Cardiovascular regulatory functions in elderly patients with hypertension.

To dissociate the effects of an elevated blood pressure on the cardiovascular regulatory functions from those of aging in the hypertensive elderly individual, resting hemodynamic measurements and circulatory autonomic functions in 30 elderly (mean age, 66 years) hypertensive (World Health Organization stages I and II) patients were compared with those in 30 healthy elderly (mean age, 65 years) normotensive volunteers. The elderly hypertensive group showed a significantly lower cardiac index and higher total peripheral resistance. beta-Receptor sensitivity, as determined by chronotropic dose of infused isoproterenol, and baroreceptor reflex sensitivity index, derived from phase II, but not phase IV, of Valsalva's maneuver, were only slightly but significantly reduced in the hypertensive group. The variability of heart rate at rest as an index of parasympathetic control of heart was similar between these two groups. Plasma norepinephrine level was significantly inversely related to resting mean blood pressure (r = -0.31, p less than 0.05) when analyzed as a whole group. Plasma renin activity, but not plasma aldosterone, was significantly decreased in the hypertensive group. To define the effects of age itself, these parameters in normotensive elderly subjects were also compared with those in 12 young normotensive subjects (mean age, 23 years). Although resting hemodynamic measurements did not differ, various circulatory autonomic functions were significantly different between these two age groups. The variability of heart rate in 24-hour ambulatory monitoring, beta-receptor responsiveness, resting vagal cardiac activity, and baroreceptor reflex sensitivity derived from phase IV of Valsalva's maneuver were significantly depressed in the elderly. Resting plasma norepinephrine level was elevated and renin-aldosterone system decreased in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

Ring-calcification of coronary artery aneurysms in an adolescent.

A 17-year-old asymptomatic boy with a history of Kawasaki disease in infancy was found to have an abnormal ring-calcification as seen in the chest roentgenogram and the electrocardiographic evidence of anteroseptal myocardial infarction. Coronary angiogram revealed aneurysms associated with ring-calcifications in the right coronary artery and subtotal obstruction of the left anterior descending coronary artery. A plain chest roentgenogram may, at times, be useful for identifying coronary aneurysms in patients with a possible history of Kawasaki disease.

Effects of long-term treatment with low doses of carteolol on cardiovascular regulatory functions in elderly patients with mild hypertension.

Circulatory autonomic functions and resting and exercise hemodynamics were studied before and six months after daily administration of 5 mg of carteolol in seven elderly patients with mild hypertension. Blood pressure was reduced in all but one patient. In maximal exercise tests, blood pressure and heart rate responses were significantly attenuated after carteolol treatment, without reduction in exercise capacity. Cardiac index at rest was not affected. Cardiac parasympathetic activity, baroreflex function, and plasma catecholamine, renin, aldosterone, atrial natriuretic peptide, and vasopressin levels did not change during treatment. The results suggest that long-term use of low doses of carteolol may reduce blood pressure without affecting circulatory regulatory functions, even in elderly patients with mild hypertension.

[Clinical significance of negative dipyridamole perfusion scintigram].

Six hundred seventy-one patients who had dipyridamole perfusion scintigraphy were classified into two groups; ie, 242 patients without perfusion defect (Group A) and 429 patients with perfusion defect (Group B). Clinical significance of negative scintigram was then assessed and correlated with coronary angiographic findings and prevalence of cardiac events. 1) Significant coronary artery disease (greater than 50% luminar narrowing) was present in 7 of 92 patients (8%) in Group A and in 235 of 285 patients (82%) in Group B. Multi-vessel coronary artery disease was found only in 2 patients (2%) in Group A and in 119 patients (42%) in Group B. 2) During a mean follow-up period of 29 months, 48 cardiac death (8%) and 19 nonfatal cardiac events (3%) occurred in 619 medically treated patients. These cardiac complications were observed in 7 of 242 patients (3%) in Group A and in 60 of 377 patients (16%) in Group B, including 4 (2%) and 44 (12%) cardiac deaths, respectively. In conclusion, it is rare to see severe organic coronary artery disease and future cardiac event in patients with negative dipyridamole perfusion scintigram. It may be, therefore, stated that it is unnecessary to perform coronary angiography in these patients, unless they have symptoms which cannot be controlled medically.

[Determinant of cardiac hypertrophy in elderly hypertension].

In order to define the factors responsible for cardiac hypertrophy in elderly hypertension, blood pressures and non-hemodynamic humoral parameters were correlated with echocardiographic left ventricular mass (LVM) in 30 elderly hypertensive patients and 30 age-matched normotensive subjects with a mean age of 65 years. Arterial blood pressures were obtained either at the clinic, after supine rest, during maximal exercise test, or with a 24 hour ambulatory monitoring device at 10 minute intervals. Interventricular septum and posterior wall thickness, but not end-diastolic diameter, were significantly increased in the hypertensives than in the normotensives. LVM was significantly correlated with all of te blood pressure parameters, having the strongest association with the mean of ambulatory systolic blood pressures (r = 0.65, p less than 0.001). On the other hand, plasma norepinephrine (r = 0.09), plasma renin activity (r = -0.14), and atrial natriuretic factor (r = -0.08), though known to influence cardiac adaptation to hypertrophy in young or middle aged hypertensives, were not correlated wit LVM. These results suggest that the heart in elderly hypertension is characterized by concentric hypertrophy, the only significant determinant of which appears to be a hemodynamic factor. Unlike younger patients, sympathetic nervous and renin-angiotensin systems may not play an important role in the development of cardiac hypertrophy in the elderly.

[Relationship between exercise endurance capacity and cardiovascular risk factors in seventh decade subjects].

Evidence suggests that physical activity is related to lower coronary risk factors in middle-aged subjects, but to date data are lacking for older persons. A total of 32 healthy male subjects in their seventh decade (64 +/- 3 years) were divided into 2 groups based on maximal exercise tests (Bruce protocol). Group I consisted of 14 individuals who showed "excellent" work capacity (exercise duration of greater than or equal to 10 min, 11 +/- 1 min), and Group II 18 individuals with "fair" work capacity (7.5 +/- 1 min). None of them showed ECG evidence of ischemia in these tests. As compared with Group II, Group I showed lower casual and 24 hour ambulatory blood pressure (136 +/- 21 vs 114 +/- 11 mmHg for the average daily systolic pressure respectively), higher apo A-I levels (116 +/- 36 vs 139 +/- 20 mg/dl) and lower apo B/A-I ratios. There was no significant difference in triglycerides, total and HDL cholesterol or apo-B levels between these two groups. Body mass index and smoking habits were similar in Groups I and II. These results suggest that even in older persons, excellent physical fitness is related to lower cardiovascular risk factors.

[Normal and abnormal aging of cardiovascular system].

Studies of normal aging in the cardiovascular system in humans are affected by the study population. Besides intrinsic biological aging, extrinsic factors including overt or latent cardiovascular diseases as well as life style variables such as physical activity, diet, alcohol and smoking may influence the age-related changes of cardiovascular function. We have recruited "normal" elderly subjects from community-dwelling volunteers by extensive health screening procedures including treadmill maximum exercise tests. Some of their cardiovascular functions, such as various cardiovascular regulatory functions, were altered compared to normal young subjects, while others such as resting hemodynamics were not. Interrelationships among various autonomic functions in the elderly were not recognized. Although general effects of life styles on circulatory regulatory functions were not clearly indicated, variables such as sodium intake or body mass index appeared to affect some of the sympathetic nervous functions. Furthermore, hypertension in the elderly had much less impact on cardiovascular functions than is generally expected, based on the results from young or middle-aged subjects. To identify factors which either modify (accelerate) or do not affect the aging of the cardiovascular functions is important not only to achieve a good aging process but also to establish therapeutic goals in elderly subjects.

[Clinical pictures and prognosis of mitral valve prolapse in the middle-aged and old-aged patients].

The age as an important factor influencing the prognosis of mitral valve prolapse (MVP) was assessed by comparing two age groups; 26 cases whose ages were younger than 49 years, and 27 cases more than 50 years. 1. The aged group had higher incidence of dyspnea and enlarged heart most probably due to insidious heart failure. 2. The aged group frequently had an apical pansystolic murmur and enlarged left atrium, indicating the progress of mitral regurgitation. These observations suggest that the careful follow-up observation is mandatory for patients with MVP of advanced age.

[Prognostic significance of large perfusion defects on thallium-201 myocardial scintigraphy in dilated cardiomyopathy].

To evaluate the prognostic significance of perfusion abnormalities, particularly large defects, in dilated cardiomyopathy (DCM), we performed thallium-201 myocardial scintigraphy and 24-hour ambulatory ECG monitoring in 27 patients. The abnormal scintigraphic patterns and the presence of ventricular tachycardia (VT) were correlated with causes of death during a follow-up period of 30.0 +/- 19.4 months. Eight patients had large defects (LD), 11 had multiple small defects (MSD), and eight had no defects (NL). The patients with LD had extensive ventricular akinesis in the region of the perfusion defect, significantly elevated LVEDP (LD 20.6 +/- 7.4 mmHg, MSD 15.5 +/- 7.6 mmHg, NL 10.3 +/- 2.3 mmHg: LD vs NL; p less than 0.01, MSD vs NL; p less than 0.05), and reduced ejection fraction (LD 23.9 +/- 9.1%, MSD 32.7 +/- 7.2%, NL 40.3 +/- 7.7%: LD vs MSD; p less than 0.05, MSD vs NL; p less than 0.01). VT was detected in 11 patients; among whom three had LD, six had MSD, and two had no defects. Among seven patients who died during follow-up (five of heart failure, one sudden death, and one non-cardiac death), five had LD and two had MSD. There were no deaths among patients without defects. Among 11 patients with VT, only one died suddenly. In conclusion, large scintigraphic defects correlated well with severe LV dysfunction, and this is an important variable in predicting outcomes in DCM.

[Accuracy of the Master's exercise test in detecting significant coronary artery disease].

To assess the significance and accuracy of noninvasive tests in detecting significant coronary artery disease (CAD; greater than 50% stenosis), the Master's exercise test, treadmill exercise test and dipyridamole-loading myocardial perfusion scintigraphy were performed and their results were compared with coronary angiographic findings in 60 patients with angina but without myocardial infarction. Among these, 27 patients had significant CAD. The Master's test performed in outpatient clinics had an 85% sensitivity and a 76% specificity in detecting significant CAD, when the degree of ST depression was equal to or exceeded 1 mm. The sensitivity further improved to 96% by adding chest pain to the criteria; then all patients with multivessel disease or critical ischemia were identified by the Master's test. Treadmill tests performed after admission had a 78% sensitivity and a 67% specificity. When the severity of ischemia was judged either by exercise capacity or the degree of ST depression or the coronary T wave, the treadmill test was superior to the Master's test. Although patients without significant CAD had longer exercise capacity and the higher maximum heart rate in the treadmill test than did those in the Master's test, these trends were similar but less marked in patients with significant CAD. Dipyridamole-loading myocardial perfusion scintigraphy showed an excellent sensitivity and specificity; 96% and 94%, respectively, in detecting significant CAD. It was particularly useful in distinguishing false positive exercise results due to left ventricular hypertrophy and coronary spasm and that in women, from true positive results. In conclusion, the Master's test is a simple and useful method for screening CAD in community hospitals and in outpatient clinics.

[Angina with long-standing coronary T waves].

The clinical significance of long-standing (greater than or equal to 24 hours) coronary T waves without abnormal Q waves was evaluated in 24 patients with angina. They were categorized in two groups; 11 with ST elevation followed by coronary T waves (Group A), and 13 with coronary T waves alone (Group B). 1. The patients had long-standing or repetitive episodes of rest angina, with clinical features of unstable angina in all but one. Fifty-five % of patients in Group A and 85% in Group B had histories of effort angina. 2. Significant (greater than or equal to twice the upper normal) elevation of serum CPK value was observed in 36% of patients in Group A and in 46% in Group B. There was no correlation between the maximum CPK value and the number of leads with the coronary T wave. 3. Coronary angiography demonstrated significant (greater than 50%) coronary artery stenosis in 27% of patients in Group A and in 77% in Group B. The incidence of severe stenosis was greater in Group B than in Group A. Angioplasty was performed in 9% of patients in Group A and in 38% in Group B. 4. During the average follow-up period of 27 months, there was one cardiac event (unstable angina) in Group A, two events (one sudden death and one unstable angina) in Group B. Each cardiac event occurred after the patients themselves discontinued their medications. This was not related to the severity of coronary artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Detection and classification of coronary artery disease by dipyridamole perfusion scintigraphy: its prognostic significance].

To detect coronary artery disease (CAD) noninvasively and to predict the occurrence of future cardiac events, 671 patients were evaluated using dipyridamole perfusion scintigraphy. 1. Although chest pain and ST depression were induced by the administration of dipyridamole in 34% and 22% of the patients, respectively, and additional intravenous aminophylline was needed in 19% of the patients, dipyridamole perfusion scintigraphy could be completed in nearly all patients. In contrast, treadmill exercise test was not accomplished in 24% of the patients. 2. The patients were classified in three groups by scintigraphic perfusion defects; i.e., group I (322 patients) with fixed defects, group II (107 patients) with reversible defects, and group III (242 patients) without perfusion defects. The patients in Group I were subclassified three groups according to three high risk parameters (extensive fixed defect, partial redistribution and diffuse slow washout)--group Ia (69 patients) with two or more high risk parameters, group Ib (144 patients) with one high risk parameter and group Ic (109 patients) without high risk parameters. 3. Coronary angiography performed in 377 patients revealed significant CAD (luminal narrowing greater than or equal to 50%) in 96%, 89%, 56%, 90% and 8% of the patients in groups Ia, Ib, Ic, II and III, respectively. Multi-vessel CAD was present in 87%, 32%, 11%, 51% and 2% of the patients in each group, respectively.

[Clinical significance of prominent negative T waves induced by exercise test].

The significance of deep T wave inversion during and after exercise in patients with coronary artery disease has not been studied well. Using the treadmill exercise test (modified Bruce's protocol) and coronary arteriography, we evaluated 361 patients suspected of having coronary artery disease. Results were compared for patients who developed significant T wave inversions of greater than 8 mm (prominent negative T wave: PNT) and for patients who had significant down-sloping ST depressions (DS). Sixteen patients had PNT (4%) which became maximum three to five min after exercise, and ranged in depth from 8 to 15 mm (10.9 +/- 2.4 mm). There were 83 patients with DS (23%). Exercise duration was 3.3 +/- 1.4 min in the PNT group and 4.4 +/- 1.9 min in the DS group (p less than 0.01). Prevalence of three-vessel disease or left main trunk disease was 88% (14 patients) in the PNT group, 28% in the DS group, and 19% (70 patients) in the entire 361 patients. Among the 14 patients who had three-vessel disease or left main trunk disease in the PNT group, the degree of multiple stenoses exceeded 90% in the major coronary arteries and that of the left main trunk stenosis exceeded 75%. The two remaining patients included one with two-vessel disease and severe 99% narrowing of the major coronary arteries and one patient having one-vessel disease with vasospastic angina during exercise. Prevalence of coronary revascularization was 69% in the PNT group and 36% in the DS group (p less than 0.025).(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlation of various types of perfusion defects with supraventricular and ventricular arrhythmias in hypertrophic cardiomyopathy].

To ascertain the relationship between the types of myocardial perfusion defects and supraventricular and ventricular tachyarrhythmias in hypertrophic cardiomyopathy (HCM), 26 patients were studied with dipyridamole-loading thallium-201 scintigraphy and the results were correlated with 24-hour ambulatory ECG, echocardiograms and hemodynamic data. Myocardial perfusion defects were detected in 10 of the 26 patients (38%); three with large defects (LD) and seven with multiple small defects (SD). The patients with defects had greater degree of asymmetric septal hypertrophy (1.82 +/- 0.49 vs 1.27 +/- 0.38, p less than 0.01) and lower cardiac indices (2.35 +/- 0.31 vs 2.70 +/- 0.43, p less than 0.05) than did the patients without defects. Paroxysmal atrial fibrillation (PAf) and/or paroxysmal supraventricular tachycardia (PSVT) were observed in six of the 10 patients with defects (60%) and in four of the 16 patients without defects (25%). Ventricular tachycardia (VT) was identified in six of the 10 patients with defects (60%) but in only three of the 16 patients without defects (19%) (p less than 0.05). Among 10 patients with defects, PAf and/or PSVT were present in six of the seven patients with SD, but not in any of the patients with LD (p less than 0.05). VT was present in five of the seven patients with SD and in one of the three patients with LD. In conclusion, 1) perfusion defects in HCM are associated with greater degree of asymmetric septal hypertrophy, the lower cardiac indices, and higher prevalences of PAf, PSVT and VT; 2) Perfusion defects can be classified in two types; ie., multiple small defects and large defects; 3) Patients with multiple small defects commonly have PAf, PSVT as well as VT. This correlation may be of clinical importance, particularly in evaluating the causes of the defects and mechanisms of these arrhythmias.