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Biomedical subjects

J Berning

Publications and source records attributed to J Berning.

At least 37 records · Page 2Linked to original sources
PubMed1992

Sensitivity and specificity of echocardiographic identification of patients eligible for safe early discharge after acute myocardial infarction.

In a prospective clinical trial of 195 consecutive unselected patients with acute myocardial infarction (AMI), systematic blinded clinical and echocardiographic examinations were performed by two observers on day 5. The purpose was to define low-risk patients with regard to in-hospital and 2-month mortality and predict the potential costs (lost patient lives) and benefits (saved in-patient days) if as a routine procedure these low-risk patients were discharged earlier. By design, low-risk patients as defined by clinical criteria were allocated to discharge on days 7 to 10 and by echocardiographic criteria on days 5 to 7 after AMI. The sensitivity of the echocardiographic low-risk identification procedure was more than twofold higher than the sensitivity of clinical low-risk identification (49% vs 24%). Both procedures were safe with a specificity of 100% for cardiac mortality. Optimal identification of low-risk patients was provided by combining data from echocardiographic and clinical evaluations (sensitivity 59%). Results of the study suggest that a bedside echocardiographic approach to estimation of global left ventricular function is more sensitive and equally specific and therefore more efficient for risk stratification on post-AMI day 5 than clinical examination alone. Thus echocardiographic examination allows identification of a larger subset of patients with AMI (greater than 40% of the population alive on day 5) who can be discharged earlier and safely, with a potential saving of in-patient days of 436 days in 87 low-risk patients minus the cost of echocardiographic studies in 195 patients. However, the best prediction was obtained by combining clinical and echocardiographic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Thrombolysis significantly reduces transient myocardial ischaemia following first acute myocardial infarction.

In order to investigate whether thrombolysis affects residual myocardial ischaemia, we prospectively performed a predischarge maximal exercise test and early out-of-hospital ambulatory ST segment monitoring in 123 consecutive men surviving a first acute myocardial infarction (AMI). Seventy-four patients fulfilled our criteria for thrombolysis, but only the last 35 patients included received thrombolytic therapy. As thrombolysis was not available in our Department at the start of the study, the first 39 patients included were conservatively treated (controls). No significant differences in baseline clinical characteristics were found between the two groups. In-hospital atrial fibrillation and digoxin therapy was more prevalent in controls (P less than 0.05). During exercise, thrombolysed patients reached a higher maximal work capacity compared with controls: 160 +/- 41 vs 139 +/- 34 W (P less than 0.02). Thrombolysis resulted in a non-significant reduction in exercise-induced ST segment depression: prevalence 43% vs 62% in controls. However, during ambulatory monitoring the duration of transient myocardial ischaemia was significantly reduced in thrombolysed patients: 322 min vs 1144 min in controls (P less than 0.05). Thrombolysed patients reached a higher heart rate during transient ischaemic episodes: 114 +/- 17 vs 93 +/- 11 b.min-1 in controls (P less than 0.001). In conclusion, thrombolytic therapy administered for a first AMI significantly reduces the burden of transient myocardial ischaemia. This may explain the improvement in myocardial function during physical activities, which was also observed in this study.

Coronary Circulation↗
PubMed1992

Rapid estimation of left ventricular ejection fraction in acute myocardial infarction by echocardiographic wall motion analysis.

Echocardiographic estimates of left ventricular ejection fraction (ECHO-LVEF) in acute myocardial infarction (AMI) were obtained by a new approach, using visual analysis of left ventricular wall motion in a nine-segment model. The method was validated in 41 patients using radionuclide ventriculography (RNV) and contrast ventriculography measurements of LVEF for comparison. ECHO-LVEF from the 41 patients correlated well with the reference methods (y = 1.5x - 14.7, r = 0.93; linear regression analysis; 95% confidence limit for a single determination of ECHO-LVEF was 17.2). Interobserver variability by linear regression was r = 0.89, SEE = 7.1 with a mean difference between paired observations of -1.5 +/- 6.9 (SD). In a random sample of 18 patients (45 observations), ECHO-LVEF allowed separation between RNV-LVEF values greater than or equal to 40 and less than 40, representing low and high risk groups following AMI. Thus, the results showed that simple, readily available wall motion-derived estimates of LVEF were as closely associated with LVEF measured by standard reference methods as were previously published, more cumbersome, planimetric echocardiographic methods. Reporting on global LVEF function in LVEF units rather than in nonstandardized wall motion scores of index values may facilitate intra- and interhospital communication and the use of optimized echocardiographic risk stratification after AMI.

Echocardiography↗
PubMed1992

Risk stratification after acute myocardial infarction by means of echocardiographic wall motion scoring and Killip classification.

In order to perform risk stratification, 195 consecutive, unselected patients with acute myocardial infarction (AMI) underwent independent echocardiographic and clinical evaluation of their left ventricular function by means of the wall motion index (WMI) and Killip classification 5 days after AMI. The patients were prospectively allocated to a low, medium or high risk class depending on WMI alone, and the 1-year mortality in these classes was 2, 34 and 37%, respectively (p < 0.0001). The 1-year mortality of the patients in Killip class I, II, or III and IV was 6, 26 and 48%, respectively (p < 0.00001). The number of patients allocated to the low risk group by means of WMI was 87, and the number of patients in Killip class I was 86. Since these groups were not identical, a total of 103 patients, i.e. 53% of the study population, could be identified as low risk patients regarding 1-year mortality 5 days after AMI, when WMI and Killip classification were used in combination. We conclude that the combination of echocardiographic and clinical evaluation of left ventricular function after AMI provides a strong and yet very simple procedure to identify low risk patients, which could be easily implemented in the routine work of coronary care units.

Adult↗
PubMed1992

Prognostication in acute myocardial infarction by early echocardiographic estimation of left ventricular ejection fraction. Multivariate statistical comparison with a clinical prognostic index and its components.

The purpose of this study was to define the prognostic value concerning in-hospital, two-month, and one-year mortality of an early echocardiographic estimation of left ventricular ejection fraction, relative to traditional clinical variables and a clinical prognostic index, in an unselected series of 193 patients following acute myocardial infarction. Left ventricular ejection fraction was determined within 72 hours by echocardiographic wall motion analysis within the frame of a nine-segment model. Clinical variables (age, number of acute myocardial infarctions, reinfarction, heart failure, cardiac arrest, ventricular arrhythmias, asystole, supraventricular tachycardia, nodal rhythm) and a calculated, previously published index, based on these variables, were recorded on day five post infarction and predischarge. The Killip class was recorded at the time of echocardiography. All variables were compared by a multivariate approach (Cox regression model). The results showed that left ventricular ejection fraction was the strongest predictor of early and late mortality and increasingly so over the period of observation. Age and maximal Killip class had a modest additional prognostic value, whereas the composite clinical prognostic index had no predictive power when early left ventricular ejection fraction was included in the statistical model.

Adult↗
PubMed1991

[Prognosis in early and late ventricular fibrillation after acute myocardial infarction].

Of 413 patients with in-hospital ventricular fibrillation complicating acute myocardial infarction 281 had early (less than 48 hours post infarction) ventricular fibrillation and 132 had late ventricular fibrillation. In-hospital and longterm prognoses were not influenced by time of ventricular fibrillation, but advanced age and signs of reduced left ventricular function were found to be independent significant risk factors for short and longterm prognoses.

Adult↗
PubMed1991

[Transesophageal echocardiography. A new cardiologic examination method].

Transoesophageal echocardiography is a new diagnostic method which uses the oesophagus as an ultrasonic window to the heart and central vessels. The images obtained are often of supreme quality compared to those obtained by conventional transthoracic echocardiography, because the distance between the transducer and the heart is reduced. The equipment, the examination technique, and preliminary experience after 80 examinations are described. It is concluded that the technique is particularly informative in patients with endocarditis or mitral valve disease and that the transoesophageal approach has become essential for the diagnosis of prosthetic valve dysfunction. Furthermore, the technique allows visualization of the descending aorta, which is often impossible to image from the precordial window, and the technique has proved useful in the emergency diagnostic elucidation of aneurysm of the thoracic aorta. So far a limited number of formal investigations comparing the results of transoesophageal echocardiography with the results of reference methods have been performed, however, practical clinical experience is already sufficiently extensive to state that transoesophageal echocardiography has come to stay. Disregarding coronary angiography it seems probable that combined transthoracic and transoesophageal echocardiography with time will eliminate the need for cardiac catheterization and angiography.

Contraindications↗
PubMed1991

Relative prognostic value of clinical heart failure and early echocardiographic parameters in acute myocardial infarction.

The relative prognostic value of clinical heart failure and early M-mode and 2-dimensional echocardiographic indexes of left ventricular performance was compared in a study of 205 consecutive patients with acute myocardial infarction (AMI). Statistical analysis showed that an early wall motion score was a stronger predictor of 1-year mortality than the occurrence of clinical heart failure early, late or at any time during the hospital course of AMI. The finding of clinical heart failure had an independent prognostic value of intermediate strength. M-mode echocardiographic parameters only had a weak independent prognostic value, possibly related to their content of information on left ventricular end-systolic dimension.

Adult↗
PubMed1990

Prognosis of late versus early ventricular fibrillation in acute myocardial infarction.

To determine the prognosis of late ventricular fibrillation (VF) after acute myocardial infarction (AMI), the length of the monitoring period after AMI was extended. All patients in this series were continuously monitored in a coronary care unit to ensure observation of all VF within 18 days of AMI. From 1977 to 1985, 4,269 patients were admitted with AMI and 413 (9.6%) had in-hospital VF. Of these 281 (6.8%) had early VF (less than 48 hours after AMI) and 132 (3.2%) had late VF (greater than or equal to 48 hours after AMI). In-hospital mortality was 50 and 54% for early and late VF, respectively (p = 0.31). Kaplan-Meier survival analysis showed better survival after discharge for patients with early versus late VF (p = 0.009) but this difference was fully explained by the presence of heart failure. Survival analysis showed the same prognosis after 1, 3 and 5 years for early and late VF, when VF was not associated with heart failure. When VF was associated with heart failure (secondary VF) early VF had a greater mortality than late VF after 2 and 5 years. Logistic regression analysis showed that heart failure (relative risk 1.9 [1.1 to 3.1]) and cardiogenic shock (relative risk 3.9 [1.8 to 8.5]) were significant risk factors for in-hospital death. Late VF compared to early VF had no prognostic implication (relative risk 1.0 [0.6 to 1.6]). For patients discharged from the hospital, risk factors were heart failure (1.8 [1.1 to 2.8]) and previous AMI (1.6 [1.3 to 2.1]).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Early estimation of risk by echocardiographic determination of wall motion index in an unselected population with acute myocardial infarction.

In a prospective series of 201 consecutive patients with creatine kinase-MB--documented acute myocardial infarction (AMI), postadmittance and predischarge echocardiographic wall motion indexes (WMI) were determined (median 45 hours vs 14 days after AMI). No significant change of left ventricular systolic performance was found between postadmittance and predischarge examinations in 179 survivors (WMI 1.3 +/- 0.4 vs 1.4 +/- 0.4, p greater than 0.05). Hospital mortality was 11% (22 of 201), cumulated 2-month mortality 15% (31 of 201) and cumulated 1-year mortality 26% (52 of 201). Mortality increased rapidly with decreasing left ventricular function as determined by WMI. When early WMI was less than 1.0, 1-year mortality was 51% (28 of 55) versus 8% (7 of 83) when WMI was greater than 1.3 (p less than 0.0001). Ventricular fibrillation (n = 24) and cardiogenic shock (n = 27) carried a much better prognosis when WMI showed good left ventricular function. When WMI was less than 1.0, 1-year mortality was 83% (10 of 12) versus 93% (13 of 14) in ventricular fibrillation and cardiogenic shock, respectively, whereas it was 0% (0 of 4) versus 33% (2 of 6) when WMI was greater than 1.3. In 15% of patients major discrepancies between early Killip class and WMI were noted. WMI showed much smaller fluctuations during the hospital course of AMI than did Killip class and appeared to be a more stable prognostic marker. Large-scale, early risk stratification by echocardiography has now become available and appears to facilitate a rational, individualized discharge policy in the coronary care unit and to provide an improved basis for randomization of patients in controlled studies aimed at tailoring new treatment in AMI.

Aged↗
PubMed1989

Interobserver agreement and accuracy of bedside estimation of right and left ventricular ejection fraction in acute myocardial infarction.

Ninety-eight patients with acute myocardial infarction were examined by 3 clinicians who, independently of each other, gave an estimate of left ventricular (LV) and right ventricular (RV) ejection fraction (EF) in each patient. Their estimates were based on physical examination, chest x-ray, electrocardiogram, patient history and clinical course during admission. Ejection fractions were estimated as belonging to 1 of 4 categories: normal (LVEF greater than or equal to 0.53, RVEF greater than or equal to 0.57), mildly reduced (LVEF 0.40 to 0.52, RVEF 0.45 to 0.56), moderately reduced (LVEF 0.30 to 0.39, RVEF 0.35 to 0.44) or severely reduced (LVEF less than 0.30, RVEF less than 0.35). Radionuclide ventriculography was carried out immediately after the physical examination. LVEF was correctly estimated in 43% of all examinations, deviated from radionuclide LVEF by 1 LVEF category in 45% and by 2 LVEF categories in 12%. The 3 clinicians agreed on estimated LVEF in only 32% of the patients. RVEF was correctly estimated in 67% of the examinations, but none of the clinicians identified greater than 43% of the relatively few patients with reduced radionuclide RVEF and they greatly disagreed as to who among the patients had a reduced RVEF. Previous myocardial infarction, electrocardiographic infarct location, Killip class, physical signs of left- and right-sided heart failure, radiographic pulmonary congestion and cardiomegaly were analyzed to determine which were the most helpful in predicting LVEF and RVEF. The results disclosed that several variables, traditionally believed to be reliable indexes of reduced ventricular function, were surprisingly poor predictors of LVEF and RVEF.

Adult↗
PubMed1989

[Radiographic examination of the thorax, fluoroscopy and echocardiography in cardiac calcification].

The value of radiographic examination of the thorax, fluoroscopy and echocardiography in demonstration and localization of intracardiac calcifications were compared in an investigation of 40 patients with valvular heart disease prior to planned cardiac catheterization or operation. Radiographic examination of the thorax revealed only the most severe calcifications. By means of echocardiography it proved possible to undertake a simple semi-quantitative characterisation of the calcified tissue with acceptable intra- and inter-observer variation. Echocardiography and fluoroscopy were found to be of equal value in demonstration of the degree of calcification of the heart. Echocardiography was, however, superior to fluoroscopy in fine localization of the calcifications. The relative and additive values of the methods could be illustrated employing Bayes' theorem and could be represented graphically provided that the observations carried out with the three methods could be considered independent of one another. It is concluded that radiographic examinations of the thorax is unsuitable for screening for cardiac calcifications. Fluoroscopy can no longer be considered to be the method of choice in assessing lesions of this type but should be employed in cases where echocardiography does not provide sufficient information or is not available. The greatest certainty in demonstration of calcifications is obtained with combined employment of fluoroscopy and echocardiography.

Adult↗
PubMed1989

Symptoms and signs of heart failure in patients with myocardial infarction: reproducibility and relationship to chest X-ray, radionuclide ventriculography and right heart catheterization.

102 patients with myocardial infarction (MI) were examined by three clinicians, who independently recorded the following symptoms and signs: dyspnoea, a displaced apex beat, S3-gallop, rales, neck vein distension, hepatomegaly, and dependent oedema. Chest X-ray, radionuclide ventriculography, and (in 40 patients) right heart catheterization were carried out immediately after the physical examination. The clinicians frequently disagreed as to the presence of physical signs of heart failure in individuals. Moreover, these signs were of limited value in identifying patients with pulmonary vascular congestion on chest X-ray, reduced left or right radionuclide ventricular ejection fractions, enlarged ventricular volumes or haemodynamic evidence of ventricular dysfunction. We conclude that clinicians frequently disagree in the recognition of physical signs of heart failure, and that these signs have an unpredictable relationship to radiographic, radionuclide and haemodynamic measures of ventricular performance in patients with MI. Nevertheless, physical signs are useful in identifying patients with high risk of cardiac death.

Adult↗
PubMed1986

Different patterns of hemodynamic abnormalities in patients with ischemic heart disease compared with patients with congestive cardiomyopathy.

48 patients with chest pain or unexplained heart failure were examined with exercise test, systolic time intervals, apexcardiogram and left- and right-sided heart catheterization including coronary arteriography. The 23 patients with ischemic heart disease (IHD) and 19 patients with congestive cardiomyopathy (COCM) could as groups be separated by several of the parameters. Two major patterns of change were present when using the whole range of parameters, probably reflecting that the heart and circulation had compensated for left ventricular dysfunction in different ways in IHD and COCM. Comparing patients with the same ejection fraction (EF), preejection-period index (PEPI) pre-ejection-period/left ventricular ejection time (PEP/LVET) and systolic blood pressure/left ventricular end systolic volume index (SBP/LVESVI), were all more abnormal in patients with COCM than with IHD at most EF levels. The best separation between the diseases was obtained using exercise capacity in combination with PEP/LVET. The correlations between invasive and noninvasive parameters underlined that no single parameter can satisfactorily characterize the circulatory function in patients with individual differences in preload, afterload, pulse rate, cardiac volumes, compliance and contractility. No or poor correlations were found between exercise capacity and the different function parameters used.

Adult↗
PubMed1984

Clinically suspected severe ischaemia-induced mitral regurgitation. Spectrum of lesions and features of high surgical risk by echocardiography.

Eighteen patients with clinical signs suggesting severe mitral regurgitation secondary to ischaemic heart disease were assessed by echocardiography. Non-ischaemic diseases needing specific therapy were revealed in six patients. In the other 12 patients echocardiography demonstrated myocardial lesions explaining the mitral regurgitation. Apart from the distinction between non-ischaemic conditions and lesions induced by ischaemia, echocardiography seems to be helpful in the demonstration of severe yet operable mitral valve regurgitation due to a small ischaemic lesion. Such cases are opposed to functional mitral regurgitation caused by extensive myocardial injury as demonstrated by two-dimensional echocardiography and reflected by a minimum mitral valve/septum separation of more than 2 1/2 cm on the M-mode echocardiogram. These conditions make symptomatic improvement by mitral valve surgery unlikely and carry an extremely high operative mortality. A more precise definition by heart catheterization is required when serious clinical heart failure is not explained by the echocardiographic finding of severe global myocardial impairment.

Aged↗