Showing papers in "European Heart Journal in 1992"

Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs.

Abstract: A new artificial aortic valve prosthesis was developed for implantation by the transluminal catheter technique without thoracotomy or extracorporal circulation. The new heart valve was prepared by mounting a porcine aortic valve into an expandable stent. Before implantation, the stent-valve was mounted on a balloon catheter and compressed around the deflated balloon. The stent-valve mounted balloon catheter was then advanced retrogradely to the ascending aorta or the aortic root in anaesthetized pigs. Implantation was performed by balloon inflation which expanded the stent-valve to a diameter exceeding the internal diameter of the vesselemdash thus ensuring a stable fixation against the vessel wall. A total of nine implantations were performed in seven 70 kg closed chest pigs. Sub- and supracoronary implantation was performed in two and three pigs, respectively, while implantation in both positions was done in two. Angiographic and haemodynamic evaluation after implantation revealed no significant stenosis (< 16 mmHg) in any of the nine valves and trivial regurgi-tation in only two. Complications were associated with restriction of the coronary blood flow in three animals. This preliminary study indicates that artificial aortic valves can be implanted in closed chest animals by transluminal catheter technique.

The European ST-T database: standard for evaluating systems for the analysis of ST-T changes in ambulatory electrocardiography.

Abstract: The project for the development of the European ST-T annotated Database originated from a 'Concerted Action' on Ambulatory Monitoring, set up by the European Community in 1985. The goal was to prototype an ECG database for assessing the quality of ambulatory ECG monitoring (AECG) systems. After the 'concerted action', the development of the full database was coordinated by the Institute of Clinical Physiology of the National Research Council (CNR) in Pisa and the Thoraxcenter of Erasmus University in Rotterdam. Thirteen research groups from eight countries provided AECG tapes and annotated beat by beat the selected 2-channel records, each 2 h in duration. ST segment (ST) and T-wave (T) changes were identified and their onset, offset and peak beats annotated in addition to QRSs, beat types, rhythm and signal quality changes. In 1989, the European Society of Cardiology sponsored the remainder of the project. Recently the 90 records were completed and stored on CD-ROM. The records include 372 ST and 423 T changes. In cooperation with the Biomedical Engineering Centre of MIT (developers of the MIT-BIH arrhythmia database), the annotation scheme was revised to be consistent with both MIT-BIH and American Heart Association formats.

Isolated single coronary artery: a review of 50 000 consecutive coronary angiographies

Abstract: Single coronary artery is a rare congenital anomaly of the coronary arteries where only one coronary artery arises from the aortic trunk by a single coronary ostium, supplying the entire heart. A database consisting of the angiographic reports of 50,000 consecutive coronary angiographies performed in adult patients in the University Hospital of Leuven between March 1973 and August 1991 was searched for the diagnosis of single coronary artery. All films concerned were reviewed and classified according to their anatomical type. Thirty-three cases of single coronary artery were retrieved, yielding an incidence of 0.066%. Patient characteristics and clinical data are described, with a discussion on the pathological importance of this finding.

Metoprolol-induced reduction in postinfarction mortality: pooled results from five double-blind randomized trials

Abstract: Several postinfarction trials have evaluated the effect of secondary prophylaxis with different beta-blockers. Although so called meta-analysis of the results from all the trials have shown a beneficial effect of postinfarction beta-blockade, many of the individual studies have shown inconclusive results, mainly due to low statistical power. In order to obtain an evaluation of the merits of postinfarction therapy with metoprolol, data from the five available studies with metoprolol have been pooled into one database. In the total material 5474 patients (4353 men, 1121 women) have been studied during double-blind therapy with metoprolol 100 mg twice daily or matching placebo. The follow-up ranges from 3 months to 3 years. In total 4732 patient years of observation have been obtained. In total there were 223 deaths in the placebo-treated patients as compared to 188 deaths in the metoprolol-treated patients (P = 0.036), which corresponds to mortality rates of 97.0 and 78.3 per 1000 patient years, respectively. The mortality reduction was found both in men and women. As has been reported from individual postinfarction beta-blocker trials, the pooled results showed a marked reduction in sudden deaths (104 in the placebo group, 62 in the metoprolol group, P = 0.002). In a Cox regression model the influence of sex, age and smoking habits on the effect of metoprolol was evaluated. None of these factors influenced the metoprolol effect significantly. It is concluded that metoprolol therapy after acute myocardial infarction reduces the total number of deaths, and especially sudden cardiac deaths. The mortality reduction was independent of gender, age and smoking habits. Available data support a continuous beneficial effect.

Arterial elastic properties in man: a comparison of echo-Doppler indices of aortic stiffness

Abstract: Non-invasive assessment of mechanical properties of the aorta may prove useful in the early detection of atheroma. We have evaluated several of the available echocardiographic indices using ability to detect age-related changes in putatively disease-free vessels as a measure of sensitivity to changes in aortic mechanical properties. Suprasternal imaging was used in 49 healthy non-smoking volunteers to measure minimum and maximum aortic arch diameters. Maximal flow velocities, with corresponding acceleration times and heart periods, were determined in the descending aorta in 24 of these subjects. Blood pressure was recorded non-invasively immediately after the echocardiographic study. Doppler derived measurements of aortic flow acceleration did not relate to age (P greater than 0.05). Three different 2D echo assessments of aortic distensibility, however, all showed a close relationship to age. Ep elastic modulus and Beta index (derived from different stress-strain mechanical relationships) were significantly related to age with r = 0.69 and 0.65 respectively. There were no significant effects of gender or left ventricular systolic function on these relationships. There was a tendency for the relationship between these distensibility indices and age more closely to fit an exponential than a linear relationship. We conclude that 2D echocardiographic assessment of aortic distensibility is able to detect sensitively changes in aortic mechanical properties. Even in the absence of risk factors for cardiovascular disease there is a marked reduction in aortic distensibility with increasing age.

Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis.

Abstract: Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

Incidence of heart failure in eastern Finland: a population-based surveillance study.

Abstract: Heart failure is a frequent disorder, but there is little population-based data available on its incidence. We have studied the incidence of heart failure in 45–74-year-old inhabitants in four rural communities in eastern Finland (total population 37600; 11000 45–74 years of age). The aim was to identify all patients in whom symptoms had started and in whom a diagnosis of heart failure had been established during a 2-year study period. General physicians, working in community health centres in the study area, referred all their patients with suspected heart failure to the study. A register of drug reimbursement, hospital discharge and other health care registers were used to identify patients who had not been referred. The Boston criteria were used to verify the diagnosis. One hundred and thirteen subjects (51 men and 62 women) were enrolled, of whom 51 (38 men and 13 women) had definite heart failure. Age-adjusted incidence rate of heart failure (per 1000. year−1) was 4.0 in men and 1.0 in women, and the incidence rates increased with age in both sexes. Coronary heart disease or hypertension was evident in 41 (80%) cases. The striking difference in the incidence rates between men and women is probably explained by the excessive occurrence of coronary heart disease among men in eastern Finland.

Dobutamine stress echocardiography: its role in the diagnosis of coronary artery disease

Abstract: We have assessed the usefulness of dobutamine infusion for the diagnosis of coronary artery disease by using two-dimensional echocardiography and 12-lead electrocardiogram. Dobutamine was infused at incremental doses (up to a maximum of40 µg kg−1min−1) in 52 patients with chest pain; all the patients underwent coronary angiography; significant coronary artery disease was quantitatively defined as ≥ 50% diameter stenosis. Thirty-six patients were on betablockers. The test was considered positive when new regional wall motion abnormalities appeared during dobutamine infusion. No significant side effects occurred in any patient during the test. Transient wall motion abnormalities were detected in 20 of 37 patients with coronary artery disease (sensitivity = 54%); ischaemic ST segment changes were present on ECG in nine patients (sensitivity = 24%). Dobutamine stress echocardiography was negative in 12 of 15 patients with coronary artery diameter stenosis <50% (specficity=80%). Exercise electrocardiography (ECG) was performed in 35 of these 52 patients. Maximum heart rate and systolic blood pressure were signficantly higher during exercise than during dobutamine stress test (127±23 vs 99 ± 24 beats min−1, P<0.0001; 179±25 vs 152±30 mmHg, P <0.0001). The exercise ECG test was positive in 12 of the 26 patients with significant coronary artery disease (sensitivity = 46%), and dobutamine stress echocardiography in 16 (sensitivity = 62=). Dobutamine stress echocardiography test is a safe and feasible diagnostic test for the noninvasive diagnosis of coronary artery disease and can be performed in patients unable to exercise. It provides similar diagnostic accuracy compared to routine exercise testing, adding information on the location and extent of myocardial ischaemia.

The time sequence of electrical and mechanical activation during spontaneous beating and ectopic stimulation

Abstract: The relation between the sequence of electrical (E) and mechanical (M) activation was studied at the LV anterior wall of open-chest dogs (n = 11). M activation was defined as the onset of epicardial fibre shortening, as measured with a recently developed video technique. E activation was determined with a brush of extracellular electrodes. The delay between activation of basal and apical regions was consistently larger for M activation than for E activation: during spontaneous beating: 20.5 +/- 7.30 ms vs 8.8 +/- 3.31 ms, during right ventricular outflow tract pacing: 50.3 +/- 7.69 ms vs 39.0 +/- 5.31 ms and during left ventricular apex pacing 40.1 +/- 10.03 ms vs 25.4 +/- 9.30 ms, respectively (P less than 0.05 in all cases). The E-M time interval was consistently shorter in early than in late activated regions: 32 +/- 10 vs 41 +/- 8 ms during RV outflow tract pacing (P = 0.09) and 24 +/- 30 vs 40 +/- 24 ms during LV apex pacing (P less than 0.05). Electrical asynchronies larger than 40 ms resulted in decreases of systolic blood pressure and stroke volume. This study shows that the asynchrony of cardiac motion exceeds that of electrical activation because the time interval between electrical activation and onset of fibre shortening is larger the later a particular region is activated. Possible explanations for this phenomenon are discussed.

Long-term prognosis of patients with paroxysmal atrial fibrillation complicating acute myocardial infarction

Abstract: The aim of the study was to assess the relationship between paroxysmal atrial fibrillation during acute myocardial infarction and the long-term prognosis of patients after acute myocardial infarction. The incidence of paroxysmal a trial fibrillation among 5803 consecutive hospitalized patients was 9.9% (557/5803). Incidence rose with increasing age (≤59 years, 4.2%), (60–69 years, 10.5%), (≥ 70 years, 16.0%) and was slightly (but not significantly) higher in women (11.0%) than in men (9.6%). The presence of congestive heart failure and mean age represented two major discriminants between patients with paroxysmal atrial fibrillation (70% and 68.6 years) in comparison with their counterparts (35% and 62.3% years). Hospital mortality was significantly higher (25.5%) in patients with paroxysmal atrial fibrillation than in those without (16.2%). However, the effect of paroxysmal atrial fibrillation disappeared when other factors influencing the short term prognosis (i.e. heart failure) were taken into account by a multivariate logistic regression analysis. The covariate adjusted relative odds of in-hospital mortality then fell to 0.82. The 1- and5-year mortality rates were 18.6% and 43.3% in patients with paroxysmal atrial fibrillation as compared to 82% and 25.4% (P <0.001), respectively, in patients free of paroxysmal atrial fibrillation. Using a proportional hazards analysis of mortality through the first quarter of 1988 (average follow-up time, 5.5 years) the net risk of dying among patients with paroxysmal atrial fibrillation complicating the acute myocardial infarction is estimated at 1.28 (90% confidence interval, 1.12–1.46) relative to counterparts free of the complication. Thus the appearance of paroxysmal atrial fibrillation appears to be unrelated to hospital death but independently related to long-term mortality in patients discharged alive, although the magnitude of the association is relatively small compared to the pre-infarction clinical status and the presence of factors directly representing left ventricular dysfunction.

Inter-study variability in left ventricular mass measurement. Comparison between M-mode echography and MRI.

Abstract: In order to compare variability in M-mode echography and MRI in the assessment of left ventricular mass, 20 echogenic patients without evidence of coronary artery disease were investigated. Two MR and two M-echo examinations were performed within 4 days by different trained operators, each unaware of the other's results. M-mode echo was carried out according to Devereux's method, using the 'Penn-Cube' formula. MR protocol included multislice (8 to 12) true, short-axis spin-echo imaging (10 mm thick with a 1 to 3 mm gap) encompassing the entire left ventricle. Planimetry was manually traced with standardized window settings. Correlations between both echographic and both MR measurements showed r = 0.89, SEE = 22.7 g and r = 0.96, SEE = 11.2 g, respectively. Mean inter-study variability was 11 +/- 6.4% and 6.75 +/- 3.8% (P = 0.0021). The threshold value corresponding to the 95th percentile of the variability data was 21.5% for echography and 13.5% for MR. In conclusion, MR appeared to be a significantly more reproducible examination tool, when compared with M-mode echo, for the evaluation of left ventricular mass (variability, 63% higher with echo than with MR). The main practical consequence of this result lies in the reduced number of patients required to demonstrate a significant change in the LVM with MR as compared with echography.

Arrhythmia profile in acromegaly.

Abstract: In a controlled study, the cardiac involvement and arrhythmia profile of 32 patients with acromegaly were correlated with endocrine parameters (somatomedine C, growth hormone), clinical score and duration of the disease. Data were compared with those of 50 controls free of cardiac disease. Stress ECG, 24 h Holter monitoring and echocardiography were performed. Supraventricular premature complexes occurred no more often in acromegalics than in controls. Both prevalence and severity of ventricular arrhythmia, however, were significantly higher in patients compared to controls (P less than 0.01). 15/32 (48%) acromegalic patients had complex ventricular arrhythmias (Lown III-IV) as compared with 6/50 (12%) normal subjects (P less than 0.01). Repetitive ventricular arrhythmias (Lown IV a/b) occurred in 10/32 (31%) patients, but only in 4/50 (8%) controls (P less than 0.01). Furthermore, the frequency of ventricular premature complexes increased with duration of acromegaly (P less than 0.01). No correlation was found between the severity of ventricular arrhythmia and hormone levels. Left ventricular muscle mass was significantly increased (285 +/- 139 g, P less than 0.02) due to concentric hypertrophy. Severity of ventricular arrhythmias correlated with left ventricular mass and with clinical activity score (P less than 0.01). Thus, compared to controls, acromegalic patients show more frequent and complex ventricular arrhythmias and left ventricular hypertrophy. Duration of the disease rather than hormone levels seems to be relevant for these pathological changes.

Haemodynamic significance of the atrioventricular plane displacement in patients with coronary artery disease

Abstract: Echocardiographic quantitative assessment of the atrioventricular plane displacement (AVPD) in systole towards the apex has been used to estimate global left ventricular (L V) function. The study population consisted of 106 patients with coronary artery disease (CAD) with or without previous myocardial infarction and 40 age-matched healthy subjects. The AVPD was recorded from the apical four-and two-chamber views at four sites corresponding to the septal, lateral, anterior and posterior walls of the left ventricle. A mean displacement (A Vmean) was calculated from the above sites. A Vmean was significantly decreased in patients with CAD compared to healthy subjects (P<0.001). In patients in whom the left ventricular ejection fraction (L VEF) was calculated from cineangiograms a good correlation between A Vmean and LVEF was found (r = 0.89, P < 0.001, SEE= 6.4). Selecting an A Vmean of 10 min or more to define a normal L VEF ( 2.55%) resulted in a sensitivity of 92% and a specificity of 87% in predicting a normal versus abnormal left ventricular systolic function. It is concluded that the ease of recording the A VPD by echocardiography provides a simple and valuable non-invasive method to assess global left ventricular function in patients with CAD.

Sudden death from pulmonary thromboembolism: chronobiological aspects.

Abstract: The aim of this study was to determine whether sudden cardiac death from pulmonary embolism exhibits any chronobiological rhythm Five hundred and seven consecutive subjects dying suddenly outside of hospital and brought into our Emergency Department from January 1983 to December 1989 were studied The time and date of event were accurately recorded All subjects underwent autopsy and 48 of them were found to have died of pulmonary embolism (23 males, mean age 739 +/- 8 years and 25 females, mean age 76 +/- 12 years) All data were analysed by means of single cosinor[19,20] In the subjects with pulmonary emboli both a circadian and a circannual rhythmicity were found, with a significant acrophase respectively in the morning (hmin 1146, P = 0003) and in winter (-193, P = 0009)

Epidural spinal electrical stimulation for severe angina: a study of its effects on symptoms, exercise tolerance and degree of ischaemia.

Abstract: The effectiveness of epidural spinal electrical stimulation has been studied in 14 patients with severe intractable angina unresponsive to standard therapies including bypass grafting. After implantation of the neurostimulator units the patients were assessed by a symptom questionnaire, treadmill exercise testing and right atrial pacing. There was a significant improvement of symptoms and GTN consumption fell markedly. With the neurostimulator on, exercise duration increased from a mean (CI) of 414 (153) to 478 (149) s, and total ST segment depression was less both at maximum exercise (7.1 (4.5) vs 5.6 (4.2) mm) and at 90% of the maximum control heart rate (3.5 (3.7) vs 2.6 (4.3) mm), with similar rate-pressure product at maximum exercise. With right atrial pacing the maximum heart rate reached before onset of angina was increased (143 (14) to 150 (7) b.min-1) and total ST segment depression was less at all heart rates. Benefit has persisted in some patients for over 2 years without any apparent adverse sequelae. Epidural spinal electrical stimulation is, therefore, an alternative therapy for some patients with intractable angina which has not responded to standard therapies.

Native valve infective endocarditis in the general population: a 10-year survey of the clinical picture during the 1980s

Abstract: In a population of 930,000 inhabitants all records of native valve infective endocarditis diagnosed in the decade 1980-89 were reviewed. Using strict case definitions 132 clinically well-defined or post-mortem diagnosed cases were found. Included were cases referred to the local department of cardiology, as well as cases treated in non-specialized departments. Of 132 cases found 23 were only diagnosed post mortem. The male/female ratio was 71/61. The median prehospital duration of symptoms was 20 days (range 0-180 days) and the median in-hospital diagnostic delay was 5 days (range 0-54 days). Known cardiac disease was found in 42% of cases, a possible portal of entry was found in 33%, but in 36% there were no predisposing factors. Remarkably, only two patients had known rheumatic heart disease and none had a known dental focus. During the clinical course 55% experienced cardiac failure and 17% embolic episodes. In 19 patients surgery was required. Of 111 culture-positive cases streptococci were found in 61 and staphylococci in 45 cases. Echocardiography was performed in 95 cases with echocardiographic signs of endocarditis in 65 patients. Overall mortality was 33% with a mortality in clinically diagnosed cases of 18%. Of 14 cases needing immediate surgical intervention, two died.

Acute myocardial infarction (AMI) in Finland—baseline data from the FINMONICA AMI register in 1983–1985

Abstract: The acute myocardial infarction (AMI) register of the FINMONICA study, the Finnish part of the WHO-coordinated multinational MONICA project, operates in the provinces of North Karelia and Kuopio in eastern Finland and in Turku, Loimaa and in communities around Loimaa in southwestern Finland. The AMI register serves as an instrument for the assessment of trends in mortality from coronary heart disease (CHD) and of the incidence andattack rates of AMI among 25–64-year-old residents of the study areas. This report describes the methods used in the FINMONICA A MI register and the findings during the first 3 years of the study, in 1983–1985. The criteria of the multinational WHO MONICA project were used in the classification of fatal events and in the diagnosis of non-fatal definite AMI, but based on the experience within the FINMONICA study, stricter diagnostic criteria than those originally described in the WHO MONICA protocol were used for non-fatal possible AMI. This led to a marked improvement in the comparability of the data from the three study areas with regard to the incidence and attack rates of non-fatal AMI. During the 3-year period the total number of registered events was 6266 among men and 2092 among women. Among men the incidence and attack rates of AMI and mortality from CHD were higher in eastern than in southwestern Finland. Also among women the incidence and attack, rates of AMI were higher in eastern than in southwestern Finland, whereas there was no regional difference in mortality from CHD among women. The mortality findings of the FINMONICA AMI Register were in good agreement with the official CHD mortality statistics of Finland.

Oxygen consumption during corridor walk testing in chronic cardiac failure.

Abstract: We have examined the use of a 6-min corridor walk test in the assessment of functional capacity in 16 patients with chronic cardiac failure. VO2 was determined concurrently by a portable ‘Oxylog’. Three tests were performed sequentially, and although there was a significant increase in distance walked and highest VO2 achieved between the first and second tests, good reproducibility was attained between the second and third tests. Both walk test variables correlated well with previously determined peak achieved VO2, and NY HA classes were separated adequately. Corridor walk testing, with or without measurement of VO2 should be a useful adjunct to maximal exercise testing in interventional studies.

Haematological prognostic indices after myocardial infarction: evidence from the diet and reinfarction trial (DART).

Abstract: Data from the Diet and Reinfarction Trial were examined to check the prognostic effects of plasma fibrinogen, plasma viscosity, white blood cell count, haemoglobin and mean platelet volume in 92 deaths among 1755 men who had recently recovered from acute myocardial infarction. All these variables were significantly associated with all-cause mortality over the following 18 months (haemoglobin negatively, the others positively). Those who gave up smoking following their infarct had a lower mortality than those who continued to smoke (4.1% and 7.9% respectively), and this effect appeared to be mediated by fibrinogen levels. Smoking habit accounted for only part of the prognostic effect of fibrinogen and white blood cell count. Haematological variables have an important prognostic significance after myocardial infarction. Cessation of smoking after myocardial infarction is worthwhile and has a favourable effect on plasma fibrinogen.

Morphometric investigation of human myocardium in arterial hypertension and valvular aortic stenosis

Abstract: Both arterial hypertension and aortic stenosis lead to pressure overload of the left ventricle. As intramyocardial vasculature is confronted with pressure overload in hypertension but not in aortic stenosis, structural differences are to be expected in both forms of left ventricular hypertrophy. With the aid of morphometry, we investigated human myocardium from autopsied hearts from six patients with arterial hypertension and 10 controls, as well as myectomy specimens from cardiac surgery from 14 patients with aortic stenosis. Mean left ventricular myocytic diameter was significantly (P<0·05) increased compared with controls (12·4±1·5 µm) during hypertension (+27%) as well as aortic stenosis (+65%) (P<0·05). This was combined with a greater volume density of perimyocytic fibrosis (controls = 0·8±0·4 Vv%) during hypertension (+250%) and aortic stenosis (+587%) (P<0·05). Walls of intramyocardial arterioles (external diameter 20–40 and 40–80 µm) were thickened to 32% and 44% (P<0·05) during hypertension, but not during aortic stenosis. Compared with controls, perivascular fibrosis of these arterioles was increased by +215% and 61% (P<0·05), respectively, during hypertension, but not during aortic stenosis. Conclusions Myocytic hypertrophy and increased perimyocytic fibrosis accompany intraventricular pressure overload (hypertension and aortic stenosis) in human hearts. Myocardial structure as a result of arterial hypertension, but not aortic stenosis, is also characterized by intramyocardial arteriole wall-thickening and increased perivascular fibrosis. Thus, distinct structural reaction patterns are noted in the cardiac hypertrophy associated with hypertension and aortic stenosis.

Heart involvement in AIDS: A prospective study during various stages of the disease

Abstract: The goal of our study was to evaluate the incidence of heart involvement in AIDS patients during various stages of the disease. Between January 1988 to September 1991, we conducted a prospective study in 114 anti-HIV positive patients. The patients, whose mean age (+/- SD) was 34.6 +/- 5.4 years (range 20 to 54), were divided into three groups: anti-HIV positive asymptomatic (n = 31; 27%), AIDS related complex (ARC) group IV-A (n = 11; 10%), and AIDS subgroups IV-C1 (n = 62; 54%) and IV-D (n = 10; 9%). Overall, 84 patients (74%) were i.v. drug abusers, 24 (21%) were homosexuals, and six (5%) were partners at risk. Zidovudine (AZT) was administered to 94 patients (82%). Opportunistic infections and/or secondary malignancies were detected in 72 patients (63%). Electrocardiographic changes were of little clinical relevance. Of 72 AIDS patients, 47 (65.2%) presented a cardiac involvement: 12 subjects (16.6%) were affected by a dilated cardiomyopathy, 13 (18%) by pericardial effusion, three (4.1%) by mitral valve prolapse, four (5.5%) by myocarditis, five (6.9%) by valvular bacterial endocarditis, and 10 (13.8%) by alterations of left ventricle regional contractility. During a mean follow-up period of 44 months, 29 AIDS patients (40.2%) died. Death was attributed to a cardiac event in four patients; autopsy could be performed in 24 of the 29 patients who died. Our results demonstrate that heart involvement is present in 45.6% of HIV-infected patients, but only in the end-stage of the disease (AIDS) and it is presumably due to opportunistic infections and/or secondary malignancies.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular hypertrophy as a risk factor in arterial hypertension

Abstract: Data on the evolution and prognostic implications of left ventricular hypertrophy (LVH) determined by ECG, chest X-ray and echocardiogram in the Framingham Study are reviewed. Echocardiographic examination provides the most sensitive and specific measure of left ventricular hypertrophy, providing a quantitative evaluation of the anatomical condition. Chest X-ray evaluation is also more sensitive than the ECG, but less specific than the echocardiogram. When ECG-LVH is present, X-ray and echocardiographic LVH are often found; but, when negative, the ECG clearly does not exclude anatomical LVH. The incidence of each variety of LVH increases with age, weight and blood pressure. Although it may also appear following coronary heart disease (CHD), valvular deformity and congenital cardiac defects, the former are the major determinants of LVH in the general population. Each contributes independently to the occurrence of LVH. LVH has emerged as a powerful non-invasive indicator of increased vulnerability to the occurrence of major cardiovascular disease outcomes in hypertension. It appears that X-ray and echocardiographic LVH measure anatomical hypertrophy, whereas the ECG variety is also indicative of ischaemic myocardial involvement when repolarization abnormality is present. Hypertension clearly predisposes to both anatomical and ECG-LVH which cannot be taken as an incidental compensatory feature since at any blood pressure those with ECG-LVH, X-ray or echo LVH are distinctly more prone to cardiovascular sequelae. ECG-LVH carries a greater risk than anatomical (X-ray) LVH. ECG-LVH with repolarization abnormality is more dangerous than that with voltage alone. The latter appears to reflect chiefly the severity and duration of accompanying hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Torsades de Pointes after treatment with terfenadine and ketoconazole.

Abstract: An episode of QT prolongation with symptomatic Torsades de Pointes is described which developed in a 22-year-old healthy female following 5 days therapy with terfenadine and ketoconazole on an ordinary dosage.

Follow-up of a 1-year media campaign on delay times and ambulance use in suspected acute myocardial infarction.

Abstract: In order to reduce the delay times from onset of symptoms to arrival in hospital, and increase the use of ambulance in patients with suspected acute myocardial infarction (AMI), a media campaign was initiated in an urban area. An initial 3-week intense campaign was followed by a maintenance phase of 1 year. Delay times and ambulance use during the campaign were compared with the previous 21 months. Among patients admitted to a coronary care unit (CCU) due to suspected AMI, the median delay time was reduced from 3 h to 2 h 40 min and the mean delay time was reduced from 11 h 33 min to 7 h 42 min (P less than 0.001). Among patients with confirmed AMI the median delay time was reduced from 3 h to 2 h 20 min and the mean delay time from 10 h to 6 h 27 min (P less than 0.001). We conclude that a 1-year media campaign can reduce delay times in suspected AMI, and that this effect appears to continue at 1 year, but ambulance use seems to be more difficult to influence.

Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy.

Abstract: To assess the potential improvement in left ventricular ejection fraction after cardioversion of chronic atrial fibrillation to sinus rhythm in idiopathic dilated cardiomyopathy, we studied prospectively 17 patients, aged 58 +/- 6 years, by radionuclide angiocardiography at rest. Left ventricular ejection fraction was determined before treatment and at a mean delay of 4.7 months after cardioversion. Return to sinus rhythm was obtained in 12 patients, pharmacologically or by electrical cardioversion. Five patients remained in atrial fibrillation. No clinical, echocardiographic or haemodynamic finding could predict the success of cardioversion. In chronic atrial fibrillation, the ejection fraction did not change significantly: 30.0 +/- 9.1% (19 to 44%) at the first evaluation and 29.5 +/- 8.3% (22 to 41%) after 4.7 months. After successful cardioversion, left ventricular ejection fraction improved from 32.1 +/- 5.3% (24 to 41%) to 52.9 +/- 9.7% (37 to 71%) (P less than 0.001). The difference was 20.8 +/- 11.3% and left ventricular ejection fraction was normalized in 50% (6/12) of the patients. There was a significant reduction in the cardiothoracic ratio on chest X-rays and of the left ventricular end-diastolic diameter on echocardiography; fractional shortening increased (27.7 +/- 4.3% vs 20.3 +/- 2.7%, P less than 0.01). A third evaluation was realized after a mean delay of 11.7 months in the patients with successful cardioversion. Sinus rhythm was present in 83% (10/12) of the patients: seven patients were reevaluated by radionuclide angiography. The improvement in left ventricular function observed at the 4.7 months evaluation was still present. In two patients with recurrence of atrial fibrillation, there was a severe deterioration of left ventricular systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular diastolic and systolic function in normotensive obese subjects: influence of degree and duration of obesity

Abstract: The present study was carried out to evaluate systolic and diastolic parameters in overweight and moderately obese, but otherwise healthy subjects, and in a lean control group, to determine whether degree and duration of obesity can influence left ventricular function. A total of 27 subjects, 17 overweight or with moderate obesity and 10 lean, healthy subjects were included. Patients were divided into three groups according to their body mass index (BMI) and to Garrow's criteria as follows: lean control group (BMI less than 25 kg.m-2); overweight subjects (BMI from 25 to 30 kg.m-2); moderately obese subjects (BMI greater than 30 less than 40 kg.m-2). Systolic and diastolic parameters were measured using blood pool gated radionuclide angiography. Left ventricular (LV) ejection fraction (EF), peak ejection rate (PER), time to PER (tPER), peak filling rate (PFR) and time to PFR (tPFR) were evaluated. PER and PFR values were normalized for end-diastolic volume (EDV). EF and PFR were significantly lower (P less than 0.05) both in moderately obese and in overweight subjects and tPFR was significantly (P less than 0.05) prolonged in both groups in comparison to lean controls. Only in moderately obese subjects was PER significantly (P less than 0.05) decreased and tPER significantly (P less than 0.05) prolonged in comparison to lean controls. As compared to overweight individuals, moderately obese subjects were characterized by a significant decrease (P less than 0.05) in LVEF and PER and by a significant increase (P less than 0.05) in tPER, without relevant change in PFR and in tPFR.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacological stress echocardiography in the diagnosis of coronary artery disease and myocardial ischaemia: a comparison between dobutamine and dipyridamole

Abstract: The objective of this study was to relate regional wall motion abnormalities assessed by dobutamine and dipyridamole stress echocardiography to quantitative measurements of coronary artery stenoses in consecutive patients referred for coronary angiography, and to compare haemodynamic effects of and complications related to the two agents. Patients underwent stress echoes on separate days in random sequence and had coronary angiography within 3 days of stress echocardiography. Echocardiograms were assessed by two investigators unaware of the patients' coronary anatomy. Coronary angiograms were also assessed quantitatively using the computer-assisted Cardiovascular Angiography Analysis System. There were 46 consecutive patients referred for coronary angiography; 28 were using beta-antagonists. Main outcome measures were sensitivity and specificity for dobutamine and dipyridamole stress echocardiography for detection of coronary artery disease (wall motion abnormalities at rest or stress) and myocardial ischaemia (stress induced new wall motion abnormalities). Sensitivity for the detection of myocardial ischaemia was found to be 57% for dobutamine and 64% for dipyridamole. Specificities were 78% and 89% respectively. Sensitivities for detection of coronary artery disease (lesion > or = 50% diameter stenosis) was 79% for dobutamine and 82% for dipyridamole; specificities were 78% and 89% respectively. These differences between the two agents are not significant. There were no severe side effects with either agent. Mean heart rate rose significantly with both tests but was higher with dobutamine; mean systolic blood pressure rose with dobutamine and fell with dipyridamole. It was concluded that dobutamine and dipyridamole stress echocardiography have similar sensitivities and specificities for detection of myocardial ischaemia and coronary artery disease although the haemodynamic effects of the two agents are different. Both are free from serious complications.

Morning peak in the incidence of myocardial-infarction - experience in the isis-2 trial

Abstract: To investigate the circadian pattern of acute myocardial infarction (MI) in a large international patient population, the time of day of the onset of symptoms was prospectively determined in 12,163 consecutive patients randomized in the ISIS-2 Trial (Second International Study of Infarct Survival). Overall, there was a marked circadian variation (P less than 0.001) in the incidence of MI characterized by a sharp increase from 0600 h to 0800 h, with a peak period from 0800 h to 1100 h followed by a gradual decline from 1100 h to 1800 h. During the evening and night there was a steady trough, with no evidence of a second peak. Although there was some scatter, this circadian pattern was similar among patients of five different geographic regions on three continents and in various subcategories of patients defined with respect to age, gender, previous MI, and aspirin intake prior to MI. The circadian pattern of diabetics, however, was different compared with non-diabetics (P less than 0.005, adjusted less than 0.01), and it demonstrated no significant variation. This increased morning incidence of MI indicates specific triggering mechanisms that are particularly likely to occur during, or just before, that time of day. Further investigation of physiological changes during the day is needed to identify any such triggers of MI and so perhaps to aid in improving preventive strategies of the disease.

Height: a risk marker for ischaemic heart disease: prospective results from the Caerphilly and Speedwell Heart Disease Studies.

Abstract: The predictive power of height for future ischaemic heart disease (IHD) was examined in 4860 men from two communities in South Wales and the West of England. At follow-up, men in the shortest fifth of the height distribution had experienced twice as many incident IHD events (fatal and non-fatal myocardial infarction) as was the case for men from the tallest fifth. Adjustment for age, social class and smoking habit failed to alter these relationships significantly. In the data from South Wales, determinants of height were examined; birth rank and number of siblings showed a trend with height. This trend was found only in men whose fathers were manual workers and may be related to inadequate nutrition in the higher birth ranks and larger families. These results support the suggestion that early childhood factors may be relevant to IHD in middle age and possible mechanisms are discussed.

Superiority of L-propionylcarnitine vs L-carnitine in improving walking capacity in patients with peripheral vascular disease: an acute, intravenous, double-blind, cross-over study.

Abstract: The effects of L-propionylcarnitine on walking capacity were assessed in a group of patients with peripheral vascular disease. In 12 patients, 300 mg of L-propionylcarnitine, given intravenously as a single bolus did not affect walking capacity, while 600 mg increased both initial claudication distance from the placebo value of 179 +/- 114 to 245 +/- 129 m (P less than 0.05), and maximal walking distance from 245 +/- 124 to 349 +/- 155 m (P less than 0.05). Once the efficacious dose of L-propionylcarnitine was assessed, its effect was compared to that of an equimolar dose of L-carnitine (500 mg i.v.) according to a double-blind, double-dummy, cross-over design. In 14 patients, both treatments improved walking capacity; however, the analysis of variance showed that the increase in maximal walking distance with L-propionylcarnitine was greater than that with L-carnitine (P less than 0.05). Finally, in seven additional patients, the effects of L-propionylcarnitine and L-carnitine on the haemodynamics of the affected limb were assessed by an ultrasonic duplex system. Results indicated that both drugs did not affect the blood velocity and the blood flow rate in the ischaemic leg, thus suggesting that the beneficial effect on walking capacity was dependent on a metabolic effect. In conclusion, L-propionylcarnitine improves walking capacity in patients with peripheral vascular disease, probably acting through a metabolic mechanism. On a molar basis, this beneficial effect is greater than that observed with L-carnitine and, thus, the findings of the present study may have clinical relevance in terms of treatment cost and patient compliance.