冠心病心脏舒张功能的多普勒超声心动图与左心导管法对比研究
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摘要
背景:流行病学资料显示左室舒张功能不全和舒张性心力衰竭患者占慢性充血性心力衰竭病人总数的40%～50%,而这些患者的射血分数正常或相对正常。多普勒超声心动图已成为目前无创评价心室舒张功能最常用、最重要的方法,二尖瓣环的超声组织多谱勒的舒张早期峰值(Ea)、二尖瓣口血流脉冲多谱勒舒张早期血流峰值(E)、舒张晚期峰值(A)、舒张早期二尖瓣血流速度E波与多普勒组织成像舒张早期二尖瓣环速度比值(E/Ea)都可预测左室舒张功能,但其特异性及敏感性有待于研究及证实。因此,我们收集了40例患者在冠状动脉造影时,用左心导管法确定LVEDP,与超声心动图指标相比较,来评价超声心动图指标预测左室舒张功能的特异性及敏感性。
目的:观察二尖瓣环的超声组织多谱勒的舒张早期峰值(Ea)、二尖瓣口血流脉冲多谱勒舒张早期血流峰值(E)、舒张晚期峰值(A)与导管法测得的左室舒张末期压力(LVEDP)的相关性分析,以通过无创伤的超声心动图检查评价左心室舒张功能。
方法:选择因反复胸痛行冠脉造影患者40例。经冠状动脉造影术确认冠状动脉狭窄程度<50%的患者作为无显著冠状动脉狭窄组;经冠状动脉造影术确认一支及一支以上内径1.5mm及以上的冠状动脉狭窄=75%的患者作为冠心?CHD)组。所有入选患者行冠状动脉造影术后,然后置入6F猪尾导管于左心室,连接充液换能器,测量并记录左室舒张末压。于冠脉造影术前24小时内行经胸二维超声心动图检查,获取左心房内径(LAD)、左心室舒张末内径(LVEDD)、左心室收缩末内径(LVESD)左心室后壁厚度(LVPWT),室间隔厚度(IVST);然后用双平面-辛普森方法测量左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)和左室射血分数(LVEF);测量二尖瓣口舒张早期峰值血流速度(E)、舒张晚期峰值血流速度(A),计算两者比值E/A;用多普勒组织成像技术测量舒张早期运动速度峰值(Ea)、舒张晚期运动速度峰值(Aa),计算两者比值Ea/Aa;再计算出E/Ea比值。用SPSS 13.0统计软件包比较无显著冠状动脉狭窄组和CHD组参数之间的差异,分析超声心动图指标与LVEDP的相关性。
结果:
1两组一般情况比较:年龄、性别、血脂、血糖、肝功能、肾功能、收缩压、舒张压无显著差异。
2超声心动图指标
2.1 CHD组LAD(37.66±5.94mm)、E/Ea比值(11.68±2.84)较无显著冠状动脉狭窄组LAD(30.45±3.49mm)、E/Ea比值(8.60±1.90)增高(P<0.05);CHD组较无显著冠状动脉狭窄组A峰、Aa均增高(P<0.05)。
2.2 CHD组LVEF(60.39±10.03)、E峰(72.90±11.19cm/s)较无显著冠状动脉狭窄组LVEF(62.67±8.79)、E峰(77.33±7.20cm/s)虽略有降低,但无显著性差异(P>0.05);CHD组IVST、LVPWT、LVEDD、LVESD、LVEDV、LVESV虽有所增高,但与无显著冠状动脉狭窄组比较,无显著性差异(P>0.05)。
2.3 CHD组Ea(6.49±1.40 cm/s)、Ea/Aa(0.79±0.28)、E/A(1.04±0.17)较无显著冠状动脉狭窄组Ea(9.36±2.12cm/s)、Ea/Aa(1.57±0.63)、E/A(1.20±0.27)均降低(P<0.05)。
2.4 CHD组E/Ea升高主要与Ea的明显降低有关,因两组E峰比较无显著性差异;CHD组的E/A降低,虽然同时伴有E峰的降低和A峰的升高,但主要与A峰的升高有关;CHD组Ea/Aa的降低,虽然同时伴有Ea的降低和Aa的升高,但主要是Ea的降低。
3心导管指标
CHD组LVEDP平均为(16.60±6.21mmHg),无显著冠状动脉狭窄组为(8.51±1.68mmHg),CHD组较无显著冠状动脉狭窄组明显增高,两者相比有显著的统计学差异(P<0.05)。
4线性相关分析
E/Ea与LVEDP呈正相关(r值为0.8175,P<0.05),LAD、LVEDV与LVEDP呈正相关(r值分别为0.3777,0.3798,P<0.05),E/A与LVEDP无显著相关(r值为-0.1260,P>0.05)。
5 E/A及E/Ea异常发生率与LVEDP异常发生率的比较E/Ea=10估计LVEDP=15mmHg的敏感性为94%,高于E/A估计LVEDP=15mmHg的敏感性(26%),两者相比P<0.05,有显著的统计学差异;E/Ea=10估计LVEDP>15mmHg的特异性为73%,高于E/A估计LVEDP=15mmHg的特异性(44%),两者相比P<0.05,差异有显著性。
结论:
1严重的冠状动脉狭窄对左心室舒张功能有明显影响。
2多普勒超声心动图是评价左室舒张功能的重要手段,其中,左室舒张功能明显下降时,Ea也明显下降,E/Ea则与LVEDP相关,二者结合可用于评价舒张功能受损的严重程度及左室充盈压。
3左房大小与LVEDP相关,与Ea、E/Ea等多普勒超声心动图指标结合,可以作为评价左室舒张功能的重要指标,以提高诊断或排除左室舒张功能不全的准确性和可靠性。
4在CHD中,E/Ea比值比E/A比值更能准确评价左室舒张功能,尤其是预测LVEDP。
Background:Epidemiologic data indicate that left ventricular diastolic dysfunction(DD) and diastolic heart failure(DHF),that is symptomatic DD and a distinct form of heart failure,are very common in 40-50%of patients with chronic heart failure have normal or relatively normal left ventricular ejections fractions.Doppler echocardiography has become the most common and important method to evaluate left ventricular diastolic function because of its non-invasion.
Early diastolic velocities of mitral annulus(Ea),transmitral diastolic early peak inflow velocity(E),transmitral diastolic late peak inflow velocity(A) and the ratio of mitral velocity to early diastolic velocity of the mitral annulus(E/Ea) can predict left ventricular diastolic function,but the specificity and the sensitivity need to be studied and verified.Therefor,we collection forty patients performed cardiac catheterization for selected coronary artery angiography to measure LVEDP and compared with echocardiographic finding to evaluate the specificity and the sensitivity in predicting LVEDP by echocardiographic finding.
Objective:To observe the early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak velocity of the mitral inflow(E)and the late diastolic peak velocity of mitral inflow(A) and the relationship between the velocities and left ventricular end diastolic pressure(LVEDP) which obtained bycardiac catheterization.
Methods:Forty patients with repeated chest pain performed cardiac catheterization for selected coronary artery angiography.Patients with the degree of coronary artery stenosis (50%which were diagnosed by cardiac catheterization were as a non-obvious coronary stenosis group.The patients with one or more coronary arteries(the diameter=1.5mm) stenosis =75% were as coronary heart disease group.After the coronary artery angiography,LVEDP were measured and recorded. Echocardiography was performed before 24 hours of the angiography.Left atrial dimensions(LAD),left ventricular end diastolic(LVEDD) and systolic dimension(LVESD), interventricular septal thickness(IVST),left ventricular posterior wall thickness(LVPWT) were measured by echocardiography. Measurements of left ventricular end-diastolic volume (LVEDV),end-systolic volume(LVESV) and ejection fraction(LVEF) was obtained by biplane Simpson's method.The early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak filling velocity of mitral inflow(E),late diastolic peak filling velocity(A) were analyzed.E/Ea ratio and E/A ratio were calculated.SPSS 13.0 software package was used to compare the differences of the parameters between two groups and to analyze the correlation between the LVEDP and the parameters from the echocardiogram.
Results:
1 There were no statistically significant difference between non-obvious coronary stenosis group and CHD group in age, sex,serum levels of lipid,serum levels of glucose,liver function, renal function,systolic blood pressure and diastolic blood pressure(P>0.05).
2 Echocardiographic finding:
2.1 Significant more increases were noted in LAD in CHD group than non-obvious coronary stenosis group(30.45±3.49mm, P<0.05).E/Ea ratios in CHD group were significantly higher than those in non-obvious coronary stenosis group(11.68±2.84 vs 8.60±1.90,P<0.05).Compared with the measurements of non-obvious coronary stenosis group increased A and Aa were found in CHD group(P<0.05).
2.2 LVEF and E peaks in CHD group were lower than those in non-obvious coronary stenosis group(60.39±10.03 vs 62.67±8.79 and 72.90±11.19 cm/s vs 77.33±7.20 cm/s),but there was no statistical difference between CHD group and non-obvious coronary stenosis group(P>0.05).Compared with non-obvious coronary stenosis group,increased IVST,LVPWT, LVEDD,LVESD,LVEDV and LVESV were found in CHD group,but there was no statistical difference(P>0.05).
2.3 Significant more decreases were noted in Ea,Ea/Aa and E/A in CHD group than non-obvious coronary stenosis group(6.49±1.40cm/s vs 9.36±2.12cm/s,0.79±0.28 vs 1.57±0.63, 1.04±0.17 vsl.20±0.27,P<0.05).
2.4 The increase in E/Ea ratio in CHD group was mainly because of the decreased Ea.The decreased Ea was the major reason for decreased Ea/Aa in CHD group,though Aa increase in CHD group at the same time.For decreased E/A in CHD group,the increased A is the major reason.
3 Linear correlation analyses:Significant correlations were found between E/Ea ratio and LVEDP(r=0.8175,P<0.05). There was no significant correlations between E/A and LVEDP (r=-0.1260,P>0.05).Correlations were found between LAD and LVEDP(r=0.3777,P<0.05),E/A and LVEDP(r=0.3798,P<0.05).
4 The comparison of abnormality incidence rate between E/A,E/Ea and LVEDP.The Sensitivity of E/Ea=10 estimating LVEDP>15mmHg was 94%and was better than 16%of E/A(P<0.05).The specificity of E/Ea=10 predicting LVEDP>15mmHg was 73%and the specificity of E/A was 44%.There was a significant statistical difference in the specificity between E/Ea and E/A.
Conclusions:
1 Severe coronary stenosis had a great influence on left ventricular diastolic function.
2 Doppler echocardiography is an important tool in the evaluation of left ventricular diastolic function.Ea correlates with the degree of left ventricular dysfunction.E/Ea ratio correlates with LVEDP,and the combination of Ea and E/Ea ratio is useful in the evaluation of diastolic function.
3 Left atrial size,which correlates with LVEDP,may be an important morphologic index in the estimation of left ventricular diastolic function by combining with other Dopplerechocardiography indexes such as Ea and E/Ea.
4 In CHD,E/Ea is more accurate reflection of left ventricular diastolic function than E/A,especially for estimation of LVEDP.
目的:观察二尖瓣环的超声组织多谱勒的舒张早期峰值(Ea)、二尖瓣口血流脉冲多谱勒舒张早期血流峰值(E)、舒张晚期峰值(A)与导管法测得的左室舒张末期压力(LVEDP)的相关性分析,以通过无创伤的超声心动图检查评价左心室舒张功能。
方法:选择因反复胸痛行冠脉造影患者40例。经冠状动脉造影术确认冠状动脉狭窄程度<50%的患者作为无显著冠状动脉狭窄组;经冠状动脉造影术确认一支及一支以上内径1.5mm及以上的冠状动脉狭窄=75%的患者作为冠心?CHD)组。所有入选患者行冠状动脉造影术后,然后置入6F猪尾导管于左心室,连接充液换能器,测量并记录左室舒张末压。于冠脉造影术前24小时内行经胸二维超声心动图检查,获取左心房内径(LAD)、左心室舒张末内径(LVEDD)、左心室收缩末内径(LVESD)左心室后壁厚度(LVPWT),室间隔厚度(IVST);然后用双平面-辛普森方法测量左室舒张末期容积(LVEDV)、左室收缩末期容积(LVESV)和左室射血分数(LVEF);测量二尖瓣口舒张早期峰值血流速度(E)、舒张晚期峰值血流速度(A),计算两者比值E/A;用多普勒组织成像技术测量舒张早期运动速度峰值(Ea)、舒张晚期运动速度峰值(Aa),计算两者比值Ea/Aa;再计算出E/Ea比值。用SPSS 13.0统计软件包比较无显著冠状动脉狭窄组和CHD组参数之间的差异,分析超声心动图指标与LVEDP的相关性。
结果:
1两组一般情况比较:年龄、性别、血脂、血糖、肝功能、肾功能、收缩压、舒张压无显著差异。
2超声心动图指标
2.1 CHD组LAD(37.66±5.94mm)、E/Ea比值(11.68±2.84)较无显著冠状动脉狭窄组LAD(30.45±3.49mm)、E/Ea比值(8.60±1.90)增高(P<0.05);CHD组较无显著冠状动脉狭窄组A峰、Aa均增高(P<0.05)。
2.2 CHD组LVEF(60.39±10.03)、E峰(72.90±11.19cm/s)较无显著冠状动脉狭窄组LVEF(62.67±8.79)、E峰(77.33±7.20cm/s)虽略有降低,但无显著性差异(P>0.05);CHD组IVST、LVPWT、LVEDD、LVESD、LVEDV、LVESV虽有所增高,但与无显著冠状动脉狭窄组比较,无显著性差异(P>0.05)。
2.3 CHD组Ea(6.49±1.40 cm/s)、Ea/Aa(0.79±0.28)、E/A(1.04±0.17)较无显著冠状动脉狭窄组Ea(9.36±2.12cm/s)、Ea/Aa(1.57±0.63)、E/A(1.20±0.27)均降低(P<0.05)。
2.4 CHD组E/Ea升高主要与Ea的明显降低有关,因两组E峰比较无显著性差异;CHD组的E/A降低,虽然同时伴有E峰的降低和A峰的升高,但主要与A峰的升高有关;CHD组Ea/Aa的降低,虽然同时伴有Ea的降低和Aa的升高,但主要是Ea的降低。
3心导管指标
CHD组LVEDP平均为(16.60±6.21mmHg),无显著冠状动脉狭窄组为(8.51±1.68mmHg),CHD组较无显著冠状动脉狭窄组明显增高,两者相比有显著的统计学差异(P<0.05)。
4线性相关分析
E/Ea与LVEDP呈正相关(r值为0.8175,P<0.05),LAD、LVEDV与LVEDP呈正相关(r值分别为0.3777,0.3798,P<0.05),E/A与LVEDP无显著相关(r值为-0.1260,P>0.05)。
5 E/A及E/Ea异常发生率与LVEDP异常发生率的比较E/Ea=10估计LVEDP=15mmHg的敏感性为94%,高于E/A估计LVEDP=15mmHg的敏感性(26%),两者相比P<0.05,有显著的统计学差异;E/Ea=10估计LVEDP>15mmHg的特异性为73%,高于E/A估计LVEDP=15mmHg的特异性(44%),两者相比P<0.05,差异有显著性。
结论:
1严重的冠状动脉狭窄对左心室舒张功能有明显影响。
2多普勒超声心动图是评价左室舒张功能的重要手段,其中,左室舒张功能明显下降时,Ea也明显下降,E/Ea则与LVEDP相关,二者结合可用于评价舒张功能受损的严重程度及左室充盈压。
3左房大小与LVEDP相关,与Ea、E/Ea等多普勒超声心动图指标结合,可以作为评价左室舒张功能的重要指标,以提高诊断或排除左室舒张功能不全的准确性和可靠性。
4在CHD中,E/Ea比值比E/A比值更能准确评价左室舒张功能,尤其是预测LVEDP。
Background:Epidemiologic data indicate that left ventricular diastolic dysfunction(DD) and diastolic heart failure(DHF),that is symptomatic DD and a distinct form of heart failure,are very common in 40-50%of patients with chronic heart failure have normal or relatively normal left ventricular ejections fractions.Doppler echocardiography has become the most common and important method to evaluate left ventricular diastolic function because of its non-invasion.
Early diastolic velocities of mitral annulus(Ea),transmitral diastolic early peak inflow velocity(E),transmitral diastolic late peak inflow velocity(A) and the ratio of mitral velocity to early diastolic velocity of the mitral annulus(E/Ea) can predict left ventricular diastolic function,but the specificity and the sensitivity need to be studied and verified.Therefor,we collection forty patients performed cardiac catheterization for selected coronary artery angiography to measure LVEDP and compared with echocardiographic finding to evaluate the specificity and the sensitivity in predicting LVEDP by echocardiographic finding.
Objective:To observe the early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak velocity of the mitral inflow(E)and the late diastolic peak velocity of mitral inflow(A) and the relationship between the velocities and left ventricular end diastolic pressure(LVEDP) which obtained bycardiac catheterization.
Methods:Forty patients with repeated chest pain performed cardiac catheterization for selected coronary artery angiography.Patients with the degree of coronary artery stenosis (50%which were diagnosed by cardiac catheterization were as a non-obvious coronary stenosis group.The patients with one or more coronary arteries(the diameter=1.5mm) stenosis =75% were as coronary heart disease group.After the coronary artery angiography,LVEDP were measured and recorded. Echocardiography was performed before 24 hours of the angiography.Left atrial dimensions(LAD),left ventricular end diastolic(LVEDD) and systolic dimension(LVESD), interventricular septal thickness(IVST),left ventricular posterior wall thickness(LVPWT) were measured by echocardiography. Measurements of left ventricular end-diastolic volume (LVEDV),end-systolic volume(LVESV) and ejection fraction(LVEF) was obtained by biplane Simpson's method.The early diastolic peak velocity of mitral annulus(Ea),the early diastolic peak filling velocity of mitral inflow(E),late diastolic peak filling velocity(A) were analyzed.E/Ea ratio and E/A ratio were calculated.SPSS 13.0 software package was used to compare the differences of the parameters between two groups and to analyze the correlation between the LVEDP and the parameters from the echocardiogram.
Results:
1 There were no statistically significant difference between non-obvious coronary stenosis group and CHD group in age, sex,serum levels of lipid,serum levels of glucose,liver function, renal function,systolic blood pressure and diastolic blood pressure(P>0.05).
2 Echocardiographic finding:
2.1 Significant more increases were noted in LAD in CHD group than non-obvious coronary stenosis group(30.45±3.49mm, P<0.05).E/Ea ratios in CHD group were significantly higher than those in non-obvious coronary stenosis group(11.68±2.84 vs 8.60±1.90,P<0.05).Compared with the measurements of non-obvious coronary stenosis group increased A and Aa were found in CHD group(P<0.05).
2.2 LVEF and E peaks in CHD group were lower than those in non-obvious coronary stenosis group(60.39±10.03 vs 62.67±8.79 and 72.90±11.19 cm/s vs 77.33±7.20 cm/s),but there was no statistical difference between CHD group and non-obvious coronary stenosis group(P>0.05).Compared with non-obvious coronary stenosis group,increased IVST,LVPWT, LVEDD,LVESD,LVEDV and LVESV were found in CHD group,but there was no statistical difference(P>0.05).
2.3 Significant more decreases were noted in Ea,Ea/Aa and E/A in CHD group than non-obvious coronary stenosis group(6.49±1.40cm/s vs 9.36±2.12cm/s,0.79±0.28 vs 1.57±0.63, 1.04±0.17 vsl.20±0.27,P<0.05).
2.4 The increase in E/Ea ratio in CHD group was mainly because of the decreased Ea.The decreased Ea was the major reason for decreased Ea/Aa in CHD group,though Aa increase in CHD group at the same time.For decreased E/A in CHD group,the increased A is the major reason.
3 Linear correlation analyses:Significant correlations were found between E/Ea ratio and LVEDP(r=0.8175,P<0.05). There was no significant correlations between E/A and LVEDP (r=-0.1260,P>0.05).Correlations were found between LAD and LVEDP(r=0.3777,P<0.05),E/A and LVEDP(r=0.3798,P<0.05).
4 The comparison of abnormality incidence rate between E/A,E/Ea and LVEDP.The Sensitivity of E/Ea=10 estimating LVEDP>15mmHg was 94%and was better than 16%of E/A(P<0.05).The specificity of E/Ea=10 predicting LVEDP>15mmHg was 73%and the specificity of E/A was 44%.There was a significant statistical difference in the specificity between E/Ea and E/A.
Conclusions:
1 Severe coronary stenosis had a great influence on left ventricular diastolic function.
2 Doppler echocardiography is an important tool in the evaluation of left ventricular diastolic function.Ea correlates with the degree of left ventricular dysfunction.E/Ea ratio correlates with LVEDP,and the combination of Ea and E/Ea ratio is useful in the evaluation of diastolic function.
3 Left atrial size,which correlates with LVEDP,may be an important morphologic index in the estimation of left ventricular diastolic function by combining with other Dopplerechocardiography indexes such as Ea and E/Ea.
4 In CHD,E/Ea is more accurate reflection of left ventricular diastolic function than E/A,especially for estimation of LVEDP.
引文
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2 Deswal A.Diastolic dysfunction and diastolic heart failure:mechanisms and epidemiology.Curr Cardiol Rep.2005May;7(3):178-83
3 Ommen SR,Echocardiographic assessment of diastolic function.Curr Opin Cardiol,2001,16(4):240
4 Nishimura RA,Housemans PR,Hatle HK et al.Assessment of diastolic function of the heart:Back ground and current aPPlications of DoPPler Echocardiography.Part1.Physiologic and pathophysiologic features.Mayo ClinProe.1989,11:64-71
5 Dash H,Johnson RA,Dinsmore RE,et al.Cardiomyopathic syndrome due to coronary artery disease.I:Relation to angiographic extent of coronary disease and to remote myocardial infarction.Br Heart J,1977,39(7):733-739
6 叶任高,陆再英主编。内科学[M].北京:人民卫生出版社,2000,258
7 叶任高,陆再英主编。内科学[M].北京:人民卫生出版社,2000,809-810
8 Dougherty AH,Naccarelli GV,Gray EL,et al.Congestive heart failure with normal systolic function.Am J Cardiol,1984,54:778-782
9 Hanlin SK,Villars PS,Kanusky JT,et al.Role of diastole in left ventricul ar function,Ⅱ:diagnosis and treatment.Am J Crit care,2004,13(6):453-466
10 David A.Kass,J ean G.F,Bronzwaer,waiter J.Paulus,What mechanisms underlie diastolic dyfuncitom in heart failure Circ Res.2004,94(6):1533-1542
11 魏玲,杨丽霞,石燕昆,等。扩张型心肌病患者静息心率及ST段改变的临床意义初探。西南国防医药,2002,12(4):317
12 De Sutter J,de Backer J,van de Veire N,et al.Effects of age,gender,and left ventricularmass on sep talmitral annulus velocity(E') and the ratio of transmitral early peak velocity to E'(E/E').Am J Cardiol,2005,95(8):1020-1023
13 Sohn DW,Chai IH,L ee DJ,et al.A ssessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular disatolic function.J Am Coll Cardiol,1997,30(2):474-480
14 Ommen SR,Nishimura RA,Appleton CP,et al.Clinicalutility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressure:A comparative simultaneous Doppler- catheterization study.Circulation,2000,102(15):1788-1794
15 Hillis GS,Moller JE,Pellikka PA,et al.Noninvasive estimation of left ventricular filling pressure by E/Ea is apowerful predictor of survival after acute myocardia- linfarction.J Am Coll Cardiol,2004,43(3):360-367
16 Dokainish H,Zoghbi WA,Lakkis NM,et al.Optimal Noninvasive assessment of left ventricular filling pressures:a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.Circulation,2004,109(20):2432-2439
17 Nagueh SF,Middleton KJ,Kopelen HA,et al.Dopplertissue Imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1527-1533
18 Garcia MJ,Ares MA,Ashen et al.An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure.J Am Coll Cardiol,1997,29(2):448-454
19 张梅 张运等Chinese Journal of Cardiovascular Medicine,2002,17(1):76-77
20 Nagueh SF,Middleton KJ,Kopelen HA,et al.Doppler tissue imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1527-1533
21 Ommen SR,Nishimura RA,Appleton CP,et al.Clinical utility of Doppler echocardiography and Tissue Doppler Imaging in the estimation of left ventricular filling pressures:A comparative simultaneous Doppler-catheterization study Circulation,2000,102(15):1788-1794
22 Gaertner R,Louedec L.Doppler echocardiographic estimation of left ventricular end-diastolic pressure after MI in rats.Prunier Fabrice,2002,283:H346-H352
23 Quinones MA.Assessment of Diastolic Function.Prog-Cardiovasc Dis,2005,47(5):340-355
1 Roger VL,Weston SA,Redifield MM,et al.Trends in heart failure incidence and survival in a community-based population.JAMA,2004,292(3):344-350
2 Redfied MM,Jacobsen SJ,Burnett JC,Jr,et al.Burden of systolic and diastolic ventricular dysfunction in the community:appreciating the scope of the heart failure epidemic.JAMA,2003,289(2):194-202
3 Fischer M,Baessler A,Hense HW,et al,Prevalence of left ventriculai diastolic dysfunction in the community.Results from a Doppler echocardiographic-based survey of a population sample.Eur Heart J,2003,24(4):320-328
4 Hunt SA,Baker DW,Chin MH,et al.ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult:Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines:Developed in Collaboration With the International Society for Heart and Lung Transplantation;Endorsed by the Heart Failure Society of America.Circulation,2001,104(24):2996-3007
5 Hunt SA,Abraham WT,Chin MH,et al.ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult:a report of the American College of Cardiology/American Heart Association Task Force on practice Guidelines:developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation:endorsed by the Heart Rhythm Society.Circulation,2005,112(12):154-235
6 Ren X,Ristow B,Na B,et al.Prevalence and prognosis of asymptomatic left ventricular diastolic dysfunction in ambulatory patients with coronary heart disease.Am J Cardiol,2007,99(12):1643-1647
7 Hamlin SK,Villars PS,Kanusky JT,et al.Role of diastole in left ventricular function,Ⅱ:diagosis and treatmeat.Am J Crit Care,2004,13(6):453-466
8 Pickering TGHeart Failure and Hypertension:The Diastolic Dilemma.J Clin Hypertens,2004,6(11):647-650
9 Zile MR,Brutsaert DL.New concepts in diastolic dysfunction and diastolic heart failure:Part Ⅱ:causal mechanisms and treatment.Circulation,2002,105(12):1503-1508
10 Villars PS,Hamlin SK,Shaw AD,et al.Role of diastole in left ventricular function,Ⅰ:Biochemical and biomechanical events.Am J Crit Care,2004,13(5):394-403
11 Tian R,Nascimben L,Ingwall JS,et al.Failure to maintain a low ADP concentration impairs diastolic function in Hypertrophied rat heart.Circulation,1997,96(4):1313-1319
12 Cazorla O,Freiburg A,Helmes M,et al.Differential expression of cardiac titin isoforms and modulation of cellular stiffness.Circ Res,2000,86(1):59-67
13 Opitz CA,Linke WA.Plasticity of cardiac titin/connectin in heart development.J Muscle Res Cell Motil,2005,26(6-8):333-342
14 Martos R,Baugh J,Ledwidge M,et al.Diastolic heart failure:evidence of increased myocardial collagen turnover inked to diastolic dysfunction.Circulation,2007,115(7):888-895
15 Brower GL,Gardner JD,Forman MF,et al.The relationship between myocardial extracellular matrix remodeling and ventricular function.Eur J Cardiothorac Surg,2006,30(4):604-610
16 Jalil JE,Doering CW,Janicki JS,et al.Fibrillar collagen and myocardial stiffness in the intact hypertrophied rat left ventricle.Circ Res,1989,64(6):1041-1050
17 Osadchii OE.Cardiac hypertrophy induced by sustained beta-adrenoreceptor activation:pathophysiological aspects.Heart Fail Rev,2007,12(1):66-86
18 Higaki J,Aoki M,Morishita R,et al.In vivo evidence of the importance of cardiac angiotensin-converting enzyme in the pathogenesis of cardiac hypertrophy.Arterioscler Thromb Vasc Biol,2000,20(2):428-434
19 Young MJ,Lam EY,Rickard AJ.Mineralocorticoid receptor activation and cardiac fibrosis.Clin Sci(Lond),2007,112(9):467-475
20 Rickard AJ,Funder JW,uller PJ,et al.The role of the glucocorticoid receptor in mineralocorticoid/salt-mediated cardiac fibrosis.Endocrinology,2006,147(12):5901-5906
21 Paulus WJ,Bronzwaer JG.Nitri oxide's role in the heart:control of beating or breathing.Am J Physiol-Heart Circ Physiol,2004,287(1):H8-13
22 Maciver DH,Townsend M.A novel mechanism of heart failure with normal ejection fraction.Heart,2007,4:4(Epub ahead of print)
23 Yip G,Wang M,Zhang Y,et al.Left ventricular long axis function in diastolic heart failure is reduced in both diastole and systole:time for a redefinition.Heart,2002,87(2):121-125
24 Anonymous.How to diagnose diastolic heart failure.European Study Group on Diastolic Heart Failure.Eur HeartJ,1998,19(7):990-1003
25 Paulus WJ,Tschope C,Sanderson JE,et al.How to diagnose diastolic heart failure:a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Association of the European Society of Cardiology.Eur HeartJ,2007,28(20):2539-2550
26 Paraskevaidis IA,Tsiapras DP,Karavolias GK,et al.Doppler-derived left ventricular end-diastolic pressure prediction model using the combined analysis of mitral and pulmonary A waves in patients with coronary artery disease and preserved left ventricular systolic function.Am J Cardiol,2002,90(7):720-724
27 Temporelli PL,Giannuzzi P,Nicolosi GL,et al.Dopplerderived mitral deceleration time as a strong prognostic marker of left ventricular remodeling and survival after acute myocardial infarction:results of the GISSI-3 echo substudy.J Am Coll Cardiol,2004,43(9):1646-1653
28 Jensen JL,Williams FE,Beiby BJ,et al.Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique.J Am Soc Echocardiogr,1997,10(1):60-66
29 Hyodo E,Hiata K,Hirose M,et al.Clinical Use of Doppler Echocardiography and Doppler Tissue Imaging in the Estimation of Myocardial Ischemia During Dobutamine Stress Echocardiography.J Am Soc Echocardiogr,2007(Epub ahead of print)
30 Hori Y,Kunihiro S,Hoshi F,et al.Comparison of themyocardial performance index derived by use of pulsed-Doppler echocardiography and tissue Doppler imaging in dogs with volume overload.Am J Vet Res,2007,68(11):1177-1182
31 Alam M,Witt N,Nordlander R,et al.Detection of abnormal left ventricular function by Doppler tissue imaging in patients with a first myocardial infarction and showing normal function assessed by conventional echocardiography.Eur J Echocardiogr,2007,8(1):37-41
32 Kasner M,Westermann D,Steendijk P,et al.Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction:a comparative Dopplerconductance catheterization study,Circulation,2007,116(6):637-647
33 Hillis GS,Moller JE,Pellikka PA,et al.Noninvasive estimation of left ventricular filling pressure by E/Ea is a powerful predictor of survival after acute myocardial infarction.J Am Coll Cardiol,2004,43(3):360-367
34 Dokainish H,Zoghbi WA,Lakis NM,et al.Optimal noninvasive assessment of left ventricular filling pressures:a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.Circulation,2004,109(20):2432-2439
35 Nagueh SF,Middleton KJ,Kopelen HA,et al.Doppler tissue imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1572-1533
36 Weiss JL,Frederiksen JW,Weisfeldt ML.Hemodynamic determinants of the time-course of fall in canine left ventricular pressure.J Clin Invest,1976,58(3):751-760
37 Marino P,Little WC,Rossi A,et aL Can left ventricular diastolic stiffness be measured noninvasively.J Am Soc Echocardiogr,2002,15(9):935-943
38 Weber KT,Brilla CG.Pathological hypertrophy and cardiac interstitium.Fibrosis and rennin-angiotensin-aldosterone system.Circulation,1991,83(6):1894-1865
39 Wilke A,Funck R,Rupp H,et al.Effect of the renin-anfiotensin-aldosterone system on the cardiac Interstitium in heart failure.Basic Res Cardiol,1996,91 (Suppl2):79-84
40 Weber KT,SunY,Guarda E.Structural remodeling in Hypertensive heart disease and the role of hormones.Hypertension,1994,23(6 Pt 2):869-877
41 Lorell BH,Isoyama S,Grice WN,et al.Effects of ouabain and isoproterenol on left ventricular diastolic function during low-flow ischemia in isolated,blood-perfused rabbit heart.Circ Res,1988,63(2):457-467
42 The Digitalis Investigation Group.The effect of digoxin on mortality and morbidity in patients with heart failure.The New England Journal of Medicine(N Engl J Med),1997,336(8):525-533
43 Ahmed A,Aronow WS,Fleg JL.Predictors of mortality and hospitalization in women with heart failure in the Digitalis Investigation Group trial.Am J Ther,2006,13(4):325-331
44 Ahmed A,Aronow WS,Fleg JL.Higher New York heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function.Am Heart J,2006,151(2):444-450
45 Ahmed A,Rich MW,Love TE,et al.Digoxin and reduction in mortality and hospitalization in heart failure:a comprehensive post hoc analysis of the DIG trail.Eur Heart J,2006,27(2):178-186
46 Setaro JF,Zaret BL,Schulman DS,et al.Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diadtolic filling and normal left ventricular systolic performance.Am J Cardiol,1990,66(12):981-986
2 Deswal A.Diastolic dysfunction and diastolic heart failure:mechanisms and epidemiology.Curr Cardiol Rep.2005May;7(3):178-83
3 Ommen SR,Echocardiographic assessment of diastolic function.Curr Opin Cardiol,2001,16(4):240
4 Nishimura RA,Housemans PR,Hatle HK et al.Assessment of diastolic function of the heart:Back ground and current aPPlications of DoPPler Echocardiography.Part1.Physiologic and pathophysiologic features.Mayo ClinProe.1989,11:64-71
5 Dash H,Johnson RA,Dinsmore RE,et al.Cardiomyopathic syndrome due to coronary artery disease.I:Relation to angiographic extent of coronary disease and to remote myocardial infarction.Br Heart J,1977,39(7):733-739
6 叶任高,陆再英主编。内科学[M].北京:人民卫生出版社,2000,258
7 叶任高,陆再英主编。内科学[M].北京:人民卫生出版社,2000,809-810
8 Dougherty AH,Naccarelli GV,Gray EL,et al.Congestive heart failure with normal systolic function.Am J Cardiol,1984,54:778-782
9 Hanlin SK,Villars PS,Kanusky JT,et al.Role of diastole in left ventricul ar function,Ⅱ:diagnosis and treatment.Am J Crit care,2004,13(6):453-466
10 David A.Kass,J ean G.F,Bronzwaer,waiter J.Paulus,What mechanisms underlie diastolic dyfuncitom in heart failure Circ Res.2004,94(6):1533-1542
11 魏玲,杨丽霞,石燕昆,等。扩张型心肌病患者静息心率及ST段改变的临床意义初探。西南国防医药,2002,12(4):317
12 De Sutter J,de Backer J,van de Veire N,et al.Effects of age,gender,and left ventricularmass on sep talmitral annulus velocity(E') and the ratio of transmitral early peak velocity to E'(E/E').Am J Cardiol,2005,95(8):1020-1023
13 Sohn DW,Chai IH,L ee DJ,et al.A ssessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular disatolic function.J Am Coll Cardiol,1997,30(2):474-480
14 Ommen SR,Nishimura RA,Appleton CP,et al.Clinicalutility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressure:A comparative simultaneous Doppler- catheterization study.Circulation,2000,102(15):1788-1794
15 Hillis GS,Moller JE,Pellikka PA,et al.Noninvasive estimation of left ventricular filling pressure by E/Ea is apowerful predictor of survival after acute myocardia- linfarction.J Am Coll Cardiol,2004,43(3):360-367
16 Dokainish H,Zoghbi WA,Lakkis NM,et al.Optimal Noninvasive assessment of left ventricular filling pressures:a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.Circulation,2004,109(20):2432-2439
17 Nagueh SF,Middleton KJ,Kopelen HA,et al.Dopplertissue Imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1527-1533
18 Garcia MJ,Ares MA,Ashen et al.An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure.J Am Coll Cardiol,1997,29(2):448-454
19 张梅 张运等Chinese Journal of Cardiovascular Medicine,2002,17(1):76-77
20 Nagueh SF,Middleton KJ,Kopelen HA,et al.Doppler tissue imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1527-1533
21 Ommen SR,Nishimura RA,Appleton CP,et al.Clinical utility of Doppler echocardiography and Tissue Doppler Imaging in the estimation of left ventricular filling pressures:A comparative simultaneous Doppler-catheterization study Circulation,2000,102(15):1788-1794
22 Gaertner R,Louedec L.Doppler echocardiographic estimation of left ventricular end-diastolic pressure after MI in rats.Prunier Fabrice,2002,283:H346-H352
23 Quinones MA.Assessment of Diastolic Function.Prog-Cardiovasc Dis,2005,47(5):340-355
1 Roger VL,Weston SA,Redifield MM,et al.Trends in heart failure incidence and survival in a community-based population.JAMA,2004,292(3):344-350
2 Redfied MM,Jacobsen SJ,Burnett JC,Jr,et al.Burden of systolic and diastolic ventricular dysfunction in the community:appreciating the scope of the heart failure epidemic.JAMA,2003,289(2):194-202
3 Fischer M,Baessler A,Hense HW,et al,Prevalence of left ventriculai diastolic dysfunction in the community.Results from a Doppler echocardiographic-based survey of a population sample.Eur Heart J,2003,24(4):320-328
4 Hunt SA,Baker DW,Chin MH,et al.ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult:Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines:Developed in Collaboration With the International Society for Heart and Lung Transplantation;Endorsed by the Heart Failure Society of America.Circulation,2001,104(24):2996-3007
5 Hunt SA,Abraham WT,Chin MH,et al.ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult:a report of the American College of Cardiology/American Heart Association Task Force on practice Guidelines:developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation:endorsed by the Heart Rhythm Society.Circulation,2005,112(12):154-235
6 Ren X,Ristow B,Na B,et al.Prevalence and prognosis of asymptomatic left ventricular diastolic dysfunction in ambulatory patients with coronary heart disease.Am J Cardiol,2007,99(12):1643-1647
7 Hamlin SK,Villars PS,Kanusky JT,et al.Role of diastole in left ventricular function,Ⅱ:diagosis and treatmeat.Am J Crit Care,2004,13(6):453-466
8 Pickering TGHeart Failure and Hypertension:The Diastolic Dilemma.J Clin Hypertens,2004,6(11):647-650
9 Zile MR,Brutsaert DL.New concepts in diastolic dysfunction and diastolic heart failure:Part Ⅱ:causal mechanisms and treatment.Circulation,2002,105(12):1503-1508
10 Villars PS,Hamlin SK,Shaw AD,et al.Role of diastole in left ventricular function,Ⅰ:Biochemical and biomechanical events.Am J Crit Care,2004,13(5):394-403
11 Tian R,Nascimben L,Ingwall JS,et al.Failure to maintain a low ADP concentration impairs diastolic function in Hypertrophied rat heart.Circulation,1997,96(4):1313-1319
12 Cazorla O,Freiburg A,Helmes M,et al.Differential expression of cardiac titin isoforms and modulation of cellular stiffness.Circ Res,2000,86(1):59-67
13 Opitz CA,Linke WA.Plasticity of cardiac titin/connectin in heart development.J Muscle Res Cell Motil,2005,26(6-8):333-342
14 Martos R,Baugh J,Ledwidge M,et al.Diastolic heart failure:evidence of increased myocardial collagen turnover inked to diastolic dysfunction.Circulation,2007,115(7):888-895
15 Brower GL,Gardner JD,Forman MF,et al.The relationship between myocardial extracellular matrix remodeling and ventricular function.Eur J Cardiothorac Surg,2006,30(4):604-610
16 Jalil JE,Doering CW,Janicki JS,et al.Fibrillar collagen and myocardial stiffness in the intact hypertrophied rat left ventricle.Circ Res,1989,64(6):1041-1050
17 Osadchii OE.Cardiac hypertrophy induced by sustained beta-adrenoreceptor activation:pathophysiological aspects.Heart Fail Rev,2007,12(1):66-86
18 Higaki J,Aoki M,Morishita R,et al.In vivo evidence of the importance of cardiac angiotensin-converting enzyme in the pathogenesis of cardiac hypertrophy.Arterioscler Thromb Vasc Biol,2000,20(2):428-434
19 Young MJ,Lam EY,Rickard AJ.Mineralocorticoid receptor activation and cardiac fibrosis.Clin Sci(Lond),2007,112(9):467-475
20 Rickard AJ,Funder JW,uller PJ,et al.The role of the glucocorticoid receptor in mineralocorticoid/salt-mediated cardiac fibrosis.Endocrinology,2006,147(12):5901-5906
21 Paulus WJ,Bronzwaer JG.Nitri oxide's role in the heart:control of beating or breathing.Am J Physiol-Heart Circ Physiol,2004,287(1):H8-13
22 Maciver DH,Townsend M.A novel mechanism of heart failure with normal ejection fraction.Heart,2007,4:4(Epub ahead of print)
23 Yip G,Wang M,Zhang Y,et al.Left ventricular long axis function in diastolic heart failure is reduced in both diastole and systole:time for a redefinition.Heart,2002,87(2):121-125
24 Anonymous.How to diagnose diastolic heart failure.European Study Group on Diastolic Heart Failure.Eur HeartJ,1998,19(7):990-1003
25 Paulus WJ,Tschope C,Sanderson JE,et al.How to diagnose diastolic heart failure:a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Association of the European Society of Cardiology.Eur HeartJ,2007,28(20):2539-2550
26 Paraskevaidis IA,Tsiapras DP,Karavolias GK,et al.Doppler-derived left ventricular end-diastolic pressure prediction model using the combined analysis of mitral and pulmonary A waves in patients with coronary artery disease and preserved left ventricular systolic function.Am J Cardiol,2002,90(7):720-724
27 Temporelli PL,Giannuzzi P,Nicolosi GL,et al.Dopplerderived mitral deceleration time as a strong prognostic marker of left ventricular remodeling and survival after acute myocardial infarction:results of the GISSI-3 echo substudy.J Am Coll Cardiol,2004,43(9):1646-1653
28 Jensen JL,Williams FE,Beiby BJ,et al.Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique.J Am Soc Echocardiogr,1997,10(1):60-66
29 Hyodo E,Hiata K,Hirose M,et al.Clinical Use of Doppler Echocardiography and Doppler Tissue Imaging in the Estimation of Myocardial Ischemia During Dobutamine Stress Echocardiography.J Am Soc Echocardiogr,2007(Epub ahead of print)
30 Hori Y,Kunihiro S,Hoshi F,et al.Comparison of themyocardial performance index derived by use of pulsed-Doppler echocardiography and tissue Doppler imaging in dogs with volume overload.Am J Vet Res,2007,68(11):1177-1182
31 Alam M,Witt N,Nordlander R,et al.Detection of abnormal left ventricular function by Doppler tissue imaging in patients with a first myocardial infarction and showing normal function assessed by conventional echocardiography.Eur J Echocardiogr,2007,8(1):37-41
32 Kasner M,Westermann D,Steendijk P,et al.Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction:a comparative Dopplerconductance catheterization study,Circulation,2007,116(6):637-647
33 Hillis GS,Moller JE,Pellikka PA,et al.Noninvasive estimation of left ventricular filling pressure by E/Ea is a powerful predictor of survival after acute myocardial infarction.J Am Coll Cardiol,2004,43(3):360-367
34 Dokainish H,Zoghbi WA,Lakis NM,et al.Optimal noninvasive assessment of left ventricular filling pressures:a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters.Circulation,2004,109(20):2432-2439
35 Nagueh SF,Middleton KJ,Kopelen HA,et al.Doppler tissue imaging:a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures.J Am Coll Cardiol,1997,30(6):1572-1533
36 Weiss JL,Frederiksen JW,Weisfeldt ML.Hemodynamic determinants of the time-course of fall in canine left ventricular pressure.J Clin Invest,1976,58(3):751-760
37 Marino P,Little WC,Rossi A,et aL Can left ventricular diastolic stiffness be measured noninvasively.J Am Soc Echocardiogr,2002,15(9):935-943
38 Weber KT,Brilla CG.Pathological hypertrophy and cardiac interstitium.Fibrosis and rennin-angiotensin-aldosterone system.Circulation,1991,83(6):1894-1865
39 Wilke A,Funck R,Rupp H,et al.Effect of the renin-anfiotensin-aldosterone system on the cardiac Interstitium in heart failure.Basic Res Cardiol,1996,91 (Suppl2):79-84
40 Weber KT,SunY,Guarda E.Structural remodeling in Hypertensive heart disease and the role of hormones.Hypertension,1994,23(6 Pt 2):869-877
41 Lorell BH,Isoyama S,Grice WN,et al.Effects of ouabain and isoproterenol on left ventricular diastolic function during low-flow ischemia in isolated,blood-perfused rabbit heart.Circ Res,1988,63(2):457-467
42 The Digitalis Investigation Group.The effect of digoxin on mortality and morbidity in patients with heart failure.The New England Journal of Medicine(N Engl J Med),1997,336(8):525-533
43 Ahmed A,Aronow WS,Fleg JL.Predictors of mortality and hospitalization in women with heart failure in the Digitalis Investigation Group trial.Am J Ther,2006,13(4):325-331
44 Ahmed A,Aronow WS,Fleg JL.Higher New York heart Association classes and increased mortality and hospitalization in patients with heart failure and preserved left ventricular function.Am Heart J,2006,151(2):444-450
45 Ahmed A,Rich MW,Love TE,et al.Digoxin and reduction in mortality and hospitalization in heart failure:a comprehensive post hoc analysis of the DIG trail.Eur Heart J,2006,27(2):178-186
46 Setaro JF,Zaret BL,Schulman DS,et al.Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diadtolic filling and normal left ventricular systolic performance.Am J Cardiol,1990,66(12):981-986