Elevated systolic blood pressure as a predictor of long-term cancer mortality: analysis by site and histologic subtype in 10,000 middle-aged and elderly men.

The association of a casual reading of blood pressure (BP) in 1963 to subsequent 15-year cancer mortality was examined in a cohort of 10,059 middle-aged and elderly men. Systolic BP (SBP), but not diastolic BP, predicted significantly long-term cancer mortality occurring in 369 subjects. The covariate-adjusted relative risk (RR) estimated by Cox's proportional hazard model was 1.10 [95% confidence interval (CI), 1.00-1.21]. In patients aged less than 60 at the beginning of the study, increased cancer mortality was mainly observed in association with SBP of more than 150 mm Hg. In subjects aged 60 or above, the estimated RR was 1.21 (95% CI, 1.03-1.42). Exclusion of 40 men in whom diagnosis made prior to 1963 or death occurred through 1965 did not alter the results. An excess mortality in men who reported pharmacologic treatment for hypertension while under follow-up was fully accountable by their age, BP, and smoking habits. Analysis by site suggested that the association was mainly due to increased mortality from cancer of the digestive and genitourinary organs (estimated RR's, respectively, 1.20 and 1.26; 95% CI's, respectively, 1.03-1.39 and 0.99-1.59). Analysis by histologic subtype suggests an association with adenocarcinoma (RR = 1.19, 95% CI, 1.04-1.37) but not squamous cell or transitional cell carcinomas, myeloma, lymphomas, and leukemias.

Transluminal carbon dioxide-laser catheter angioplasty for dissolution of atherosclerotic plaques.

Carbon dioxide laser energy was used for the dissolution of atheromatous plaques. Flexible, nontoxic infrared optical fibers were used for the transmission of the carbon dioxide laser beam intraarterially. Dissolution of plaques and recanalization of obstructed arteries were achieved both in vitro and in vivo with controllable damage to the vessel walls.

Unusual pericardial calcification in Gaucher's disease.

Gaucher's disease is a hereditary metabolic disorder characterized by the abnormal accumulation of glucocerebrosides in reticuloendothelial cells. A 58-year-old man had Gaucher's disease and suffered from hypersplenism, cirrhosis of the liver, and free-floating calcifications in the pericardial space. The literature of the pericardial involvement in Gaucher's disease is reviewed.

Correlation between effects of hydralazine on force and on the adenyl cyclase system of ventricular myocardium in dogs and cats.

Hydralazine is a potent arteriolar dilator, which increases cardiac output in patients with heart failure. Previous studies suggested that these beneficial effects might be due in part to a positive inotropic effect. The present study further investigated the effect of hydralazine on myocardial contractility and adenyl cyclase activity. In isolated cat papillary muscles, bath concentrations of hydralazine up to 10(-4) mol X litre-1 did not alter force development, whereas 10(-3) mol X litre-1 hydralazine increased isometric force by 31%. This effect was blocked by 10(-6) mol X litre-1 propranolol and was absent after catecholamine depletion produced by previous reserpine treatment. In canine ventricular myocardium hydralazine in all concentrations used (10(-7) to 10(-3) mol X litre-1) increased control adenyl cyclase activity. This increase was statistically significant in 10(-6) to 10(-3) mol X litre-1 concentrations, reaching a maximum of 69.5% at 10(-4) mol X litre-1. In cat ventricular myocardium 10(-6) to 10(-3) mol X litre-1 hydralazine increased the cyclic AMP production, although to a lesser magnitude than that in canine tissue. Hydralazine 10(-5) mol X litre-1 produced a 37.8% increase, and the maximum effect of 45.2% occurred at 10(-3) mol X litre-1. The positive effects of hydralazine were completely abolished by the addition of propranolol in dogs as well as in cats. Thus the adenyl cyclase stimulation induced by hydralazine is mediated through the beta receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced risk of coronary heart disease mortality in lean hypertensive men.

A recently presented hypothesis contends that the excess coronary heart disease mortality associated with hypertension is more prominent in lean men than in overweight men. This hypothesis was addressed using data collected in the Israeli Ischemic Heart Disease Study (n = 10,059). The ratios of age-adjusted 15-year death rates in hypertensive and normotensive men were 4.7, 2.8, 2.0, and 1.9 in the Quetelet index groups of less than 2.29, 2.29 to 2.56, 2.56 to 2.83 and greater than 2.83 g/cm2, respectively. The corresponding ratios for all-cause mortality were 2.2, 2.1, 2.0, and 1.7, respectively. The group with the highest all-cause age-adjusted mortality, at 33.6%, was that of the leanest (less than 2.29 g/cm2, bottom 20% of the Quetelet index distribution) hypertensive subjects. The same group also displayed the highest coronary heart disease mortality (age-adjusted rate, 18.2%). The findings persisted for both smokers and nonsmokers and after exclusion of men with coronary heart disease or diabetics at intake, men on antihypertensive medication, or those who died in the first 2 years of follow-up (1963-1965). A multivariate risk score for developing myocardial infarction was calculated, based on levels of age, systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, cigarette smoking, diabetes mellitus, and Quetelet index. This score varied little across the four Quetelet index groups in hypertensive men: 5-year mean estimated risks of myocardial infarction were between 70 and 74/1000. In normotensive men the scores increased from 19/1000 in the leanest subjects to 29/1000 in the overweight ones.(ABSTRACT TRUNCATED AT 250 WORDS)

The human coronary microcirculation: an electron microscopic study.

The ultrastructure of the terminal vascular bed of human coronary arteries was studied in the myocardial tissue obtained at surgery from different locations in the heart in five patients. The following vessels were identified: (1) Arterioles; slender and prolonged endothelial cells, flat nuclei and two to three layers of smooth muscle cells. (2) Precapillary sphincters: short endothelial cells, large nuclei bulging into the lumen, close myoendothelial junctions and a single layer of circular smooth muscle. (3) Capillaries: composed of one or more slender endothelial cells. (4) Venules: flat endothelial cells and nuclei, no muscular layer, rich collagen tissue. The function of these structures is believed to be as follows: the arterioles are the smallest blood-distributing arteries in the heart. The precapillary sphincters control blood flow to the capillaries; pressor substances present in the blood are picked up by endothelial cells, pass rapidly through the myoendothelial junctions and cause contractions of the smooth circular muscle layer; the bulging nuclei of endothelial cells then passively obstruct the lumen almost completely. The main exchange of gases and nourishing substances takes place in the capillaries. We postulate that in some pathologic conditions, abnormal constriction of the sphincters may cause diminished flow and be the basis for some well defined or unclear ischemic events.

Segmental study of the terminal coronary vessels in coarctation of the aorta: a natural model for study of the effect of coronary hypertension on human coronary circulation.

An electron microscopic study of the coronary terminal circulation (starting with the small coronary arteries) was carried out on small pieces of myocardium operatively resected from the left ventricle on 11 patients with coarctation of the aorta. The patients were 4 to 20 years of age. Structural modifications were found in the small coronary arteries and arterioles. Two patterns of morphologic alterations were noted in these small resistance vessels. In the first pattern, seen in most of the children, the components of the arterial wall were still distinguishable, and well represented portions of smooth muscle layers were visualized together with muscle cells showing signs of degeneration and more or less widespread collagenous islets. The second pattern, seen in young adults, was characterized by a total collagenous transformation of the arterial wall. In contrast, the smaller microvessels (precapillary sphincter, metarterioles and capillaries) appeared free of pathologic change. It is postulated that the precapillary sphincters play a special protecting and regulating role in the coronary microcirculation in such cases with elevated coronary pressure. It is suggested that surgery should be performed at an early age to prevent further development of structural changes in the microvessels. The microcirculatory damage may contribute to the increased surgical mortality in patients with coarctation of the aorta operated on at a later age. These findings should trigger further research on the small coronary vessels in systemic hypertension.

Subaortic stenosis: an unrecognized problem in transposition of the great arteries.

Right ventricular (subaortic) obstruction has only rarely been described in complete transposition of the great arteries. five patients with complete transposition of the great arteries in whom subaortic stenosis was angiocardiographically demonstrated were studied. All had a pressure gradient of 30 to 55 mm Hg across the aortic outflow tract. Two of the patients manifested mild tricuspid insufficiency, and another two had coarctation of the aorta. The etiologic, anatomic, hemodynamic and prognostic aspects of this unusual anomaly are discussed. An angiocardiographically demonstrated series of this anomaly has not been reported on before.

Systematic analysis of contrast echocardiograms.

Contrast echocardiography was first described in 1968. Since then, many reports have described clinical and experimental uses for the technique. Contrast echocardiography is performed at least occasionally in most echocardiography laboratories, but most physicians use this technique merely to determine the presence of a shunt or, more rarely, for structure identification. Contrast echocardiography can provide much more information. Some different types of information available from contrast echocardiographic records are discussed, including timing of contrast appearance within the cardiac cycle, relative timing of appearance in different cardiac structures, relative intensity of contrast opacification, cyclical changes in contrast opacification, negative contrast effect, slope of contrast trajectories on M-mode contrast echocardiography, and clearance times.

Diagnosing tricuspid regurgitation by direct imaging of the regurgitant flow in the right atrium using contrast echocardiography.

To determine whether tricuspid regurgitation (TR) can be diagnosed by direct imaging of regurgitant flow in the right atrium (RA) using contrast echocardiography, echocardiography was performed in 35 patients using peripheral intravenous injections of 5% dextrose solution. Fifteen patients had TR judged by v-wave synchronous contrast appearance on the inferior vena cava echogram (a previously validated method for diagnosing TR), 5 of whom had clinically obvious TR. Twenty patients had no TR on inferior vena cava contrast echocardiography, 9 of whom were normal volunteers. On subsequent blind review, 13 of the 15 patients with TR were correctly identified on the basis of the regurgitant contrast flow just posterior to the tricuspid valve in the RA. Of the 20 without TR, 19 were correctly identified and there was 1 false-positive result. Using different criteria for the diagnosis (insisting on imaging of flow across the tricuspid valve in systole), another blinded observer correctly diagnosed only 8 of the 15 patients as having TR, but had no false-positive results. To avoid false-positive results, it is important to realize that there are 2 regions where retrograde flow can normally be seen in the RA: (1) briefly at the onset of systole coincident with tricuspid valve closure, and (2) in the posterior RA, as distinct from the anterior RA area just behind the tricuspid valve where TR is diagnosed in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiography in discrete subaortic stenosis.

Thirty-seven patients with discrete subaortic stenosis (DSS) underwent 2-dimensional echocardiography (2-D echo) and cardiac catheterization. The peak systolic pressure gradients ranged from 0 to 150 mm Hg. Thirty-two patients had membranous DSS and 5 had fibromuscular DSS. Of 37 patients with DSS, 2-D echo diagnosed the presence and type in 35; in 2, a membrane was demonstrated by angiography. Of the 35 patients accurately diagnosed by 2-D echo, angiography corroborated the diagnosis in 33, but failed to show the membrane in 2. Subsequent cardiac surgery confirmed the accuracy of the echocardiographic diagnosis in these 2 patients. In all patients with membranous DSS, the anterior insertion of the membrane was demonstrated. In 9 of them the posterior insertion was demonstrated by tilt of the transducer but the anterior insertion disappeared. In 4 patients both insertions were demonstrated simultaneously and in 3 patients the membrane was demonstrated as a continuous line. In 4 of the 5 patients with fibromuscular DSS, both insertions of the lesion were demonstrated simultaneously. However, 2-D echo was unsuccessful in assessing the severity of obstruction. In only 1 patient did demonstration of the whole subaortic membrane as a continuous line below the aortic valve correlate with severe obstruction. Thus, the presence and type of DSS, but not the degree and severity, can be accurately and reliably diagnosed by means of 2-D echo.

Exercise-induced left ventricular dysfunction in young men with asymptomatic diabetes mellitus (diabetic cardiomyopathy).

Radionuclide ventriculographic studies were performed at rest and during exercise on 30 consecutive men, aged 21 to 35 years with diabetes mellitus without evidence of coronary artery or any other cardiovascular disease, and in 20 normal age-matched subjects. Sixteen (53%) were treated with insulin and 14 (47%) were treated with either diet (6 patients) or oral antidiabetic therapy (8 patients). All patients from both groups had normal left ventricular (LV) ejection fraction (EF) at rest. In 5 of the 30 diabetic patients (17%), LVEF decreased after exercise, in 8 (27%) it remained unchanged and in 17 it increased normally. Mean LVEF at rest and after exercise in this group was 66 +/- 7% and 72 +/- 7% (+/- standard deviation), respectively. In all normal subjects, LVEF increased after exercise. Mean LVEF at rest and after exercise in the normal group was 66 +/- 7% and 76 +/- 9%, respectively. No patient had evidence of regional dysfunction at rest or after exercise. LV function was not related to serum glucose levels during the test, modality of treatment, insulin dependency or duration of the disease. Three of 4 patients with diabetic microvascular complications showed LV dysfunction. In 4 of 5 patients in whom LVEF decreased after exercise, thallium studies showed normal perfusion. Thus, diabetes mellitus may cause exercise-induced global LV dysfunction in young men with no evidence of cardiovascular disease. This phenomenon apparently does not seem to follow the known course of diabetic microvascular complications.

Correction of tetrad of Fallot with reduced incidence of right bundle branch block.

In 20 patients who underwent a modified surgical repair of tetrad of Fallot complete right bundle branch block developed in only 8 (40 percent). Standard and intraoperative conduction studies indicated that in these patients the right bundle branch block was due to injury of the right bundle branch near the ventricular septal defect (proximal right bundle branch block). The modified operative technique is aimed at minimizing the injury to the right ventricle and it includes a significantly shorter than usual ventriculotomy incision and avoidance of the septal (moderator) band during infundibulectomy. Intra- and postoperative hemodynamic studies of these patients revealed that relief of the right ventricular outflow obstruction was optimal.

Dysplastic aortic valve with absence of aortic valve cusp: an unreported cause of congenital aortic insufficiency.

Three patients are described in whom dysplasia of the aortic valve was associated with total absence of one of the semilunar aortic cusps and congenital aortic insufficiency. Two of the three survived aortic valve replacement.

Ventricular reentry and automaticity in myocardial infarction. Effect of size of injury.

The effects of the size of acute myocardial infarction on ventricular reentry and automaticity were studied in 36 mongrel dogs. Large transmural myocardial infarctions were produced by ligation of the left anterior descending coronary artery (major ligation; diameter of infarction above 4.0 cm), and small subendocardial or intramural infarctions were produced by ligating a small diagonal branch of the left anterior descending coronary artery (minor ligation; diameter of infarction less than 1.5 cm). Reentrant arrhythmias were induced by rapid ventricular stimulation, and ventricular automaticity was determined during vagal stimulation. Ventricular automaticity became enhanced only 30 to 45 minutes after both major and minor coronary arterial ligations; however, the animals with major ligations attained a higher level of increased automaticity. While automaticity became enhanced in both groups reentrant arrhythmias could never be produced artificially (or observed spontaneously) in the animals with myocardial infarctions. The dependence of the so-called reentrant arrhythmias on the size of the infarction is a major support for the theory of reentry as the basis for these arrhythmias.

Arteriosclerotic aneurysm of the coronary artery.

The findings in a patient with an angiographically proven aneurysm of the coronary artery are described. The case is reviewed in the light of 115 similar cases reported in the literature. The patient had had numerous episodes of variant angina, a feature not previously described in coronary arterial aneurysms, which may be related to embolic showers originating from the aneurysm.

Impeded coronary flow in anatomic correction of transposition of the great arteries: prevention, detection, and management.

Six infants and a 3-year-old boy underwent primary anatomic repair (arterial switch) of their dextro-transposition of the great arteries (d-TGA). Three died: one on the operating table because of an irreducible kink in the left main coronary artery, one because of postoperative bleeding and tamponade, and one because of a postoperative management error. In the four survivors the preoperative left ventricular-to-right ventricular systolic pressure interrelationships were 35 to 115, 54 to 73, 30 to 80, and 70 to 90 mm Hg. While left ventricular inability to take over the systemic pressure did not appear to be a problem in any of our cases, reduced coronary perfusion seemed to be the rule rather than the exception in this operation. One approach to the problem of obstructed coronary flow is first to construct continuity of the "new" aorta, unclamp it, and mark the appropriate places for coronary anastomoses on the fully distended aorta. It is our conviction that further improvement in the operative technique and better understanding of the risk factors will eventually make the primary anatomic repair of d-TGA the operation of choice for most dextro-transpositions.

Myectomy versus myotomy as an adjunct to membranectomy in the surgical repair of discrete and tunnel subaortic stenosis.

The results of membranectomy and deep myectomy in the left ventricular outflow tract were compared to those of membranectomy and myotomy in 42 patients who underwent surgical repair of discrete and tunnel subaortic stenosis. Fifteen consecutive patients (Group A) underwent membranectomy and myotomy, and 27 consecutive patients (Group B) underwent membranectomy and myectomy. Two patients of Group A and nine of Group B had tunnel subaortic stenosis. The preoperative mean (+/- standard deviation) peak systolic gradients across the left ventricular outflow tract in patients with discrete subaortic stenosis types I and II were 64 +/- 29 mm Hg in Group A and 52 +/- 3 mm Hg in Group B (p = not significant). In the patients with tunnel subaortic stenosis the preoperative mean gradients were 97 +/- 74 mm Hg in Group A and 73 +/- 26 mm Hg in Group B (p = not significant). In patients with discrete subaortic stenosis types I and II, postoperative catheterization at a mean follow-up of 21 months revealed residual mean gradients of 29 +/- 24 mm Hg in Group A and 10 +/- 13 mm Hg in Group B (p less than 0.01). In the patients with tunnel subaortic stenosis, the postoperative mean gradients were 25 +/- 7 and 30 +/- 30 mm Hg in Groups A and B, respectively (p = not significant). We conclude that in the surgical management of discrete subaortic stenosis types I and II, deep myectomy (in addition to membranectomy) produces better relief of the left ventricular outflow obstruction than do membranectomy and myotomy. In patients with tunnel subaortic stenosis myectomy is less effective than in the non-tunnel type but still produces acceptable results and may delay radical procedures to a later age.

Coarctation of the aorta with congenital hemangioma of the face and neck and aneurysm or dilatation of a subclavian or innominate artery. A new syndrome?

Congenital cutaneous hemangioma associated with congenital heart disease is extremely rare. We report four infants with congenital cavernous hemangioma of the face and neck and coarctation of the aorta. Three also had congenital aneurysm of a subclavian or innominate artery. One patient also had mild congenital valvular aortic stenosis. The unusual combination of lesions may represent a new syndrome.

Uninterrupted inferior vena cava with azygos continuation.

Azygos continuation of the inferior vena cava is diagnosed in infants in the presence of obstruction to flow in the inferior vena cava due to infrahepatic interruption. Recently we studied in an infant complex congenital heart disease in which there was azygos continuation of the inferior vena cava without infrahepatic interruption or any other obstructive lesion of this vessel. The blood from the lower part of the body drained into the right atrium by two wide patent veins: the inferior vena cava and the azygos system. The angiocardiographic observations of this condition in an infant are reported for the first time to our knowledge, and the embryologic development is briefly reviewed.