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Symptoms and Signs of Myocardial Ischemia

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Stress Echocardiography

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A transient regional imbalance between oxygen supply and demand usually results in myocardial ischemia, the signs and symptoms of which can be used as a diagnostic tool. Myocardial ischemia results in a typical “cascade” of events in which the various markers are hierarchically ranked in a well-defined time sequence. Flow heterogeneity, especially between the subendocardial and subepicardial perfusion, is the forerunner of ischemia, followed by regional dyssynergy, and only at a later stage by electrocardiographic changes, global left ventricular dysfunction, and pain. The ideal marker of ischemia should provide absolute values of sensitivity and specificity, as well as a diagnosis of the site and severity of ischemia. Unfortunately, such a marker does not exist; in contrast, we have a number of imperfect markers that can provide a reasonably good noninvasive estimation of the presence, extent, and severity of myocardial ischemia. The pathophysiological concept of the ischemic cascade is translated into a gradient of sensitivity of different available clinical markers of ischemia, with regional wall motion abnormalities being the most specific and regional reduction in coronary flow reserve the most sensitive.

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References

  1. Ross J Jr (1991) Myocardial perfusion-contraction matching. Implications for coronary heart disease and hibernation. Circulation 83:1076–1083

    PubMed  Google Scholar 

  2. Nesto RW, Kowalchuk GJ (1987) The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 59:23C–30C

    Article  PubMed  CAS  Google Scholar 

  3. Malliani A (1986) The elusive link between transient myocardial ischemia and pain. Circulation 73:201–204

    PubMed  CAS  Google Scholar 

  4. Surawicz B (1986) ST-segment, T-wave, and U-wave changes during myocardial ischemia and after myocardial infarction. Can J Cardiol(Suppl A):71A–84A

    Google Scholar 

  5. Keenan NG, Pennell DJ (2007) CMR of ventricular function. Echocardiography. 24:185–193

    Article  PubMed  Google Scholar 

  6. Gould KL (2006) Physiological severity of coronary artery stenosis. Am J Physiol Heart Circ Physiol 291:H2583–H2585

    Article  PubMed  CAS  Google Scholar 

  7. Picano E (1992) Stress echocardiography: from pathophysiological toy to diagnostic tool. Point of view. Circulation 85:1604–1612

    PubMed  CAS  Google Scholar 

  8. Picano E, Palinkas A, Amyot R (2001) Diagnosis of myocardial ischemia in hypertensive patients. J Hypertension 19:1177–1183

    Article  CAS  Google Scholar 

  9. Tennant R, Wiggers CJ (1935) The effects of coronary occlusion on myocardial contraction. Am J Physiol 112:351–361

    Google Scholar 

  10. Kemp HG (1973) Left ventricular function in patients with the anginal syndrome and normal coronary angiograms. Am J Cardiol 32:375–380

    Article  PubMed  Google Scholar 

  11. Picano E, Lattanzi F, Masini M, et al (1987) Usefulness of dipyridamole-echocardiography test for the diagnosis of syndrome X. Am J Cardiol 60:508–512

    Article  PubMed  CAS  Google Scholar 

  12. Panza JA, Laurienzo JM, Curiel RV, et al (1997) Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography. J Am Coll Cardiol 29:293–301

    Article  PubMed  CAS  Google Scholar 

  13. Astarita C, Palinkas A, Nicolai E, et al (2001) Dipyridamole-atropine stress echocardiography versus exercise SPECT scintigraphy for detection of coronary artery disease in hypertensives with positive exercise test. J Hypertens 19:495–502

    Article  PubMed  CAS  Google Scholar 

  14. Lucarini AR, Picano E, Lattanzi F, et al (1991) Dipyridamole echocardiography testing in essential hypertensive patients. Targets and tools. Circulation 83(Suppl III):III68–III72

    PubMed  CAS  Google Scholar 

  15. Maseri A, Crea F, Kaski JC, et al (1991) Mechanisms of angina pectoris in syndrome X. J Am Coll Cardiol 17:499–506

    Article  PubMed  CAS  Google Scholar 

  16. Chauhan A, Mullins PA, Petch MC, et al (1994) Is coronary flow reserve in response to papaverine really normal in syndrome X? Circulation 89:1998–2004

    PubMed  CAS  Google Scholar 

  17. Legrand V, Hodgson JM, Bates ER, et al (1985) Abnormal coronary flow reserve and abnormal radionuclide exercise test results in patients with normal coronary angiograms. J Am Coll Cardiol 6:1245–1253

    PubMed  CAS  Google Scholar 

  18. Buchthal SD, Den Hollander JA, Merz NB, et al (2000) Abnormal myocardial phosphorus-31 nuclear magnetic resonance spectroscopy in women with chest pain but normal coronary angi-ograms. N Engl J Med 324:829–835

    Article  Google Scholar 

  19. Crake T, Canepa-Anson R, Shapiro LM, et al (1987) Continuous recording of coronary sinus saturation during atrial pacing in patients with and without coronary artery disease or with syndrome X. Br Heart J 57:67–72

    Google Scholar 

  20. Panting JR, Gatehouse PD,Yang GZ, et al (2002) Abnormal subendocardial perfusion in cardiac syndrome X detected by cardiovascular magnetic resonance imaging. N Engl J Med 346:1948–1953

    Article  PubMed  Google Scholar 

  21. Carpeggiani C, L'Abbate A, Marzullo P, et al (1998) Multiparametric approach to diagnosis of non-Q wave acute myocardial infarction. Am J Cardiol 63:404–408

    Article  Google Scholar 

  22. Lazzeroni E, Picano E, Morozzi L, et al (1997) Dipyridamole-induced ischemia as a prognostic marker of future adverse cardiac events in adult patients with hypertrophic cardiomyopathy. Echo Persantine Italian Cooperative (EPIC) Study Group, subproject hypertrophic cardiomy-opathy. Circulation 96:4268–4272

    PubMed  CAS  Google Scholar 

  23. Gaddi O, Tortorella G, Picano E, et al (1999) Diagnostic and prognostic value of vasodilator stress echocardiography in asymptomatic type-2 diabetic patients with positive exercise Thallium scintigraphy: a pilot study. Diabet Med 16:762–766

    Article  PubMed  CAS  Google Scholar 

  24. Maseri A (1980) Pathogenetic mechanisms of angina pectoris: expanding views. Br Heart J 43:648–660

    Article  PubMed  CAS  Google Scholar 

  25. Haiat R, Desoutter P, Stoltz JP (1983) Angina pectoris without ST-T changes in patients with documented coronary heart disease. Am Heart J 105:883–884

    Article  PubMed  CAS  Google Scholar 

  26. Maseri A, Mimmo R, Chierchia S, et al (1975) Coronary spasm as a cause of acute myocardial ischemia in man. Chest 68:625–633

    Article  Google Scholar 

  27. Distante A, Picano E, Moscarelli E, et al (1985) Echocardiographic versus hemodynamic monitorino during attacks of variant angina pectoris. Am J Cardiol 55:1319–1322

    Article  PubMed  CAS  Google Scholar 

  28. Parodi O, Uthurralt N, Severi S, et al (1981) Transient reduction of regional myocardial perfusion during angina at rest with ST-segment depression or normalization of negative T waves. Circulation 63:1238–1347

    PubMed  CAS  Google Scholar 

  29. Rovai D, Distante A, Moscarelli E, et al (1985) Transient myocardial ischemia with minimal electrocardiographic changes: an echocardiographic study in patients with Prinzmetal's angina. Am Heart J 109:78–83

    Article  PubMed  CAS  Google Scholar 

  30. Picano E, Distante A,Masini M, et al (1986) Echocardiographic documentation of myocar-dial ischemia in presence of angina pectoris without ST-T changes. Can J Cardiol 1(Suppl A):67A–70A

    Google Scholar 

  31. Picano E, Masini M, Lattanzi F, et al (1986) Role of dipyridamole-echocardiography test in electrocardiographically silent effort myocardial ischemia. Am J Cardiol 58:235–237

    Article  PubMed  CAS  Google Scholar 

  32. Bolognese L, Rossi L, Sarasso G, et al (1992) Silent versus symptomatic dipyridamole induced ischemia after myocardial infarction: clinical and prognostic significance. J Am Coll Cardiol 19:953–959

    PubMed  CAS  Google Scholar 

  33. Cohn PF (1992) Silent left ventricular dysfunction during dipyridamole echocardiography: a new prognostic marker. J Am Coll Cardiol 19:960–961

    PubMed  CAS  Google Scholar 

  34. Klodas E, Miller TD, Christian T F, et al (2003) Prognostic significance of ischemic electro-cardiographic changes during vasodilator stress testing in patients with normal spect images J Nuclear Cardiol 10:4–8

    Article  Google Scholar 

  35. Cortigiani L, Lombardi M, Michelassi C, et al (1998) Significance of myocardial ischemic electrocardiographic changes during dipyridamole stress echocardiography. Am J Cardiol 82:1008–1012

    Article  PubMed  CAS  Google Scholar 

  36. Palinkas A, Toth E, Amyot R et al (2002) The value of ECG and echocardiography during stress testing for identifying systemic endothelial dysfunction and epicardial artery stenosis. Eur Heart J 23:1587–1595

    Article  PubMed  CAS  Google Scholar 

  37. Carluccio E, Biagioli P, Bentivoglio M et al (2003) Effects of acute myocardial ischemia on QT dispersion by dipyridamole stress echocardiography. Am J Cardiol 91:385–390

    Article  PubMed  Google Scholar 

  38. Preda I (2002) Differentiation between endothelial dysfunction and epicardial coronary artery stenosis with the aid of stress ECG and echocardiography. A novel return of the old ECG! Eur Heart J 23:1561–1562

    Article  PubMed  CAS  Google Scholar 

  39. Rigo F (2005). Coronary flow reserve in stress-echo lab. From pathophysiologic toy to diagnostic tool. Cardiovasc Ultrasound 3:8

    Article  PubMed  Google Scholar 

  40. Rigo F, Murer B, Ossena G, et al (2008). Transthoracic echocardiographic imaging of coronary arteries: tips, traps, and pitfalls. Cardiovasc Ultrasound 6:7

    Article  PubMed  Google Scholar 

  41. Rigo F, Richieri M, Pasanisi E, et al (2003). Usefulness of coronary flow reserve over regional wall motion when added to dual-imaging dipyridamole echocardiography. Am J Cardiol 91:269–273

    Article  PubMed  Google Scholar 

  42. Rigo F, Gherardi S, Galderisi M, et al (2006). The prognostic impact of coronary flow-reserve assessed by Doppler echocardiography in non-ischaemic dilated cardiomyopathy. Eur Heart J. 27:1319–1323

    Article  PubMed  Google Scholar 

  43. Rigo F, Sicari R, Gherardi S, et al (2008). The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stress echo. Eur Heart J. 29:79–88

    Article  PubMed  Google Scholar 

  44. Bodi V, Sanchis J, Lopez-Lereu M P, et al (2009) Prognostic and therapeutic implications of dipyridamole stress cardiovascular magnetic resonance on the basis of the ischemic cascade. Heart 95:49–55

    Article  PubMed  CAS  Google Scholar 

  45. Donato L (1986) Concluding remarks: the “stunned” cardiologist. Can J Cardiol(Suppl A): 260A–262A

    Google Scholar 

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Authors
  1. Eugenio Picano
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Editors and Affiliations

  1. Director General Institute of Clinical Physiology of Pisa, National Research Council, 1st Fisiologia Clinica, Via G. Moruzzi, 1, Pisa, 56124, Italy

    Eugenio Picano MD, PhD

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Picano, E. (2009). Symptoms and Signs of Myocardial Ischemia. In: Picano, E. (eds) Stress Echocardiography. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-76466-3_3

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  • DOI: https://doi.org/10.1007/978-3-540-76466-3_3

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-76465-6

  • Online ISBN: 978-3-540-76466-3

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