Showing papers by "John G.F. Cleland published in 1988"

The effects of frusemide and angiotensin-converting enzyme inhibitors and their combination on cardiac and renal haemodynamics in heart failure.

Abstract: Few studies exist on the interaction of diuretics and angiotensin-converting enzyme inhibitors in patients with chronic heart failure. Twelve subjects with heart failure were studied before and after their usual oral dose of frusemide in random order on consecutive days during fixed sodium, potassium and water intake. Patients then received 10 mg day-1 of enalapril for 5 days and subsequently restudied before and after their usual dose of frusemide. Frusemide was not observed to have an effect on systemic or renal haemodynamics prior to enalapril, but urine volume and sodium content rose as expected. Treatment with enalapril, in the absence of frusemide, was associated with a fall in mean blood pressure from 89 +/- 5 mmHg to 85 +/- 4 mmHg (P less than 0.02) and a rise in renal blood flow from 424 +/- 202 ml min-1 to 494 +/- 225 ml min-1 (P less than 0.02), but cardiac output and glomerular filtration rate were again unchanged. Addition of frusemide to enalapril therapy resulted in a greater fall in mean blood pressure (87 +/- 5 mmHg to 79 +/- 4 mmHg; P less than 0.01) and an increase in cardiac output (3.1 +/- 1.1 l min-1 to 3.6 +/- 1.0 l min-1; P less than 0.02). Renal blood flow increased further than after enalapril alone to 579 +/- 211 ml min-1, but the glomerular filtration rate fell to 63 +/- 26 ml min-1 (P less than 0.01) and the filtration fraction fell to 19 +/- 5% (P less than 0.001). Weight gain occurred and the diuretic response to frusemide was reduced during this early phase of enalapril therapy.

Arrhythmias, catecholamines and electrolytes.

Abstract: The prognosis in patients with heart failure secondary to left ventricular dysfunction is poor. Although survival can be related to the extent of cardiac functional impairment, many patients die suddenly rather than in refractory heart failure. Ambulatory electrocardiography has revealed a high prevalance of simple and complex ventricular arrhythmias in these patients, which was the most important predictor of subsequent mortality in our patients. Factors predisposing to arrhythmias are many, but increased catecholamines and electrolyte abnormalities are among the more obvious. In patients who have undergone treatment for congestive heart failure, serum and total body potassium are reduced, and this is closely and inversely related to the state of activation of the renin-angiotensin system. Renin and noradrenalin are also closely and directly correlated, while both are inversely related to the arterial pressure. Treatment with angiotensin-converting enzyme inhibitors tends to reverse these neuroendocrine and electrolyte abnormalities and reduces the frequency of ventricular arrhythmias. Whether this will have a favorable impact on mortality, and, in particular, on sudden death, remains to be seen.

Cyclical Cushing's syndrome presenting as short stature in a boy with recurrent atrial myxomas and freckled skin pigmentation.

Abstract: SUMMARY A young male patient demonstrated unusual features of Cushing's syndrome, atrial myxomas and freckled skin pigmentation. At 4.5 years of age he presented with intermittent swelling of his face and abdomen associated with weight gain and mild hypertension. A left atrial myxoma, suspected from routine physical examination, was surgically removed at 6.1 years of age. The initial mild symptoms clinically thought to be due to Cushing's syndrome, persisted intermittently without any consistent biochemical abnormality. At 10 years of age height velocity decreased and at 12 years early osteoporosis was observed radiologically. Repeated dexamethasone tests revealed a paradoxical increase in cortisol and corticotrophin from normal basal levels. Further investigation showed a cyclical pattern of hypercortisolism. The removal of a pituitary microadenoma failed to correct the features of Cushing's syndrome or prevent intermittent hypercortisolism. At 15.3 years a second left atrial myxoma was removed. This was followed by bilateral adrenalectomy. Histologically the features were consistent with primary pigmented nodular adrenocortical disease. This is the first patient described with cyclical Cushing's syndrome as part of this unusual complex of disorders.

Total Body Electrolyte Composition in Patients with Heart Failure: A Comparison with Normal Subjects and Patients with Untreated Hypertension

Abstract: Total body elemental composition was measured in 40 patients with well documented heart failure who were oedema-free on digoxin and diuretics. The results were compared with values for 20 patients with untreated essential hypertension matched for height, weight, age, and sex. Total body potassium alone was also measured in 20 normal subjects also matched for anthropomorphic measurements. Patients with hypertension had a very similar total body potassium content to that of normal subjects, but patients with heart failure had significantly reduced total body potassium. This could not be explained by muscle wasting because total body nitrogen, largely present in muscle tissue, was well maintained. When total body potassium was expressed as a ratio of potassium to nitrogen mass a consistent depletion of potassium was revealed in the group with heart failure. Potassium depletion was poorly related to diuretic dose, severity of heart failure, age, or renal function. Activation of the renin-angiotensin-aldosterone system was, however, related to hypokalaemia and potassium depletion. Such patients also had significantly lower concentrations of serum sodium and blood pressure. Serum potassium was related directly to total body potassium. Despite the absence of clinically apparent oedema total body chlorine was not consistently increased in heart failure, but the calculated extracellular fluid volume remained expanded in the heart failure group. Total body sodium was significantly increased in patients with heart failure, but less than half of this increase could be accounted for by extracellular fluid volume expansion. Potassium depletion in heart failure may account in part for the high frequency of arrhythmias and sudden death in this condition.

Plasmacytosis and renal failure after readministration of streptokinase for threatened myocardial reinfarction.

Abstract: of the membranes, and if these women are removed the statistical differences also disappear. Many obstetricians would not consider premature rupture of the membranes as a medical indication for induction as it does not pose such a threat to pregnancy as maternal hypertension or an abnormal antenatal trace of fetal heart rate. We realise, however, that others wish to see statistical significance as well as clinical significance, so we have reanalysed our data to include these seven women in the conservative group. This does not change the significance value given above as only one of the seven women had a caesarean section for fetal distress, detected as an abnormal cardiotocograph and a low scalp pH in the first stage of labour. The remaining women had spontaneous vaginal deliveries. The supplementary analysis shows more clearly that routine induction of labour at 42 completed weeks of gestation significantly increased both the need for caesarean section for fetal distress (6% v 2%; 95% confidence interval 0% to 9%) and the overall need for operative delivery for fetal distress (14% v 7%; 95% confidence interval 0% to 14%) with no effect on short term measures of neonatal outcome.

Arrhythmias in heart failure--the role of amiodarone.

Abstract: An in-hospital diagnosis of heart failure due to left ventricular dysfunction carries a very poor prognosis, which has been reported to be as high as 50% per annum. In many cases death has been sudden and unexpected and not strictly related to a refractory heart failure. In association with this, it has become more widely appreciated that ventricular tachyarrhythmias, often asymptomatic, are frequent in patients with left ventricular dysfunction, and in some studies, the frequency of ventricular arrhythmias has been the most powerful predictor of mortality. Several other variables have been reported as being predictors of a poor prognosis, including electrolyte abnormalities, poor left ventricular function, high plasma norepinephrine, and low blood pressure. In a prospective follow-up series of 152 patients with heart failure secondary to left ventricular dysfunction, we found that ventricular arrhythmias were the strongest predictor of subsequent mortality, while treatment with amiodarone was associated with longer survival. High plasma renin and norepinephrine concentrations were also associated with a poor prognosis and both were directly correlated with the frequency of ventricular arrhythmias. In previous double-blind studies we have demonstrated a reduction in ventricular arrhythmias with both captopril and enalapril, and this has been associated with a reduction in plasma norepinephrine and an increase in serum and total body potassium. Nonetheless, arrhythmias in these patients were by no means abolished despite correction of these neuroendocrine and electrolyte abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)