bluuebunny/crossref_metadata_2025 huggingface dataset:
Selectively N‐Protected Enantiopure 2,5‐Disubstituted Piperazines: Avoiding the Pitfalls in Solid‐Phase Fukuyama–Mitsunobu Cyclizations
Authors: Ottesen Lars K. , Olsen Christian A. , Witt Matthias , Jaroszewski Jerzy W. , Franzyk Henrik
Published: February 2009

Robust protocol! A diverse array of piperazine scaffolds was obtained by a robust solid‐phase‐synthesis protocol involving multistep elaboration of a resin‐bound aziridine (see scheme). Microwave‐assisted on‐resin protectinggroup introduction and manipulation as well as intramolecular Fukuyama–Mitsunobu cyclization conditions were key features.

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An efficient solid‐phase route to ring‐substituted piperazines from O‐linked resin‐bound (S)‐aziridine‐2‐methanol is described. Regioselective microwave‐assisted aminolysis followed by intramolecular Fukuyama–Mitsunobu cyclization constitute the key features of the protocol. Simple piperazines and diazepanes were readily obtained without preceding N‐protection of the acyclic intermediate, whereas attempts to extend this protocol to chiral 2,5‐disubstituted piperazines failed. Modifications encompassing N‐carbamoylation prior to ring‐closure were therefore investigated. However, standard carbamoylating agents, for example, Fmoc‐Cl and Alloc‐Cl tended to give bis‐protected by‐products. Thus, novel microwave‐assisted solid‐phase N‐protection procedures were developed for efficient introduction of Fmoc, Boc and Alloc groups. The subsequent cyclization proceeded in moderate to excellent yields depending on the bulk of the side chain and type of N‐protecting group. This protocol readily provided novel cis‐ and trans‐2,5‐disubstituted piperazines displaying a variety of N‐protecting group patterns after further on‐resin manipulations. Also, unexpected by‐products obtained during these optimization studies were identified and characterized. This includes nosylated ureas arising from an alternative cyclization pathway. Finally, post‐cleavage oxidation gave access to the Fmoc/Boc‐protected α‐amino acid as well as the corresponding aldehyde. The chiral piperazines described in this work will enable construction of combinatorial libraries with a higher chemical diversity compared to those containing simple N,N′‐difunctionalized piperazines, often present in drug‐like compounds.
Copper(I) Zeolites as Heterogeneous and Ligand‐Free Catalysts: [3+2] Cycloaddition of Azomethine Imines
Authors: Keller Murielle , Sido Abdelkarim Sani Souna , Pale Patrick , Sommer Jean
Published: February 2009

Clicking in zeolites: Copper(I)‐exchanged zeolites proved to be practical and efficient catalysts for the cycloaddition of azomethine imines with alkynes, providing a convenient access to N,N‐bicyclic pyrazolidinone derivatives (see scheme). With high regioselectivity, 100 % atom economy, and convenient product isolation, this heterogeneously catalyzed version of the Dorn cycloaddition corresponds to click‐chemistry criteria.

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Copper(I)‐exchanged zeolites were used as heterogeneous ligand‐free catalysts for [3+2] cycloaddition of azomethine ylides, which allows versatile, efficient, and highly regioselective synthesis of pyrazolone derivatives. These cheap and easy‐to‐prepare catalysts exhibit wide scope and compatibility with functional groups. They are very simple to use, easy to remove (by simple filtration), and recyclable (up to six times without loss of activity).
Comprehensive analysis of exertional ECG changes before and after oral propranolol
Authors: Hossack K. F. , Bruce R. A. , Kusumi F.
Published: February 2009

In 12 patients with symptomatic coronary heart disease and three normal persons, comprehensive analyses of the electrocardiographic changes associated with symptom‐limited upright exercise are made by computer analysis of the electrocardiogram recorded using a Frank XYZ lead system. This analysis provided a display of the 12 lead ECG, vectorcardiogram, polarcardiogram, and spatial cardiogram and measurements of spatial magnitudes of heart vectors. The effect of 40 mg of oral propranolol was assessed by repeating the exercise protocol 60‐90 min later. There is evidence that propranolol reduces the electrocardiographic features of myocardial ischemia. This reduction in myocardial ischemia correlates with reductions in pressure rate product and heart rate. The presence of infarct criteria with exercise is variable and not apparently influenced by propranolol.
Plasma lipoprotein patterns in patients hospitalized for coronary artery bypass surgery
Authors: Leszczynski D. E. , Cleveland J. C. , Kummerow F. A.
Published: February 2009

Preoperative plasma samples from coronary artery bypass surgery patients were analyzed for relative levels of high‐density lipoproteins (HDL) and low‐density lipoproteins (LDL) in order to assess the HDL:LDL ratio as an indicator of risk for coronary heart disease. Fasting blood samples were drawn from bypass patients prior to surgery, and bypass patient mean plasma lipid data were compared with values from three other groups: randomly selected, newly admitted hospitalized patients; acutely ill student outpatients; and healthy hospital employees. Sudan Black B prestained plasma samples were electrophoresed on polyacrylamide gels, and HDL:LDL ratios were determined by densitometric gel scan and automatic peak integration. Of the four study groups, the bypass patient group had the lowest mean HDL:LDL ratio; the low ratios were due particularly to reduced levels of HDL2. Chemical analyses indicated that the bypass patient group also had lower mean HDL‐cholesterol and higher mean total cholesterol and triglyceride levels than the other groups. When group age and sex differences were taken into account, the bypass group, especially males, also had low ratios. The results also strongly indicated that stresses involved with illness and hospitalization unrelated to clinical coronary heart disease (CHD) can adversely affect lipoprotein patterns.
DPTI/STTI—An index of the myocardial oxygen supply/demand ratio?
Authors: Baller D. , Zipfel J. , Hellige G.
Published: February 2009

The DPTI/STTI (diastolic pressure‐time index/tension‐time index) ratio is applied as an indicator of myocardial ischemia particularly in cardiovascular and anesthesiologic care units. The validity of the DPTI/STTI ratio was examined in intact dogs with large variations of oxygen supply and demand. The correlation of DPTI/STTI to the directly measured oxygen supply/demand ratio was poor even under maximal coronary vasodilatation. Many data points were far below the critical DPTI/STTI values (reported previously) without occurrence of myocardial ischemia, failure, or edema. Therefore caution is necessary if the DPTI/STTI ratio is to be applied to humans.
Role of aminophylline in refractory heart failure: a comparison to the vasodilator sodium nitroprusside, the old and the new
Authors: Dibianco R. , Rosenfeld S. P. , Katz R. J. , Simpson A. G. , Fletcher R. D. , Singh S.
Published: February 2009

Aminophylline [(theophylline ethylene diamine (TED)] reportedly improves cardiac hemodynamics by lowering vascular resistances and increasing contractility. TED as used clinically has not been compared to the vasodilator sodium nitroprusside (NP). To assess the relative hemodynamic effects of these two commonly used agents, the following comparison was made.

Ten patients with congestive cardiomyopathy in chronic refractory heart failure [New York Heart Association (NYHA) class IV] were studied. All patients demonstrated cardiomegaly by chest x ray and echocardiography (LVd= 6.3 ± 0.7 cm) and markedly abnormal hemodynamics during baseline observations (see Table I). Hemodynamic measurements at baseline were compared after TED infusion (mean blood level = 16±12 m̈g/m/TED) and during intravenous NP. No significant changes in heart rate occurred during either therapeutic intervention; a fall in mean arterial pressure of 10 mmHg (p<0.01) was observed during NP therapy; atrioventricular (AV) block with ventricular fibrillation was successfully treated in one patient after TED. Theophylline ethylene diamine demonstrated no detectable cardiac hemodynamic effects 60–90 min post infusion despite proven blood levels, whereas NP exhibited distinctly beneficial effects in this patient group.

Previous studies demonstrating improved hemodynamics occurring with TED have been limited to the time of infusion or within the following 40 min, a time when TED blood levels are maximum and therefore closest to toxicity.

The results of this study suggest that TED demonstrates no beneficial hemodynamic effects in refractory heart failure as early as 1 h after infusion despite blood levels in the therapeutic range.
Spectrum of heart muscle abnormalities related to alcoholism
Authors: Ahmed S. S. , Levinson G. E. , Fiore J. J. , Regan T. J.
Published: February 2009

To assess the diastolic and systolic performance characteristics of the left ventricle in alcoholism, three patient groups with a history of heavy alcohol consumption were compared with normal subjects. In those with symptoms related to chest pain or palpitations, heart size was normal on x ray. In groups III and IV, dyspnea was associated with varying degrees of cardiomegaly and a high prevalence of absent septal Q on the ECG.

Despite substantial differences in physical findings, all three groups exhibited a significant increase in end‐diastolic pressure. Group I was distinguished by the fact that end‐diastolic volume was not increased but actually somewhat diminished. Groups II and III were characterized by a significant increase in end‐diastolic volume and tension. The latter was enhanced to a significantly greater extent in group III and was the most prominent hemodynamic abnormality in this group. A major change in the index of contractility, as well as in the rate of relaxation, occurred in group I. Further moderate depression of these indices was observed in the groups with enhanced diastolic volume. In the patients who had mitral regurgitation a more severe depression of left ventricular function was present in the alcoholic group than in a nonalcoholic control group, and was presumably due to the toxic effects of ethanol on the left ventricle.

Thus, in those alcoholic patients who develop cardiac alterations, the earliest abnormality is characterized by diminished left ventricular compliance and a moderate contractility deficit without heart failure. In those who progress, end‐diastolic tension is substantially enhanced and further reduction in contractility indices is observed. The potential for reversibility is discussed.
Fungal endocarditis complicated by mycotic aneurysm of sinus of valsalva, interventricular septal abscess, and infectious pericarditis: Unique m‐mode and two‐dimensional echocardiographic findings
Authors: Incarvito J. , Yang S. S. , Papa L. , Fernandez J. , Chang K. S.
Published: February 2009

A 26‐year‐old male with fungal aortic endocarditis is presented in whom unique M‐mode and two‐dimensional echocardiographic findings permitted a diagnosis of mycotic aneurysm of right sinus of Valsalva and ventricular septal abscess preoperatively. The aneurysm was excised, and the affected aortic and tricuspid valves were replaced with valve prostheses.
Correlation of false negative myocardial infarct scintigraphy with postmortem studies
Authors: Codini M. A. , Hawkins E. T. , Turner D. A.
Published: February 2009

Negative myocardial infarct scintigrams with 99mtechnetium stannous pyrophosphate (99mTc‐PYP) were obtained in two patients with acute massive transmural infarct. Both patients died soon after scintigraphy. Because necropsy was performed within hours after death, we were able to correlate the distribution of the tracer within the acutely infarcted tissue with the myocardial scintigram. The clinical implication is that a single myocardial scintigram may be grossly inaccurate in detecting and quantifying infarct size. The scintigraphic findings should always be correlated with the electrocardiographic and enzymatic findings in evaluating patients with possible myocardial infarct.
Prinzmetal's variant angina induced only by alcohol ingestion
Authors: Sato A. , Taneichi Y. , Sekine I. , Okabe F. , Ueda A. , Takahashi M. , Ito T. , Su K.‐M. , Sada T. , Matsumoto S. , Ito Y.
Published: February 2009

Prinzmetal's variant angina occurred in a 52‐year‐old man 10–11 h after the ingestion of alcohol, when blood levels of alcohol decreased almost to the zero level. Coronary arteriograms revealed significant narrowing in the left circumflex artery and the left anterior descending artery and minimal wall irregularity in the right coronary artery; however, both exercise and pharmacologic stress tests were negative. A withdrawal from an acute exposure to alcohol was discussed as a possible causative mechanism of the alcohol‐induced Prinzmetal's variant angina in this case.
Evaluation of technician audiovisual scanning of ambulatory electrocardiograph recordings utilizing the rapid oscillographic printout technique of validation
Authors: Dibianco R. , Katz R. J. , Fletcher R. D. , Bortz Costello R. , Gottdiener J. S. , Singh S. N.
Published: February 2009

Summary: The accuracy of technician audiovisual scanning of ambulatory electrocardiographic recordings, coupled with physician review of demonstrative rhythm strips, was validated using the rapid oscillographic printout technique. Seventy‐five patients underwent 24‐h ambulatory electrocardiographic recordings which were routinely evaluated by audiovisual scanning for the highest hourly grades of ventricular ectopic activity (VEA). Printouts of three random hours per 24‐hours were then obtained (one hour per 8‐hour period). The total beat oscillographic printouts, written at 120 × real time, were then graded by at least two authors and compared to the results of audiovisual scanning. Hourly VEA grades were: 0 = no ventricular ectopy; 1 = ≤ 10 unifocals; 2 = > 10 unifocals; 3 = ≤ 10 multifocals; 3A = > 10 multifocals; 4 = couplets; 5 = triplets or salvos. VEA grades were further grouped into high grade (2, 3A, 4 or 5) and low grade (0, 1, or 3) categories. The comparison of rapid oscillographic total beat printout to technician audiovisual scanning coupled with physician review of ambulatory electrocardiographic data produced the following conclusions: (1) The highest hourly VEA grade was exactly identified 65% (146/225) of the time, or was closely approximated (identified within one grade of the highest VEA grade) 80% (181/225) of the time. Excluding errors that were secondary to overlooking rare electrical events, technicians successfully identified 88% (199/225) of hours for the highest VEA grade; (2) patients with high grade and low grade VEA were identified with an accuracy of 91% (51/55) and 95% (19/20), respectively; (3) technician reports which combined each of the three random hours per patient were more predictably accurate when positive for high grade VEA (98% of patients, 50/51) than for low grade VEA (79% of patients, 19/24); p < 0.05); (4) “underreading” errors in audiovisual scanning were almost six times more frequent as those of “overreading” (67 vs. 12 instances, respectively), with a failure to recognize low frequency electrocardiographic events as the most prevalent type of error. This study demonstrates the use of the rapid oscillographic printout technique for the display of ambulatory electrocardiographic data in hard copy compressed form which was successfully used to validate technician performance in the audiovisual scanning of ambulatory ECG recordings.
A new atrial transseptal pacing electrode
Authors: Udall J. A.
Published: February 2009

Summary: The atrial septum provides a convenient structure to which a transvenous electrode can be attached securely. The Brockenbrough cardiac catheterization technique has been used to gain access to the left atrium. A new electrode has been fabricated which can be inserted into the left atrium through the lumen of a Brockenbrough catheter. The electrode is composed of a stainless steel coil attached inside the proximal end of a platinum cylinder at the cardiac terminal. Three Elgiloy wires, having a wing configuration, are attached inside the distal end of the platinum cylinder. The coil and cylinder are insulated by silicone rubber and the metallic surface area of the distal electrode tip equals 5 mm2. This electrode has been implanted without difficulty or complications in five patients with tachycardia‐bradycardia syndrome.
The treatment of hypertension by labetalol‐a new alpha‐ and beta‐adrenoreceptor blocking agent
Authors: Stern N. , Teicher A. , Rosenthal T.
Published: February 2009

Summary: A new alpha‐ and beta‐blocking agent, labetalol, was used to treat 50 hypertensive patients, 34 of them with refractory hypertension. A significant reduction in hypertension was achieved with relatively few adverse reactions. The combination of alpha and beta blockers in labetalol with their mutually opposing characteristics offers an interesting and promising approach to the control of hypertension.
A clinical evaluation of sustained release metoprolol durules in the treatment of angina pectoris
Authors: Ccomerford M. B. , Besternabm E. M. M.
Published: February 2009

Summary: A clinical comparison of the sustained release form of metoprolol, consisting of a 200 mg metoprolol durule, with 100 mg conventional metoprolol twice daily, has been carried out to assess the therapeutic control of ten patients with stable angina pectoris. Objective measurements of heart rate, blood pressure, and ECG recordings were assessed during exercise on a bicycle ergometer. Ten patients completed the 8‐week double‐blind study. There were similar changes in heart rate and blood pressure at rest and during exercise, both at 2h and at 12 and 24 h postdose. Although similar exercise tolerance was achieved on both regimes, there was significantly less ST‐segment depression at 24h post durule, in comparison with the 12h post conventional metoprolol reading, suggesting that metoprolol durules produce a more effective reduction in the degree of myocardial ischemia.
Thrombolytic therapy for a thrombosed bjork‐shiley tricuspid valve prosthesis
Authors: Hellestrand K. J. , Morgan J. J. , Chang V. P.
Published: February 2009

Summary: A 67‐year‐old man in whom mitral and tricuspid Bjork‐Shiley tilting disc prostheses had been implanted 68 months previously presented with thrombotic obstruction of his tricuspid prosthesis. Initial cardiac catheterization demonstrated a significant transprosthetic tricuspid diastolic gradient (9.5 mmHg) with a calculated prosthetic valve orifice area (0.62 cm2) indicating a critical degree of stenosis. The resting cardiac index was markedly reduced (1.5 l/m2/min). Following an intravenous infusion of streptokinase for 66 hours, repeat cardiac catheterization revealed a 50% reduction in transprosthetic diastolic gradient across the tricuspid valve (4.7 mmHg), a greater than fourfold increase in prosthetic valve orifice area (2.87 cm2) with a normal resting cardiac index (3.1 1/m2/min).
Acute myocardial infarction in patients with normal coronary arteries after acute ethanol intoxication
Authors: Moreyra A. E. , Kostis J. B. , Passannante A. J. , Kuo P. T.
Published: February 2009

Three cases are presented where acute myocardial infarction occurred in young individuals after an episode of heavy alcohol intake. Subsequent coronary arteriograms demonstrated normal coronary arteries. Several mechanisms by which acute ethanol intoxication might precipitate myocardial infarction are discussed. To our knowledge, no similar cases have been reported.
Echocardiographic diagnosis of an unusual anterior mediastinal mass
Authors: D'Cruz I. A. , Chiemmongkoltip P.
Published: February 2009

X‐ray chest and CAT scan suggested an anterior mediastinal mass in a girl who had prominent left parasternal pulsations. M‐mode and two‐dimensional echocardiography demonstrated an extracardiac fairly rigid cystic mass between right ventricle and chest wall, which proved to be a cystic chondroma arising from the fourth left costal cartilage.
Chronic tocainide therapy for refractory high‐grade ventricular arrhythmias
Authors: Haffajee C. I. , Sacks G. M. , Alpert J. S. , Howe J. P. , Ockene I. S. , Paraskos J. A. , Dalen J. E.
Published: February 2009

Tocainide, an oral analog of lidocaine, was evaluated as a long‐term antiarrhythmic agent in 21 patients with symptomatic complex ventricular ectopic activity (10 with hemodynamically significant ventricular tachycardia) refractory to currently available antiarrhythmics singly, and in combination for periods of 3 days to 35 months (mean 13.6 months). Tocainide appeared to be an effective and safe agent for the control of these refractory symptomatic ventricular arrhythmias in 14 of the 21 patients (66%). Minor central nervous system and gastrointestinal side effects were present in most of the patients, usually early on in therapy, and only precluded long‐term use in 2 patients. Furthermore, lidocaine responsiveness was a good predictor of to‐cainide effectiveness in this group of patients. Tocainide precipitated atrioventricular (A‐V) block in one patient with pre‐existing A‐V nodal disease; two patients developed a skin rash while on tocainide therapy. These two patients had previously developed lupus‐like syndromes and skin rashes while on procainamide. The ANA titers had been falling in these two patients while on tocainide, and in one of these patients with true systemic lupus erythematosus, rechallenge with tocainide failed to produce skin rash. Tocainide's long plasma half‐life and high oral bioavailability permit an 8‐h regime. We conclude that tocainide is an effective, safe antiarrhythmic agent with tolerable side effects.
Submitral atheromatous lesions in monkey and man
Authors: Feinstein S. , Pick R. , D'Cruz I. , Abrahams C. , Liswood‐Strauss A.
Published: February 2009

Posterior submitral recess (PSMR) calcification is a common autopsy finding in elderly people, but its pathogenesis is undetermined. In this communication we show that, in part at least, the PSMR changes at autopsy are atheroma‐like with lipid around the sclerosis and calcific deposits. These changes in the PSMR showed a statistically significant correlation with the presence of hypertension and with an autopsy finding of severe coronary atherosclerosis. We showed, for the first time, that similar fibrosis and lipid deposition in the PSMR can be produced in high‐fat, high‐cholesterol fed macaque monkeys (Macaca arctoides) with or without concomitant experimentally produced hypertension. It is concluded that changes in the PSMR in monkeys and man are strongly related to atherosclerosis and hypertension.
Flecainide‐induced aggravation of ventricular tachycardia
Authors: Hohnloser S. , Zeiher A. , Hust M. H. , Wollschläger H. , Just H.
Published: February 2009

Flecainide acetate is a new class I antiarrhythmic agent which slows atrial, A‐V nodal and ventricular conduction velocity, and prolongs refractoriness of these structures (Borchard et al., 1982; Hodess et al., 1979). Recent studies with oral flecainide therapy suggested its high potential for suppression of ventricular tachycardia in humans (Anderson et al., 1981; Duff et al., 1981; Hodges et al., 1982). Its favorable pharmacokinetics with an average plasma half‐time of about 20 hours allows in most patients twice daily dosing (Duff et al., 1981). Usually, the drug seemed to be well tolerated and side‐effects, such as blurred vision, could be resolved with smaller but still effective doses (Duff et al., 1981). Actually, the ideal antiarrhythmic agent which represents a high degree of effectiveness, a low level of toxicity, a wide therapeutic range, and a prolonged antiarrhythmic action does not exist (Dreifus and Ogawa, 1977). In this report we describe a patient with flecainide‐induced aggravation of ventricular tachycardia necessitating resuscitation because of severe hemodynamic deterioration.
Suspect myocardial infarction: Hospital management and prognosis
Authors: Morris A. L. , Reimer J.
Published: February 2009

The management of 442 consecutive patients admitted for suspect acute myocardial infarction (AMI) was compared at two urban hospitals. The community hospital utilized an unmonitored observation unit (OU) more frequently than did the university hospital (39% vs. 9%, respectively). Progression to acute myocardial infarction (AMI) occurred in 25% of admissions, 5‐7% of whom died. Mortality without AMI was rare. Availability of the OU appeared to result in reduced coronary care unit (CCU) utilization and in shorter hospital stays for low‐risk patients who comprised fully 37% of hospital admissions. Low‐ and high‐risk subgroups (12% vs. 34% risk of AMI) were identified by normal versus abnormal admission electrocardiograms (EKG). Two‐thirds of the low‐risk patients with AMI were diagnosed by the next hospital day. A normal EKG on both the day of admission and on the second hospital day identified a population with less than 1% risk of in‐hospital AMI. The increased use of non‐CCU facilities for many ?MI patients appears to be appropriate. However, only randomized allocation trials, which were never performed for patients with definite AMI, would establish the relative efficacy of CCU versus non‐CCU treatment.
Safety and effectiveness of a portable external automatic defibrillator‐pacemaker
Authors: Rozkovec A. , Crossley J. , Walesby R. , Fox K. M. , Maseri A.
Published: February 2009

Sudden cardiac death in the community can be reduced by early resuscitation. The commonest arrhythmia encountered in this setting is ventricular fibrillation. A portable external automatic defibrillator‐pacing machine for use by emergency services and laymen after basic training, has recently been introduced. This device has a tongue‐abdominal pathway for sensing the electrocardiogram and respiration, as well as delivery of current. In its automatic mode, the machine cannot defibrillate unless the patient's breathing and gag reflex are virtually absent. The decision‐making characteristics of the machine were defined in isolation from the patient using simulated ECG signals and recordings of arrhythmias obtained during cardiac surgery and during electrophysiological studies. The pathway was evaluated separately by attaching it to a conventional defibrillator and using it in the elective cardioversion of 15 patients. Electrode sites were examined and creatine phosphokinase (CPK) and creatinine phosphokinase isoenzyme (CPKMB) release determined following conversion. Repeated playback of the same 34 minutes of selected recordings showed that decisions were consistent 95% of the time. Automatic pacing always occurred with asystole. ECG signals less than 0.35 mV in amplitude were not recognized, but a manual override switch could be operated in those circumstances where there was failure to act upon fine ventricular fibrillation. Defibrillation of 50% of the recordings of supraventricular and ventricular tachycardia did occur, but this could not have happened in practice unless the patient was unconscious, and in addition, the operator failed to countermand this decision. The tongue‐abdominal pathway yielded good recordings of the ECG. There was no significant damage to the tongue and the defibrillator charges employed were comparable to those that would be used with conventional chest paddles. In conclusion, the tongue‐abdominal pathway was safe and the machine, although its ECG logic made some inappropriate decisions, had sufficient safeguards to recommend its use in the emergency setting of the victim collapsing out of hospital.
A noninvasive comparison of left ventricular performance in sickle cell anemia and chronic aortic regurgitation
Authors: Willens H. J. , Lawrence C. , Frishman W. H. , Strom J. A.
Published: February 2009

Abnormalities of the cardiovascular system are common in patients with sickle cell anemia (SS). Noninvasive testing to document left ventricular dysfunction has yielded conflicting results. Left ventricular performance was evaluated in 27 patients with SS by M‐mode and 2‐D echocardiography, and systolic time intervals. Comparisons were made to 25 normal controls, and to 22 patients with chronic aortic regurgitation. Left ventricular diastolic diameter (LVDD) and cardiac index (CI) were significantly greater in the patients with SS than in controls (LVDD 5.3±0.4 vs. 4.7±0.5 cm; CI 4.2±1.3 vs. 3.1±0.8 liters/min/m2; both p<0.001). Left ventricular ejection fraction (EF) was slightly, but significantly less (62.9±7.3 vs. 67.0±5.4; p<0.05). In comparison to the patients with chronic aortic regurgitation, the LVDD in the patients with SS was slightly, but significantly lower (LVDD 5.3±0.4 vs. 5.9±0.6 cm; p<0.05). There was no significant difference between the patients in EF or CI (EF 62.9±7.3 vs. 63.3±4.4; CI 4.2±1.3 vs. 5.0±1.0 liters/min/m2; NS). Left ventricular EF was below 55 in three patients who also had hypertension at the time of examination. We conclude that patients with SS have resting left ventricular performance consistent with a high output state. Significant left ventricular dysfunction related to sickle cell disease alone was not demonstrated in this population, although the addition of hypertension appears to deleteriously affect resting left ventricular performance.
International symposium on coronary arteries in infants and children
Authors: Schneeweiss A. , Neufeld H. N.
Published: February 2009

The symposium took place in Tel Aviv on October 17‐20th, 1982. Over 100 investigators and clinicians from Europe, the United States, Japan, and Israel participated. The first day was devoted to risk factors for atherosclerosis in childhood. New evidence, supporting the predominance of the genetic factor in determining the risk for coronary atherosclerosis was reviewed. It included a high incidence of preatherosclerotic changes in children of population groups with a high incidence of coronary artery disease (Eastern Finland, Caucasians in the United States, Ashkenazi Jews in Israel), compared with low incidence of preatherosclerotic changes in the coronary arteries of children of population groups with low incidence of coronary artery disease (Western Finland, Blacks in the United States, Yemenite Jews, and Bedouins in Israel). The risk factors that can be influenced, including hypertension, hyperlipemia, and smoking at a young age, were reviewed. In the discussion it was emphasized that the long‐term results of changing the lifestyle of whole population groups are not yet well recognized. Several studies of mass intervention aimed at primary prevention are now being performed.
Percutaneous transluminal coronary angioplasty in multivessel coronary disease patients: Short‐ and long‐term follow‐up in single and multiple dilatations
Authors: Dorros G. , Lewis R. F. , Mathiak L. M.
Published: February 2009

Transluminal coronary angioplasty was successfully performed in 658 of 752 patients with multivessel disease. An angiographic success was achieved in 1198 of 1358 lesions (88%). One lesion was attempted in 338 patients (45%); 2 in 273 (37%); 3, in 101 (13%); and, 4 or more in 40 cases (5.3%). Significant complicatsions occurred in 39 patients (5.2%): 19 (2.5%) had a transmural infarction; 26 (3.5%) required urgent myocardial revascularization; and 14 (1.9%) died. An apparent lesion recurrence occurred in 233 of 658 (35%) patients with 162 of 171 (95%) having a successful second coronary angioplasty. A second apparent lesion recurrence occurred in 37 of 162 patients (23%) with 24 of 28 (86%) having a successful third coronary angioplasty. Clinical improvement (mean follow‐up: 31 ± 17 months) persisted in 81% of successful patients. The cumulative probability of survival was 91.5% at 72 months. Survival was adversely affected, at 63 months, by the presence of prior bypass surgery (no prior bypass surgery, 94% vs. prior bypass surgery, 86%; p<0.05): at 24 months by a low left ventricular ejection fraction (≤35%, 82% vs. left ventricular ejection fraction >35%, 95%; p<0.01) and, at 57 months, in the multiple dilatation group with prior bypass surgery (no bypass surgery 96% vs. prior bypass surgery 84%; p<0.05). Multiple dilatation had a beneficial effect upon survival, at 27 months, in patients with a left ventricular ejection fraction ≤35% [single dilatation, 74% vs. multiple dilatation, 93%; p<0.001], and in patients ≥70 years, at 39 months (79% vs. multiple dilatation, 92%; p<0.01). These data suggest that coronary angioplasty can be an effective treatment in patients with multivessel coronary disease without the need to dilate all diseased vessels, with good success, acceptable complication rates, and a reasonable expectation of satisfactory long‐term clinical improvement.
ST‐segment depression in inferior ECG leads during percutaneous transluminal coronary angioplasty for left anterior descending artery
Authors: Hiasa Y. , Wada T. , Hamai K. , Nakaya Y. , Mori H.
Published: February 2009

The mechanism of inferior ST depression during percutaneous transluminal coronary angioplasty (PTCA) for the left anterior descending artery (LAD) was studied in 108 patients with isolated LAD lesion. in 49 patients (Group I) ST depression in inferior leads was observed, and 59 patients (Group II) showed no inferior ST depression. in the lateral lead (I or aVL), the incidence (43 cases; 88% vs. 5 cases; 9%) and degree (1.5±0.8 mm vs. 0.2 ±0.4) of ST elevation were significantly greater in Group I than in Group II. There was a significant inverse correlation (r=‐0.57, p<0.01) between ST depression in the inferior lead and ST elevation in the lateral lead, but no correlation was found between anterior leads (V 2–4) and the inferior leads. Elevation of diastolic pressure of the pulmonary artery (8.7±4.8 vs. 5.7±2.8 mmHg) and lowering of systolic pressure of the femoral artery (‐25.7±24.3 vs. ‐11.8±8.3 mmHg) were significantly greater in Group I. These findings suggest that ST depression in the inferior leads during LAD angioplasty was due to a purely electrical phenomenon and not to the concomitant ischemia of the inferior wall. However, this change was more frequently seen in patients with larger myocardial ischemia and, presumably, was more often related to ST elevation in the lateral lead, which is reciprocal in position.
Cardiac manifestations of noncardiac tumors. Part I: Direct effects
Authors: Weinberg B. A. , Conces D. J. , Waller B. F.
Published: February 2009

Cardiac manifestations of secondary tumors of the heart may exert their effects directly by endocardial, myocardial, epicardial, or cavitary deposits (metastatic lesions), indirectly via tumor products such as in carcinoma, or mediated by therapy (chemotherapy, radiation) to treat the primary neoplasm. Part I of this review summarizes the frequency of metastatic cardiac involvement by various tumors and discusses pericardial manifestations (effusion, tamponade, constriction), one of the most common consequences of direct cardiac involvement by secondary tumors.
Implantable cardioverter‐defibrillators (ICDs) 1989: How close are we to the ideal device?
Authors: De Belder M. A. , Camm A. J.
Published: February 2009

Major technical advances over the last few years have led to significant improvements in implantable cardioverter‐defibrillators. Tachycardias can be detected using a number of criteria which include rate, rate of onset, duration, and stability of tachycardia. A number of target tachyarrhythmias can be distinguished in the same patient and differentiated from sinus or other benign tachycardias. Different tachycardias can then be treated with different electrical therapies. Therapies now incorporated in the latest generation of implantable devices include comprehensive antitachycardia pacing techniques, low‐energy cardioversion and high‐energy cardioversion‐defibrillation. Bradycardia support pacing is also incorporated. Improvements in the electrodes used for sensing tachycardia and delivering therapy have resulted in the first implants of devices without the need forthoracotomy. Improvements in capacitor technology have resulted in a gradual reduction in the size of devices in spite of their increasing sophistication. Further research is needed to evaluate different shock charges and waveforms. Tachycardia prevention by implanted devices is also a field of much current research. Thus, though not yet ‘ideal,’ the latest generation of implantable cardioverter‐defibrillators represents an important therapeutic option in the treatment of ventricular tachyarrhythmias.
Drug‐related syncope
Authors: Davidson E. , Fuchs J. , Rotenberg Z. , Weinberger I. , Agmon J.
Published: February 2009

The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty‐one patients were found to have drug‐related syncope. Thirty‐nine experienced syncope related to drugs administered for cardiovascular disease. The most frequently associated diseases were anginal syndrome (22 patients), hypertension (13 patients), and a history of myocardial infarction (6 patients). Thirty‐eight patients experienced symptomatic orthostatic hypotension following drug taking (nitrates in 19 patients, beta blockers in 10 patients, nifedipine in 3 patients, prazosin and quinidine in 2 patients each, methyldopa and verapamil in 1 patient each). One patient developed complete heart block as a result of digoxin intoxication. Two patients developed the characteristic picture of anaphylactic reaction (1 with ampicillin, 1 with dipyrone). During one‐year follow‐up, without the offending medications, no further syncopal episodes were reported by these patients. We conclude that drug‐related syncope was more common among our patients with syncope than had been reported previously. It is suggested that drug‐related syncope should be taken into consideration in any patient with syncope who is treated by any of the above‐mentioned drugs.
Reperfusion therapy in acute myocardial infarction: Present status and controversy
Authors: Mueller H. S.
Published: February 2009

Coronary thrombolysis revolutionized the treatment of acute myocardial infarction. Most of the experience was obtained with intravenous use of streptokinase and tissue‐type plasminogen activator, the latter being superior to streptokinase in regard to coronary recanalization. Numerous other promising thrombolytic agents are being investigated. Both streptokinase and tissue‐type plasminogen activator decreased mortality in large trials; comparison studies in terms of efficacy are presently being performed (GISSI 2). Aspirin is an important adjunct to thrombolytic therapy; it decreased mortality by itself (ISIS 2). Heparin is conventionally used together with thrombolysis. Its efficacy is under study (GISSI 2). Intracranial hemorrhage is the most devastating complication of thrombolysis. With the present dosage regimens, the incidence is approximately 0.5%. Percutaneous transluminal coronary angioplasty in conjunction with thrombolysis accomplished frequent and persistent recanalization of the infarct artery with low mortality, including high risk patients. The TIMI IIB study demonstrated that the results of a “conservative strategy” with aggressive management of recurrent ischemic events were comparable to those of an “invasive strategy.” Subgroup analysis should, however, be awaited. High risk patients with low ejection fraction or with shock benefit by early mechanical coronary recanalization. The role of throm bolysis in the “late” stage of transmural myocardial infarction or in the acute ischemic syndrome (unstable angina/non‐Q‐wave myocardial infarction) is unclear and presently under investigation.
Are antiarrhythmic drugs safe?
Authors: Katritsis D. , Camm A. J.
Published: February 2009

The indications for antiarrhythmic therapy are far from clearly defined and the choice of treatment is usually based on empiric strategies. Antiarrhythmic agents can have serious side effects. Systemic adverse effects are usually use‐related and reversible with withdrawal of the drug. Impairment of left ventricular function is considerable in patients with heart failure. The most important, life‐threatening side effect of antiarrhythmic drugs is their proarrhythmic tendency which gives rise to certain concern about their clinical use. Aggravation of arrhythmia often occurs without symptoms, goes unrecognized by the patient, and is exposed only by monitoring, exercise testing, or invasive electrophysiological testing. Patient monitoring with electrolyte measurement, Holter recording, and electrophysiological reassessment can reveal or reduce the proarrhythmic risk but cannot eliminate the problem completely. The institution of antiarrhythmic therapy should be considered in highly symptomatic or life‐threatening arrhythmias after careful consideration of the benefit‐risk ratio.
Hypertrophic cardiomyopathy evolving into a hypokinetic and dilated left ventricle: Coronary embolization as a probable pathogenetic mechanism
Authors: Gravanis M. B. , Robinson P. H. , Hertzler G. L.
Published: February 2009

A long‐term follow‐up (9 years) in a patient with hypertrophic cardiomyopathy revealed an evolution to a hypokinetic and dilated left ventricle. The patient underwent heart transplantation, and therefore the native heart was available for morphologic studies. Gross and microscopic stigmata of hypertrophic cardiomyopathy were present, as well as evidence of left ventricular dilatation. Multiple myocardial scars in both ventricles indicated past ischemic episodes, most probably due to coronary embolization from left ventricular mural thrombi. Other possible pathogenetic mechanisms for the progression of hypertrophic cardiomyopathy to a dilated one are discussed.
Managing the pregnant patient with heart disease
Authors: Burlew B. S.
Published: February 2009

Pregnancy and its associated hemodynamic challenge presents potential risks to the patient with cardiac disease, whether acquired or congenital. The hematologic changes which occur during pregnancy include alterations in blood volume, hematocrit, and blood viscosity. There are also alterations in cardiac output and regional blood flow patterns. These hemodynamic alterations are associated with signs and symptoms which can be impressive yet benign, or can suggest poor outcome, depending on the underlying cardiovascular disorder. The clinician is faced with the sometimes difficult task of differentiating the benign from the dangerous while making appropriate management decisions. In this article, diagnosis and current management of many of the more common acquired and congenital cardiac abnormalities are discussed as they pertain to the gravid female. The effects of common cardiovascular medications in pregnancy are also briefly reviewed.
A comparison of heparinized low osmolality ionic and nonionic contrast media in 500 patients undergoing cardiac angiography
Authors: Feldman R. L.
Published: February 2009

Low osmolar contrast media (CM) cause less hemodynamic and electrical changes than conventional CM, and many cardiologist have switched to the newer agents. Recently, concerns about a possible increased frequency of thromboembolic complications with low osmolar CM have been raised. This study compared two low osmolar heparinized CM, one ionic (Hexabrix) and the other nonionic (Isovue), in 500 consecutive patients undergoing either diagnostic catheterization (417) or coronary angioplasty (83). Adverse effects were uncommon (37 patients), but were more frequent with Hexabrix (12%) than Isovue (3%); p < 0.05. The most common adverse effects were nausea or vomiting. Death, related to abrupt occlusion of a severe left main stenosis occurred in one patient who received Hexabrix, and acute pulmonary edema occurred in one patient who received Isovue. No apparent thromboembolic complication occurred. In conclusion, both low osmolar CM were well tolerated, but Hexabrix caused more transient nausea or vomiting. Both CM were safe and the incidence of thromboembolic complications when prospectively looked for was very low.
Tomographic views of normal and abnormal hearts: The anatomic basis for various cardiac imaging techniques. Part I
Authors: Waller B. F. , Taliercio C. P. , Slack J. D. , Orr C. M. , Howard J. , Smith M. L.
Published: February 2009

Recent developments have taken place in the diagnosis of cardiovascular disorders in the area of cardiac imaging techniques. From a previous era of imaging by silhouettes (chest roentgenography, fluoroscopy, angiocardiography), we have emerged into an era of imaging by tomographic scanning (echocardiography, radionuclide tomography, computed tomography, magnetic resonance). A basic understanding of tomographic cardiac anatomy is the foundation for proper use and interpretation of these new imaging modalities. The present report provides a description of the techniques of tomographic cutting of necropsy cardiac specimens and illustrates some of the pathologic cardiac abnormalities cut in these tomographic planes. Part I of this report describes position of the heart and tomographic axis planes, preparation of the heart and methods of cutting at necropsy, and the short‐axis, two‐chamber, and four‐chamber views of the heart.
Economic reprioritization of PET
Authors: Gleason John. M. , Frickm Mathis. P.
Published: February 2009

In a previous issue of the journal Gould, Mullani and Williams wrote an editorial entitled“PET, PTCA and Economic Priorities.”1 The whole subject of positron emission tomography and its use with rubidium to diagnose coronary artery disease vis‐à‐vis thallium imaging is a controversial issue of current interest. As of this writing, scientists and clinicians have vocalized strong views for each imaging technique as the best clinically suitable method to diagnose hemodynamically significant coronary artery disease. I do not pretend to know who is right, but I can assure the reader of the emotionally charged nature of this controversy. The article by Gould and colleagues generated a response by an economist, Dr. Gleason, which subsequently generated a reply by Gould. I thought this topic was of sufficient interest to the readers of Clinical Cardiology that it should be given special article status because of the important issues raised.
Sinus of valsalva aneurysms
Authors: Goldberg N. , Krasnow N.
Published: February 2009

Sinus of Valsalva aneurysms are rare cardiac anomalies which may be acquired or congenital. The congenital aneurysm is more common than the acquired form, with an incidence ranging from 0.1 to 3.5% of all congenital heart defects. Acquired aneurysms may result from trauma, endocarditis, syphilis, Marfan's syndrome, and senile‐type dilatation in which the three sinuses dilate as a result of the normal aging process. This review focuses on both congenital and acquired aneurysms with particular attention to the noninvasive diagnosis of this anomaly.
A new cardiac auscultation simulator
Authors: Takashina T. , Masuzawa T. , Fukui Y.
Published: February 2009

We have successfully developed a new cardiac auscultation simulator by applying recently developed digital and computer technology, which digitally records, stores, modifies, and plays back heart sounds and murmurs characteristic of various heart diseases. The simulator is capable of playing back different heart sounds or murmurs at each auscultatory site (aortic, pulmonic, tricuspid, and mitral) of a human chest‐sized mannequin (made of urethane foam), through four built‐in speakers. We were able to listen to accurate reproductions of heart sounds and murmurs at the same timing as in real patients by any type of stethoscope used in routine medical practice. This compact and portable educational apparatus, which simulates realistic auscultatory sounds, will impact greatly on the medical training of cardiac auscultation for physicians, medical students, nurses, and paramedicals.