bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Diagnosis
Authors: FOWLER NOBLE O.
Published: June 2012

In the majority of instances, the clinical diagnosis of angina pectoris can be made from the history alone. The chest discomfort is characteristically a sensation of deep pressure, is occasionally of burning quality, is found near the sternum, not sharply localized, and has a gradual buildup. Its duration is most often 2-10 min, but may be 30 sec to 30 min or more. Physical effort, emotional strain, large meals, nightmares, or sexual intercourse are common precipitating factors. Nitroglycerin tends to relieve the distress within 1-2 min, but the response is often difficult to evaluate, especially with angina of brief duration or with acute unstable rest angina. Physical examination of the anginal patient is often negative between attacks. During an attack of rest angina, the physical examination usually reveals increased systolic blood pressure and tachycardia. A fourth heart sound and a delayed apical systolic murmur may be found. Premature ventricular beats may develop.

The resting electrocardiogram is normal in the majority of patients with angina pectoris. During the anginal attack, the electrocardiogram usually reveals an increase of the heart rate and ischemic flat or downsloping S-T-segment depressions of 0.08-sec duration or more. The exercise electrocardiogram is most useful when the stress is sufficient to increase the heart rate to 85 or 90% of the predicted maximum for the age of the patient. An abnormal exercise electrocardiogram is found in 80-90% of patients with angina when they are tested by the graded treadmill exercise test of Sheffield and Reeves, but in only 50-60% of those tested by the Master's exercise test.

Varieties of angina pectoris which may differ from the foregoing include: Prinzmetal's variant angina, unstable angina (acute coronary insufficiency, crescendo angina), atypical angina, and angina with syncope.

Angina pectoris must be distinguished from the discomfort of anxiety neurosis, hiatal hernia, cervical spine disease, gallbladder disease, Tietze's syndrome, and post-herpetic neuralgia.
Physical Signs, Apexcardiography, Phonocardiography, and Systolic Time Intervals in Angina Pectoris
Authors: MARTIN C. EDWIN , SHAVER JAMES A. , LEONARD JAMES J.
Published: June 2012

Coronary artery disease and angina pectoris are frequently associated with disordered myocardial function which may cause abnormalities in precordial motion, heart sounds, and/or systolic time intervals. The pathophysiologic basis for these abnormalities has been studied by correlating them with more direct measurements of myocardial function. Large a waves on the apexcardiogram and atrial gallops are related to accentuated left ventricular a waves which reflect diminished left ventricular compliance. Uncoordinated left ventricular contraction (asynergy) may cause abnormal systolic motion which can sometimes be recorded on the apexcardiogram. Ventricular (early diastolic) gallops in coronary artery disease are usually associated with extensive obstructive lesions, left ventricular asynergy, and a low cardiac output. Transient paradoxic splitting of the second sound in angina pectoris has been reported though rarely documented by phono-cardiography. Mitral insufficiency due to papillary muscle dysfunction implies significant damage to the papillary muscles and the surrounding ventricular wall, usually by severe coronary artery disease. Systolic time intervals are a sensitive technic which may reflect diminished contractility (prolonged preejection period) or low stroke volume (shortened left ventricular ejection time) in patients with coronary artery disease. However, systolic time intervals are also sensitive to many other pharmacologic and hemodynamic influences, including changes in left ventricular preload and afterload which may result in misleading values. Therefore, as a technic for evaluating individual patients with coronary artery disease and angina pectoris, the role of systolic time intervals remains limited.
Management of the Patient with Severe Angina Pectoris
Authors: SAMPSON JOHN J. , HYATT KENNETH H.
Published: June 2012

Severe angina pectoris may be reduced to tolerable levels by suppressing below the pain threshold those factors elevating systolic blood pressure and heart rate and prolonging systolic ejection period. Their product parallels myocardial oxygen consumption (MVO
2
) as noted in several excellent reviews. The level of this product associated with angina, the "angina index," defines the individual threshold for onset of angina.

Prevention of angina-inducing physical and psychic stress is desirable, but often impractical, and the use of nitroglycerin preceding or following stress may lead to years of acceptable life. Prolonged, spontaneous, or readily induced angina, especially with a change in pattern, may be due to an acute coronary occlusive episode, whether defined as a prodromal period or an actual myocardial infarct. This form of attack requires close observation and appropriate care. The psychic stress-prone patient may repeatedly present a benign duplicate of such pain production, producing a diagnostic challenge. Routine protection of the angina patient, especially against arrhythmias, is discussed.

Different therapeutic modalities for control of intractable angina are presented, many with promise, but those currently giving the best results are: (1) elimination of precipitating conditions, i.e. (a) brady- and tachyarrhythmias, (b) hypertension, (c) hyperthyroidism, (d) mechanical obstruction of ventricular outflow, and (e) heart failure (2) beta-adrenergic blocking agents, i.e. propranolol, with or without nitrates or nitroglycerin; and (3) surgical revascularization preceded by selective coronary angiography.

The aortocoronary saphenous vein bypass has been effective in prompt relief of angina in patients with viable myocardium and potentially good flow in the distal artery, with acceptably low operative mortality from skilled teams. Mechanical efficiency and thus congestive failure may improve, and there is hope for increased longevity. Contraindications are poorly defined, especially as related to its performance in recent infarction of varying magnitude. With only 3 years' experience in determining long-term benefits, it seems rational to repeatedly redefine indications for surgery, but currently not to operate on every patient with "significant" coronary disease.
Constriction of the Fetal Ductus Arteriosus Induced by Oxygen, Acteylcholine, and Norepinephrine in Normal Dogs and those Genetically Predisposed to Persistent Patency
Authors: KNIGHT DAVID H. , PATTERSON DONALD F. , MELBIN JULIUS
Published: June 2012

Functional closure of the isolated perfused ductus arteriosus was studied in normal dog fetuses and in fetuses receiving various known proportions of their genes from dogs with patent ductus arteriosus (PDA). Constriction of the ductus in response to O
2
, acetylcholine (ACh), and norepinephrine (NE) was evaluated by plotting changes in input conductance against time. Ductuses from the control (normal dog) fetuses constricted in response to high PO
2
, ACh, and NE, indicating that in the dog the response of the ductus arteriosus to these agents is qualitatively similar to that in other mammals. Hypoxia relaxed the O
2
constricted ductus. After two to three cycles of oxygenation and hypoxia, the ductus became refractory to O
2
but remained responsive to ACh and NE. Ductuses from PDA-related fetuses tended to be more widely patent when hypoxic and did not respond to O
2
, ACh, and NE to a degree comparable to the control fetuses. Both the proportion of subnormal ductal responses and degree of abnormality in the PDA-related group increased as the degree of relationship to dogs with PDA increased. These experimental results are consistent with the polygenic mode of inheritance previously demonstrated for canine PDA. It is suggested that the liability to defective ductal closure in the dog results from a quantitatively inherited inability of the ductus to constrict.
Coronary Arterial-Right Heart Fistulae
Authors: JAFFE RICHARD B. , GLANCY D. LUKE , EPSTEIN STEPHEN E. , BROWN B. GREGORY , MORROW ANDREW G.
Published: June 2012

Long-term follow-up is described of seven patients with fistulae between a coronary artery and the right atrium or right ventricle. Left-to-right shunt flow ranged from minimal to 2.2:1. Of six patients followed 3½ to 17 years (average 10) without operation, five demonstrated symptomatic, electrocardiographic, hemodynamic, and angiographic stability. In the sixth patient, a second angiographic study, performed 15 years after the first one, showed the right coronary artery to be occluded proximal to its fistulous communication with the right ventricle, and a left-to-right shunt could no longer be detected. Four of the seven patients underwent operative closure of a fistulous opening into the right atrium, and all four have been restudied postoperatively. Right heart pressures and the degree of dilatation of the involved coronary artery were essentially unchanged following operation. One patient, who had a moderate-sized shunt preoperatively, noted alleviation of her fatigue and demonstrated electrocardiographic improvement. Analysis of flow dynamics did not suggest that the shunt predisposed to shear-induced intimal damage of the dilated feeding coronary artery, but did suggest such changes might occur in the narrow fistulous communication. We conclude that little anatomic and functional change occurs in patients with coronary artery fistulae and small-to-moderate shunts over rather prolonged medical follow-up periods, and that operative closure does not reduce the size of the dilated proximal coronary artery. Since it is unclear whether the abnormality predisposes to premature coronary atherosclerosis, a better understanding of the natural history of the disease is necessary before the precise role of operation in patients with small-to-moderate shunts can be defined.
Anatomy of the Conduction System
Authors: TITUS JACK L.
Published: June 2012

Some, but not all, cardiac arrhythmias are related to pathologic lesions of the cardiac conduction system. Common atrial dysrhythmias and first-degree atrioventricular (A-V) block rarely are explained on the basis of anatomic lesions in specific sites of the conduction system or its blood supply. Second-degree A-V block of Mobitz type II, which may be a precursor of complete (third-degree) heart block, commonly is associated with fibrotic lesions of uncertain etiology in the branching part of the bundle of His or the bundle branches. Ischemic lesions are found less often, and other pathologic processes rarely are present. Chronic complete heart block most often results from nonspecific, fibrotic interruption of the distal bundle of His, or of the first parts of the bundle branches after their origins. Ischemic lesions are uncommonly the cause of chronic block. High-grade A-V block complicating acute myocardial infarction may be associated with infarction of the A-V conduction system, but often morphologic evidence of ischemia cannot be identified. Congenital variants in anatomy of the conduction system are responsible for some relatively uncommon arrhythmias.
Accelerated Angina Pectoris
Authors: SCANLON PATRICK J. , NEMICKAS RIMGAUDAS , MORAN JOHN F. , TALANO JAMES V. , AMIRPARVIZ FIROUZ , PIFARRE ROQUE
Published: June 2012

Eighty-five patients with accelerated (preinfarction) angina are reported. Six suffered acute myocardial infarction awaiting catheterization and coronary angiography, so were not studied. Seventy-nine had coronary arteriography and other angiographic and hemodynamic studies. Fifteen of these 79 patients had normal coronary arteriograms; 64 had significant coronary artery obstruction. The clinical manifestations in 64 abnormal patients did not differ from those with normal arteriograms. Hemodynamic abnormalities correlated with the severity of arteriographic abnormalities. Of 70 patients with coronary artery disease, including the six not studied because of infarction, 48 were treated surgically with a mortality of 12.5%. Mortality for those 22 patients treated without surgery was 27%. Mortality could be correlated with certain risk factors: (1) congestive heart failure; (2) more than three-vessel coronary disease; (3) left ventricular end-diastolic pressure > 12 mm Hg; (4) cardiac index <2.7 liters/min/m
2
; (5) stroke index <35 ml/beat/m
2
; (6) estimated cardiac work (mean aortic pressure x cardiac index) <240 units; and (7) ejection fraction <0.50. Cardiac catheterization and angiography were performed without major complications in 97% of patients.
Geometry of Left Ventricular Contraction in the Systolic Click Syndrome
Authors: LIEDTKE A. JAMES , GAULT JAMES H. , LEAMAN DAVID M. , BLUMENTHAL MELVIN S.
Published: June 2012

Left ventricular (LV) shape change during systole was characterized in nine patients with typical clinical findings of the systolic click syndrome (SCS) by means of cineangiographic measurements of three segmental diameters of the LV cavity and of the mitral valve ring (MVR) and contrasted with findings in eight patients with normal LV function. In the latter group, shortening of the proximal, midventricular, and apical segment diameters was comparable, averaging 38.6, 40.3, and 46.8%, respectively; MVR shortening averaged 31.8%. The velocity of fiber shortening, estimated as mean circumferential fiber shortening rate (mean FSR), was also similar in the three segments (1.66, 1.84, and 2.09 circ/sec). In patients with SCS, the extent of shortening and mean FSR in the proximal ventricular segment were consistently reduced (average 22.2%,
P
< 0.005; and 0.96 circ/sec,
P
< 0.025 respectively), and the MVR exhibited either reduced extent of contraction (four patients) or was unchanged or increased in diameter during systole (five patients). However, shortening of the midventricular and apical segments was normal, averaging 37.5 and 40.5%, respectively, as was the mean FSR in these segments (averages 1.60 and 1.70 circ/sec).

These findings are consistent with a primary disorder of the myocardium in SCS localized to the inflow region of the left ventricle.
Ventricular Ectopic Rhythms following Vagal Stimulation in Dogs with Acute Myocardial Infarction
Authors: KERZNER JAY , WOLF MARSHALL , KOSOWSKY BERNARD D. , LOWN BERNARD
Published: June 2012

Vagal stimulation inducing significant bradycardia did not precipitate ventricular fibrillation in any of 34 dogs subjected to ligation of the left anterior descending coronary artery. Vagal stimulation, however, did result in two distinct types of ventricular arrhythmias occurring at different times following coronary occlusion. Within 3 hours, couplets and salvos were provoked which were overdriven by pacing at slow rates. From 4.5 to 9 hours ventricular tachycardia resulted which was slower in rate than the intrinsic sinus rhythm and could be overdriven only by pacing at rates faster than the ectopic mechanism. The response to acetylcholine administration was similar to that of vagal stimulation. By pacing in the presence of complete heart block or by the use of beta-adrenergic blockade, bradycardia was shown to be the basis for the ventricular arrhythmias. Reentry is believed to be the mechanism for the ectopics provoked by bradycardia early after coronary acclusion, while enhanced Purkinje fiber automaticity may account for the late arrhythmias.
Myocardial Infarction as a Complication of Coronary Bypass Surgery
Authors: BREWER DAVID L. , BILBRO ROBERT H. , BARTEL ALAN G.
Published: June 2012

Serial postoperative ECGs were reviewed for all patients undergoing saphenous vein-coronary artery bypass graft (CABG) during 1969-71. Only the development of new pathologic Q waves were accepted as indicative of definite acute myocardial infarction (AMI). ST-T changes regardless of characteristics were not accepted as evidence of AMI. Operative mortality was 11% (27/253) with 59% (10/17) of those autopsied having AMI. Autopsy findings showed no false positives by ECG. Of survivors, 15% (33/220) had AMI. Another 2% (five) developed leftbundle conduction abnormalities and were considered probable for AMI. Among all patients having CABG, 20% (49/243) had AMI by ECG or autopsy.

Comparing patients with and without AMI, there was no significant difference in coronary risk factors, hemodynamic data, number of vessels diseased, or site(s) of grafts. There was a significant difference in preoperative functional class for angina in the two groups. Seventy-six percent of those in the MI group had New York Heart Association class IV chest pain, whereas only 52.6% of the group without MI were class IV (
P
< 0.05). In those with triple grafts (14 patients), five had AMI (36%) compared to 14% (20/143) with one or two grafts (
P
< 0.02). Of patients with a pump time greater than 120 min, 29% (8/28) had AMI compared to 11% (16/146) with shorter pump times (
P
< 0.02). A significantly larger number of the MI group developed class IV congestive heart failure postoperatively than the group without MI (13 vs 2%,
P
< 0.02).

Despite the use of stringent criteria, this study shows that AMI complicating CABG is a common event. Those developing AMI at surgery had more severe chest pain preoperatively, had prolonged pump times, and a significantly larger number received triple grafts. Postoperatively, there was a higher incidence of severe congestive heart failure in those having an infarct at surgery.
Correlation between Effects of Ouabain on the Canine Electrocardiogram and Transmembrane Potentials of Isolated Purkinje Fibers
Authors: ROSEN MICHAEL R. , GELBAND HENRY , HOFFMAN BRIAN F.
Published: June 2012

Isolated canine Purkinje fiber bundles (PF) were perfused with the blood of intact donor dogs to correlate changes induced by ouabain (O) in the PF transmembrane potential (TP) and the donor ECG. O was administered intravenously to the donor, and standard microelectrode technics were used to record the TP. The only significant O effect prior to occurrence of toxic arrhythmias was induction of ST-T wave changes in the ECG and prolongation of action potential duration (APD). Early O toxicity was defined as the onset of junctional or ventricular premature contractions or junctional tachycardia. Simultaneous with early toxicity there were decreases in AP amplitude, resting membrane potential, maximal slope of phase O depolarization, APD, and plateau, and slowing of conduction, which often varied in extent from cycle to cycle. With increased duration of early toxicity or onset of late toxicity (ventricular tachycardia), TP changes were accentuated. Increased automaticity occurred at the time of early toxicity when plasma potassium concentration ([K + ]
o
) < 4 mEq/liter. In three of seven instances in which [K + ]
o
> 4.0 mEq/liter, low amplitude potentials were recorded during phase 4. The possible role of these potentials in relation to the generation of toxic arrhythmias is discussed.
Feasibility and Effectiveness of Low-Energy Catheter Defibrillation in Man
Authors: MIROWSKI M. , MOWER MORTON M. , GOTT VINCENT L. , BRAWLEY ROBERT K.
Published: June 2012

The effectiveness of low energy intraventricular catheter defibrillation was evaluated in 11 patients undergoing coronary artery surgery, in whom ventricular fibrillation occurred after anoxic arrest of 21-42 min. A distal electrode catheter was introduced through an atriotomy into the right ventricular apex. In eight patients the proximal electrode was a saline-soaked sponge placed on the superior vena cava, while in three this electrode formed an integral part of the superior vena cava cannula used in cardiopulmonary bypass. Intraventricular catheter defibrillation was accomplished in nine patients using 5-15 w-sec, considerably less energy than required for paddle defibrillation. There were no apparent short or long-term ill effects. Unsuccessful defibrillation in the two remaining patients was ascribed to difficulties in electrode placement. The effectiveness of low energy intraventricular catheter defibrillation in man, in addition to raising basic electrophysiologic questions, provides background for the development of the transvenous automatic defibrillator for protection of selected high-risk patients.
Significance of High Degree Atrioventricular Block in Acute Posterior Myocardial Infarction
Authors: ROTMAN MICHAEL , WAGNER GALEN S. , WAUGH ROBERT A.
Published: June 2012

This report evaluates the morbidity and mortality, during hospitalization and follow-up, of a subgroup of patients with posterior or diaphragmatic myocardial infarction (PDMI) who developed high degree A-V block via a type I mechanism and in the absence of power failure (pulmonary edema or cardiogenic shock). This subgroup was not at any higher risk of hospital morbidity, hospital mortality, or 1-year mortality than three other groups: (a) patients with PDMI but neither high degree A-V block nor initial power failure; (b) patients with other infarct sites who developed high degree A-V block in the absence of power failure; and (c) patients with other infarct sites but neither high degree A-V block nor initial power failure. The significance of subgrouping patients with high degree A-V block by the quantity of clinical heart failure is exemplified by a review of the literature and the present study.
Systemic Arterial Disease with Myocardial Infarction
Authors: ROSENBERG HELMAR G.
Published: June 2012

This report deals with two cases of infants who died of myocardial infarction. Autopsy revealed an occlusive, diffuse, generalized lesion in medium and small-sized arteries, with particular involvement of the heart, skin, gastrointestinal tract, kidneys, pancreas, and liver. It showed a fibrous thickening of the intima; the internal lamina elastica, the media, and the adventitia remained unchanged. A pathogenic interpretation of the vascular lesions is attempted, and their asynchronism in the most seriously involved organs is pointed out. The vascular lesions have a great resemblance to those seen in progressive arterial occlusive disease. Despite the antecedent of chronic arsenic poisoning through drinking water, no demonstrable etiologic evidence was found in the vascular lesions; nevertheless, its connection with arsenic, as in blackfoot disease, should be considered.
Type I, Type II, and Type III Gaps in Bundle-Branch Conduction
Authors: AGHA ABDUL S. , CASTELLANOS AGUSTIN , WELLS DAVID , ROSS MELVIN D. , BEFELER BENJAMIN , MYERBURG ROBERT J.
Published: June 2012

"Gaps" in bundle-branch conduction were observed in three patients using the combined technic of premature atrial stimulation and His bundle recordings.

In type I gap a complete LBBB pattern disappeared at shorter coupling intervals because the premature atrial impulses encountered enough delay at the A-V node to reach the left bundle branch after the end of its effective refractory period. When this occurred, the H
1
-H
2
intervals were longer and the H
2
-V
2
intervals shorter than that at which complete LBBB had been present.

In type II gap a complete RBBB pattern disappeared at shorter coupling intervals because the premature atrial impulses were so delayed within the proximal His-Purkinje system that they reached the right bundle branch after the end of its effective refractory period. When this occurred the H
1
-H
2
intervals were shorter and the H
2
-V
2
longer than that at which complete RBBB had been present.

In the patient with type III gap and complete LBBB, conduction to the ventricles through the right branch failed at long coupling intervals but was resumed at shorter coupling intervals while the H
1
-H
2
intervals were shorter, and the H
2
-V
2
intervals similar, to those at which block had occurred. True supernormal conduction was excluded in the first two cases. Nevertheless, this phenomenon, as well as a longitudinal dissociation, varying pulsatile vagal discharges acting on an area of depressed conductivity, and phase 4 diastolic depolarization in the right branch coexisting with complete block in the left branch, could have been responsible for type III gap.
Intravascular Platelet Aggregation in the Heart Induced by Stress
Authors: HAFT JACOB I. , FANI KAZEM
Published: June 2012

Sixteen rats, stressed by immersion in ice-cold water for 25-45 min, were found to have platelet aggregates in myocardial small vessels on electron microscopic study. None of six similar nonstressed control rats had platelets in myocardial vessels. It is concluded that stress, probably via catecholamine secretion that enhances platelet stickiness, can induce intravascular platelet aggregation. It is possible that this mechanism plays a part in the relationship between stress and acute clinical myocardial infarction.
Sequential Circulatory Changes following Acute Myocardial Infarction in Man
Authors: FRIESEN W. GLENN
Published: June 2012

After informed consent, 12 men with documented acute myocardial infarction had hemodynamic studies performed within 18 hours after onset of symptoms. These were repeated on the second day, at 3-5 weeks, and at 3-5 months in the 10 who survived. One half of the patients were "uncomplicated" and significant differences with the "complicated" patients were seen in pulmonary artery pressure, mean arterial pressure on the first day, acute phase stroke volume and cardiac index, and the total blood volume within 48 hours. The optimal heart rate at each stage was determined by atrial pacing and was found to be 110 ± 10 beats/min. Abnormalities in
p
H, blood gases, and circulation time were related to the cardiac index. Control groups with and without coronary artery disease were studied prior to angiography to obtain information regarding preinfarction circulatory status, and significant impairment of the ejection fraction was noted even in angina patients without prior infarction. The sequential circulatory changes and possible compensatory mechanisms available were discussed.
Variant Angina of Prinzmetal with Normal Coronary Arteriograms
Authors: CHENG TSUNG O. , BASHOUR TALI , KELSER GEORGE A. , WEISS LOWELL , BACOS JAMES
Published: June 2012

Variant angina of Prinzmetal has been generally presumed to be caused by a significant focal obstruction in a single major coronary artery which should be an ideal lesion for aortocoronary saphenous vein bypass graft. Recognition of this clinical syndrome would then be of particular diagnostic and therapeutic importance if such a consistent association can be demonstrated. Of five patients with variant angina studied in our cardiac catheterization laboratories, four had normal coronary arteriograms. Two important conclusions may be derived from this study. First, identical ECG changes may be observed both in the presence and absence of pain and thus the incidence and severity of the variant angina could be underestimated. Second, until a larger series of patients with variant angina is studied by coronary arteriography, one must exercise reservation in assuming that all patients with the clinical syndrome are operative candidates for saphenous vein bypass surgery.
Effects of Nitroglycerin on Responses of the Systolic Time Intervals to Exercise
Authors: HARRIS WILLARD S. , AYTAN NESET , POUGET JEAN M.
Published: June 2012

The effects of 0.6 mg sublingual nitroglycerin on responses of the left ventricular (LV) systolic time intervals to a 4-min exercise step test were determined in 10 patients with angina and 10 normal controls. In normal subjects, the exercise test shortened total electromechanical systole corrected for heart rate (Q2
c
22 msec but left the LV ejection time corrected for heart rate (LVET
c
) unchanged. By contrast, in the angina group, exercise failed to shorten the Q2
c
but prolonged the LVET
c
25 msec. In both groups, nitroglycerin shortened the LVET
c
and Q2
c
after exercise. By decreasing LV afterload, preload, and hypoxia, and by improving LV function, nitroglycerin abolished the abnormal marked prolongation of LVET
c
after exercise in angina patients and converted the failure of their Q2
c
to shorten after exercise into a normal shortening of Q2
c
. Nitroglycerin also had marked effects at rest, which contributed importantly to its effects on the systolic temporal responses to exercise. Suppression by nitroglycerin of LVET
c
prolongation after exercise diminishes myocardial oxygen consumption and is antianginal. Most important, assessment of this action provides an objective, though noninvasive, means to evaluate the efficacy of nitrates in improving LV performance with exercise in angina patients.
Angina Pectoris in Men
Authors: FRANK CHARLES W. , WEINBLATT EVE , SHAPIRO SAM
Published: June 2012

Prognosis of men whose first manifestation of coronary heart disease was angina without antecedent infarction was found to resemble closely that of men followed after an initial MI. Overall mortality over a period of 4.5 years following a baseline examination was the same in the two cohorts: 17.5%.

In both groups of men electrocardiographic abnormalities and blood pressure elevation identified subsets of coronary patients with a relatively poor prognosis, but the course of disease was apparently not influenced by the serum cholesterol level. Among the men with angina no relationship emerged between symptomatic status at time of baseline and risk of mortality in the ensuing observation period.

The findings are from the HIP (Health Insurance Plan of Greater New York) study of the incidence and prognosis of coronary heart disease, a prospective study of a general population of 110,000 men and women aged 25-64 years.
Prosthetic Replacement of the Mitral Valve
Authors: LEVINE FREDERICK H. , COPELAND JACK G. , MORROW ANDREW G.
Published: June 2012

The late postoperative results of isolated mitral valve replacement in 100 patients operated upon from 1961 to 1965 are summarized. Eighty-three of the patients survived operation, and 52 are still alive. Seventy-six percent of patients surviving operation were alive 5 years later, and 64% after 8 years. Of the entire group of 100 patients operated upon, 63% were alive after 5 years and 51% after 8 years. Sixteen of the 31 late deaths were definitely attributable to the presence of the prosthesis: systemic arterial emboli (eight patients), valve thrombosis (two), perivalvular leak (one), ball variance (two), endocarditis (two), and intracerebral hemorrhage due to anticoagulants (one). Congestive heart failure was the primary cause of death in the remaining patients. Predominance of either stenosis or regurgitation preoperatively did not significantly alter late survival, nor did coexistent tricuspid regurgitation. High operative and early postoperative mortality was seen in patients with associated aortic regurgitation. Patients who were in class IV preoperatively had a higher mortality (50% alive at 5 years) than those in class III (70% alive), but no difference in mortality was noted between patients who preoperatively had normal sinus rhythm and those who had atrial fibrillation. Forty-nine percent of patients have sustained systemic emboli, and these have occurred throughout the postoperative period. Currnetly, 50% of patients are class I, 42% are class II, and only 8% are class III. Prosthetic mitral valve replacement has provided gratifying long-term symptomatic improvement in the majority of patients.
Functional 2:1 A-V Block within the His-Purkinje System
Authors: DAMATO ANTHONY N. , VARGHESE P. JACOB , CARACTA ANTHONY R. , AKHTAR MASOOD , LAU SUN H.
Published: June 2012

In eight subjects in whom the effective refractory period of the His-Purkinje system was determined to be longer than that of the A-V node or atrium, abrupt acceleration of the atrial rate resulted in either 2:1 block within the His-Purkinje system or 1:1 A-V conduction. The former conduction pattern simulated a type II second-degree A-V block. The occurrence of either 2:1 block within the His-Purkinje system or 1:1 A-V conduction was determined primarily by (1) an effective refractory period of the His-Purkinje system which exceeded that of the A-V node, (2) the coupling interval of the first atrial capture beat and its effect or lack thereof on the refractory period of His-Purkinje system as it relates to changes in ventricular cycle length, and (3) the relative speed of A-V nodal conduction time. The distinction between this functional 2:1 block within the His-Purkinje system and a true type II second-degree block is discussed from both the clinical and electrophysiologic points of view. Functional 2:1 block within the His-Purkinje can also result when sudden acceleration of atrial rate occurs spontaneously such as in atrial flutter or A-V nodal reentrant atrial tachycardias.
Effect of Aspirin on Brachial Artery Occlusion following Brachial Arteriotomy for Coronary Arteriography
Authors: HYNES KIERAN M. , GAU GERALD T. , RUTHERFORD BARRY D. , KAZMIER FRANCIS J. , FRYE ROBERT L.
Published: June 2012

The effect of oral aspirin in doses known to influence in vitro platelet aggregation was evaluated in patients undergoing brachial artery catheterization. Neither arterial thrombus formation nor pulse reduction was affected in patients given aspirin when compared to controls. Aspirin in small doses does not decrease the incidence of vascular occlusion after brachial artery catheterization.
Hyperlipoproteinemia
Authors: BROWN D. F. , DAUDISS K.
Published: June 2012

The prevalence of five types of hyperlipoproteinemia identified by Fredrickson, Levy, and Lees has been identified in 1301 male and female blood donors, aged 18-64 years. No patients with type I or V hyperlipoproteinemia were encountered, and only three patients with type III hyperlipoproteinemia were discovered. Type IV hyperlipoproteinemia was the most prevalent disorder in this population and was significantly more prevalent in males than females-261/1000 vs 81/1000, respectively. The prevalence rate of type II hyperlipoproteinemia in male and female subjects was 87/1000 and 104/1000, respectively. Subjects with type IV, but not those with type II hyperlipoproteinemia, were significantly more obese than normal. High-density lipoprotein levels were lower than normal in patients with type IV and with type II hyperlipoproteinemia irrespective of sex, while in normal subjects high-density lipoproteins were significantly higher in females. Densitometry of stained electrophoretically separated lipoproteins correlated highly with lipid content of these fractions but was not considered sufficiently accurate for use as a quantitative technic.
Pediatric Congenital Cardiac becomes a Postoperative Adult
Authors: PERLOFF JOSEPH K.
Published: June 2012

The following commentary on the changing population of congenital heart disease will deal with: incidence and survival patterns—an overview; effects of diagnostic and surgical interventions on survival patterns—changing population; ultimate goals and aspirations—what are we trying to accomplish?; types of surgical intervention—desirability of primary anatomic repair in infancy; and the problem of residua—setting the stage for future research.
The Coronary Drug Project
Authors:   THE CORONARY DRUG PROJECT RESEARCH GROUP
Published: June 2012

The Coronary Drug Project (CDP) is a nationwide collaborative clinical trial sponsored by the National Heart and Lung Institute (NHLI). The primary objective is to evaluate the efficacy of several lipid influencing drugs in the long-term therapy of coronary heart disease in men of ages 30 through 64 with ECG evidence of previous myocardial infarction. The following six treatment regimens were included for study in the CDP: Equine estrogens 2.5 mg per day and 5.0 mg per day; clofibrate 1.8 g per day; dextrothyroxine 6.0 mg per day; nicotinic acid 3.0 g per day; and lactose placebo. There are 53 clinics participating in the CDP along with a Coordinating Center, Central Laboratory, ECG Reading Center, Drug Procurement and Distribution Center, and NHLI Medical Liaison Office. A total of 8341 patients were enrolled. All patients were randomly assigned to one of the six treatment groups in a double blind fashion and are being followed for a minimum of five years. The primary response variable in the CDP is total mortality; other major response variables include cause-specific mortality and various non-fatal cardiovascular events such as recurrent myocardial infarction, acute coronary insufficiency, and others. The CDP data are reviewed periodically by a Data and Safety Monitoring Committee for evidence of adverse and beneficial treatment effects. A detailed description of the study population with respect to demographic, clinical, biochemical, electrocardiographic, and other characteristics at baseline is given. In addition, some interrelationships among these baseline characteristics are presented.
Relationship between Ventricular Premature Contractions on Routine Electrocardiography and Subsequent Sudden Death from Coronary Heart Disease
Authors: FISHER F. DAVID , TYROLER HERMAN A.
Published: June 2012

The association between ventricular premature contractions (VPC) on routine ECG and sudden death (SD) from coronary heart disease (CHD) during an ll-year period was examined in a historic prospective study of 1,214 white male factory workers, ages 35-69, in Canton, North Carolina. Prevalence of VPC was 92 (6.7%) increasing from 2% to 15% with age. Sixty of the 118 deaths were ascribed to CHD, 38 (63.3%) with 24-hour SD, and 27 (45%) with 1-hour SD. The relative risk of 1-hour SD for those with VPC was not increased (0.9); the risk of 24-hour SD was increased only minimally (1.3). Within the age band 50-59, the relative risk of 24-hour sudden death was 2.4 but the presence of other electrocardiographic abnormality carried the same increased risk. For the Canton population, using VPC on routine ECG as predictor of sudden death yielded no advantage over other ECG abnormalities.
Use of Phentolamine in Acute Myocardial Infarction Associated with Hypertension and Left Ventricular Failure
Authors: KELLY DAVID T. , DELGADO CESAR E. , TAYLOR DEAN R. , PITT BERTRAM , ROSS RICHARD S.
Published: June 2012

In 11 patients with hypertension associated with acute myocardial infarction intravenous phentolamine decreased the elevated left ventricular filling pressure. Cardiac index increased with a small decrease in arterial pressure, and therefore the same or increased stroke work was achieved at a lower filling pressure. In patients with acute hypertension myocardial oxygen demand was decreased and this may tend to increase infarct size. The potentially beneficial effects were less great in patients with chronic hypertension antedating the myocardial infarction.
Saliva Calcium and Potassium Concentrations in the Detection of Digitalis Toxicity
Authors: SWANSON MARGO , CACACE LARRY , CHUN GEORGE , ITANO MASASHI
Published: June 2012

Stimulated whole saliva was collected from 118 subjects: 36 were not receiving digitalis; 40 received digitalis but were nontoxic; 14 were digitalis-toxic; 24 had impaired renal function; and four subjects were followed during the administration of digitalis. Saliva calcium and potassium products in the digitalis-toxic group were significantly higher than in the nontoxic group. Subjects with impaired renal function had a significantly higher saliva calcium and potassium product than those with normal renal function. The subjects followed during the administration of digoxin showed an apparent correlation between electrocardiogram changes and an elevated saliva calcium and potassium product. This study has demonstrated that a whole-saliva calcium and potassium product over 300 in subjects on digoxin with normal renal function correlates with a diagnosis of digitalis toxicity.
Effect of Extrasystoles on Idioventricular Rhythm
Authors: KLEIN HERMAN O. , LEBSON ROBERT , CRANEFIELD PAUL F. , HOFFMAN BRIAN F.
Published: June 2012

When premature ventricular contractions (PVCs) occur in the idioventricular rhythm of patients with complete heart block (CHB), one of several rhythm alterations may occur: the postextrasystolic or returning cycle (RC) may be prolonged, unaltered, or even shortened without any apparent reason. To elucidate the mechanisms by which these alterations occur, the effect of spontaneous and of electrically induced PVCs was studied in five patients with CHB. Over 500 observations were obtained. PVCs occurring late in the basic cycle, i.e., after the T wave of the last spontaneous idioventricular beat, almost uniformly resulted in lengthening of the first RC. In sharp contrast, PVCs elicited early in the cycle, i.e., during the T wave, were followed by a shortened RC in 95% of instances. The underlying electrophysiologic mechanisms responsible for the relationship of RC length to degree of prematurity of the PVC are discussed.
An Angiographic Severity Index for Pulmonary Embolism
Authors: WALSH PETER N. , GREENSPAN RICHARD H. , SIMON MORRIS , SIMON ALLAN L. , HYERS THOMAS M. , WOOSLEY PAUL C. , COLE CHRISTINE M.
Published: June 2012

This report has discussed the use of an angiographic severity index for pulmonary embolism in the analysis of pulmonary angiograms from 160 patients admitted to the Urokinase-Pulmonary Embolism Trial. Angiographic studies done before and after treatment with urokinase or heparin were analyzed independently by three radiologists who had no knowledge of treatment assignment. A subjective evaluation and a subsequent objective recording of abnormalities were made. The computation of a severity index was based on a numerical grading system for definite abnormalities specific for pulmonary embolism (intraluminal filling defects and vascular obstructions).

The procedure for computing the severity index was simple enough that recorded abnormalities were coded and punched by a statistical clerk and analyzed by computer. Correlations between subjective evaluations and objective severity indices were high. There was excellent agreement among the three radiologists for both subjective and objective methods. Highly significant treatment differences were detected.

The angiographic severity index might help to classify patients, predict prognosis, plan clinical studies, and assess treatment effects.
Repair of Transposition of the Great Arteries in 123 Pediatric Patients
Authors: CHAMPSAUR GERARD L. , SOKOL DAVID M. , TRUSLER GEORGE A. , MUSTARD WILLIAM T.
Published: June 2012

From May 1963 to July 1972, 123 patients ranging in age from 20 days to 15 years, with D-transposition of the great arteries, underwent an intraatrial baffle operation using a pericardial baffle. They previously had had a total of 121 various palliative procedures.

Twenty-six children (21%) died in the early postoperative period. The operative mortality was 13% in transposition of the great arteries with intact ventricular septum, 45% in trasnposition of the great arteries plus ventricular septal defect, and 33% in transposition of the great arteries plus ventricular septal defect and left ventricular outflow tract obstruction. By contrast the overall mortality has decreased to 15% in the 72 patients operated upon over the last 2 years.

There were 12 late deaths, 10 of which occurred within the first year postoperatively. Unexplained heart failure accounted for four deaths. Two sudden deaths were attributed to arrhythmias. Three patients died of proven pulmonary venous obstruction, one of them at reoperation. Pulmonary hypertension, reoperation for detachment of the baffle, and hypoglycemia were each the cause of one late death. There were no proven cases of tricuspid incompetence.

Eighty children have been repeatedly reexamined for up to 8 years and 6 months. The actuarial 6-year survival was 74.8% for survivors of operation.

Seventy-three children were leading a normal life at the time of the report.
Ventricular Septal Defect Associated with Aortic Insufficiency
Authors: KAWASHIMA YASUNARU , DANNO MICHIAKI , SHIMIZU YUKIHIKO , MATSUDA IKARU , MIYAMOTO TAKESHI , FUJITA TSUYOSHI , KOZUKA TAKAHIRO , MANABE HISAO
Published: June 2012

Thirty-five consecutive patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) who underwent corrective surgery are presented. There were seven operative and three late deaths among the patients operated upon before 1968. No death, however, was encountered among the most recent 18 consecutive patients. The VSD was closed directly in 14 patients and with a Teflon patch in 21. The aortic valve was repaired in 16 patients, replaced in eight, and no interference was indicated in 11.

They were classified from the surgical viewpoint according to the location of the VSD, the anatomic type of the right ventricular outflow tract, and the severity of the aortic herniation as follows: type Ia, supracristal VSD and AI without aortic cusp herniation; type lb, supracristal VSD and AI with aortic cusp herniation and conal muscular rim beneath the pulmonic valve; type Ic, supracristal VSD and AI with aortic cusp herniation without conal muscular rim beneath the pulmonic valve; type IIa, infracristal VSD and AI without aortic cusp herniation; type IIb, infracristal VSD and AI with aortic cusp herniation; type III, infracristal VSD and AI with infundibular pulmonic stenosis (PS); type IV, supracristal VSD and AI with infundibular PS.

In type Ia and IIa, VSD was closed directly and the aortic valve was replaced. In most of type Ib, VSD was closed directly and no direct procedure was performed upon the aortic valve. In most of type Ic, VSD was closed with a Teflon patch and the aortic valve was repaired. In type IIb, VSD was closed with a Teflon patch and the procedure upon the aortic valve was not uniform. In type III, VSD was closed with a Teflon patch and the aortic valve was repaired in most of them. In type IV, VSD was closed with a Teflon patch and no direct procedure was performed upon the aortic valve.

The basic policy for repair of this association of anomalies is selected according to the above mentioned anatomic classification.
Disturbances in Cardiac Conduction and their Management
Authors: MERIDETH JOHN , PRUITT RAYMOND D.
Published: June 2012

A simple classification of atrioventricular block, criteria for diagnosis, and suggested therapy are discussed. The differences between Mobitz I and II second-degree A-V block are reviewed.

Good management of patients who have bundle-branch or other forms of intraventricular block depends on informed judgment which includes consideration of (1) the effect of intraventricular conduction disturbances on the pumping action of the heart, and (2) the likelihood that a specific intraventricular conduction disturbance will be complicated by complete heart block.

Evidence suggests that common forms of intraventricular disturbance, unlike ventricular fibrillation, do not alter significantly the pumping action of the heart. The role of intraventricular conduction disturbances in the genesis of ventricular fibrillation is assessed.

We concluded that only when right bundle-branch block is combined with block of the anterior or posterior fascicle of the left bundle branch is complete heart block sufficiently imminent to warrant special concern. If bilateral block is associated with symptoms of episodic severe bradycardia, pacemaker therapy is indicated.
Angina Pectoris at Rest with Preservation of Exercise Capacity
Authors: MACALPIN REX N. , KATTUS ALBERT A. , ALVARO ANTHONY B.
Published: June 2012

Twenty patients with Prinzmetal's variant of angina are described and the literature on the subject is reviewed. This syndrome is characterized by anginal attacks at rest with S-T segment elevation, while exercise capacity is well preserved. Coronary arteriography usually demonstrates significant, focal, obstuctive disease of the major coronary artery predicted from the distribution of S-T elevation seen in the ECG during attacks. Occasionally the coronary disease is minimal or absent. The cause of attacks is believed to be transient, spastic occlusion of a major coronary artery, which was actually observed during surgery in one case. Because of this unusual pathophysiology, these patients may not make ideal candidates for isolated saphenous vein bypass surgery. Other diagnostic, therapeutic, and prognostic implications of this interesting anginal syndrome are discussed.