Management of patients with unstable angina in a general cardiology unit.

AIMS: To review the clinical management of patients with unstable angina and to relate prospectively initial risk stratification, according to the Braunwald criteria, to subsequent cardiovascular events. METHODS: From February to April 1996 we performed a three month prospective review of all patients with a diagnosis of unstable angina admitted to the coronary care unit at Auckland Hospital. RESULTS: One hundred and four patients (61% male), with a mean age of 64 years, were classified as high (58%), intermediate (41%) or low risk (1%) for an adverse cardiac event. Twelve (12%) patients had a documented myocardial infarction, of whom 11 were in the high-risk group (p = 0.038). During hospitalisation there was one death. Twelve (12%) patients underwent inpatient exercise testing, five of whom proceeded to a coronary angiogram prior to hospital discharge. Twenty-two (21%) unstable patients underwent inpatient angiography without prior exercise testing. Twenty-one (20%) patients required revascularisation on the same admission: percutaneous coronary angioplasty (n = 14) or coronary artery bypass grafting (n = 7). Twelve of these 21 patients were in the high-risk group (p = 0.999, NS). CONCLUSION: Patients admitted with unstable angina had low inpatient mortality but a 12% rate of subsequent myocardial infarction. Braunwald low-risk unstable angina patients were not admitted to the coronary care unit. Braunwald high-risk patients were more likely to develop a subsequent myocardial infarction. Stratification of patients into intermediate or high-risk groups did not relate to initial medical management or subsequent revascularisation. Thus, while this method of risk stratification may predict cardiovascular events, it may be of limited clinical use in the New Zealand environment.

Left ventricular function in scleroderma.

Scleroderma affects the left heart directly and indirectly via the effects of systemic hypertension. Using transthoracic echocardiography, we evaluated 35 patients with scleroderma and compared them with matched control subjects. Compared with controls, there were no differences between left ventricular dimensions, wall thickness, calculated mass or fractional shortening. However, the left atrium was enlarged (P = 0.006) and the mitral deceleration time was prolonged (P = 0.0005) in patients with scleroderma; suggesting abnormal diastolic function. After adjusting for potential confounders, duration of Raynaud's was found to be an independent predictor of deceleration time (P = 0.04), E/A peak velocity ratio (P = 0.04), A peak velocity (P = 0.004) and A velocity time integral (P = 0.0001), all measures of diastolic function. This group of individuals with scleroderma have evidence of abnormal diastolic function of the left ventricle despite normal left ventricular size and systolic function, and in the absence of hypertrophy. This finding is independent of the use of vasoactive medications and history of systemic hypertension, and thus may be due to primary myocardial involvement by scleroderma. The tendency to abnormal diastolic function of the left ventricle correlated with the duration of Raynaud's phenomenon.

Determinants of left ventricular hypertrophy and systolic dysfunction in chronic renal failure.

To evaluate determinants of left ventricular hypertrophy (LVH) and left ventricular (LV) systolic dysfunction in chronic renal failure (CRF), M-mode and two-dimensional echocardiography were performed in 38 undialyzed patients with CRF (serum creatinine > or = 3.4 mg/dL), 54 patients receiving continuous ambulatory peritoneal dialysis, 30 patients receiving hemodialysis, and 59 healthy age- and sex-matched volunteers. Left ventricular (LV) wall thickness and LV dimensions were greatest in dialysis patients, intermediate in CRF patients, and least in control subjects. LV mass index calculated from M-mode measurements was 78.7 g/m2 +/- 14.8 g/m2 in controls, 120.5 g/m2 +/- 28.7 g/m2 in CRF patients, and 136 +/- 45.0 g/m2 in dialysis patients (P < 0.0001). LV fractional shortening and LV velocity of circumferential shortening were lower in dialysis patients than in CRF patients and controls (fractional shortening 36.5% +/- 5.6% in controls, 36.2% +/- 7.2% in CRF patients, and 29.8% +/- 8.9% in dialysis patients; P < 0.0001). Echocardiography was normal in only 24 dialysis patients (29%) and 14 CRF patients (37%) (P = NS). Thirty-nine dialysis patients (46%) and 10 CRF patients (26%) had LVH (P = NS). Thirty dialysis patients (36%) and five CRF patients (13%) had LV systolic dysfunction (P < 0.05). LV hypertrophy with LV systolic dysfunction was present in 15 dialysis patients but no CRF patients (P < 0.05). There were no significant differences between hemodialysis patients and continuous ambulatory peritoneal dialysis patients in M-mode echocardiographic measurements or the frequency of LVH and LV systolic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholesterol-lowering and blood pressure effects of immune milk.

The plasma cholesterol-lowering and blood pressure effects of a skim milk powder (immune milk) produced from dairy cows hyperimmunized with a multivalent bacterial vaccine were assessed in a double-blind crossover study of hypercholesterolemic subjects who consumed daily 90 g immune milk or a normal product. There was a significant reduction in plasma total and LDL cholesterol of 5.2% (95% CI 2.5, 7.9) and 7.4% (95% CI 4.1, 10.7), respectively, with 10 wk of immune milk consumption compared with control, but no change in HDL cholesterol or triglycerides. A significant systolic and diastolic blood pressure-lowering effect (5 and 4 mm Hg, respectively) was also demonstrated. Thus, immune milk may be a useful adjunct in the dietary management of hypercholesterolemia and the mechanisms of its cholesterol-lowering and blood pressure effects warrant further study.

The heart of the matter.

Coronary heart disease deaths have declined in New Zealand, as in other Western countries, during the past two decades. This is probably due to a combination of population lifestyle changes and improved treatment of the disease. However, the social class gradient for coronary disease has reversed and it is now more common in lower socio-economic groups who are increasingly disadvantaged in our community. Socioeconomic factors are powerful, primary determinants not only of coronary disease but also of many of the other health problems outlined in the New Zealand Health Charter. Policy making and health services delivery shape societal conditions essential for true health. These factors are considered in relation to the spectrum of human communication and the current transitional changes in our health system.

Treatment of primary hypercholesterolaemia with simvastatin. New Zealand multicentre evaluation.

OBJECTIVE: To assess the efficacy of simvastatin in a large patient cohort. DESIGN: In an open multicentre study, after a four week placebo phase, patients were treated with simvastatin for 24 weeks; a subgroup continued therapy for a further 24 weeks. Efficacy of simvastatin (a) with prolonged use over three years, and (b) in combination with bezafibrate was assessed in an open single site study. SETTING: Lipid or cardiology specialist hospital outpatient clinics. PATIENTS: For the open multicentre study, 228 patients with primary hypercholesterolaemia (total cholesterol level greater than 6.5 mmol/L) were recruited, of whom 224 met entry criteria and completed the study. Forty-seven of these patients continued therapy for one year. In the open single site study, 22 patients (with low density lipoprotein [LDL] cholesterol levels greater than 4.3 mmol/L) participated in studies of long term use (n = 9) or of combined therapy (n = 13). INTERVENTION: Therapy in the open multicentre study began with 10 mg of simvastatin per day, doubling to 20 mg after six weeks and then 40 mg after 12 weeks of therapy if total cholesterol levels persisted above 5.2 mmol/L. In the study of long term use, simvastatin (40 mg daily) was taken continuously over three years. In the study of combination therapy, bezafibrate (600 mg daily) was taken in addition to simvastatin (40 mg daily) for 10 months. MAIN OUTCOME MEASURES: Plasma lipid and lipoprotein concentrations. RESULTS: In the multicentre study, total plasma cholesterol levels were reduced by 32.8% from 9.11 +/- 1.84 (in mmol/L, mean +/- SD) to 6.12 +/- 1.25 (P less than 0.001), and LDL cholesterol levels by 41.4% from 6.90 +/- 1.92 to 4.04 +/- 0.31 (P less than 0.001). The effect of therapy was sustained in those patients continuing therapy to 48 weeks. The study of long term use found no significant attenuation of effect over three years of monotherapy. Combined simvastatin/bezafibrate therapy reduced the LDL cholesterol concentration by a further 19.9% (P less than 0.001) from levels achieved on simvastatin alone. CONCLUSIONS: Simvastatin is an effective, well tolerated lipid lowering drug, without significant attenuation of effect with prolonged use. Simvastatin plus bezafibrate appears to be a potentially useful drug combination.

Endocarditis in the 80s in a general hospital in Auckland, New Zealand.

The clinical and investigative features of 102 episodes of infective endocarditis were analysed retrospectively. The most frequent presenting symptoms (malaise, fever, sweats, myalgia, weight loss) were non-specific. Fever, cardiac murmur, tachycardia, vascular phenomena and a change in mental state were the most common physical signs at admission. Anaemia was present in half the episodes and renal and liver dysfunction in about one-third. Streptococci (61) and staphylococci (31) were the causative organisms in all but 10 episodes. The commonest predisposing factors were underlying cardiac disease (52 per cent) and a preceding focus of infection (14.6 per cent). Left ventricular failure (33 per cent) and focal neurological disease (29 per cent) occurred frequently. Valvular surgery was performed in 20 episodes, with two in-hospital deaths. Overall hospital mortality was 27.5 per cent and death was most commonly neurological (11/28). A higher mortality was associated with elevated total white blood count, microscopic haematuria, renal or liver dysfunction at admission, S. aureus endocarditis, the development of left ventricular failure or focal neurological disease, age greater than or equal to 60 years and persistence of fever after one week of antibiotic therapy. The absence of both renal dysfunction at admission and subsequent microscopic haematuria identified a group with a very low hospital mortality (4.7 per cent). The three-year mortality of the entire group was 43.5 per cent.