Circadian blood pressure changes and cardiac geometry in essential arterial hypertension.

To study a relationship between ambulatory blood pressure (BP) and left ventricular geometry in mild to moderate arterial hypertension, 24 h ambulatory blood pressure monitoring (ABPM) at half-hourly intervals in the daytime and hourly at night (Spacelabs 90207) and echocardiographic examinations were performed in 60 hypertensives aged 42 +/- 7.9 years and in eight normotensives. The patients were subdivided into four groups according to the relative wall thickness (RWT) and left ventricular mass index (LVMI). Concentric remodelling was identified on the basis of increased RWT, eccentric hypertrophy in case of increased left ventricular mass, and concentric hypertrophy when both parameters were increased. Group I consisted of 15 patients with normal left ventricle; group II, 19 patients with concentric remodelling; group III, 7 patients with eccentric hypertrophy; and group IV, 19 patients with concentric hypertrophy. Analysis of correlations of maximal and mean systolic (SBP) and diastolic BP (DBP) values and BP variability with left ventricular mass and relative wall thickness revealed the strongest correlation in group IV between concentric hypertrophy and peak SBP in the entire 24 h and in the daytime, mean SBP in the daytime and SBP variability in the entire 24 h. No significant correlations were found in groups I, II, III or controls. In conclusion, SBP variability assessed non-invasively with ABPM correlates positively with left ventricular mass. BP variability seems insignificant for left ventricular geometry.

[Ventricular fibrillation in a patient with mitral valve prolapse syndrome]. / Migotanie komór u chorej z zespolem wypadania platka zastawki mitralnej.

A patient with mitral valve prolapse who had cardiac arrest as a result of ventricular fibrillation is described. After two weeks of unconsciousness all brain functions gradually improved and full intellectual efficiency was regained. Exact study of the case did not reveal any other possible reason for ventricular fibrillation but mitral valve prolapse syndrome.

[Silent myocardial ischemia in patients after myocardial infarction]. / Ciche niedokrwienie miesnia sercowego u chorych po przebytym zawale serca.

Twenty-six men and women, aged 36-65 years, were studied 8-12 weeks after the first myocardial infarction with regard to silent ischemic ST-segment depression and heart rate by using 24-hour ambulatory electrocardiography and bicycle exercise testing. In 22 patients ambulatory ST-segment recordings revealed 81 episodes of ST-segment depression, including 34 (41.9%) painful and 47 (58.1%) painless episodes. Mean maximal ST-segment depression during symptomatic and asymptomatic episodes was 3.6 +/- 1.0 mm and 2.4 +/- 1.1 mm, respectively (p less than 0.02). Painless episodes most frequently occurred between 06.00 a.m. and 12.00 a.m. Ambulatory monitoring revealed a twofold increase in painful episodes at heart rate below 100 beats/min, whereas at heart rate above 125/min painless episodes were more frequent. Exercise testing showed a sevenfold increased incidence of ST-segment depression also at heart rate above 125 beats/min. In conclusion, silent myocardial ischemia is a frequent event in patients shortly after the first myocardial infarction, and painless episodes occur particularly frequently at high heart rates. Episodes of silent ischemia are found more frequently during ambulatory ECG monitoring than exercise testing. Studies on silent myocardial ischemia may be particularly relevant in the detection of the risk of myocardial infarction.

[Thrombolytic therapy of myocardial infarction. Prognostic value of early reduction of elevation of ST segment]. / Zawal serca leczony trombolitycznie. Znaczenie rokownicze wczesnej redukcji uniesienia odcinka ST.

In-hospital mortality, infarction mass (estimated enzymatically) and electrocardiographic indexes (total ST-segments elevation, number of leads with R-wave presence and total R-waves amplitude) were assessed in 532 patients with acute myocardial infarction, randomized to two treatment groups: 272 treated with streptokinase (SK) and 260 with heparin (H). Echocardiographic contractility indexes (contractility disturbances area index, contractility disturbances index, left ventricle diastolic diameter) and heart volume estimated from X-ray film were also assessed. There were no significant differences in mortality and infarction area between the two groups. In 175 patients total ST-segments elevation was reduced by at least 50%, in the rest 340 patients this reduction was less significant. In the group with early elevated ST-segment reduction there were less in-hospital deaths (p less than 0.01), smaller infarction mass (p less than 0.0001) and significantly less disturbed electrocardiographic contractility indexes. Results suggest that simple electrocardiographic index, namely reduction of ST-segment elevation by 50% after 2 hours of treatment may be a useful prognostic tool, independent on treatment options, as far as in-hospital mortality, necrosis mass and left ventricle contractility disturbances are concerned.

[Localization of myocardial infarction with the help of EKG and two-dimensional echocardiography. Controversies]. / Lokalizacja zawalu serca za pomoca ekg i echokardiografii dwuwymiarowej. Kontrowersje.

A multicentre study of the localization of myocardial infarction (MI) using ECG and 2-dimensional echocardiography (Echo-2D) was performed on the 21st day of the onset of MI. The study population consisted of 650 pts (mean age 55.0 years), 553 males and 97 females. The purpose of the study was: 1) to compare the site of MI as diagnosed by ECG and Echo-2D, 2) to determine the controversies in the diagnosis between these two methods. Consistent results of both methods were obtained in 408 pts (62.8%) of the group. In 61 pts (9.4%) the diagnosis of MI by ECG and Echo-2D was undefined. In 181 pts (27.8%) the inconsistencies of ECG and Echo-2D evaluations were demonstrated; in 106 pts ECG changes were undefined, but evident Echo-2D changes were found; on the contrary, in 51 pts MI diagnosed by ECG was not confirmed by Echo-2D. In 24 pts entirely inconsistent results were shown. 209 pts (32%) with myocardial contractility disorders in the apical region of the heart diagnosed by Echo-2D showed different MI localisation as determined by ECG: 147 pts had anterior or antero-lateral MI, 28 pts--postero-inferior MI, 12 pts--apical MI and 22 pts--another one. By these findings it has been shown that ECG and Echo-2D are compatible methods but not replaceable ones.

[Use of nitroglycerin in the treatment of congestive heart failure]. / Zastosowanie nitrogliceryny w leczeniu zastoinowej niewydolnosci krazenia.

Nitroglycerin and its derivatives have become widely used agents in the treatment of severe forms of heart failure. Their beneficial effects in this disease results from their ability to reduce preload and afterload of the heart muscle leading to an increase of cardiac index, a decrease in mean pulmonary artery and wedge pressures as well as pulmonary and peripheral vascular resistances. This is associated with reducing the patients' complaints. Intravenous nitrates are used in the treatment of myocardial infarction complicated by an increased left ventricular filling pressure as well as in various forms of acute and worsening left ventricular failure, mainly in pulmonary edema. Oral and transdermal nitrates are administered in chronic congestive heart failure NYHA class III and IV.

[Pathological processes with accumulation of fluid in the pericardial sac]. / Procesy chorobowe przebiegajace z plynem w worku osierdziowym.

Fluid in the pericardial sac may accumulate due to transudate, inflammatory process in the pericardium, shunting of blood from the ventricles or large vessels into the pericardial cavity. The presence and amount of fluid is best evaluated by using echocardiography. Pathological fluid in the pericardial sac does not cause major hemodynamic disorders until the intrapericardial pressure is normal. This condition is treated mainly pharmacologically. An increase in the intrapericardial pressure and its equalization with the right and left ventricular diastolic pressure lead to cardiac tamponade which is characterized by decreased cardiac output and increased central venous pressure. Severe tamponade may result in cardiac arrest due to electromechanical dissociation. In lighter cases one can observe tachycardia, tachypnoe, fall in arterial blood pressure, rise in central venous pressure, paradoxical pulse. The patients complain of dyspnea and chest pain. Cardiac tamponade may be due to all causes of fluid accumulation in the pericardial sac, but most frequently it results from perforation or rupture of the left ventricle or aorta, and severe idiopathic, viral, uremic or neoplastic pericarditis. Therapy in cardiac tamponade consists of removal of the pericardial fluid by means of pericardiocentesis, pericardiotomy or pericardiectomy.

[Psychotherapy and pharmacotherapy: alternative or complimentary methods of treatment?]. / Psychoterapia i farmakoterapia: alternatywne czy komplementarne metody leczenia?

Controversial arguments of proponents and opponents of combining psychotherapy and pharmacotherapy are discussed. The authors argue that in some circumstances the combined treatment is optimal. However, its application requires high skills and knowledge of the therapists.

[Myocardial infarction in a patient with congestive cardiomyopathy]. / Zawal miesnia sercowego u chorego z kardiomiopatia zastoinowa.

A rare case of myocardial infarction developing in the course of congestive cardiomyopathy has been reported. The author describes diagnostic difficulties associated with the presence of combined heart diseases. The role of newer diagnostic methods (determination of CK-MB activity, Tl201 scintigraphy) has been pointed to in establishing the correct diagnosis. Marked worsening of the prognosis in congestive cardiomyopathy complicated by the infarction has been noted.

[Syncope as a cardiologic problem]. / Omdlenia jako problem kardiologiczny.

Syncope is a frequent clinical event. It is mainly caused by a suddenly reduced cerebral blood flow. There are two reasons for sudden cerebral underperfusion: cardiogenic - associated with cardiac disorders and neurocardiogenic - resulting from a sudden fall of arterial blood pressure due to impaired autoregulation of the circulation. Cardiogenic syncopes prevail in cardiac diseases associated with impaired blood flow and cardiac arrhythmias. They develop in aortic stenosis, hypertrophic cardiomyopathy, atrial myxoma, myocardial infarction, pulmonary embolism, cardiac tamponade. Cardiac arrhythmias associated with syncope include ventricular tachycardia, supraventricular tachycardia in the preexcitation syndrome, sinus bradycardia, II degrees and III degrees atrioventricular block, atrial fibrillation with rapid ventricular response. The prognostic value and pathomechanisms loss of consciousness in these disease states have been discussed. Neurocardiogenic syncopes include vasovagal syncope, carotid sinus syndrome, orthostatic hypotension, event-induced syncope. It is frequently difficult to establish the reason for syncope. Physical examination and a history should be taken first followed by noninvasive studies such as standard ECG, exercise testing, carotid sinus compression, Holter monitoring, tilt testing, signal-averaged ECG. Noninvasive diagnosis helps establish the cause of syncope in 53-62% of cases and is indispensable before proceeding to electrophysiological testing. Such testing should be limited to patients with organic heart disease, in whom previous examinations did not reveal the etiology of loss of consciousness.

[Isosorbide dinitrate treatment of silent myocardial ischemia in patients after myocardial infarction]. / Próba leczenia dwunitroisosorbitem cichego niedokrwienia miesnia serca u chorych po zawale serca.

In a group of 17 men and women aged 38-65 years (means = 51.1) three months after the first myocardial infarction we studied changes in silent ischemic ST segment depression by using Holter monitoring and exercise stress testing before and after 120 mg/daily of oral isosorbide dinitrate (Isoket). Repeated ECG monitoring and exercise stress test were performed after two weeks. It was found that before isosorbide dinitrate therapy 16 out of 17 patients had 56 episodes of ST segment depression of 1-5 mm including 6 (37.5%) symptomatic episodes and 10 (62.5%) asymptomatic episodes. The number of asymptomatic episodes after isosorbide dinitrate therapy decreased more than five times (p less than 0.001), their duration was three times shorter (p less than 0.01). ST segment depressions were also significantly smaller. During isosorbide dinitrate therapy the duration of stress test was almost doubled and the achievable heart rate increased (p less than 0.02; p less than 0.05). The magnitude of ST segment depression during exercise testing also decreased significantly (p less than 0.01) and at heart rate below 100 beats/min ischemic ST segment depression were not observed, in contrast to pre-treatment period. Thus it may be concluded that silent myocardial ischemia is a frequent event in patients after the first myocardial infarction and isosorbide dinitrate significantly decreases the number of symptomatic and asymptomatic episodes detected by Holter monitoring.

[Certain characteristics of myocardial infarction in young patients as compared with those over 65 years old]. / Niektóre odrebnosci zawallu serca u ludzi mlodych w porównaniu z grupa wiekowa powyzej 65. roku zycia.

Death rate due to myocardial infarction shows constantly growing tendency, especially in young subjects. This fact is even referred to as overmortality of young and middle-aged men. The aim of the present study was to evaluate certain clinical elements of myocardial infarction in young subjects. Out of 668 patients with acute myocardial infarction treated at the I Cardiac Department in Cracow from 1979 to 1988 a group of 102 patients (5 women, 97 men) below 45 years of age (mean = 40) was selected. The control group consisted of 241 patients with myocardial infarction, including 146 men and 98 women over 65 years of age (mean = 73). The following clinical date were analyzed: sex, presence of retrosternal pain and its aggravation, time from the onset of pain to hospitalization, anginal pain preceding the infarction and such complication as sudden cardiac arrest, pulmonary edema, cardiogenic shock, in-hospital deaths. The infarction in patients below 45 years of age occurred mainly in men. They experienced retrosternal pain more frequently than the elderly patients. It did not, however, affect the time of hospitalization. Serious complications of the infarction developed less frequently in younger patients and the in-hospital mortality was also lower in that group.

Silent myocardial ischaemia in Holter monitoring and exercise stress testing after a first myocardial infarction.

Silent ischaemic ST segment depression and heart rate changes during ambulatory 24 h electrocardiography and bicycle exercise stress testing were studied 8-12 weeks after the first myocardial infarction in 22 patients, aged 36-65 years (X = 50.2). During Holter monitoring it was found that 18 patients had 64 episodes of ST segment depression, including 27 (42.2%) symptomatic and 37 (57.8%) asymptomatic episodes. Mean maximal ST segment depression in painful and painless episodes was 3.5 +/- 1.1 mm and 2.4 +/- 1.2 mm (P less than 0.02), respectively. The mean maximal heart rate in symptomatic and asymptomatic episodes was 112 +/- 14.2 beats min-1 and 115 +/- 16.8 beats min-1 (NS), respectively. No significant difference was found in the duration of symptomatic and asymptomatic episodes. Ambulatory asymptomatic episodes were most frequent between midnight and noon (63.2%). It was observed that when heart rate was below 100 beats min-1 symptomatic episodes were twice as frequent during monitoring while during exercise testing ST segment depression at this heart rate occurred only in two cases. In contrast, there were more asymptomatic episodes at heart rate above 125 beats min-1 and exercise-induced ST segment depression were five times more frequent. One may conclude that silent ischaemia is a frequent phenomenon in the early period after the first myocardial infarction and asymptomatic episodes occur particularly frequently during rapid heart rate (over 125 beats min-1). Episodes of silent ischaemia are found more frequently during Holter monitoring than exercise stress testing.