Early intervention in acute myocardial infarction: significance for myocardial salvage of immediate intravenous streptokinase therapy followed by coronary angioplasty.

Sixteen patients with acute myocardial infarction underwent treatment with streptokinase up to 3 hours after the onset of chest pain. Nine patients (group I) received streptokinase within 1 hour of the onset of pain, and seven patients (group II) received it within 2 to 3 hours. All underwent multigated radionuclide ventriculography after streptokinase therapy and 1 week later. Percutaneous transluminal coronary angioplasty of the infarct artery was performed within 24 hours in all patients. An effort-limited treadmill stress test was performed before discharge. There was no mortality or serious complication. Mean peak total creatine kinase was 521 +/- 289 mU/ml in group I, and 1,614 +/- 709 mU/ml in group II (p less than 0.05). The mean initial left ventricular ejection fraction was 47 +/- 11% in group I and 37 +/- 10% in group II. After early angioplasty (within 24 hours) and at 1 week recovery, left ventricular ejection fraction increased to 53 +/- 9% in group I (p less than 0.05) and to 40 +/- 7% in group II (p = NS). Seven of the nine patients in group I had normal radionuclide ventriculograms at discharge compared with none of the seven patients in group II. Thrombolytic therapy administered less than 1 hour after the onset of symptoms of acute myocardial infarction followed by angioplasty of the infarct artery results in preservation of left ventricular function, whereas therapy given after 2 hours has only a limited effect.

Infrared thermography in the detection and management of coronary artery disease.

Infrared thermography was used to measure and map precordial skin temperature in 60 patients undergoing elective coronary angiography; 9 patients were normal and 51 had coronary artery disease (CAD). Thermograms were graded by quartile area (zero to 4 plus) and magnitude of thermal asymmetry (recorded as degrees celsius). The presence, mean area and degree of thermal asymmetry were significantly greater in patients with CAD. Twenty-two patients subsequently underwent successful revascularization with angioplasty with a highly significant decrease in the presence, magnitude and degree of thermal asymmetry. The results demonstrate that CAD is associated with precordial thermal asymmetry. The area and magnitude of thermal asymmetry is greater in patients with CAD than in control subjects without angiographically significant CAD. Successful revascularization changed the asymmetric precordial pattern to a more symmetric one. Infrared thermography is a promising technique for the detection of CAD before and after revascularization.

Pacemaker Twiddler's syndrome.

Twiddler's syndrome may result from pulse generator manipulation or from spontaneous rotation due to movement around an inadequately secured electrode. In this case, the electrode became coiled in the right ventricular outflow tract.

Cardiorespiratory effects of antagonism of diazepam sedation with flumazenil in patients with cardiac disease.

The specific benzodiazepine antagonist flumazenil is currently under intense study. Despite much clinical experience, no detailed invasive hemodynamic studies of its use in cardiac patients have been published. In the present study, hemodynamic and respiratory variables were measured in 10 cardiac patients undergoing catheterization of the right and left sides of the heart, before and after sedation with intravenous diazepam, and after reversal of sedation with flumazenil. A sleep dose of diazepam (12.2 +/- 5.1 mg, mean +/- SD) caused only slight decreases in mean arterial pressure (103 +/- 12 to 98 +/- 14 mm Hg; P less than 0.05), pulmonary capillary wedge pressure (13.2 +/- 6.3 to 11.7 +/- 6.6 mm Hg; P less than 0.05), and left ventricular end-diastolic pressure (20.8 +/- 7.5 to 17.3 +/- 10.0 mm Hg; P less than 0.05), with no significant changes in respiratory gas homeostasis. Intravenous flumazenil (0.22 +/- 0.07 mg) resulted in spontaneous awakening and return to full orientation, yet caused no significant alteration in either hemodynamic or respiratory variables measured. Reversal of diazepam-induced sedation by flumazenil in cardiac patients appears safe and effective.

Anomalous origin of the right coronary artery from the ascending aorta. Diagnosis by digital subtraction angiography.

The anomalous origin of a coronary artery often poses diagnostic difficulties at angiography. The right coronary artery is more rarely affected than the left. A patient is presented in whom the right coronary artery arose from the ascending aorta. The diagnosis of this rare anomaly was facilitated by the use of digital subtraction aortography and allowed selective angiography of the artery with an appropriately shaped catheter.

Percutaneous transluminal coronary angioplasty as a cause of isolated right ventricular infarction.

Acute myocardial infarction is a recognized major complication of percutaneous transluminal coronary angioplasty (PTCA). Isolated right ventricular infarction is rare. A 60-year-old patient underwent PTCA 24 h following clinically successful thrombolytic therapy for an acute occlusion of a dominant right coronary artery. Following successful PTCA of this artery, a right ventricular branch was noted to be occluded. This was associated with chest pain, elevated venous pressure, S-T segment elevation in ECG leads V1-3, and a transient rise in serum creatine kinase. The clinical course was uneventful and a week later the right ventricular ejection fraction had increased from 18 to 36%. The long-term effects of right ventricular infarction are benign and occlusion of a right ventricular branch during PTCA is rarely of clinical significance.