevation infarction. Left ventricular transient dyskinesias (LVTD), however, frequently occur without ST-segment elevation and when present, these patients always have open arteries. Our aim was to assess the baseline features, clinical presentation, natural history and compare long-term prognosis in an LVTD-cohort with a first non-ST-segment elevation acute coronary syndrome (NSTEMI) group. METHODS: We performed a prospective observational study including consecutive patients in two groups: (i) LVTD group: 62 patients with this syndrome between 2003 and 2007. Inclusion criteria were LV segmental transient motion abnormalities; ECG new alterations and elevated troponin; absence of recent significant head trauma or obstructive coronary artery lesions. (ii) Control group: 169 patients admitted for a first NSTEMI in 2004. RESULTS: Median follow-up was 35 months. Mean age was 65 years. LVTD group included 83.9% females. NSTEMI group was predominantly males. Eleven in-hospital deaths happened in NSTEMI cohort and none in LVTD. Four patients in the LVTD group required readmission and two patients died. In the NSTEMI group, heart failure, unstable angina, myocardial infarction (P<0.001) and death (P=0.11) were more frequent. Cox regression showed that diabetes mellitus, significant onset mitral regurgitation and NSTEMI versus LVTD were found as event-independent predictors. CONCLUSION: LVTD diagnosis represents a decreased risk of events when compared with classic non-ST-segment acute coronary syndrome, pointing out a different pathophysiologic mechanism.

Zamorano JL, Sánchez V, Almería C, Serra V, Rodrigo JL, Sánchez-Harguindey L. · Servicio de Cardiología. Hospital Clínico San Carlos. Madrid. · Rev Esp Cardiol. · Pubmed #11060252 links to  free full text

Abstract: INTRODUCTION: Dobutamine stress echocardiography is an accurate technique for the noninvasive diagnosis of coronary artery disease. However, interobserver variability is an important limitation of stress echocardiography. Image quality and echocardiographer experience have been described to influence interobserver agreement. AIM: The aim of this study was to determine whether use of contrast agents during dobutamine stress echocardiography improves the agreement between an experienced and a unexperienced observer, and if learning period would be influenced by the use of contrast. METHODS: Two blind observers interpreted all the studies: one experienced echocardiographer (A) and one unexperienced observer (B) in this technique. The contrast agent Levovist/Levograf 2.5 g was administered by two bolus (at rest and at peak stress). In all cases, second harmonic imaging and stress digitalisation packs were used. The kappa test was used to determine interobserver agreement. RESULTS: Fifty-two unselected consecutive studies in 51 patients were analyzed. Twenty-two studies were performed with contrast. The agreement between the experienced and the unexperienced observer was Kappa 0.58 and 0.52, with and without the use of contrast, with no statistically significant difference being archived. CONCLUSIONS: The routine use of contrast provides better although not significant, interobserver agreement. However, this improvement is not sufficient to substitute specific training.