Showing papers in "European Heart Journal in 1981"

Non-invasive detection of late potentials in man--a new marker for ventricular tachycardia.

Abstract: Late potentials occurring after the QRS complex were searched for from the body surface using high-gain amplification and signal averaging techniques with filler sellings between 100 and 300 Hz at a sampling rate of 10 kHz. The number of repetitions of the averaging process ranged between 150 and 300 Hz. Sixty-seven patients were studied. In 11 control subjects, no late potentials were delected within the ST segment. Late potentials were observed in 3/27 patients without previously documented ventricular tachycardia all having left ventricular aneurysms. All three patients had evidence of increased ventri-l cular vulnerability (one dying from ventricular tachycardia; one with stimulus-inducible ventricular tachy–cardia; one with multiple episodes of ventricular fibrillation after surgery). In patients with previously k documented ventricular tachycardia and/or fibrillation, late potentials occurred in 7/14 cases (50%), mainly in those with aneurysms (6/8 patients = 7596/ In another 15 patients with ventricular tachycardia and/or fibrillation who were on an effective long-term antiarrhylhmic regimen no late potentials were found. Mean onset of late potentials after the QRS complex was 38 ± 20.1 ms, mean amplitude was 3.9 ± 2.0 uv, and mean duration was 17.1 ± 5.4 ms. We conclude that late potentials which represent late depolarization of a mass of ventricular tissue after slow conduction, herald increased susceptibility to ventricular tachyardia mainly in patients with ventricular aneurysms.

Chronic sinus node disease: natural course and indications for pacing

Abstract: The natural history of sinus node disease has been analysed from reported as well as original data. Because of the widespread use of pacemakers in sinus node disease the perfect study of its true prognosis will probably never be made. Nevertheless, available data strongly indicate that the outlook for identified patients with the disorder who do not have sever symptoms is favorable. Even for the severely symptomatic group, the prognosis seems to be much better than in atrioventricular conduction disease. Pacemaker implantations in this condition should therefore, in general, be restricted to the symptomatic patient in whom the symptoms have been shown to coincide with bradycardia. International differences in the extent of pacing use have been analysed from current statistics. It is concluded that different attitudes to pacing in sinus node disease account for a substantial part of these differences

Controlled trial of a long-acting quinidine for maintenance of sinus rhythm after conversion of sustained atrial fibrillation

Abstract: The prophylactic efficacy of quinidine arabogalactane-sulfate (QAGS), a long-acting derivative of quinidine was compared to no treatment in a randomized controlled trial in patients with DC converted sustained atrial fibrillation. Three months after countershock, 26 out of 103 treated patients and 46 out of 104 untreated patients were no longer in sinus rhythm (P<0.01). Baseline and follow-up characteristics of the two groups were well balanced apart from the use of cardiac glycosides. There were more cardiac glycoside users in the control group but the relapse rate was unrelated to this treatment. Patients of the QAGS group still in sinus rhythm at three months and who were good compliers, were randomly allocated to continue or stop QAGS. In this subset, the failure rate, one year after countershock was still lower in long-term QAGS treated patients.

Electrocardiographic findings and their association with mortality in the Copenhagen City Heart Study.

Abstract: In the Copenhagen City Heart Study 9348 men and 10 314 women, aged 20 or more, were examined. A resting 12 lead electrocardiogram was recorded in each subject. The prevalence of all electrocardiographic signs with the exception of axis deviation, high amplitude R wave, minor T wave abnormality, prolonged and short P(Q)R interval was very low below the age of 40 in men and below the age of 50 in women. Rates for Q-QS abnormalities, left axis deviation, ST depression and T wave abnormalities, premature beats, and atrial fibrillation increased with age, and the prevalence was higher for men than for women. In comparison with other European studies, the prevalence of major and minor electrocardiographic abnormalities of our study is high, similar to those found in Finland. We found a strong association between total mortality and major ST depression and T wave abnormalities in both sexes. A similar strong correlation was observed between mortality and Q-QS and LBBB in men. In conclusion, the electrocardiogram has an extremely limited value in population screening below the age of 50. The well-known correlation between electrocardiographic signs and ischaemic heart disease mortality was confirmed by our data in relation to total mortality.

Electrophysiological effects of propafenone studied with programmed electrical stimulation of the heart in patients with recurrent paroxysmal supraventricular tachycardia

Abstract: Propafenone is an antiarrhythmic which possesses the properties of a class I agent. Its electrophysiological effects were studied with programmed electrical stimulation of the heart in 12 patients suffering from recurrent episodes of reentrant supraventricular tachycardia (atrioventricular nodal tachycardia:five cases; circus movement tachycardia involving an accessory pathway: six cases; atrial flutter and fibrillation with the Wolff-Parkinson- White syndrome: one case). Propafenone was perfused intravenously at a dose of 2 mg/kg over W min. It lengthened the transnodal conduction time, the H V interval, the VA conduction time (over the A V node) and the refractory period of right atrial muscle. The effects of the drug on accessory pathways used in the anterograde direction were measurable in four cases. Complete blockade along the bypass was seen in one instance and prolongation of the effective refractory period in the other three. In the retrograde direction, four patients out of six showed prolongation of the refractory period of the accessory pathway, after drug injection. Perfused intravenously during episodes of tachycardia, the drug interrupted the rhythm disorder in 10 out of 11 cases, but on three occasions, this was achieved by spontaneous ventricular premature beats which were not present prior to initiation of treatment. Tachycardia could still be initiated in six patients after propafenone (five out of six with circus movement tachycardia, one out of five with AV nodal tachycardia). The effects of chronic oral propafenone administration (300 mg t.d.s.) were assessed in five patients; they were similar to those observed after acute intravenous injection. Propafenone is a promising drug for the treatment of A V nodal tachycardia and might be useful for protection against high ventricular rates in patients with the preexcitation syndrome.

Prolongation of the Q-T interval caused by sotalol--possible association with ventricular tachyarrhythmias.

Abstract: The case history of a patient is reported who had two episodes of unconsciousness while on anti-hypertensive therapy consisting of hydrochloroihiazide, hydralazine, and sotalol (480-640 mg as a single daily dose). Ventricular fibrillation which was successfully reverted to sinus rhythm was verified as the cause of the second episode. A ventricular arrhythmia might also have been the cause of the first attack. Marked prolongation of the Q- Tc interval (up to 0'68 s), which returned to normal after discontinuation of sotalol was observed in connection with the episodes. Except for sotalol, no other factors known to cause prolongation of the Q-T interval were found. Later, administration of a single dose of 640 mg of sotalol in the coronary care unit caused a reversible prolongation of the Q-T interval paralleling the course of sotalol concentration in the serum. Atenolol in a dose of 100 mg was associated with a reduction in the response of the pulse to tilting and nitroglycerin administration similar to that observed after sotalol administration, but prolongation of the Q-T interval did not occur after atenolol. Thus, the effect on the Q- T interval was not related to the beta-blocking effect of sotalol. These observations suggest that high therapeutic doses of sotalol can cause a marked prolongation of the Q-T interval which may be associated with ventricular arrhythmias

Reappraisal of the effect of acute betablockade on left ventricular filling dynamics in hypertrophic obstructive cardiomyopathy

Abstract: While propranolol (PR) has been shown to be effective in reducing the outflow tract gradient(OTG)in L hypertrophic obstructive cardiomyopathy, there is debate as to whether it can produce an increase of left ventricular (L V) diastolic distensibility. Biplane L V cine-angiography was carried out simultaneously with LV high-fidelity pressure measurements in nine patients with mild to moderate hypertrophic obstructive cardiomyopathy (peak OTG at rest 0 to 85 mm Hg, mean 22 mm H g) before and 15 min after i.v. PR (0.15 mg/kg body weight). Following PR, heart rate decreased from 85 to 69 beats/min (p<0.005). LV end-diaslolic volume and pressure increased insignificantly from 90 to 93 ml/ml2 and from 21 to 24 mm Hg, respectively. Frame by frame analysis of the LVcine-angiograms at 20 ms intervals was used to construct instantaneous diastolic pressure–volume curves. Although in three patients who had undergone prior myeclomy there was some right- and downward shift of the pressure–volume relationship following betablockade, the pooled data of eight patients whose individual pressure-volume relation fitted reasonably well to a monoexponential curve showed no significant change either in the constant of LV chamberl stiffness or in the pressure intercept after PR. Moreover, L Vfilling dynamics were compared at two points of the LV pressure curve (at the lowest LV pressure = point 1 and prior to the a wave m< point 2). L V inflow in ml/m2 and in per cent of stroke volume index as well as mean filling rate were similar at points 1 and 2 before and after PR. Change in LV shape index (= 4n × area/perimeter1) from end-systole to end-diastole decreased from 0.22 to O.17 (P<0.02) after PR. In conclusion, acute betablockade neither consistently alters LV distensibility as assessed by the pressure-volume relationship nor improves the extent and rate ofL V diastolic filling. In contrast, the diastolic change of geometry following PR is altered in such a way that compared to the control state, pressure independent L Vfilling is impeded rather than facilitated

Estimation of left ventricular volume from apical orthogonal 2-D echocardiograma

Abstract: In 42 consecutive patients undergoing biplane left ventricular cine-angiography, left ventricular volumes were first determined ultrasonically using a phased array transducer. To this end, two orthogonal apical long axis views were recorded one illustrating all four chambers, the other being the ‘RA O equivalent’ view. Left ventricular volumes wer estimated by applying the area-length method to both two-dimensional echocardiograms and cine-angiograms, consistently including in the former the left ventricular outflow tract of the ‘RAO equivalent’ view. The echocardiographic approach employed was shown to yield good predictions of the angiographic results. For the end-diastolic volume the correlation is characterized by r=0.98 and SEE 21 ml or 9.7% of the angiographic mean and for the end-systolic volume by r=0.97 and SEE 17 ml or 18.1% of the mean. The correlation for the ejection fraction showed an r value of 0.87 and a SEE of 5.4%. Equally good correlations were obtained in the subgroup with wall motion disorders for which the r values of the end-diastolic and end-systolic volumes were both 0.98 and that of the ejection fraction was 0.89

Myocardial Thallium201imaging in hypertrophic obstructive cardiomyopathy

Abstract: Thallium 201 Myocardial perfusion imaging was performed at rest and during exercise in 14 patients with hypertrophic obstructive cardiomyopathy without coronary artery disease. The regional myocardial Thallium201-uptake and distribution ratio of these patients were analysed by a semiquantitalive computerized method and compared with those of six normal subjects. Four of the 14 patients had no Thallium201 imaging defect. Out of a total of260 analysed regions of interest in the remaining patients, five regions with reversible and 25 with irreversible Thallium201 defects could be demonstrated. Most of these defects were localized in the interventricular septum. The Thallium201 defects were not related to the age of the patients and there was no relationship between the occurrence of reversible Thallium201 defects and a pathological myocardial lactate extraction rate during maximal atrial pacing. In patients with left ventricular outflow obstruction at rest (n= 10) the percentage of irreversible defect regions in the Thallium201-scintigram (8.5%) was more than twice as high as in those patients with a provocable pressure gradient (3.9%). These data suggest that hypertrophic obstructive cardiomyopathy is often associated with regional ischemia or fibrosis despite normal coronary arteries. Therefore, in these patients, Thallium201 scintigraphy can not be used as a non-invasive screening method to exclude or prove coronary artery disease

Congenital complete heart block in adolescence and adult life. A follow-up study

Abstract: The clinical course in 70 adult patients with isolated congenital complete heart block is described. The mean age at follow-up was 31 years. Twenty-seven patients were diagnosed before one year of age. Seventy per cent of patients below 30 years of age and 29%ents above 30 years were symptom free. One group of 48 patients was prospectively followed for 12 years. During this time nine were paced and two died. No reliable indicators of bad prognosis were found. Aeliologically, congenital complete heart block is probably a mixed group and the difficulty of distinguishing congenital from acquired block is discussed.

Smoking, blood pressure and serum cholesterol as risk factors of acute myocardial infaction and death among men in Eastern Finland

Abstract: The impact of smoking, serum cholesterol and blood pressure on the risk of acute myocardial infarction and death due to all causes and cardiovascular diseases was studied in a random sample of men aged 35 to 59 years from the North Karelia and Kuopio counties of Eastern Finland. This is an area with an exceptionally high incidence of coronary heart disease. Altogether, 4034 men were studied with a participation rate of 92%. These men were followed-up with a myocardial infarction register and death certificate data. During the first five years 256 deaths occurred among all subjects. There were 66 acute myocardial infarctions in the North Karelian men reporting no recent coronary heart disease. Smoking, elevated serum cholesterol and blood pressure were independently and jointly related to an increased risk of acute myocardial infarction and death due to all causes and to cardiovascular disease. Smokers had a 2–3-fold age-adjusted risk of acute myocardial infarction, a 2-2-fold risk of any death and a 2.1-fold risk of cardiovascular death compared with non-smokers. The age-adjusted risk ratios for systolic blood pressure of 160 mm Hg or more were 1.3, 1.4 and 1.9 and those for serum cholesterol at least 8 mmol/l (309 mg/100 ml) 2.6, 1.5 and 2.6 concerning myocardial infarction, all deaths and cardiovascular deaths, respectively. All risk ratios except that of systolic blood pressure for acute myocardial infarction were significant at levels of at least P < 0.05

Volume loading in patients with ischemic right ventricular dysfunction

Abstract: Volume loading tests with dextran 40 were performed on 36 patients undergoing hemodynamic monitoring and diagnosed as acute myocardial infarction with ischemic right ventricular dysfunction. This diagnosis was made when right atrial pressure was higher than JO mm Hg and greater than, equal to or not more than 5 mm Hg less than pulmonary capillary pressure in basal conditions (24 patients), or after dextran administration (12 patients). The patients were divided into two groups according to basal cardiac index: group A: 16 patients with cardiac index 2.2 l/min/m2 and group B: 20 patients with cardiac index <2.2l/min/m2. In group B, the right atrial and pulmonary capillary pressures associated with the higher cardiac index were 15.6 ± 4.2 and 16.8 ± 3.3 mm Hg respectively. Ventricular function curves were plotted comparing variations in right atrial and pulmonary capillary pressures with cardiac index and right and left ventricular net work index. The response to volume loading was variable in both groups. Patient mortality in group B was related to basal left ventricular net work index (P<0.05), to a cardiac .index lower than 2.2l/min/m2 after dextran administration (V < 0.02) and to the following ventricular function curves slopes δA cardiac index/δ, right atrial pressure (P <0.05), A cardiac index/δ, pulmonary capillary pressure (P<0.05) and A left ventricular net work index/δ pulmonary capillary pressure (P<0.05). This indicates that mortality is dependent on global cardiac function and more precisely on left ventricular function. Volume loading is useful to demonstrate the presence of ischemic right ventricular dysfunction, to assess right ventricular function, to find the optimal values of ventricular filling pressure in patients with low output, and to determine the prognosis.

Successful treatment of suicidal verapamil poisoning with calcium gluconate.

Abstract: A 33 year old man ingested approximately 3000 mg of verapamil in attempted suicide. Verapamil and norverapamil concentrations 4.5 h after ingestion were 1250 and 1350 ng/ml. The patient had a heart rate of 79 beats/min, a systolic blood pressure of 60 mm Hg and atrioventricular dissociation. Metaraminol had no significant effect on blood pressure or heart rate. During infusion of 10 ml 10% calcium gluconate, systolic blood pressure rose to 80 mm Hg and both QRS and P waves changed polarity. The clinical condition improved and sinus rhythm was established 5 h later. Calcium can be recommended as the first line of treatment in verapamil intoxication.

The effect of beta2adrenergic blockade on serum potassium and glucose levels during open heart surger

Abstract: Changes in serum potassium and glucose levels during cardiopuimonary bypass were studied in 20 ± patients undergoing coronary artery bypass surgery. Ten had previously been treated with propranolol and 10 with metoprolol using mean daily dosages of 244 and 215 mg respectively. In the propranolol group there was a mean rise in serum potassium of l.13 mmol7/l (P= <0.01) whereas there was no significant. change in the metoprolol group. In both groups there was an initial rise in blood glucose which remained elevated in the propranolol group but fell towards normal in the metoprolol group. Metabolic changes due to beta1 adrenergic blockade are not generally recognized but may have profound clinical significance in some patients.

An early intervention secondary prevention study with oxprenolol following myocardial infarction

Abstract: A randomised double–blind placebo controlled trial was designed to evaluate the efficacy of oxprenolol 40 mg b.d. in the prevention of cardiac events between 2–56 days following uncomplicated acute myocardial infarction. Three hundred and thirteen male and female patients were recruited over three years; the study was terminated when it became evident that a conclusive result could not be obtained within any reasonable extension of the planned trial duration. This was largely due to the better than expected prognosis of selected patients. Our study highlights some of the difficulties in clinical trials in this field

Early exercise test for evaluation of long-term prognosis after uncomplicated myocardial infarction

Abstract: The prognostic value of early load-limited exercise testing has been assessed in 200 men younger than 66 years three weeks after uncomplicated myocardial infarction. Positive criteria of the test were: typical angina, ischemic ST depression λ 0.1 mV, increase in heart rdte of 35 beats/min or more above the resting heart rate, poor systolic blood pressure rise (< 5 mm Hg) and malignant ventricular premature beats. No complications of exercise testing were noted.The prognostic value of the positive test and of the different positive criteria independently predicting cardiac mortality was studied during a follow-up of three months to six years (mean three years and one month). The positive test was predictive of cardiac mortality (P <0.005). Exercise angina (P <0.05), ischemic ST depression (P < 0.005) and excessive increase in heart rate (P < 0.01) were also predictive of mortality, whereas a poor systolic blood pressure rise and malignant premature beats were not. We conclude that patients without complications three weeks after acute myocardial infarction can safely perform load-limited exercise testing and that the prognostic value of this test during the succeeding years is considerable.

Sex differences in the prevalence of ischemic heart disease and in the response to a stress test in a working population.

Abstract: In a study 4422 males and 1663 females aged 18–60 years were examined in order to determine the prevalence of ischemic heart disease and the response to an exercise stress test. The prevalence of ischemic heart disease was 7.3 times as high in males as it was in females. In normotensive, asymptomatic subjects under 45 years of age an abnormal electrocardiographic response to stress testing was 3.8 times higher in females than it was in males (95% confidence limits 2.2–6.3). However, in an older age group, it was more frequent in males. The predictive value of a positive test after a six-year follow-up was 18.0 per 100 in males and 8.6 per 100 in females. These results confirm that the positive response to stress testing has different meanings in males and females.

Left ventricular volumes and ejection fraction by single plane two-dimensional apex echocardiography

Abstract: Left ventricular end-diastolic and end-systolic volumes and ejection fraction were calculated by means of single plane two-dimensional apex echocardiography (echo) in 34 consecutive patients undergoing left ventricular cine-angiography (angio). Adequate echocardiographic studies could be obtained in 30 patients. Of these 10 were normal, 10 had valvular heart disease and 10 coronary artery disease. We consistently used the right anterior oblique equivalent view because of its comparability with the cine-angiographic right anterior oblique projection. Stop frames from the tape-recorded two-dimensional echocardiograms were processed with the same computer programme already in use for cine-angiographic measurements. Good correlations were found between echo and angio for end-diastolic and end-systolic volume index (r=0.84 and r=0.85, respectively) and for ejection fraction (r = 0.91). Thus two-dimensional apex echocardiography using the right anterior oblique equivalent view offers a simple non-invasive means of calculating left ventricular volumes and ejection fraction

The long-term prognosis after myocardial infarction: a five year follow-up study

Abstract: A five year follow-up study was done on about 1200 patients discharged from hospital after an acute myocardial infarction. With different statistical methods the long-term prognosis was estimated. With multivariate analyses it was possible to find variables with high prognostic significance for increased mortality. Variables of importance were age, previous myocardial infarction, left heart failure, maximum heart rate, atrial fibrillation, maximum value of S-GOT and heart volume. A logistic function was used to estimate the risk of dying for every patient and a division into decile classes after an increasing risk was made. The three most predictive variables from the logistic function were used in an isownic model. Highrisk groups consisted of patients with signs of left heart failure with two or more previous myocardial infarction.

Variable threshold of exertional angina: a clue to a vasospastic component.

Abstract: A patient with a history of exertional angina occurring at variable levels of effort underwent three consecutive exercise stress tests to evaluate his coronary reserve. The first test was negative, the second was positive with S-T segment depression, and the third showed S-Tsegment depression at the beginning of each stage with a return to normal at the end of each stage and S-T segment elevation in lead V2 at the maximal level of effort. Coronary arteriography during a stress test revealed incomplete spasm with asymptomatic S-T segment depression at the site of a 75% stenosis and the complete occlusion of the vessel at a higher level of effort associated with symptomatic S-T segment elevation. A similar electrocardio–graphic and angiographic pattern was observed both during ergonovine maleate injection and during a cold pressor test. Changes in coronary vasomotor tone may play an important role in anginal attacks occurring at a variable level of exertion and during cold exposure

Subendocardial myocardial infarction: a follow-up study of 55 cases.

Abstract: Fifty-five consecutive patients without antecedent myocardial necrosis and presenting with an acute episode of subendocardial myocardial infarction were studied and followed–up for an average of 19.1±8 months (range 6–36). Both enzymatic and scintigraphic studies confirmed the small size of the infarcts. The short–term prog–nosis of these patients was good and showed alow in-hospital mortality (2%) and complication rate (15%). In contrast with the initial outcome, the subsequent follow-up was characterized by a high incidence of severe complications (cumulative incidence at two years: death 13% recurrent myocardial infarction 32%; episodes of unstable angina 32%). This is most probably accounted for by the extent and severity of coronary atherosclerosis disclosed in some of these subjects. Indeed, 11 out of the 18 patients who under–went coronary arteriography were found to have triple vessel disease or left main coronary stenosis. Patients showing extensive anterior ST–T changes with lateral or inferior involvement had a particularly poor prognosis (10 out of 11 suffered late complications). These data confirm the need for careful assessment of patients with subendocardial myocardial infarction.

Early assessment of risk in patients with acute myocardial infarction.

Abstract: In 360 patients with acute myocardial infarction, non-invasive clinical parameters were recorded during the first 24 h following admission. Serum enzymes (CK, CK-MB, ASA T and LDH) were serially measured at 4 h intervals during three days. Forty-two patients (12%) died within two weeks of hospitalization. The study population was divided into training (159 patients) and control (201 patients) groups. As individual variables, age, previous history of infarction (PI) or angina, conduction disturbances and left ventricular impairment exerted an unfavourable influence on the short-term prognosis. Serum LDH activity observed at the time of CK peak was a better predictor of risk than ASAT and CK peak levels. No significant difference was demonstrated for CK-MB peak level between survivors and non-survivors. Stepwise logistic discrimination was applied to all parameters (clinical and biochemical) recorded within 24 h after admission in the patients of the training group. Only three variables were retained in the selection procedure namely, LDH at CK peak, age and number of previous infarctions. These variables jointly provide the best prediction of high and low risk patients. The final risk index based on the three selected parameters, i.e. R=000189LDH+0.0978age+1.37PI−11-9,was validated on the patients of the control sample. According to the risk R obtained, all patients were allocated into four classes of increasing risk. Two well-defined groups of patients could be identified readily at the end of the first day following admission: one with high risk of mortality (60% death) and one with good prognosis (37% of the total population, mortality rate <1%), the latter consisting of patients who might benefit from early discharge from the coronary care unit.

The left ventricular end-systolic pressure-volume ratio. Studies during changes in load and inotropism in the human

Abstract: Ascending aortic pressures and left ventricular volumes were measured simultaneously in 65 patients in the basal state and during changes:(1)in load by sodium nitroprusside (n = 21) or by angiotensin (n = 6), (2) in inotropism by post-extra-systolic potentiation (PESP)(n = 18) and increase in heart rate (atrial pacing)(n = 20). Thirty patients had normal hearts (group I), 35 had or had had the symptoms left ventricular failure complicating the course of an idiopathic cardiomyopathy (group II). All were in sinus rhythm. The slope of the end-systolic pressure (ESP)—end-systolic volume (ESV) relationship (ETS) and the ESP/ESV. ratio (EES) were greater in group I than in group II. There was no difference between ETS and EES. EES discriminated the normal patients from those with cardiomyopathy as well as (dp/dt) max, [dp/dt)/Pt] max, EF or VCF. In the two groups, EES was independent of loading changes. This ratio increased after post-extra-systolic potentiation and during atrial pacing. Two findings in patients with ventricular failure were unexplained: (1) in 1/3 of the patients EES did not correspond to the maximum value of the instantaneous pressure-volume ratio: (2)the Vd was higher in group II than in group I and close to 48 ml.

Long-term treatment of congestive heart failure by Captopril: hemodynamic, biological and clinical effects

Abstract: Congestive heart failure is frequently associated with an increase in peripheral resistance induced by stimulation of the renin angiotensin system and of the sympathetic nervous system. The clinical, biological and hemodynamic effects of Captopril (SQ 14225), an oral inhibitor of angiotensin converting enzyme, were measured in 20 patients with heart failure poorly controlled by digitalis,diuretics and vasodilator therapy. After two months of Captopril administration from 150 to 250 mg per day, NYHA functional class improved from 34 to 206 (P<0.01). Heart rate decreased from 84.20 ± 17.46 to 76.26 ± 15.86 beats/min (mean ± standard error of the mean), (P<0.05). Mean arterial pressure was not significantly reduced from 89.25 ± 17.21 to 82.70 ± 10.86 mm Hg. Systemic vascular resistance decreased from 2234 ± 560 to 1680 ± 381 dynes scm−5 (P<0.001), and pulmonary wedge pressure fell from 20.25 ± 7.10 to 14.60 ± 5.96 mm Hg fP<0.001). Cardiac index rose from 1.91 ± 0.41 to 2.37 ± 0.55 l/min/m2 (P<0.001) and stroke work index also increased from 23.62 ± 9.78 to 33.35 ± 14.48 g/syst/m2. Plasma renin activity increased from 2.08 ± 2.99 to 6.73 ± 3.98 ng/mlh (P<0.001), and plasma aldosterone level fell from 21 ± 135 to 10.65 ± 4.16 ng/100 ml(P<0.01). Clinical improvement remained stable in seven patients for more than six months. In all cases theoptimal dose did not need to be altered because of lachyphylaxis. Side effects were rare because of the lowdoses used (mean = 200 mg). The results suggest that Captopril may be useful in the treatment of congestive heart failure.

Coronary arteriography prior to valve replacement.

Abstract: Coronary arteriograms performed prior to valve replacement in 643 patients (mean age 55 ± 8 years; age range 31–77–years) were reviewed in order to assess their value in patients with and without angina. Significant coronary artery disease was more common in the 199 patients with angina (42%) than in the 444 patients without angina (14%), and was more common in those patients who had one or more coronary heart disease risk factors (31%) than in those without (8%). In the patients without angina, the incidence of significant coronary disease was greater in those with at least one risk factor (21%) than in those with no risk factors (4%) and was related to the number of risk factors present. The yield, therefore, of abnormal arteriograms in patients in whom both angina and risk factors are absent is very small, whereas the yield becomes progressively greater in those with angina and in angina-free patients who possess risk factors.