bluuebunny/crossref_metadata_2025 huggingface dataset:
An evaluation of the avionics pressurometer iii 1978 at home and in hospital
Authors: Gould B. A. , Hornung R. S. , Cashman P. M. M. , Altman D. , Raftery E. B.
Published: February 2009

The Avionics Pressurometer III is the only noninvasive indirect ambulatory blood pressure system which provides 24‐h blood pressure measurements, but it has been subjected to limited evaluation. We report a critical evaluation comparing it to simultaneous intra‐arterial blood pressures both at home and at hospital as well as during standardized exercise. Comparisons with simultaneous indirect methods were also made. Twenty‐two hypertensives undergoing intra‐arterial ambulatory blood pressure monitoring wore the two recorders for one day. The mean difference (standard deviation SD) for intra‐arterial blood pressure—Avionics blood pressure was 2 (SD 8.6) /‐14 (SD 10.3)mmHg at home and ‐3 (SD 15.4)/‐11 (SD 12.3) mmHg at hospital. At the end of exercise the figures for the same comparison were ‐7 (SD 16)/0 (SD 15.6) mmHg. In general the agreement between intra‐arterial and Avionics pressurometer recordings was closer for systolic than for diastolic blood pressures but there was wide variation for individuals as shown by the standard deviations about the mean difference. We did not use the recorder at night as patients complained that the noise kept them awake and so night‐time blood pressures were not attainable. We do not think the recorder performed satisfactorily during physical exertion, and in view of its expense, this recorderis of limited potential value in supplying accurate information.
Deficiency of apolipoproteins a‐i and c‐iii and severe coronary heart disease
Authors: Hiasa Y. , Maeda T. , Mori H.
Published: February 2009

A 55‐year‐old woman with severe coronary arteriosclerosis and skin xanthomas is described. The patient had a normal total cholesterol level of 168 mg/dl. Her level of high‐density lipoprotein cholesterol was markedly reduced (3 mg/dl). On apolipoprotein analysis, apolipoproteins A‐I and C‐III were not detectable, and the level of apolipoprotein A‐II was found to be at a low level (3.5 mg/dl). This case may possibly belong to a distinct new disease entity of deficiencies of apolipoprotein A‐I and C‐III in which coronary arteriosclerosis appears prematurely and severely.
Clinical studies on diabetic myocardial disease using exercise testing with myocardial scintigraphy and endomyocardial biopsy
Authors: Gend A. , Mizuno S. , Nunoda S. , Nakayama A. , Igarashi Y. , Sugihara N. , Namura M. , Takeda R. , Bunko H. , Hisada K.
Published: February 2009

Nine diabetics without significant coronary stenosis participated in an exercise testing protocol with thallium‐201 myocardial scintigraphy. Endomyocardial biopsy of right ventricle was also obtained. There were 4 patients with abnormal perfusion (positive group) and 5 patients with normal perfusion (negative group). All cases of the positive group were familial diabetics and there was only one case of dietary treatment, whereas in the negative group, there were only 2 cases of familial diabetics and 3 cases receiving dietary treatment. No statistical differences between the positive and negative groups were observed for the data of exercise performance and hemodynamic parameters in cardiac catheterization at rest. However, the mean ejection fraction in the positive group (62 ± 13%) was significantly lower than in the negative group (77±4%). In both groups, the mean diameter of myocardial cells and the mean percent fibrosis of biopsy specimens showed significant increases compared with the control group. The mean percent fibrosis in the positive group (24.1±8.5%) compared with that in the negative group (16.5±5.9%) showed a tendency to increase. It is suggested that the abnormal perfusion of thallium‐201 in the positive group indicates subclinically a pathological change of microcirculation caused by diabetes mellitus.
The ear lobe crease sign and coronary artery disease in aortic stenosis
Authors: Gibson T. C. , Ashikaga T.
Published: February 2009

Ear lobe creases have been proposed as useful indirect markers of coronary artery disease. To test such a hypothesis, this physical sign was evaluated in 100 patients with symptomatic aortic stenosis undergoing cardiac catheterization to establish the hemodynamic severity of the obstruction and the degree of coronary artery involvement. This is a disorder where the coexistence of cardiac ischemia may play an important part in diagnosis and management. Criteria were established for the degree of ear lobe involvement with a grading of mild (Grade 1), moderate (Grade 2), and severe (Grade 3). Significant coronary artery disease was defined as narrowing ≥50% and a coronary score was established. Sensitivity, specificity, positive and negative predictive values were calculated, using Bayesian analysis for three levels of assumed coronary artery disease prevalence. An ear lobe crease score was correlated with a coronary artery disease score, taking into account the variables of age, sex, and body mass index. No useful statistical correlations were found and it is concluded that this physical sign is of little practical value in this clinical setting.
Acute and chronic pulmonary thromboembolism: current perspectives. part i: glossary of terms, historic evolution and prevalence
Authors: Ansari A.
Published: February 2009

Despite considerable medical as well as surgical advances, the problem of pulmonary thromboem‐bolism, both acute and chronic, continues to plague clinicians of all medical disciplines. Approximately 650,000 to 700,000 patients per year suffer from acute pulmonary thromboembolism in the United States. Of these, approximately 60,000–70,000 die as a direct result of it. Our knowledge of the etiology, pathology, pathogenesis of pulmonary infarction, pathophysiology, accurate diagnosis, proper management (including both primary and secondary prophylaxis) of deep vein thrombi and pulmonary thromboemboli has advanced considerably during the past 15 years. These advances, which have now been adopted in the clinical practice, have already begun to indicate that not only more cases of acute and chronic pulmonary thromboembolism are being recognized than before, but also the morbidity and mortality of this disease process is declining. This is likely to improve further as our quest for safe, accurate, noninvasive and inexpensive diagnostic methods continues. Medical thromboembolectomy using thrombolytic therapy is fast replacing the surgical thromboembolectomy for patients with acute massive pulmonary thromboembolism. Better thrombolytic agents, such as tissue plasminogen activator, which selectively lyses the thromboemboli without producing significant systemic lytic state and now undergoing clinical investigation, is likely to revolutionize the management of both acute and chronic pulmonary thromboembolism because of its propensity to dissolve plasminogen‐bound thrombi of any age. The majority of the patients who suffer from acute pulmonary thromboembolism recover most of their lost lung function unless cardiopulmonary reserve was compromised prior to the onset of the acute episode. Conversely, patients with chronic pulmonary thromboembolism usually have relentless progression of their disease with progressive increase in mean pulmonary artery pressure, ultimately resulting in chronic cor pulmonale and death. However, recently pulmonary thromboembolectomy for those patients who have chronic pulmonary thromboembolism resulting from thromboemboli located in the main pulmonary artery or its main branches has been performed with success and acceptable mortality. This paper reviews the subject of pulmonary thromboembolism, both acute and chronic, from the days of Virchow to the present.
Prospective comparison of exercise digital subtraction and exercise first pass radionuclide ventriculography
Authors: Detrano R. , Yiannikas J. , Simpfendorfer C. , Underwood D. A. , Salcedo E. E. , Rollins M.
Published: February 2009

In order to test the comparative sensitivities of first‐pass radionuclide and digital subtraction ventriculography in detecting wall motion abnormalities during exercise, 29 patients referred for coronary angiography were submitted to both types of stress ventriculograms. Resting and exercise ventriculograms by both techniques were reviewed by independent observers and the five equal ventricular wall segments were graded as normal, mildly, moderately, severely hypokinetic, akinetic, or dyskinetic. Of the 29 patients, 24 had arteriographically defined ischemic potential (at least >50% obstruction of a major coronary artery supplying viable myocardium). Exercise digital subtraction ventriculography correctly identified 17 (71%) of these by a worsening of wall motion during exercise, while radionuclide ventriculography identified only eight (33%) by the wall motion response. When either a worsening of wall motion or the failure to increase ejection fraction by at least 5 points were used as criteria for an abnormal test, the sensitivities of digital and radionuclide ventriculographies were 96% and 79%, respectively. Though the number of patients without ischemic potential (5 patients) was too small to judge the relative specificities, digital subtraction ventriculography appears to be more sensitive than radionuclide ventriculography in identifying exercise‐induced wall motion abnormalities and in predicting coronary occlusions.
Echocardiographic evidence of intrathoracic masses due to localized blast crisis in a patient affected by chronic granulocytic leukemia
Authors: Mancuso L. , Bondi F. , Marchì S. , Marceno R. , Malleo C.
Published: February 2009

We report a case of intrathoracic blast crisis in a patient affected by chronic granulocytic leukemia. Two‐dimensional echocardiography performed to exclude pericardial effusion showed tumor masses in area of the atrioventricular groove and by the side of the left ventricular wall, which were confirmed by computed tomography.
Embolization complicating coronary angioplasty in the presence of an intracoronary thrombus
Authors: Weyne A. E. , Heyndrickx G. R. , Vandekerckhove Y. R. , Clement D. L.
Published: February 2009

Two cases of coronary occlusion and subsequent embolization during percutaneous coronary angioplasty (PTCA) are described. Prior to PTCA, angiographic evidence of intracoronary thrombus was present. Abrupt reclosure after dilation was treated by successful redilation. However, coronary embolization of thrombus debris occurred downstream in one patient and into an adjacent coronary branch in the second patient.
Effects of alcohol on systemic and pulmonary hemodynamics in normal humans
Authors: Koskinen P. , Kupari M. , Nieminen M. S. , Suokas A. , Tötterman K. , Pajari R. , Heikkilä J.
Published: February 2009

Even at low doses, alcohol has been reported to impair left ventricular pump function. To characterize further the effects of alcohol on the normal cardiovascular system, using the Swan‐Ganz thermodilution catheter, we studied 6 healthy physicians, aged 27–36 years, while they were lightly intoxicated. Within a period of 30 min the subjects ingested 0.5 g/kg of ethanol diluted to 15% (w/v) in fruit juice. Hemodynamic measurements were obtained before the first ingestion and every half‐hour thereafter for 2 hours. A peak blood ethanol concentration (mean ± SE) of 13.3 ± 1.6 mmol/l (0.61 mg/dl) was recorded at 60 min. Unexpectedly, pulmonary artery pressure rose during the early part of the increasing blood ethanol phase, probably due to pulmonary vascular constriction. At 30 min, the systolic pulmonary artery pressure had increased by 10% (p<0.05) and the diastolic pressure by 14% (p<0.001); both returned to baseline levels by the end of the experiment. Calculated pulmonary vascular resistance rose from a baseline value of 0.50±0.30 to 0.85±0.34 units (p<0.01) at 30 min. Left ventricular preload decreased significantly during the declining blood ethanol phase: mean pulmonary capillary wedge pressure decreased from 12 ± 3 to 10 ± 2 mmHg (p<0.01), and mean right atrial pressure decreased significantly. This study suggests that alcohol causes changes in cardiac function by altering its loading conditions. The combined diuretic and systemic venodilatory actions of alcohol provide the most probable explanation for the decrease in preload.
Are anti‐platelet drugs of value in the management of patients with chronic stable angina? A study with ticlopidine
Authors: Khurmi N. S. , Bowles M. J. , Raftery E. B.
Published: February 2009

Thirty patients (28 males and 2 females) aged 46–68 years with established chronic stable angina were studied in a placebo‐controlled double‐blind crossover trial to examine the efficacy of oral ticlopidine (an antiplatelet agent) 250 mg twice daily. The baseline mean ± SEM exercise time of 7.5±0.5 min rose to 8.1 ±0.6 min after 2 weeks of placebo run‐in, 8.8±0.7 min after 4 weeks of double‐blind placebo, and to 9.2±0.6 min with ticlopidine therapy; none of these changes achieved statistical significance. Similarly, time to the development of 1 mm ST‐segment depression, maximal ST‐segment depression, heart rate, and rate‐pressure product failed to show any statistically significant changes during ticlopidine therapy. Ambulatory electrocardiographic monitoring showed that the mean number of episodes of ST‐segment depression > 1 mm remained unaltered during ticlopidine therapy. Four patients (3 during placebo, 1 during ticlopidine) stopped treatment prematurely because of unstable angina and two because of adverse effects. Our data suggest that ticlopidine has no significant effect on objective indices of myocardial ischemia in patients with chronic stable angina, that placebo has no effect on the objective in dices of myocardial ischemia derived from exercise testing and ambulatory electrocardiographic monitoring, and that exercise testing and ambulatory electrocardiographic monitoring in patients with chronic stable angina pectoris are reproducible.
Spontaneous closure of congenital ventricular septal defect in an adult
Authors: Hu D. C. K. , Giuliani E. R. , Downing T. P. , Danielson G. K.
Published: February 2009

Spontaneous closure of congenital ventricular septal defect occurs commonly in infants and young adults. Occurrence in adults—patients older than 21 years— however, is rare. For this reason, we report on spontaneous closure of a congenital ventricular septal defect in a patient older than 26 years. This case was documented by catheterization before and after spontaneous closure. The proposed mechanisms of spontaneous closure are briefly reviewed.
Prognostic value of ventricular arrhythmias and transient st‐t changes after myocardial infarction: A two‐year follow‐up with ambulatory ECG recording
Authors: Mazzocca G. , Piacenti M. , Marchesi C. , Contini C.
Published: February 2009

The aim of this study is to evaluate the frequency and prognostic significance of ventricular arrhythmias (VA) and of ST‐T changes found during 24‐h ECG recording in patients who survived an acute myocardial infarction. Eighty‐nine patients (2 females and 87 males) discharged from hospital after acute myocardial infarction were studied. Mean age was 52.2 years (SD±10) with a range of 26–68. Serial observations were carried out at 1, 2, 3, 6, and 12 months after the acute event. Eight patients died during the first two years of follow‐up, of these, 2 deaths were of noncardiac origin: one was due to gastric carcinoma and the other to pulmonary neoplasm. Of the 6 cardiac deaths, 4 were sudden and unexpected and 2 were due to reinfarction. Statistical analysis of the results obtained in the first three months of follow‐up has not shown any significant correlation between pathologic patterns and cardiac death. In the second period we found a statistically significant relationship between cardiac death and multiform VPBs (p<0.05), CVA (p<0.05), and ST‐T changes (p<0.05). More significant was the correlation between cardiac death and the presence at the same time of ST‐T changes and multiform VPBs (p<0.01).
Reversed septal motion in right ventricular volume overload: False negative sign in the presence of increased septal thickness
Authors: Ballester M. , Pons G. , Carreras F. , Cladellas M.
Published: February 2009

Paradoxical septal motion of the interventricular septum and right ventricular enlargement constitute diagnostic features of right ventricular volume overload. A diastolic septal displacement toward the left ventricle and its systolic normalization explain this phenomenon. A thick septum would, theoretically, impede such movement. One patient with a cardiac allograft and gross tricuspid regurgitation is described who, in the context of a rejection episode and in a very short interval, showed two septal motion patterns related to two different septal thicknesses. It is concluded that in a patient with large right ventricular dimension and increased septal thickness, lack of paradoxical septal motion does not rule out severe right ventricular volume overload.
Myocardial infarction in young adults under 30 years: Risk factors and clinical course
Authors: Weinberger I. , Rotenberg Z. , Fuchs J. , Sagy A. , Friedmann J. , Agmon J.
Published: February 2009

The clinical features and course of 30 patients (26 men and 4 women) under 30 years of age (mean age 27.3 years) with an acute myocardial infarction (MI) are described. The most common risk factor among this group of patients was smoking in 20 patients (66%). The prevalence of the other risk factors was low: hyperlipidemia in four patients and family history of ischemic disease in another four patients, diabetes mellitus, hypertension, and obesity each in one patient. Seven patients (23%) had none of the conventional risk factors. Three patients were exerting themselves prior to the onset of their MI pain; all of them had normal coronaries. Five patients experienced chest pain prior to MI, among them only two experienced classical angina pectoris. Eighteen patients underwent uncomplicated MI. The complications in the other 12 during the acute MI were rhythm disturbances in eight and congestive heart failure in four. Cardiac catheterization was performed in 25 patients. The occurrence of zero, one, or multivessel disease was equal. The 30 patients were followed up from six months to 15 years (mean 7 years). In 18 patients circulating aggregated platelets were measured one year after the MI. Elevated values were found in all of them (mean ±SD34.9±9.1%). In 6 of the 18, all heavy smokers, extreme values were found in the range of 39–55%. Three out of the 30 patients died within five years after their first MI. The other 15 patients developed complications, most of them angina pectoris. Five patients were hospitalized for reinfarction. None of the 30 underwent aortocoronary bypass operation. According to our study the following conclusions could be drawn in MI patients under 30: (I) The main risk factor in this group of patients was smoking, the prevalence of the other conventional coronary risks factors being low. (2) Exertion and chest pain are not prerequisite conditions preceding MI in these patients. (3) The probability of finding zero, one, or multivessel disease on coronary angiography in this group of young MI patients is equal. (4) In MI patients under 30, increased circulating aggregated platelets may play a pathogenetic role in the development of MI.
Comparative effects of calcium‐channel blockers and beta‐adrenergic blocker on early diastolic time intervals and a‐wave ratio in patients with hypertrophic cardiomyopathy
Authors: Doiuchi J. , Hamada M. , Kokubu T. , Ito T.
Published: February 2009

To compare the effects of calcium‐channel blockers with those of beta‐adrenergic blockers in patients with hypertrophic cardiomyopathy (HCM), diastolic time intervals (IIA‐O time, from the second heart sound to the O point of apexcardiogram, IIA‐MVO time, from IIA to the mitral valve opening, and MVO‐O time, from the MVO to the O point of apexcardiogram), and A‐wave ratio measured from apexcardiogram were evaluated before and after more than three months of treatment. In both groups, heart rate significantly decreased after treatment. The IIA‐MVO time was not affected by either drug. The IIA‐O and the MVO‐O times were significantly shortened by calcium‐channel blockers (from 234.6±77.4 ms to 204.6±39.2 ms; p<0.01, and from 133.1±66.4 ms to 100.3±34.0 ms; p<0.01, respectively). However, they were not affected by beta‐adrenergic blocker. A‐wave ratio significantly decreased after calcium‐channel blockers (from 18.0±9.8% to 13.7±7.3%; p<0.01) and beta‐adrenergic blocker (from 21.7±12.6% to 17.2±8.0%; p<0.01). From these observations, it is suggested that calcium‐channel blockers improved the early diastolic filling rate, whereas beta‐adrenergic blocker did not affect it. It is concluded that the effects of calcium‐channel blockers and beta‐adrengergic blocker on early diastolic time intervals were different in patients with HCM.
Effects of verapamil on left ventricular diastolic function at rest and during isometric exercise in patients with hypertrophic cardiomyopathy
Authors: Bryhn M. , Eskilsson J.
Published: February 2009

Ten patients with hypertrophic cardiomyopathy were examined with echocardiography before and during verapamil treatment to evaluate short‐term and long‐term effects of verapamil on left ventricular diastolic function. All patients were in sinus rhythm and in NYHA functional class I. Effects on filling and myocardial relaxation were documented by digitized echocardiography obtained at rest and during isometric exercise before treatment, after two weeks (short‐term) and four months (long‐term) treatment, respectively. At rest a significant decrease of the myocardial relaxation time was found during verapamil treatment. A few patients, however, returned to almost baseline conditions after an initial improvement. A small increase in the peak rate of dimension change, a parameter of filling, reached statistical significance at the end of the long‐term treatment period. Isometric exercise did not induce any changes in the diastolic parameters during verapamil treatment. A positive effect of verapamil was thus seen on both myocardial relaxation and left ventricular filling, but only in resting conditions.
Right atrial vegetation in left ventricular‐right atrial communication
Authors: Murata T. , Fujino M. , Sasaki J. , Takii M. , Arakawa K.
Published: February 2009

We report a case of right‐sided endocarditis with left ventricular‐right atrial communication in which right atrial vegetation was demonstrated by two‐dimensional echocardiography. The present case demonstrates that the right atrial vegetation in ventricular septal defect is suggestive of left ventricular‐right atrial communication.
Complete atrioventricular block in shone's syndrome
Authors: Shalev Y. , Caspi A.
Published: February 2009

A rare case of an adult patient with Shone's syndrome is presented in whom Lev's disease seems to be the major pathology underlying the development of complete A‐V block.
Position as a variable for cardiovascular responses during exercise
Authors: Cotsamire D. L. , Sullivan M. J. , Bashore T. M. , Leier C. V.
Published: February 2009

Twenty‐one normal young male subjects underwent resting and exercise (bicycle) radionuclide angiography in the full supine and 70$$ upright tilt positions in order to examine the effects of position on left ventricular size and performance, hemodynamics, and exercise duration. All subjects also underwent full (90$$) upright bicycle ergometry with respiratory gas analysis to establish the level of maximal exercise capacity for each. Body position significantly (p<0.05) affected resting and exercise cardiovascular parameters. End‐diastolic and endsystolic left ventricular volumes and stroke volume were larger in the supine position, both at rest and during exercise. The cardiac output at rest and during exercise were comparable for the two positions; an increase in resting and exercise heart rate in the 70$$ tilt position compensated for the reduced stroke volume of this posture. At maximal exercise, the 70$$ upright position was associated with a greater response in left ventricular ejection fraction, otherwise this parameter was not position related. Exercise capacity, in terms of duration and workload, was significantly higher in the supine (1870$$390 s) and full upright (1830$$250 s) positions than in the 70$$ tilt position (1730$$260 s). Changes in body position significantly alter parameters of ventricular, cardiovascular, and exercise performance.
Bidirectional flow in congenital ventricular septal defect: A doppler echocardiographic study
Authors: Zeevi B. , Berant M. , Blieden L. C. , Keren G. , Sherez J. , Laniado S.
Published: February 2009

The purpose of this study was to demonstrate the value of combined two‐dimensional and pulsed Doppler echocardiography (echo) in localizing and recording bidirectional flow in congenital ventricular septal defect. Eight children, aged 8 months to 16 years, with clinical signs of a ventricular septal defect, underwent two‐dimensional and pulsed Doppler echo study prior to cardiac catheterization. The ventricular septal defect was documented anatomically by two‐dimensional echo in all eight patients. Flow patterns in systole and diastole through the ventricular septal defect and on both sides of the defect were carefully studied. In all eight children, systolic, high velocity, pathologic, left to right flow was documented when the sampling volume was positioned on the right ventricular side of the defect. When the sampling volume was positioned inside the defect, to and fro flow, left to right in systole and right to left in diastole, was observed. In children with moderate to large defects, the diastolic flow had a peak in early diastole. Increased pressure in the right ventricle over the left ventricle during the same period was demonstrated by cardiac catheterization and coincided with the Doppler flow. The direction of flow across the defect was affected by the size of the defect and the magnitude of the net shunt. Two‐dimensional and pulsed echo Doppler were shown to be useful in demonstrating the ventricular septal defect and estimating its size and hemodynamic significance noninvasively.
Does “Physiologic” mitral valve prolapse occur with acute blood loss?
Authors: Konicek S. , Guntheroth W. G. , Cyr D. R. , Sylvester C. E. , Mack L. A. , Reichler R. J.
Published: February 2009

Intravascular volume changes are reported to affect the clinical and echocardiographic spectrum of patients with known mitral valve prolapse syndrome (MVPS). We tested whether acute blood loss can produce MVP in normal adults. Twenty‐one subjects were studied with Doppler echocardiography before and after donating 550 ml whole blood. Two subjects demonstrated minimal (1+) prolapse postphlebotomy, but in only one echocardiographic view, and without mitral regurgitation by Doppler. Three subjects demonstrated slight, early (not late or pansystolic) mitral regurgitation after phlebotomy, but without prolapse. Left atrial dimensions decreased significantly after the blood donation but the left ventricular size was not significantly smaller. The 1+ MVP is within the range of superior systolic motion found in 35% of a normal population, free of heart disease, and without intervention. We find no evidence in our study or in the literature that pathologic degrees of MVP can be produced in normal subjects by physiologic alteration in blood volume.
The relationship of ventricular arrhythmias to the angiographically and scintigraphically estimated extent of ventricular damage late after myocardial infarction
Authors: Huikuri H. V. , Korhonen U. R. , Linnaluoto M. K. , Takkunen J. T.
Published: February 2009

In order to study the quantitative relationship of ventricular arrhythmias to myocardial damage and ischemia, 61 patients with a previous myocardial infarction (at least 6 months previously) were studied by 24‐hour ambulatory ECG monitoring, cardiac catheterization, and thallium‐201 scintigraphy. Thirty‐five patients (57%) had no ectopic beats or only infrequent, unifocal ones and 26 patients (43%) had complex ventricular arrhythmias. Left ventricular function was lower in the latter (p<0.05), but the number of diseased vessels did not differ in the two groups. The reduction of thallium activity in the infarct area was more marked in patients with complex arrhythmias (p<0.001). Multiple thallium defects were not more common in arrhythmia patients, however. These data support the view that complex ventricular arrhythmias are more closely related to the severity of ventricular damage than the presence of myocardial ischemia remote to the area of previous infarction.
Current review of exercise testing: applicatiOn and interpretation
Authors: Fuller T. , Movahed A.
Published: February 2009

Exercise testing has changed dramatically in scope over the past 50 years. While initially used to assess functional capacity, it is now also utilized to detect the presence and severity of coronary artery disease (CAD), to evaluate postmyocardial infarction patients at risk for future cardiac events, to screen certain asymptomatic populations for CAD, and to evaluate dysrhythmias, peripheral vascular disease, and lung disease. Dynamic exercise in continuous multistage protocols is most popularly employed because of the more easily measured workload. The safety of exercise testing, its contraindications and termination end points are summarized. The sensitivity of exercise testing ranges between 60 and 70% while specificity has been reported between 85 and 90%. Both sensitivity and specificity are enhanced through use of radionuclide exercise thallium imaging and ventricular angiography.
Continuing medical education
Authors: Kaplan Samuel , Strong W. B.
Published: February 2009

Drug Therapy in Infants and Children with Cardiovascular Disease By A. Schneeweiss Lea and Febiger, Philadelphia (1986) 398 pages, $45.00 ISBN: 0‐8121‐1001‐3

Causation of Cardiovascular Risk Factors in Children: Prospectives on Cardiovascular Risk in Early Life Edited by Gerald S. Berensen Raven Press, New York (1985) 428 pages, illustrated, $69.50 ISBN: 0‐88167‐138‐X

Pediatric Cardiology, Volume 6 Edited by C. Marcelletti, R. H. Anderson, A. E. Becker, A. Corno, D. di Carlo, E. Mazzera Churchill Livingstone, Inc., New York (1986) 272 pages, illustrated, $75.00 ISBN: 0443‐0319‐24
Clinical experience with urokinase in intracoronary thrombolysis
Authors: Cernigliaro C. , Sansa M. , Campi A. , Bongo A. S. , Rossi P.
Published: February 2009

A prospective nonrandomized study of the thrombolytic efficacy and dose‐response effect of a highmolecular‐weight urokinase, administered into the coronary artery, was conducted in 63 patients with acute myocardial infarction. Urokinase was infused (up to 180 min) at rates of 2000, 4000, 6000, and 10,000 IU/min in four consecutive groups of patients within 184±70 min following onset of chest pain. Of 54 patients with complete occlusion of the infarct‐related vessel, 48 (89%) exhibited complete reperfusion. In 9 patients with incomplete occlusion, the degree of coronary stenosis was reduced with concomitant improvement in antegrade flow. The median effective dosage requirement of urokinase to reperfuse 50% of the treated patients was 180,000 IU. A relationship between the four infusion regimens and successful reperfusion was not found. The time to reperfusion, however, ranging from 42±30 to 60±41 min, appeared to be dose dependent. The reocclusion rate at follow‐up (10–14 days) was 18%. Ejection fraction improved (40±8 vs. 47±8%, p=0.002) in patients with low pretreatment values and in those treated within 2 h of the onset of symptoms. In‐hospital mortality was 9%. Hemorrhage requiring transfusion occurred in 8% of the patients. None of the patients had levels of circulating fibrinogen inferior to 100 mg/dl. We conclude that urokinase can induce timely coronary reperfusion in patients with evolving myocardial infarction, at moderate infusion rates, and with concomitant induction of an only mild systemic lytic state.
Electrophysiological studies in thyrotoxicosis with and without associated sick sinus syndrome
Authors: Talwar K. K. , Gupta V. , Kaul U. , Ahuja M. M. S. , Bhatia M. L.
Published: February 2009

Electrophysiological studies in 13 patients with thyrotoxicosis (5 men and 8 women, aged 17 to 76 years) are reported. Five patients presented with features of sick sinus syndrome (SSS) (Group A) while the remaining 8 patients (Group B) had no detectable cardiovascular abnormality. Sinus node function (corrected sinus node recovery and sinoatrial conduction time) was abnormal in all Group A but normal in Group B patients. Intra‐atrial, atrioventricular (AV) nodal, and infranodal conduction time and effective refractory period of atrium were normal in all patients in both groups. Effective refractory period of AV node was decreased in 6 patients (3 in each group). All Group A patients received radioiodine with complete clinical remission of sick sinus state in 4 subjects. Repeat electrophysiological studies in two of these patients, 6 and 12 months after treatment, showed complete normalization of sinus node function. This is the first reported electrophysiological study documenting the occurrence of SSS in thyrotoxicosis reversed by effective antithyroid treatment. We suggest that attempts should be made to identify underlying thyrotoxicosis in all patients with SSS, especially in the older age group. Appropriate medical treatment may prevent unnecessary implantation of permanent pacemakers in such patients.
Psychological response to an acute coronary event and its effect on subsequent rehabilitation and lifestyle change
Authors: Guiry E. , Conroy R. M. , Hickey N. , Mulcahy R.
Published: February 2009

We assessed anxiety, depression, body image, motivation, and coping ability in 264 patients admitted with a first myocardial infarction. They were followed over 1 year to determine the relationship between psychological factors and subsequent return to work, smoking cessation, weight reduction, and adoption of a leisure exercise program. Females showed a poorer reaction to illness than did males. The better‐educated, and patients in white‐collar occupations showed less depression and expressed greater motivation. Anxiety and poor body image, however, tended to be least common in the intermediate educational and occupational group. All psychological factors predicted leisure exercise change, and all but anxiety predicted smoking cessation. Poor body image was linked with failure to reduce weight. Low expressed motivation was the only factor predicting delayed return to work.
Gap in bundle‐branch conduction elicited by programmed his bundle stimulation
Authors: Littmann L. , Tenczer J.
Published: February 2009

The gap phenomenon in right bundle‐branch conduction was elicited during programmed stimulation of the His bundle. Premature beats with short and long coupling intervals showed undisturbed intraventricular conduction, while the premature beat with intermediate coupling interval blocked within the right bundle branch. The electrophysiologic mechanism of “supernormal” conduction of the earliest beats was conduction delay at a proximal site within the His bundle which allowed recovery of the right bundle branch. This study shows that programmed His bundle stimulation is a valuable method in analyzing conduction characteristics of the distal atrioventricular conduction system in cases where atrioventricular nodal refractoriness would preclude this by atrial stimulation.
Usefulness of anatomic parameters derived from two‐dimensional echocardiography for estimating magnitude of left to right shunt in patients with atrial septal defect
Authors: Chen C. , Kremer P. , Schroeder E. , Rodewald G. , Bleifeld W.
Published: February 2009

The ability of two‐dimensional echocardiography (2DE) to quantitate the atrial septal defect size and left‐to‐right shunt magnitude was examined in 75 adult patients with simple ostium secundum atrial septal defect (ASD) with left‐to‐right shunts of 19–92% of systemic flow as determined by oximetry. The ASD was visualized in 71 of 75 (95%) patients utilizing subcostal 2DE, and the end‐systolic atrial septal defect diameters in subcostal 2DE (ASDe) were measured. The maximal diameters of ASD measured during operation (ASDop) were obtained in 45 of these patients, who then underwent surgical ASD repair. The correlation between ASDe and ASDop was high (r=0.91, p<0.001), indicating accuracy of quantitating defect size via subcostal 2DE approach. However, the correlation between the left‐to‐right shunt magnitude and ASDe was only fair (r=0.76, p<0.01). In large ASDe the shunts varied greatly, while in small ASDe the shunts increased proportionally with increasing sizes of ASD. In addition, the ratio of left‐to‐right ventricular diameter (RVD/LVD) was determined. The RVD/LVD correlated relatively well with the shunt magnitudes (r=0.83, p<0.001). Using the two new echocardiographic parameters of ASDe and RVD/LVD, a high percentage (85%) of patients with a large left‐to‐right shunt requiring surgical closure can be identified. All 43 patients with ASDe >2.0 cm and RVD/LVD >1.1 had a left‐to‐right shunt >40%. In conclusion: (1) ostium secundum atrial septal defect size can be reliably quantitated by subcostal 2DE, and (2) ASDe >2.0 cm and RVD/LVD >1.1 are highly predictive of a left‐to‐right shunt >40%.
Hemodynamic effects of intravenous diltiazem in patients with acute myocardial infarction
Authors: Ogawa H. , Yasue H. , Nakamura N. , Obata K. , Sonoda R.
Published: February 2009

Experimentally, diltiazem has demonstrated favorable effects on acute myocardial infarction in animals. In this study, we administered diltiazem intravenously to 11 patients with acute myocardial infarction within 24 hours from the onset and examined the hemodynamic changes. Dose was 20 minutes of 0.5 mg/min and 20 minutes of 1.0 mg/min (i.e., total 30 mg). Hemodynamic results were decrease in heart rate, blood pressure (systolic, diastolic), mean arterial pressure, double product (p<0.01), and systemic vascular resistance (p<0.05). On the other hand, stroke volume index increased (p<0.01). There were no significant changes in mean pulmonary capillary wedge pressure, cardiac index, and stroke work index. Serum diltiazem concentrations during intravenous administration in our study were near the steady‐state plasma concentrations in which oral multiple‐dose administration of diltiazem 60 mg twice or thrice daily resulted in 2 to 3 days. It is concluded that diltiazem can be administered safely to patients with acute myocardial infarction in acute phase and has two favorable hemodynamic effects on acute myocardial infarction. One is decrease of afterload, as evidenced by the decrease in systemic vascular resistance and in mean arterial presure. Second is the decrease of double product as an index of myocardial oxygen consumption.
Effect of captopril on left ventricular end‐systolic pressure‐volume and stress‐shortening relations in severe cardiac failure
Authors: Lewis B. S. , Halon D. A. , Rodeanu M. E. , Merdler A. , Saggie Y. , Schneider H. , Rosenfeld T. , Hardoff R.
Published: February 2009

The effects of captopril on cardiovascular dynamics and left ventricular (LV) contractility were studied in 11 patients with severe congestive heart failure and very poor global LV function. Pressures were measured using a flow‐guided catheter, cardiac output by thermodilution, and LV contraction and ejection fraction by simultaneous radionuclide angiography. Ventricular loading conditions were altered by sublingual isosorbide dinitrate to facilitate construction of LV pressure‐volume and stress‐shortening curves. Captopril decreased mean arterial pressure (p<0.02) and systemic vascular resistance, while stroke and cardiac index increased in most patients. Left ventricular ejection fraction increased from 18±5 to 22±7% (p<0.05), but contractility, assessed from endsystolic pressure‐volume and end‐systolic pressure‐shortening relations, was unchanged or decreased slightly. Heart rate and double product also tended to decrease. In contrast, arteriovenous oxygen difference widened and calculated total oxygen consumption increased during captopril therapy (p<0.05). The study showed that captopril improved forward blood flow, total oxygen extraction, and LV ejection fraction following the decreased impedance to LV emptying but not at the expense of an increase in ventricular contractility. This makes captopril an attractive drug for patients with end‐stage cardiac failure and a severely damaged myocardium.
Efficacy of nisoldipine combined with beta‐adrenergic‐blocking drugs in the treatment of chronic stable angina
Authors: O'Keefe J. C. , Creamer J. E.
Published: February 2009

A double‐blind, placebo‐controlled study was performed to assess whether a new calcium antagonist, nisoldipine, in doses of either 5 mg or 10 mg daily, in combination with beta‐adrenergic‐blocking drugs (combination therapy) was more effective than beta‐adrenergicblocking drugs alone (single therapy) in the treatment of chronic stable angina. Treatments were assessed at two‐week intervals, using exercise electrocardiography and patients' anginal diaries. A significant improvement in exercise capacity and reduction in anginal attacks occurred only during nisoldipine (10 mg daily) combination therapy compared with single therapy. Mean exercise time increased from 419±146 s (single) to 454±158 s (p<0.02) after combination therapy. Exercise time to onset of 1 mm ST‐segment depression improved from 326±145 s (single) to 331±139 s after combination therapy, although the change was not significant. Mean number of anginal attacks decreased from 21±22 (single to 15±19 (p<0.01) during combination treatment, with an associated significant reduction in glyceryl trinitrate consumption. Adverse effects during combined therapy were minor and tolerable. Thus patients limited by exertional angina despite beta‐adrenergic‐blocking drugs may obtain supplemental relief of angina and myocardial ischemia with the addition of nisoldipine in a dose of 10 mg daily.
Magnesium infusion reduces the incidence of arrhythmias in acute myocardial infarction. A double‐blind placebo‐controlled study
Authors: Rasmussen H. S. , Suenson M. , Mcnair P. , Nørregård P. , Balslev S.
Published: February 2009

In a double‐blind placebo‐controlled study, 130 patients with verified acute myocardial infarction were given magnesium or placebo treatment intravenously immediately upon admission to hospital. The incidence of arrhythmias requiring treatment during the initial week of hospitalization was registered. Serum magnesium concentrations were increased from 0.7 mmol/1 to 1.3 mmol/1 as a result of the magnesium infusions. This pharmacologically induced hypermagnesemia resulted in a reduction in the incidence of arrhythmias from 47 % in the placebo group to 21 % in the magnesium group (p=0.003). In the magnesium‐treated patients, increments in serum concentrations of magnesium and potassium correlated positively (r=0.47, p<0.001). It is concluded that magnesium infusion in the postinfarct period reduces the incidence of supraventricular tachyarrhythmias, and possible pathophysiological mechanisms involved are discussed.
Antiarrhythmic effects of oral indecainide in patients with ventricular tachyarrhythmias
Authors: Macina G. , Turitto G. , Stavens C. , Fontaine J. , Hariman R. , Ursell S. , El‐Sherif N.
Published: February 2009

In order to assess the efficacy and safety of oral indecainide in patients with serious ventricular arrhythmias we studied 11 patients with high‐grade ventricular ectopy and ventricular tachycardia (VT) which were refractory to therapy with at least one standard antiarrhythmic drug. Spontaneous arrhythmias were quantitated by 24‐h Holter monitor before and during therapy with indecainide. Spontaneous VT was sustained in 4 patients and nonsustained in 7. Ten patients underwent baseline electrophysiologic study (EPS) and VT was induced in 9. The mean ejection fraction was 25±14%. Indecainide was given orally at a dose of 211±118 mg/day. The frequency of ventricular premature beats (VPBs) was significantly (>85%) decreased in 90% of patients, while ventricular couplets frequency decreased in 78%. Spontaneous VT was abolished in 5 of 11 (45%). Sustained VT was induced in 5 of 7 (71 %) patients who underwent follow‐up EPS. The QRS duration was significantly prolonged during therapy (0.13±0.04 s) compared to control (0.10±0.02 s). The PR, QTc, and JTc intervals were not significantly changed. Indecainide was well tolerated, but 2 patients died of ventricular tachyarrhythmias while receiving the drug. Indecainide suppressed VPBs in a high percentage of patients, but was much less successful in controlling VT. Caution is necessary when using this drug because of its potential for exacerbation of arrhythmia.
Functional significance of coronary collateral perfusion in preserving myocardial integrity
Authors: Fujita M. , Sasayama S. , Ohno A. , Yamanishi K. , Hirai T.
Published: February 2009

Coronary collateral perfusion to the completely obstructed coronary artery was evaluated by coronary cineangiography in 32 patients. In 13 patients, there was neither history of severe chest pain of longer than 30‐min duration nor electrocardiographic evidence of a transmural myocardial infarction (Group I). Among patients undergoing intracoronary thrombolytic therapy for the completely occluded infarct‐related coronary artery within 6 h after the onset of symptoms of the first acute myocardial infarction, 19 patients had a history of preinfarction angina (Group II). Collateral visualization (collateral index) was found to be significantly greater in Group I (2.5 ± 0.5, SD) than in Group II (0.9 ± 1.0) (p<0.01). Group I patients had a longer history of angina (25 ± 25 months) than did Group II patients (17±18 months) (p=NS). These findings indicate that well‐developed coronary collateral vessels preserve myocardial integrity upon acute coronary occlusion and that a long‐standing angina indicative of myocardial ischemia may play an important role in developing collateral channels.
Cardiac catheterization for patients with postinfarction angina
Authors: Tomlinson G. C. , Kern K. B. , Lancaster L. D. , Gay R. G. , Goldman S.
Published: February 2009

A retrospective review was conducted to determine the incidence of cardiac catheterization for postinfarction angina, the associated coronary anatomy, and the subsequent clinical course. Over one year, 30 of 178 myocardial infarctions were complicated by postinfarction angina resulting in cardiac catheterization. This was 18% of cardiac catheterizations for evaluation of coronary artery disease. Among the 30 patients, 3 had left main disease, 3 had triple‐vessel disease, 11 had double‐vessel disease, 11 had single‐vessel disease, and 2 had no significant disease. Nine patients had proximal left anterior descending disease without left main disease. In contrast to previous autopsy or surgical series, the extent of coronary artery involvement was less severe and followed a distribution similar to that found in uncomplicated myocardial infarctions. Nevertheless, 17 of the 30 patients underwent revascularization with angioplasty or bypass surgery compared with 41 of 137 without postinfarction angina (p=0.01). Clinical characteristics of the patients with postinfarction angina did not predict who would ultimately require revascularization. Cardiac catheterization is necessary for management of patients with postinfarction angina, because a majority of them will require revascularization.