Precipitating factors leading to decompensation of heart failure. Traits among urban blacks.

Potential precipitating factors that led to cardiac decompensation and subsequent hospital admission for heart failure were examined in 101 patients in a large public hospital serving a predominantly working-class minority population. Ninety-seven percent of patients were black; their age was 59 +/- 14 years (mean +/- SD); on average, they were hospitalized three times in the preceding year for problems related to their heart failure. Potential precipitating factors for decompensated heart failure were identified in 93% of patients. Lack of adherence to the prescribed medical regimen was the most commonly identified causative factor and was noted in 64% of the cases; noncompliance with diet amounted to 22%, with drugs to 6%, and with the combination of drugs and diet to 37%. Other factors also related to hospitalization were cardiac arrhythmias (29%), emotional/environmental issues (26%), inadequately conceived drug therapy (17%), pulmonary infections (12%), and thyrotoxicosis (1%). Thus, the key preventive measure necessary in at least two thirds of patients centered around better adherence to drug and/or diet regimen, highlighting the precept that better patient education is mandatory if we are to minimize the number of hospital admissions for decompensated heart failure.

Verapamil in atrial fibrillation and atrial flutter.

A double-blind randomized study was performed to compare the efficacy of intravenous verapamil with saline in 28 patients with a rapid ventricular rate and atrial fibrillation or atrial flutter. Conversion of atrial fibrillation to sinus rhythm occurred in none of 14 patients after saline and in 3 of 20 patients (15%) 7 to 160 min after verapamil. The ventricular rate in atrial fibrillation was slowed greater than or equal to 15% in 2 of 14 patients (14%) by saline, in 17 of 20 patients (85%) by 1 dose of verapamil (p less than 0.001), and in 19 of 20 patients (95%) by 1 or 2 doses of verapamil (p less than 0.001). Conversion of atrial flutter to sinus rhythm occurred in none of 4 patients after saline and in 1 of 7 patients (14%) 105 min after verapamil. The ventricular rate in atrial flutter was slowed greater than or equal to 15% in none of 4 patients by saline, in 4 of 7 patients (57%) by 1 dose of verapamil, and in 7 of 7 patients (100%) by 1 or 2 doses of verapamil (p less than 0.001).

Antihypertensive and hemodynamic effects of oxprenolol versus propranolol.

Oxprenolol is an experimental beta adrenergic blocker with intrinsic sympathomimetic activity. To compare the effects of long-term administration of oxprenolol on hypertension and hemodynamics with the effects of propranolol, 20 patients with essential hypertension were divided in a double-blind random manner into two 10-patient groups and given placebo for 2 wk, followed by equipotent doses of oxprenolol or propranolol for 5 wk and by placebo for another 2 wk. Right heart cardiac catheterization was performed at the beginning and at the end of the 5-wk beta blockade. Heart rates and blood pressures fell markedly with both agents, although standing heart rate was lowered more by propranolol than by oxprenolol. Plasma renin activity was much lower after beta blockade with either drug. There was no correlation between decreases in blood pressure and renin activity. Although during the stress of repeat cardiac catheterization heart rates remained significantly lower than control, the intra-arterial pressures were not altered significantly by oxprenolol or propranolol, nor was there significant change in pulmonary pressure, vascular resistance, or cardiac output. Thus oxprenolol closely parallels the effects of propranolol in essential hypertension. The negative chronotropic action of both drugs is more marked than their antihypertensive activity.

Effect of carbon monoxide on exercise performance in chronic obstructive pulmonary disease.

We evaluated the effect of breathing 100 ppm of carbon monoxide versus compressed, purified air for 1 hour on exercise performance in 10 patients with chronic obstructive pulmonary disease in a double-blind, randomized, crossover study. The mean arterial carboxyhemoglobin was 1.48 per cent in the carbon monoxide control period and increased from 1.43 to 4.08 per cent after breathing carbon monoxide (P less than 0.001). The mean arterial carboxyhemoglobin level was 1.52 percent in the air control period and decreased from 1.47 to 1.34 per cent after purified air (P less than 0.001). The mean exercise time until marked dyspnea decreased from 218.5 seconds in the carbon monoxide control period to 146.6 seconds after breathing carbon monoxide (P less than 0.001). The mean exercise time was 219.9 seconds in the air control period and 221.3 seconds after purified air (P not significant). Breathing 100 ppm of carbon monoxide for 1 hour caused a significant reduction in exercise performance in patients with chronic obstructive pulmonary disease.

Antianginal and myocardial metabolic properties of verapamil in coronary artery disease.

To determine the metabolic cost of administering an experimental calcium antagonist, verapamil, to patients with coronary artery disease, 12 such patients were studied at rest and during stress with atrial pacing before and after intravenous treatment with verapamil (bolus dose of 0.1 mg/kg body weight, followed by infusion at 0.005 mg/kg per min). The mean (+/- standard deviation) aortic pressure at rest (98 +/- 22 mg Hg), coronary sinus blood flow (88 +/- 17 ml/min) and myocardial oxygen consumption (10.7 +/- 2.4 ml O2/min) decreased to 88 +/- 20 mm Hg (p < 0.0004), 77 +/- 14 ml/min (p < 0.03) and 8.8 +/- 2.5 ml O2/min (p < 0.01), respectively, after administration of verapamil. With atrial pacing, these values were 105 +/- 25 mm Hg, 151 +/- 50 ml/min and 18.5 +/- 6.4 ml O2/min, respectively, before infusion of verapamil, and then decreased to 87 +/- 14 mm Hg (p < 0.006), 107 +/- 31 ml/min (p < 0.0002) and 13.3 +/- 4.4 ml O2/min (p < 0.001) during infusion. Angina occurred in all patients with atrial pacing before verapamil (threshold to pain: 93 +/- 67 seconds). After verapamil, the threshold to pain in six patients increased to 191 +/- 183 seconds; and no pain was experienced by the remaining six (p < 0.0005). Before administration of verapamil lactate extraction decreased from 24 +/- 9 to 10 +/- 11 percent (p < 0.0002) during atrial pacing, and 9 (75 percent) of the 12 patients exhibited electrocardiographic S-T segment depressions. After administration of verapamil lactate extraction normalized to 22 +/- 9 percent during atrial pacing, and the electrocardiogram reverted to baseline in all but one patient. These findings indicate that verapamil decreases left ventricular myocardial metabolic demands, and concomitantly greatly increases the threshold to angina.

Incidence of right ventricular asynergy in patients with coronary artery disease.

The effects of coronary artery disease on patterns of left ventricular contractility have been thoroughly investigated. In contrast, little is known about the incidence of right ventricular dysfunction induced by this disease. To evaluate the frequency of right ventricular asynergy, biplane right ventricular cineangiograms were obtained in 26 patients. Seven segmental axes of shortening were analyzed in each end-systolic and end-diastolic frame and normalized as percent decrease (or increase) in axis from end-diastolic length. Of 26 patients, 8 (Group I) served as normal (control) subjects. The remaining 18 patients had significant coronary artery disease; 6 of these (Group II) had no significant disease of the right coronary artery, whereas 12 (Group III) had significant obstruction of this artery. Four patients in Group II had a previous anteroseptal myocardial infarction, and six in Group III had a previous inferior myocardial infarction. There was a progressive decrease in segmental axes of shortening from Group I to II and from Group II to II, but the decrease was not significant at the level P less than 0.01. Only one patient in Group II had frank dyskinetic segmental motion of the interventricular septum (this patient had had a previous anteroseptal myocardial infarction), whereas two patients in Group III had dyskinetic segmental motion of the free right ventricular wall (both had previous inferior myocardial infarction). Therefore, coronary artery disease seldom produces significant right ventricular asynergy. Abnormal septal motion is associated with previous anteroseptal myocardial infarction; however, dyskinetic motion of the free right ventricular wall occurs only in patients with a right coronary arterial lesion and previous inferior myocardial infarction.

Hemodynamic and myocardial performance characteristics after verapamil use in congestive heart failure.

Because of its intrinsic negative inotropic effect, the administration of the recently introduced calcium antagonist, verapamil, is thought to be contraindicated in presence of congestive heart failure (CHF). Yet, as CHF is frequently associated with arrhythmias and angina pectoris, and verapamil possesses potent antiarrhythmic and antianginal properties that could be of great benefit to selected patients with CHF, this study was undertaken to determine whether verapamil can be given to such subjects safely. For this purpose, 14 patients with CHF were studied in the control (preverapamil) state with a combined hemodynamic-cineangiographic approach; the same interventions were repeated during intravenous verapamil administration (0.1 mg/kg bolus, followed by 0.005 mg/kg/min infusion). Verapamil markedly lowered mean aortic pressure (95 +/- 19 to 81 +/- 12 mm Hg, p less than 0.001) and systemic vascular resistance (1,953 +/- 873 to 1,417 +/- 454 dynes s cm-5, p less than 0.01). Simultaneously, indexes of left ventricular (LV) performance substantially improved: the ejection fraction increased from 29 +/- 13 to 37 +/- 17% (p less than 0.01), and mean velocity of circumferential fiber shortening increased from 0.45 +/- 0.18 to 0.64 +/- 0.28 circ/s (p less than 0.001). Cardiac index also increased (from 1.98 +/- 0.49 liters/m2/min before verapamil to 2.24 +/- 0.60 liters/m2/min after verapamil), although this improvement did not become statistically significant. No appreciable changes were noted in the heart rate, LV end-diastolic pressure, or mean pulmonary arterial or pulmonary capillary wedge pressure. Thus, the intrinsic negative inotropic activity of intravenous verapamil in therapeutic doses generally does not represent a serious drawback even in patients with CHF; its potent unloading vasodilatory properties more than compensate for any intrinsic decrease in LV contractility, and can thereby actually improve overall cardiac function.

Survival rates and prehospital delay during myocardial infarction among black persons.

Over a 12-month period, a consecutive series of 111 black patients admitted to a municipal hospital in Chicago was studied. The 2-week mortality rate for the entire group was 19% (95% confidence intervals, 11.7 to 26.3), and the rate was twice as high for women as for men. A history of systemic hypertension was encountered in 75% of the patients, and diabetes mellitus was present in 33%, although they were not significant predictors of mortality within this group. The delay time from onset of symptoms to arrival at the hospital was markedly prolonged compared with studies of predominantly white populations--twice as long at the median and 3 times as long at the mean. Preventive campaigns aimed at this population should include educating patients on the symptoms of coronary artery disease and encouraging them to seek prompt medical care. Attention must also be given to eliminating obstacles to access to care in this group.

Outcome of coronary artery bypass grafting in black persons.

Relatively little attention has been given to coronary artery disease in black persons in the United States. During 31 months, 73 consecutive black patients drawn from an urban working class inner city population who had undergone coronary artery bypass grafting were studied. In the total series of elective and emergency operations, 3 patients (4%) died within the first 30 days and 3 more died by the end of the first year of follow-up. Functional capacity was assessed by interviews and a questionnaire in a subset (n = 39) at least 6 months after operation. Although 79% of the patients felt that the operation had resulted in improvement of symptoms, half of them continued to report angina. Only one-third of the patients were working in the period immediately before the operation; 13% were working postoperatively. Coronary artery bypass grafting had an acceptable mortality risk in these patients, although the functional outcome was disappointing.