Incidence of bacteremia in transesophageal echocardiography: a prospective study of 140 consecutive patients.

The incidence of bacteremia related to transesophageal echocardiography was studied in 140 consecutive patients (71 women and 69 men with a mean age of 53.7 +/- 15 years). Thirty-four patients had one or more prosthetic heart valves. Blood cultures were obtained from each patient through separate venipuncture sites immediately before and after transesophageal echocardiography. An additional late blood culture was obtained in 114 patients 1 h later. The skin was cleaned with povidone-iodine and venipunctures were performed with separate butterfly needles with use of sterile gloves and drapes. Blood samples were drawn into separate syringes, transferred to aerobic and anaerobic culture bottles and processed with use of a semiautomated system. The overall incidence of blood cultures positive for bacteremia was 2% (8 of 394 bottles) and all positive cultures grew in a single blood culture bottle. Positive cultures occurred in 4 (1.4%) of 280 bottles before the procedure, in 2 (0.7%) of 280 bottles immediately after the procedure and in 2 (0.9%) of 228 late (1-h) blood culture bottles. Bacterial isolates were coagulase-negative staphylococci (n = 5), Propionibacterium (n = 2) and Moraxella (n = 1). All were considered contaminants. Mean endoscopic time in these patients was not significantly different from that in the other patients. Follow-up of patients with a blood culture positive for bacteremia revealed no clinical evidence of systemic infection. It is concluded that 1) the incidence of bacteremia related to transesophageal echocardiography is very low, and 2) the incidence of blood cultures positive for bacteremia after transesophageal echocardiography is indistinguishable from the anticipated contamination rate.

Quinidine interaction with nifedipine and felodipine: pharmacokinetic and pharmacodynamic evaluation.

Conflicting findings suggest that serum quinidine concentrations may be decreased or increased by nifedipine. We performed a double-blind, placebo-controlled trial of Latin-square design. Twelve healthy men received 3 days of pretreatment with nifedipine prolonged action (20 mg twice a day) or felodipine extended release (10 mg every day), another dihydropyridine calcium antagonist, followed by coadministration of quinidine (400 mg). Quinidine pharmacokinetics were not changed by either dihydropyridine. However, 3-hydroxyquinidine area under the concentration-time curve (AUC) and 3-hydroxyquinidine/quinidine AUC ratio were decreased by felodipine, consistent with reduced metabolite formation. Heart rates and adverse events were higher with felodipine, demonstrating lack of bioequivalence with nifedipine. The QTc interval did not deviate from that expected for the observed quinidine concentration, suggesting the pharmacokinetics of active quinidine metabolites were not markedly altered among treatments. Quinidine disposition did not appear to be changed sufficiently to be clinically important by sustained-release nifedipine and felodipine.

Quinidine therapy and digitalis toxicity.

In a 90-year-old man undergoing prolonged digitalis therapy, digitalis toxicity was precipitated by the administration of quinidine. The electrocardiogram revealed supraventricular bidirectional tachycardia, a rare but characteristic arrhythmia associated with digitalis toxicity. Upon withdrawal of digoxin, the clinical and ECG signs disappeared. A diagnosis of digitalis toxicity rather than quinidine intolerance led to appropriate treatment.

Ejection fraction velocity ratio as an indicator of aortic stenosis severity.

BACKGROUND: Despite the widespread use of the continuity equation in the estimation of aortic valve area (AVA) in patients with aortic stenosis, it is subject to errors, time consuming, and can be technically demanding. As such, simpler methods of assessing aortic stenosis severity have been pursued. METHODS: The ejection fraction velocity ratio [EFVR = ejection fraction (%) / maximal aortic velocity (m/sec)] was compared to AVA determined with the continuity equation in 857 patients with aortic stenosis and varying degrees of LV systolic dysfunction. Severe aortic stenosis was defined as an AVA < 1.0 cm2. RESULTS: There was good to excellent correlation between our index and aortic valve area (P < 0.001 for each ejection fraction subgroup). Receiver operating characteristic analysis showed that the EFVR functioned well with areas under the curve between 0.893 and 0.938. CONCLUSION: The EFVR is a simple noninvasive method for screening patients for an AVA of 1.0 cm2. It could be used as a screening test or in lieu of the continuity equation particularly when there is problematic measurement of either the LVOT diameter or velocity.

Low-cost comprehensive data system for cardiac patients.

Functional systems to collect, store and retrieve clinical, hemodynamic, and angiographic information are needed to serve clinical research and quality control in the cardiac laboratory. Computers are ideally suited for this application, but high investment and maintenance costs are a barrier for their wider use. A low-cost data processing and procedure reporting system was developed using a programmable calculator, a floppy disk drive, and a printer. Files have been started on 750 consecutive adult patients undergoing cardiac catheterization and angiography. Each file contains a clinical profile (CP), angiographic interpretation (Al), and hemodynamic data. CP and Al are coded according to a data base definition appropriate for patient care (procedure report) and research analysis. Data input is simplified by the use of multiple choice forms and prompts appearing on the calculator alphanumeric display. One floppy disk may hold 400 patient files. Immediate access to stored information for cross reference, computations, and statistical work is possible in all patients, a patient category, or an individual case. Stored items may be retrieved in coded form for analysis or translated into sentences to generate a multiple-copy procedure report. Follow-up information may be subsequently added to the patient file. Operation requires minimal training and little expertise in computer technology.

Usefulness of three additional electrocardiographic chest leads (V7, V8, and V9) in the diagnosis of acute myocardial infarction.

Additional electrocardiocardiographic chest leads (V7, V8, and V9) were used in 117 persons consecutively admitted to a coronary care unit. Among the 46 (39%) with a proven acute myocardial infarction the electrocardiograms (ECGs) of 9 (20%) showed ST-segment elevation or abnormal Q-waves, or both, in the three additional leads. In six of the nine, such changes were associated with signs of anterolateral or inferior wall infarction (in three each) on the standard 12-lead ECG, but in the other three (7% of the 46) electrocardiographic changes diagnostic of acute myocardial infarction were found only on the additional chest leads; the last three had characteristic changes in serum enzyme concentrations. This study showed that additional chest leads are helpful in detecting myocardial injury of necrosis in areas of the heart not properly reflected on the standard 12-lead ECG.

Strict reliance on a computer algorithm or measurable ST segment criteria may lead to errors in thrombolytic therapy eligibility.

BACKGROUND: There is accumulating evidence that thrombolytic therapy is underused among eligible patients with acute myocardial infarction. We sought to determine whether potential errors in electrocardiographic diagnosis might be a contributing factor. METHODS: Seventy-five electrocardiograms were interpreted on 2 separate occasions by 3 cardiologists. Two criteria were compared for thrombolysis eligibility: (1) measurement of > or =1 mm ST-segment elevation in 2 contiguous leads (measured) and (2) criterion 1 plus the subjective opinion that the changes represented acute transmural injury (interpretive). The results were compared with computerized interpretations by the Marquette 12SL system. RESULTS: Raw agreement and agreement corrected for chance between raters for both criteria were excellent and tended to be better for interpretive compared with measured criteria (kappa = 0.89 vs 0.78, respectively). Strict reliance on measured electrocardiographic criteria alone would have resulted in overuse of thrombolysis among all 3 raters. Based on the consensus opinion, the absolute overuse of thrombolysis would have been approximately 15% (P <.0034). The computer algorithm had a specificity of 100% and a sensitivity of 61.5%. Reliance on the computerized interpretation alone would have lead to underuse of thrombolytic therapy compared with consensus opinion (21.3% vs 34. 6%; P <.005). CONCLUSION: Agreement for suspected acute myocardial infarction tended to be better when the appearance of the ST segments was added to measurable ST elevation criteria. Strict reliance on measurable criteria may lead to the inappropriate overuse of thrombolysis. Although the Marquette 12SL system has excellent specificity, it has poor sensitivity for the diagnosis of thrombolysis-eligible AMI. Reliance on computerized electrocardiographic interpretation would lead to the inappropriate underuse of thrombolytic therapy in situations in which qualifying electrocardiographic criteria are actually met.

Chest pain--esophageal, cardiac, or both?

The esophagus may be the origin of chest pain clinically indistinguishable from that of ischemic heart disease. In some patients the esophageal origin of the pain may only be recognized by pharmacological provocation during manometry. We describe nine patients with chest pain which could be explained by disorders of esophageal motility--diffuse spasm in four, high pressure lower esophageal sphincter in three, and "nutcracker esophagus" in two. Methacholine provoked the pain and manometric abnormalities in five patients who had normal baseline tracings. However, seven patients given methacholine developed ischemic changes on the electrocardiogram. In one patient these were typical of Prinzmetal's variant angina. The manometric and electrocardiographic abnormalities were reversed by intravenous atropine. Ischemic heart disease and esophageal motor disorders may occur concomitantly and pose a dilemma in diagnosis and management.

Radionuclide left ventricular angiography during exercise in ischemic heart disease.

Radionuclide angiocardiography during exercise is one of the latest advances in nuclear cardiology and is being introduced into clinical practice. In this article the pathophysiological principles of this technique and the method with which it is used to evaluate patients with ischemic heart diseases are outlined, the various patterns of response in these patients are illustrated, and factors that limit the interpretation of the results, including the level of exercise achieved, are discussed.

Increased prevalence of mitral valve prolapse in patients with migraine.

Patients with classic migraine (69 women and 31 men) selected randomly from a practice list of over 1000 were matched for age, sex and neighbourhood with 100 people who did not have headache problems, and both groups underwent M-mode and two-dimensional echocardiography and clinical examination by cardiologists blinded to the subjects' clinical status. The mean ages were 34.9 +/- 11.3 years for the migraine group and 33.1 +/- 9.9 years for the control group. Definite and possible mitral valve prolapse (MVP), diagnosed according to predefined echocardiographic criteria, were found about twice as often in the migraine group as in the control group (in 15 v. 7 and 16 v. 8 patients respectively); the echocardiograms were definitely normal in 69 migraine patients and 85 controls (chi 2 = 8.39, p less than 0.025). Altogether 25% of the migraine group and 11% of the control group had evidence of MVP from a combination of the echocardiographic and auscultatory findings (chi 2 = 5.72, p less than 0.025). The odds ratio was 2.7, with 95% confidence limits of 1.17 and 6.29. The association between migraine and MVP has implications for the understanding of platelet abnormalities and episodes of cerebral ischemia occurring in both these conditions.

Left ventricular function during graded exercise in patients with coronary artery disease and in control subjects.

The left ventricular function of 30 patients with coronary artery disease and 11 control subjects was studied by electrocardiography gated cardiac blood pool scintigraphy as the participants lay on their backs and either rested or exercised on a cycle ergometer at graded levels on intensity. The control subject showed a progressive increase in ejection fraction from rest (51% +/- 7%) to intermediate (56% +/- 10%, P less than 0.05) and maximum levels of exercise (64% +/- 10%, P less than 0.001). All the patients showed a decrease in ejection fraction from rest (42% +/- 16%) to their maximal level of exercise (36% +/- 11%, P less than 0.001). However, the response of some of the patients to intermediate exercise ranged from a decrease or no change to an increase in ejection fraction. Thus, exercise at maximal intensity is necessary to induce the left ventricular dysfunction that is diagnostic of coronary artery disease.

Left ventricular function and volume during supine exercise in subjects with coronary artery disease.

Left ventricular function and volume changes during supine isotonic exercise were assessed in 32 patients with coronary artery disease (CAD) and 12 normal subjects by electrocardiographically gated blood pool cardiac scintigraphy. Ejection fraction (EF) in normal subjects was 49 +/- 10% at rest, 54 +/- 10% during intermediate exercise (P less than 0.05 vs. rest), and 62 +/- 14% during maximal exercise (P less than 0.01 vs. rest). In patients with CAD the resting EF was 42 +/- 14%, 43 +/- 23% at intermediate exercise (P = nonsignificant vs. rest) and 36 +/- 11% at maximal exercise (P less than 0.01 vs. rest). Changes of average and maximal ejection rates from rest to exercise were similar to those of EF but had a lesser degree of statistical significance. End-diastolic volume index (EDVI) in patients with CAD, at intermediate exercise was equal to that at rest, but it increased during maximal exercise (P less than 0.01). In normal subjects EDVI did not change with exercise. Thus, during supine exercise the Frank-Starling mechanism is apparent in patients with CAD but not in normal subjects. Analysis of EF response to exercise is a highly sensitive technique to detect CAD provided that adequate exercise is achieved.

Exercise electrocardiography and myocardial perfusion imaging in the diagnosis of coronary artery disease: preliminary report.

Exercise electrocardiography and rest/exercise myocardial perfusion imaging with thallium-201 were performed in 43 patients with typical angina or atypical chest pain; the results were correlated with those of coronary arteriography. Exercise electrocardiography sensitivity was 65%, specificity was 78%, predictive value for a positive result was 73% and for a negative result was 93%. The low sensitivity of the exercise electrocardiogram was mainly due to the number (13 of 43, 30%) of inconclusive results (no ST-segment change on the electrocardiogram, but failure to attain the target rate), most of which were in the group with typical angina. The predictive value of exercise electrocardiography for both a positive and negative result was excellent in typical angina. In patients with atypical chest pain, the negative predictive value was high (90%) but the positive predictive value was very low (50%). The sensitivity of myocardial perfusion imaging was 71%, specificity was 59%, positive predictive value was 52% and negative predictive value 89%. The low specificity of this test is related to the number of false-positive results obtained, most of which occurred in the group with atypical pain. When the results of exercise electrocardiography and myocardial perfusion imaging are combined, the sensitivity is increased but specificity is unacceptably low. However, myocardial perfusion imaging in patients with an inconclusive result from exercise electrocardiography (most of them in the group with typical angina) showed a sensitivity of 80%, specificity of 88%, positive predictive value of 80% and negative predictive value of 100%.

Prospective study of ambulatory monitoring and echocardiography in borderline hypertension.

This study was done to evaluate prospectively whether ambulatory blood pressure recordings (AMB) (Spacelabs) would more accurately predict increases in left ventricular mass (LVMI) than did blood pressures measured by a nurse in the absence of a physician, using a random zero sphygmomanometer (RZ) and an automated oscillometric digital device (BPI). One hundred patients being followed by their family physician with a diagnosis of borderline hypertension with at least two office diastolic readings of 90-100 mmHg were studied at baseline and every six months for two years with RZ, BPI, and AMB; echocardiography was repeated annually. Over sixty percent of the patients were normotensive in the research unit by AMB, BPI, and RZ at entry. At entry 24% of patients had increased LVMI greater than 110 g/m2 (left ventricular enlargement, LVE) and at 2 years 32% had LVE. Stepwise linear regression was used to determine which measurement was most predictive of LVE at two years. It showed that the most predictive were baseline echo LVMI and BPI systolic pressure. These two variables predicted 45% of the risk with no other variables contributing significantly. However, when BPI was removed, AMB systolic pressure contributed significantly, though the strength of prediction was reduced to 40%. In a subset of 40 patients who underwent mental stress with mental arithmetic and mirror tracing, the magnitude of systolic pressure elevation during mental stress correlated significantly with LVE over 2 years (R = 0.54, p less than 0.001).

Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial.

We performed a randomized, double-blind, placebo-controlled trial in 555 patients with unstable angina who were hospitalized in coronary care units. Patients received one of four possible treatment regimens: aspirin (325 mg four times daily), sulfinpyrazone (200 mg four times daily), both, or neither. They were entered into the trial within eight days of hospitalization and were treated and followed for up to two years (mean, 18 months). The incidence of cardiac death and nonfatal myocardial infarction, considered together, was 8.6 per cent in the groups given aspirin and 17.0 per cent in the other groups, representing a risk reduction with aspirin of 51 per cent (P = 0.008). The corresponding figures for either cardiac death alone or death from any cause were 3.0 per cent in the groups given aspirin and 11.7 per cent in the other groups, representing a risk reduction of 71 per cent (P = 0.004). Analysis by intention to treat yielded smaller risk reductions with aspirin of 30 per cent (P = 0.072), 56 per cent (P = 0.009), and 43 per cent (P = 0.035) for the outcomes of cardiac death or nonfatal acute myocardial infarction, cardiac death alone, and all deaths, respectively. There was no observed benefit of sulfinpyrazone for any outcome event, and there was no evidence of an interaction between sulfinpyrazone and aspirin. Considered together with the results of a previous clinical trial, these findings provide strong evidence for a beneficial effect of aspirin in patients with unstable angina.