Results of percutaneous transluminal coronary angioplasty for unstable angina pectoris in patients 70 years of age and older.

Between November 1980 and November 1985, 54 patients ages greater than or equal to 70 years underwent percutaneous transluminal coronary angioplasty for unstable angina, defined as recent-onset (less than 1 month) angina, new onset of rest angina (greater than or equal to 2 episodes) or accelerating class III or IV angina. In these 20 men and 34 women, disease was 1-vessel in 34 (63%) and multivessel in 20 (37%). The mean (+/- standard deviation) ejection fraction was 0.62 +/- 0.12. Angioplasty was successful in 43 patients (80%). In the 11 unsuccessful cases, emergency coronary artery bypass grafting for acute occlusion was performed in 3 and elective coronary artery bypass surgery in 8. There were no deaths. Two patients (4%) sustained Q-wave myocardial infarctions. The mean duration of follow-up for the total group was 37 months (6 to 73 months). Of the 43 patients with successful dilation, 4 died, 1 had an non-Q-wave myocardial infarction and 8 had symptomatic restenosis (4 underwent successful repeat angioplasty, 1 had repeat percutaneous transluminal coronary angioplasty and then bypass surgery, 1 had repeat bypass surgery alone and 2 had medical therapy). At last follow-up, 3 patients had stable class III or IV angina and 31 patients (72%) were angina-free.

Results of percutaneous transluminal coronary angioplasty for angina pectoris early after acute myocardial infarction.

Between May 1980 and July 1985, 70 patients underwent percutaneous transluminal coronary angioplasty (PTCA) for angina occurring 24 hours after and within 30 days of acute myocardial infarction (32 with Q-wave infarction and 38 with non-Q-wave infarction). One-vessel disease was present in 42 (60%) and multivessel in 28 (40%); the mean ejection fraction was 0.56 (greater than or equal to 0.50 in 77% of patients). PTCA was successful in 56 patients (80%) and after introduction of steerable dilating systems in February 1983 this rate became 86%. The success rate for complete occlusions was 76%. The interval from myocardial infarction to PTCA was similar in patients with successful dilation (12.7 +/- 8.1 days) and those without (13.4 +/- 8.0 days). PTCA failed in 14 patients (20%); 8 underwent emergency coronary artery bypass for acute occlusion and 4 of 6 patients whose lesions could not be crossed had elective bypass surgery. There was 1 operative death. No patient sustained a Q-wave infarction. Three patients had non-Q-wave infarctions after technically successful PTCAs. Mean follow-up was 27 months (6 to 67 months). Of the 56 patients successfully dilated, 14 (25%) had 15 cardiac events during follow-up: death (1), non-Q-wave infarction (2), repeat PTCA (7), coronary bypass (4) and recurrence of severe angina (1). The cumulative mortality was 3% and the reinfarction rate was 7% (no Q-wave reinfarctions). Forty-two (60%) of the 70 patients were free of complicating events acutely and during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Cryptococcal meningitis. A review of 32 years experience.

This study is a review of cryptococcal meningitis in Queensland, Australia, with particular reference to changes in incidence, methods of diagnosis and treatment and their effects on mortality and morbidity over the past three decades. Cryptococcal meningitis remains more prevalent among males, and aborigines. Mortality has declined dramatically since 1948, due to the use of the specific antifungal agents amphotericin B, flucytosine, and more recently miconazole. The availability of cranial computerized axial tomography and the early treatment of hydrocephalus have significantly contributed to the overall management of these patients. 75% of patients receiving a full course of treatment can now be expected to make a satisfactory recovery.

Intracoronary echo-contrast agents: abnormalities in myocardial function in a normal and reduced coronary perfusion model in dogs.

Two-dimensional echocardiography using echo-contrast enhancing agents is a promising technique for evaluating myocardial perfusion. However, the potential deleterious effects of injection of echo-enhancing agents into the coronary circulation have not been well evaluated. We utilized two experimental canine models in which the left anterior descending coronary artery was cannulated and perfused continuously by the left common carotid at normal and reduced coronary flows. Analysis of myocardial function included regional left ventricular systolic function by ultrasonic crystals, subendocardial ST segment shifts, left ventricular dP/dr analysis and measurements of coronary blood flow. One ml of each echo-contrast agent was injected into the left anterior descending coronary artery during normal coronary flow. Echo-enhancing agents included: sonicated 70% sorbitol, 50% dextrose, and 6% dextran, hand-agitated Renografin-saline, and unagitated 0.15% hydrogen peroxide, 20% fat emulsion and oxygenated Oxypherol, a perfluorocarbon compound. Two-dimensional echocardiography determined that all echo-enhancing agents except for 20% fat emulsion and Oxypherol produced good myocardial enhancement. All echo-enhancing agents which produced a good contrast effect did so at the expense of significant reversible contractile abnormalities. Each produced more than a 50% reduction in percent segment shortening. Sorbitol and hydrogen peroxide produced the most severe contractile disturbances. In the normal flow model, sorbitol produced systolic bulging and hydrogen peroxide an 83% reduction in percent segment shortening. Hydrogen peroxide induced systolic bulging in the reduced coronary flow model. Other abnormalities induced by echo-enhancing agents included ST segment shifts and malignant ventricular arrhythmias. Six percent dextran produced a good contrast effect with the least harmful myocardial consequences.

Airline pilot disability: the continued experience of a major US airline.

This study details our continued experience with preemployment screening and medical disability in a large group of pilots from one airline from 1975 through 1982. During this period, 368 pilot applicants underwent preemployment screening and 73 of these were rejected for employment because of medical reasons. The majority (45) of these were unsuitable for psychological reasons. Medical disability accounted for approximately 20% of the pilots separated from the company during the period of study. Age-specific disability rates increased rapidly after age 45 years, with cardiovascular disease responsible for more than 50% of these medical losses. Disability rates of older pilots have decreased considerably compared with previous rates: the age-adjusted rate for pilots age 45 years or older has decreased from 27.50/1,000 person-years to 8.97/1,000 person-years (p less than 0.0001). The reasons for this reduction remain unclear, but changes in the interpretation of the Federal Aviation Administration regulations and changes in company policies may have contributed. The role of preventive medicine in the form of regular medical surveillance is uncertain, with no direct evidence of a beneficial effect.

Airline pilot medical disability: a comparison between three airlines with different approaches to medical monitoring.

To study the impact of airline medical departments on pilot disability, three major U.S. airlines, nominally airlines A, B, and C, were chosen because they had distinctly different medical programs. Airline A provided essentially no medical review. Airline B performed preemployment screening and assessment of individual disability claims, along with an irregular pilot review. Airline C provided basically the same services as airline B but also screened pilots annually. The total cohort comprised 12,866 pilots providing 79,797 person-years of experience. Between 1 January 1975 and 31 December 1982, medical losses in all three airlines increased rapidly after pilots reached the age of 45 years, with cardiovascular disease responsible for approximately 50% of the losses. For pilots 45 years old or older, the age-specific disability rates in airline A were significantly higher than those in airlines B and C; rates for airlines B and C were not significantly different. The data suggest that airlines with active medical departments have lower pilot medical disability rates than do airlines without such departments. Data also suggest that preemployment screening and assessment of individual disability claims are more important determinants of long-term disability rates than are regular (annual) pilot health reviews.

Evaluation of myocardial perfusion and coronary vascular resistance following withdrawal of chronic nitroglycerin treatment in rabbits.

This investigation was performed to determine whether the abrupt withdrawal of chronically administered nitroglycerin (NTG) alters coronary vascular resistance and myocardial perfusion in an experimental rabbit model. New Zealand white rabbits received 2 inches of topical NTG (2%) applied 3 times daily over a 6 week period. Forty hours after abrupt withdrawal of NTG left ventricular blood flow was assessed by the radioactive microsphere technique. Coronary resistance was significantly increased in NTG-withdrawal rabbits at the baseline (21.5 +/- 3.1) compared to controls (13.5 +/- 1.2) and remained elevated after ergonovine administration at both the early (NTG-withdrawal: 20.9 +/- 3.5 vs controls 12.6 +/- 1.5) and late (NTG-withdrawal: 17.1 +/- 3.1 vs controls: 11.6 +/- 0.9) sampling periods. Neither ergonovine nor indomethacin significantly altered blood flow compared to earlier values. However, the NTG-withdrawal rabbits exhibited significantly lower blood flow to the left ventricle compared to controls after ergonovine administration at both early (NTG-withdrawal: 4.80 +/- 0.72 ml/min/gram vs controls: 6.98 +/- 0.79 ml/min/gram) and late (NTG-withdrawal: 5.30 +/- 0.80 ml/min/gram vs controls: 7/52 +/- 0.66 ml/min/gram) sampling periods and also following indomethacin administration (NTG-withdrawal: 4.24 +/- 0.46 ml/min/gram vs controls: 7.52 +/- 1.26 ml/min/gram). Electrocardiographic evidence of myocardial ischemia was noted in the NTG-withdrawal rabbits following intracardiac injection of microspheres. These studies show that increased sensitivity of NTG-withdrawal rabbits to ergonovine or microsphere injection is associated with increased coronary vascular resistance. However, severe myocardial ischemia was not observed.

Effect of disopyramide on left ventricular performance: the relationship of free and total concentrations of the drug and of its mono-N-dealkylated metabolite to noninvasive indices of function.

We used M-mode echocardiography and recordings of systolic time intervals to follow changes in left ventricular systolic function of 10 normal subjects during administration of 200 mg oral disopyramide every 8 h. Left ventricular function was significantly depressed (peak rate of change of dimension - 17%, p less than 0.001; mean velocity of circumferential fiber shortening - 15%, p less than 0.01; percent fractional shortening - 16%, p less than 0.05) for as long as 7 h after a dose. These changes could be correlated with those in plasma concentrations of free and total disopyramide, and of its mono-N-dealkylated metabolite (change in peak rate of change of dimension versus levels of disopyramide plus metabolite, r = -0.41, p less than 0.03; changes in ratio preejection time/ejection time versus levels of disopyramide and metabolite, r = 0.62, p less than 0.002).