Beneficial effect of dexamethasone on the "no reflow" phenomenon in canine myocardium.

The purpose of the present study was to determine if pretreatment with dexamethasone 6 mg.kg-1 would preserve coronary artery blood flow during reperfusion, thus preventing the no reflow phenomenon. Blood flow to small segments of the left ventricle was measured by the use of 15 micrometer tracer microspheres in intact dog hearts. During 2 hours of occlusion of the anterior descending coronary artery by balloon catheter, dexamethasone produced a small increase of the blood flow to perfused myocardium, when compared with untreated animals; this effect was not seen in underperfused segments of the myocardium. In nontreated animals, reperfusion of the underperfused portion of the left ventricle did not lead to a restoration of flow to normal when measured 1 hour later. In fact, the "no reflow" phenomenon resulted in a post reperfusion left ventricular segment which was similar to that measured during coronary arterial occlusion. However in the dexamethasone treated animals there was a decrease in the extent of left ventricular underperfusion from 19 to 6%. It is concluded that dexamethasone protects the border zone of canine myocardium during occlusion, and prevents the no reflow phenomenon in underperfused regions during reperfusion

Devic's syndrome and systemic lupus erythematosus: a case report with necropsy.

Systemic lupus erythematosus (SLE) rarely occurs coincident with demyelinating disease and, to our knowledge, only one previous case of Devic's syndrome with SLE has been reported.

Thallium-scan myocardial defects and echocardiographic abnormalities in patients with sarcoidosis without clinical cardiac dysfunction. An analysis of 44 patients.

Sarcoidosis of the myocardium, an illness occurring predominantly in young adults, frequently becomes clinically apparent when the disease is far advanced. Since the thallium myocardial perfusion scan (TMPS) is known to be capable of detecting granulomas, it seemed to be promising as a noninvasive means of screening for this complication of sarcoidosis. We, therefore, examined 44 consecutive patients with sarcoidosis, none of whom had clinical evidence of heart disease, utilizing TMPS, echocardiography, electrocardiography, systolic time interval ratios (PEP-LVET) and 24-hour Holter monitoring. TMPS disclosed left ventricular defects in 14 patients (32 per cent) and abnormalities of the right ventricle in an additional four patients. Left ventricular abnormalities on the TMPS were associated with echocardiographic evidence of left ventricular dysfunction (widened mitral E point septal separation) but not with abnormalities on Holter monitoring or electrocardiograms. Systolic time interval ratios were insensitive but highly specific for the presence of abnormalities on the TMPS. We conclude that the TMPS frequently discloses abnormalities in sarcoidosis, which may be a reflection of its sensitivity in this setting.

Multiclinic controlled trial of diltiazem for Prinzmetal's angina.

To assess the efficacy of a new calcium entry blocker, diltiazem (Cardizem), for prophylaxis of Prinzmetal's angina, 48 patients were studied in randomized, multiple crossover multiclinic study (2 weeks single-blind, 8 weeks double-blind). Diltiazem dosage in one crossover phase was 120 mg per day; in the other, 240 mg per day. Therapeutic response was measured by patients' diary records of angina frequency and nitroglycerin tablet consumption. Treatment with 120 mg of diltiazem per day reduced angina by 41 percent from the entry placebo period and 20 percent from the paired placebo period (p less than 0.005). Treatment with 240 mg of diltiazem per day reduced angina frequency by 68 percent from the entry placebo period and 43 percent from the paired placebo period (p less than 0.01). There were similar reductions in nitroglycerin consumption. Adverse experiences that may have been related to the medication were noted in only 5 percent of patients. There were no alterations in blood pressure or heart rate. The PR interval increased 3 percent at the 240 mg dosage level. We conclude that diltiazem is an effective and safe agent for control of symptoms of Prinzmetal's angina.

The pharmacokinetics of diltiazem in healthy American men.

Plasma diltiazem concentration was determined for 24 hours after oral administration of 30, 60, 90 and 120 mg (sustained release tablets) in healthy adult white men. The plasma concentration was too low after the 30 mg dose to calculate pharmacokinetic variables. After administration of 60 mg (n = 12), 90 mg (n = 10), and 120 mg (n = 4), peak plasma concentrations were 72, 117, and 152 ng/cm3 and time to peak concentrations were 3.9, 3.3, and 4.0 hours, respectively. Half-lives for clearance from the plasma were 4.1, 5.1, and 5.6 hours and areas under the concentration-time curve were 514, 984, and 1258 ng/hour per cc, respectively. There was wide variability among patients after the administration of a single dose. The area under the curve also tended to increase more than the multiple of the dose administered. If the plasma diltiazem concentration is quantitatively related to efficacy and toxicity, then these data suggest that dosage requirements may vary considerably from patient to patient. Therefore, if a patient fails to respond sufficiently, the plasma drug concentration should be determined to see if adequate concentration has been attained. Alternatively, if the drug should prove to have a high therapeutic index, one might simply administer more than the usually required dose of diltiazem.

Widened E point septal separation in a normal pediatric population.

To determine the age and gender distribution of the E point septal separation (EPSS), M-mode echocardiograms were obtained from 121 normal subjects aged four months to 82 years. A small but consistent age factor was found. In subjects less than age 20, EPSS was 3.0 +/- 2.6 mm, whereas in those greater than 20 years, EPSS was 1.4 +/- 1.8 (p less than .001). In females EPSS did not vary appreciably at different ages. By contrast, in males EPSS increased with age, peaking between ages 15 and 19 and then decreasing. Between ages 10 and 19, EPSS was significantly wide in males than in females. Thus, EPSS is wide in male adolescents than in adults. The cause for this phenomenon is unclear, but judging from its age and gender distribution, it may be related to the effect of androgens on the myocardium.

The pharmacokinetics and pharmacology of oral diltiazem in normal volunteers.

Oral diltiazem is being used increasingly in the treatment of Prinzmetal's angina. This study investigated the pharmacokinetics, electrocardiographic effects, and blood pressure responses of normal male volunteers to various single oral doses of diltiazem. Doses selected were 30, 60, 90, and 120 mg. Thirteen subjects received 30 mg. 12 subjects received 60 mg, 10 subjects received 90 mg diltiazem, and four subjects received 120 mg diltiazem AUCs for the 60, 90, and 120 mg doses were 565, 984, and 1258 ng/ml . hr, respectively. The values for t1/2, beta, and tmax were similar after each dosing.

The treatment of severe Raynaud's phenomenon with verapamil.

Verapamil was evaluated in 16 patients with severe Raynaud's phenomenon. Fifty per cent of patients experienced subjective improvement by history, but only one patient had a substantial reduction in the frequency of Raynaud's phenomenon as assessed by diary analysis. We conclude that verapamil is not effective in most patients with severe Raynaud's phenomenon.

Clinical experience with amrinone in patients with advanced congestive heart failure.

To examine the efficacy of chronic amrinone therapy, the drug was administered to 12 patients with advanced congestive heart failure on average for 27.9 days. The majority of patients had a persistent increase in cardiac index and a persistent decrease in systemic vascular resistance. A decrease in pulmonary arterial diastolic pressure was observed after oral amrinone administration in three patients. However, changes in pulmonary arterial pressure were not consistent in response to intravenous administration of the drug. Thrombocytopenia occurred in four patients, hypogeusia was noted by three patients, and dysosmia developed in two patients. The cumulative survival of the amrinone patients was significantly poorer than that of a second group of patients with congestive heart failure having similar symptoms. These findings indicate that there is a subset of patients with congestive heart failure who do not benefit from chronic amrinone administration and that in such patients its use (especially when given concomitantly with potentially toxic and hypotensive drugs) should be extremely guarded.

Transient myocardial uptake of Tc-99m methylene diphosphonate in a patient with amyloidosis.

A patient with autopsy-proven myocardial amyloidosis had been observed for 10 years with Tc-99m methylene diphosphonate bone scans. The bone scans manifested transient myocardial uptake. No cause other than the myocardial amyloid could be found to explain the fluctuating scan findings.

Ruptured chordae tendineae. Its association with systemic lupus erythematosus.

A case of systemic lupus erythematosus (SLE) was complicated by ruptured chordae tendineae. The mechanisms responsible for severe cardiac dysfunction in SLE are discussed.

The natural history of unexpected Doppler mitral regurgitation.

It is common for patients to be diagnosed as having valvular regurgitation by Doppler echo when no such murmur has been heard by the referring clinician. To test the hypothesis that such patients have clinically unimportant heart disease, the authors evaluated the records of 213 consecutive men in whom mitral regurgitation had been found by pulsed Doppler. In 95 patients (group I) mitral regurgitation was audible, whereas in the other 118, it was not. In 97 patients with inaudible mitral regurgitation there were no structural mitral valve abnormalities by 2D echo. This group of 97 patients (group II) was defined as having unexpected Doppler mitral regurgitation. In group II patients there was a high prevalence of hypertension (50%), congestive heart failure (44%), alcohol abuse (46%), diabetes (27%), coronary artery disease (63%), and atrial fibrillation (13%). The following variables were distributed similarly in groups I and II: survival time, age, presence of congestive heart failure or coronary artery disease, left ventricular short-axis end diastolic and end systolic dimensions, E point septal separation, and the severity of dyssynergy. Atrial fibrillation was more common in group I (p = 0.017), and group I patients had a higher Quetelet's Index (weight/height squared) (p = 0.03). In group II, the factors most closely related to survival were the presence of dyssynergy, of atrial fibrillation, or of congestive heart failure. Although no group II patient had endocarditis or required mitral valve replacement, their survival was markedly decreased compared with people of similar age in the general population. The majority of cardiogenic deaths in group II patients were due to coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival in patients with heart failure and normal basal systolic wall motion.

To assess the prognostic effect of preserved systolic function in patients with congestive heart failure (CHF), the authors analyzed survival curves in 91 nonselected adult patients with CHF. Patients were assigned to one of two groups on the basis of fractional shortening. The first group consisted of 44 patients with a normal fractional shortening (greater than 0.17), and the second group, of 47 patients with a fractional shortening of 0.17 or less. The two groups were similar in respect to all historical and physical findings. Median survival was eleven months for patients with a decreased fractional shortening and twenty-six months for patients with a normal fractional shortening. Patients with a decreased fractional shortening had a significantly shorter survival (p = 0.01). The authors conclude that congestive heart failure with preserved systolic function is common and is associated with a better prognosis, and the literature suggests it may require nonstandard therapy. Their data also suggest, however, that CHF patients with preserved systolic function cannot be reliably distinguished at the bedside. Rather, echocardiography or other tests of systolic wall motion are needed to make the diagnosis.

Should echocardiography be used to screen dizzy patients?

The value of echocardiography in the evaluation of dizziness was studied in 151 consecutive patients. Twenty-two patients, on further review, were found to have related complaints, seizures and syncope mainly, but not dizziness. Twenty-four patients had vertigo, 67 had nonvertiginous dizziness, and in 38 patients, there was insufficient information to categorize the dizziness as being vertigo or nonvertiginous dizziness. When the 22 nondizzy patients were compared with the 129 dizzy patients, the only statistically significant differences were that there were more blacks in the nondizzy group and that the aortic root dimension was, on average, 0.4 cm larger in the nondizzy group. These findings, although statistically significant, appeared to be clinically insignificant. There was, however, a high prevalence of valvular heart disease in both the nondizzy and two of the three dizzy subgroups. In most cases, the valvular abnormality had not been suspected clinically. But in no case was significant information added by echocardiography that helped in patient management. Thus, in the dizzy patient, echocardiography should be reserved for specific cardiac indications and not used as a routine screening test.

Can the parasternal long axis plane replace the apical four-chamber plane in diagnosing mitral valve prolapse?

Since the mitral anulus is now known to be saddle-shaped, use of the qualitative motion of the mitral valve (MV) leaflets in the apical four-chamber plane to diagnose mitral valve prolapse (MVP) may be unsound, in that superior systolic displacement of the MV leaflets would occur in normal subjects, as well as in patients with MVP. It has therefore been suggested that the parasternal long axis (PLAX) plane should be used to diagnose MVP. To test the feasibility of this approach, the authors examined the predictive accuracy of PLAX prolapse and other isolated echocardiographic abnormalities versus a multivariate decision tree approach. PLAX prolapse, which was significantly associated with marked (greater than 0.7 cm) apical four-chamber prolapse, mitral regurgitation, the presence of a thick mitral valve, and low relative body weight, was 100% specific for MVP but only 44% sensitive. Similarly, marked apical four-chamber prolapse was 100% specific but only 53% sensitive. Apical four-chamber prolapse, if gauged only qualitatively as present or absent, was 94% sensitive but only 50% specific. By contrast, the decision tree classified all 32 initial patients correctly, and in a second, test set, selected 6 additional patients; these 6 patients had many of the clinical features of MVP. These observations suggest that: (1) if prolapse is seen in the PLAX plane, the patient does have MVP; on the other hand, lack of prolapse in this plane does not exclude the diagnosis of MVP and (2) the apical four-chamber plane, used qualitatively, does not reliably distinguish patients with MVP from those without MVP.

Echocardiographic score versus wall motion index for risk stratification after acute myocardial infarction.

Two-dimensional echo cardiographic wall motion scores are potentially valuable prognostic indicators because of their association with subsequent mortality in patients with acute myocardial infarction. Because wall motion scores are relatively simple to obtain, they could come into widespread use. But wall motion scores have been found to have a low positive predictive accuracy in respect to one- or three-year survival and a low specificity in respect to pump failure. To clarify the value of wall motion scores in risk stratification the authors analyzed the ability of a wall motion index, in combination with other variables, to predict death within a year of acute myocardial infarction. Patients were 149 consecutive men with acute myocardial infarction. There were no exclusion criteria. By Cox regression, the variables most closely related to survival were the presence of a pericardial effusion, the age of the patient, alcoholism, and the E point septal separation. The wall motion index, by comparison, was only weakly related to survival and was therefore dropped from further analyses. The four variables most closely related to survival were then used to derive a predictive echocardiographic score. The score's negative predictive accuracy was 94%, although sensitivity and positive predictive accuracy were low. These data suggest that, even when applied nonselectively, the echocardiographic score, but not the wall motion index, appears to be an efficient way of characterizing the outcome of acute myocardial infarction, in that it reliably detects low-risk patients.

Do thallium myocardial perfusion scan abnormalities predict survival in sarcoid patients without cardiac symptoms?

Whereas the total mortality rate for sarcoidosis is 0.2 per 100,000, the prognosis, when the heart is involved, is very much worse. The authors used the difference in mortality rate to infer whether thallium 201 myocardial perfusion scan abnormalities correspond to myocardial sarcoid by making the simplifying assumption that if they do, then patients with abnormal scans will be found to have a death rate similar to patients with sarcoid heart disease. The authors therefore analyzed complete survival data on 52 sarcoid patients without cardiac symptoms an average of eighty-nine months after they had been scanned as part of a protocol. By use of survival analysis (the Cox proportional hazards model), the only variable that was significantly associated with survival was age. The patients' scan pattern, treatment status, gender, and race were not significantly related to survival. The authors conclude that thallium myocardial perfusion scans cannot reliably be used to diagnose sarcoid heart disease in sarcoid patients without cardiac symptoms.

Risk factors in alcoholic cardiomyopathy.

Although a relationship has been suggested between abstinence from alcohol and improvement in left ventricular (LV) function, no long-term studies in large groups of patients have been done to confirm this impression or to demonstrate an effect on survival. To address these questions, the authors analyzed the outcome in 105 male patients with alcoholic cardiomyopathy and 64 control male patients with nonalcoholic dilated cardiomyopathy. Survival data were available for all patients. The correlates of survival were assessed via the Cox proportional hazards model. Variables considered were age, race, drinking pattern (current drinker versus former drinker), presence of coronary artery disease (CAD), hypertension, and diabetes, and these echo variables: left atrial (LA) size, posterior wall thickness, LV end diastolic dimension (LVDD), minimal E point septal separation, wall motion, presence of incomplete mitral leaflet closure (IMLC) or low cardiac output, and the ratio of relative wall thickness to LVDD. The two study groups were comparable with respect to all echocardiographic variables. At a mean follow-up of 17.2 months +/- 12.1 months, 42.85% of the alcoholics and 41% of the nonalcoholics had died. Nonsurvival in the alcoholic group was significantly associated with only two factors: an increased LVDD and the presence of IMLC. The drinking pattern was not significantly associated with survival. By contrast, in the nonalcoholics,the variables most closely related to survival were LVDD, low cardiac output, increasing age, and abnormal wall motion. Therefore: (1) the risk factors in alcoholic and nonalcoholic cardiomyopathy are similar although IMLC appears to be a relatively specific prognostic factor for alcoholic cardiomyopathy and (2) abstinence from alcohol does not appear to improve survival.

Treatment of AIDS-associated heart disease.

Although the diagnosis of AIDS-associated heart disease is becoming routine, its treatment has not been reported except in anecdote. Also, it has been unclear whether the odds of successful treatment are altered because of the presence of cardiac involvement per se. This communication reports the authors' treatment of 18 patients with AIDS-associated heart disease. Their results are combined with the treatment results of all patients reported in the literature to date with AIDS-associated heart disease. Treatment success, defined as eradication of the organism and no relapse, was achieved in their patients with M. tuberculosis (M. tb), cardiac cryptococcosis, and Salmonella typhimurium. M. tb required emergency pericardiectomy (well tolerated in all patients), then administration of rifampin, isoniazid, and ethambutol. Cryptococcosis was treated acutely with amphotericin B and flucytosine, then with maintenance amphotericin B. The response, which included resolution of congestive heart failure, occurred within a week. Salmonella endocarditis was cured with administration of ampicillin and netilmicin for one month. When the patients' data were combined with those of patients from the literature, the authors found that the odds of successful treatment for tuberculous pericarditis were somewhat lower than if the tuberculosis was extracardiac (50% vs 67%). With cryptococcal heart disease, the odds of successful treatment were actually significantly better than when only extracardiac disease was present. The authors conclude that infectious forms of AIDS-associated heart disease are often treatable. Although some cardiac infections are less likely to respond to treatment if there is cardiac involvement, mostly the response to treatment is similar to the response with only extracardiac involvement.

Value of clinical features for distinguishing myxedema ascites from other forms of ascites.

The diagnosis of myxedema ascites is often difficult and delayed, from our experience and the reports of other investigators. To address this situation, previous reports on the diagnosis of ascites were pooled in order to distinguish the features of myxedema ascites from other forms of ascites. These features were confined to variables that would be obtained routinely from patients with ascites requiring paracentesis. The data of 26 patients with myxedema ascites, and 61 patients with ascites from another cause were analyzed. Discriminant analysis was used to select the variables that best separated patients into myxedema and non-myxedema groups. The variables selected were if the ascites was straw-colored or with a protein content less than 2.5 g/dl, if the patient was over age 40, and if there was periorbital edema or hepatomegaly. These variables correctly classified 90.8% of patients. However, considering the roughly 1% prevalence of myxedema ascites among patients with ascites, the predictive value of these variables, in combination, is only 8.7%. With this low rate, these variables should probably not be used to screen for myxedema ascites.