Analysis of in-hospital deaths from myocardial infarction after coronary care unit discharge.

Clinical records of 48 patients who died suddenly and unexpectedly following coronary care unit discharge were analyzed. Twenty-five had myocardial infarction as sole cause of death and 23 had other contributing entitles. Patients with moderate to severe congestive heart failure had a higher total incidence of specific dysrhythmias in the coronary care unit compared to others. Large infarctions involving the anterior wall, especially in patients with moderate to severe heart failure in the coronary care unit, were negative prognostic factors. Serious dysrhythmias occurred with greater frequency in patients with moderate to severe congestive heart failure compared to others. Degree of congestive heart failure was not related to death among patients with atrioventricular block in the coronary care unit. Monitoring after the coronary care unit (Intermediate coronary care unit) may further reduce mortality.

Anxiety, anger, and neurogenic tone at rest and in stress in patients with primary hypertension.

To determine whether basal blood pressure or pressor responses to stress are related to sympathetic nerve tone or to psychological factors in hypertensives, 15 hypertensives and 13 normotensives were studied by mean of a self-administered questionnaire, isometric handgrip exercise (IHE), and the mental stress of serial subtraction. Plasma norepinephrine (NE), epinephrine (E), blood pressure (BP) and heart rate (HR) were measured before and at the end of IHE and mental stress. A greater number of hypertensives had suppressed anger (p less than 0.01) and scored higher on anxiety trait (p less than 0.01) and depression (p less than 0.05). Prestress (IHE and mental) BP and NE values were significantly greater in hypertensives (all p less than 0.01). During IHE, both groups had a significant increase of BP, HR, and NE (all p less than 0.01) but E rose in hypertensives only (p less than 0.05). The percentage change of BP, HR, NE, and E during IHE was similar in both groups. The changes of BP and HR were not related to NE or E. During mental stress, HR (p less than 0.01) and E (p less than 0.05) increased in both groups. However, BP (systolic and diastolic) increased in normotensives only (p less than 0.01). Plasma NE contents were unchanged in both groups. There were significant positive correlations of anxiety trait with systolic BP (p less than 0.05), diastolic BP (p less than 0.05), and NE (p less than 0.05) and E (p less than 0.05). Although hypertensives had increased neurogenic tone related perhaps to inward anger and anxiety, the percentage responses of neurogenic tone and BP to IHE were equivalent to those of normotensives. The challenge of serial subtraction did not elicit further noradrenergic or pressor responses in hypertensives. Suppressed anger and anxiety, via increased basal neurogenic tone, may be pathogenic factors in some patients with primary hypertension.

Effects of treadmill exercise on total and myocardial creatine phosphokinase.

The percentage of increase in total and MB creatine phosphokinase (CPK) after treadmill exercise was determined in 29 patients--ten patients with ST segment depression greater than 1 mm (group 1) and 19 patients with no ST segment depression (group 2). Values were determined pretest and 6, 12, and 24 hours after exercise. The mean exercise duration was 8 min, 18 sec. Total CPK increased within the normal range 12 hours after exercise in group 1 patients exercising less than 8 min, 18 sec, and in all patients exercising longer. The MB CPK remained unchanged after exercise in all patients. These data suggest that while normal range variation of total CPK occurs after treadmill exercise testing, the myocardium does not release MB CPK, regardless of the level of treadmill exercise our patients performed or the development of presumed ischemic ST segment responses. Abnormal elevation of MB CPK suggests myocardial damage.

Diastolic flutter of aortic valves in aortic regurgitation: a report of seven cases.

Seven patients with aortic regurgitation, manifesting diastolic flutter of the aortic valve cusps (DFAVC) in the echograms, are described. Five patients with infective endocarditis revealed coarse or fine, irregular DFAVC. Two patients with severe aortic regurgitation and a musical murmur manifested regular DFAVC with a frequency identical to that of a simultaneously recorded diastolic murmur. Of the 5 patients with infective endocarditis, 4 required urgent aortic valve replacement and 1 died. The 2 patients with musical murmurs are clinically stable without surgery. This report extends the clinical spectrum of patients with DFAVC and describes the character of the flutter in patients with muscial murmurs. Furthermore, it suggests that DFAVC is a sign of severe aortic regurgitation.

Recurrent myocardial infarction with patent coronary arteries.

Two separate episodes of severe chest pain occurred several years apart in a 25-year-old male patient with typical clinical findings of acute myocardial infarction with each episode. Cardiac catheterization following the second infarction confirmed the presence of myocardial dysfunction with apical akinesis and dyskinesis. Both coronary arteries were radiologically patent; however, there was evidence of probable recanalization of the right coronary artery. Several months later, the patient developed flank pain, hematuria, progressive renal failure, and cardiac decompensation, and died with intractable arrhythmias. At autopsy, a large apical mitral thrombosis was found and was the presumptive source of multiple systemic emboli.

Effects of nitroglycerin on supine and upright exercise in mitral stenosis.

Resting, supine, and upright exercise hemodynamics were studied in 11 patients with pure or predominant mitral stenosis before and after 0.4 mg sublingual nitroglycerin. Resting mean pulmonary wedge pressure was reduced from 27 +/- 1.6 to 21 +/- 1.6 mm Hg (p less than 0.001), while mean cardiac index (2.98 +/- 0.40 vs 2.68 +/- 0.30 cc/min/m2; NS) and mean heart rate (82 +/- 4.4 vs 87 +/- 6.7 bpm; NS) were unchanged after nitroglycerin. Resting mean left ventricular end-diastolic pressure dropped from 11 +/- 1.7 to 8 +/- 1.1 mm Hg (p less than 0.02) after nitroglycerin, while stroke index (37 +/- 5.1 vs 32 +/- 3.8 mm Hg; NS) was unchanged. Left ventricular systolic pressure fell from 122 +/- 6.0 to 111 +/- 3.1 mm HG (p less than 0.001) after nitroglycerin. At peak supine exercise similar qualitative changes were observed. Mean pulmonary wedge pressure was lower after nitroglycerin (43 +/- 2.3 vs 36 +/- 2.1 mm Hg; p less than 0.02), while cardiac index (3.62 +/- 0.39 vs 3.4 +/- 0.26 cc/min/m2; NS) and heart rate (116 +/- 7.1 vs 113 +/- 4.6 bpm; NS) were not different. Left ventricular end-diastolic pressure (13 +/- 1.4 vs 10 +/- 1.3; NS) was slightly but not significantly reduced by nitroglycerin. Left ventricular stroke index (34 +/- 3.4 vs 31 +/- 2.2 mm Hg; NS) was unchanged by nitroglycerin. Left ventricular systolic pressure (137 +/- 7.3 vs 127 +/- 6.1 mm Hg; p less than 0.02) was reduced 10 mm Hg at peak supine exercise after nitroglycerin. During upright exercise, peak heart rate (160 +/- 8.1 vs 160 +/- 8.0 bpm; NS) and peak systolic blood pressure (117 +/- 5.7 vs 112 +/- 2.8 mm Hg; NS) were not changed with nitroglycerin. Exercise duration was improved after nitroglycerin (5.02 +/- 0.62 vs 5.66 +/- 0.65 minutes; p less than 0.02). Thus sublingual nitroglycerin lowers mean pulmonary wedge pressure to reduce pulmonary congestive symptoms, improves supine exercise hemodynamics, and may enhance treadmill exercise duration in some patients with pure or predominant mitral stenosis.

Long-term effects of minoxidil therapy on renal function of patients with refractory hypertension: the significance of albuminuria.

The addition of minoxidil therapy reduced blood pressure effectively for 6--52 months (average, 24) in 25 of 28 patients with refractory hypertension. One patient was nonresponsive; 2 were noncompliant. Patients who had a serum creatinine up to 4 mg% and greater than 750 mg of albuminuria per day had further deterioration of renal function of 5.3 +/- 1.4% per month compared to that of 0.2 +/- 0.4% per month in patients without albuminuria (p less th5% was not as helpful predicting preservation of renal function in patients with refractory hypertension after adding minoxidil as was the absence of albuminuria.

Central and peripheral noradrenergic tone in primary hypertension.

The contents of norepinephrine (NE), epinephrine (E), dopamine (DA), normetanephrine (NMN), and 4-hydroxy-3-methoxyphenylethylene glycol (MHPG) were measured in the plasma and cerebrospinal fluid (CSF) of 66 patients with primary hypertension and 24 patients with normal blood pressure and minor neurological disorders. Plasma and CSF NE and NMN concentrations were raised in the hypertensive patients. The plasma and CSF NE levels and arterial blood pressure of a small subset of hypertensive patients were normalized after clonidine therapy. In hypertensive patients the content of DA was lower and the ratio of NE/DA was greater; CSF and plasma NE contents were related to the level of arterial blood pressure; and the content of MHPG in CSF was linked strongly with NE content in plasma and CSF and to the level of arterial blood pressure. Thus both central sympathetic nerve tone and peripheral sympathetic nerve tone were enhanced in young patients with uncomplicated hypertension. The elevated levels of neurohormones and their metabolites in some patients with primary hypertension may be related to increased synthesis and release of neural NE and may be pathogenic in the blood pressure elevation.

Central and regional normetadrenaline in evaluation of neurogenic aspects of hypertension: aid to diagnosis of phaeochromocytoma.

1. Free normetadrenaline concentrations in plasma of patients with phaeochromocytoma were elevated 20-1000-fold as compared with values in primary hypertensive subjects. 2. Spinal fluid normetadrenaline was 1.8-16% of the simultaneous plasma values in patients with phaeochromocytoma, whereas levels in spinal fluid exceeded those of plasma in primary hypertension. 3. Spinal fluid noradrenaline was 7.9-58% of simultaneous values of plasma noradrenaline in patients with phaeochromocytoma, whereas values in plasma and cerebrospinal fluid were similar in primary hypertension. 4. Plasma noradrenaline and normetadrenaline levels were both elevated in veins from regions subsequently found to harbour chromaffin tumours. 5. The excessive amounts of normetadrenaline produced in phaeochromocytoma enters plasma but not spinal fluid and can be used for diagnosis and localization of phaeochromocytoma.

Anger, anxiety, guilt and increased basal and stress-induced neurogenic tone: causes or effects in primary hypertension?

1. Basal plasma and spinal fluid noradrenaline were increased in patients with primary hypertension and phaeochromocytoma compared with normotensive patients (P less than 0.01). 2. Patients with primary hypertension had more anger (P less than 0.01), anxiety (P less than 0.01) and guilt (P less than 0.05) than normotensive patients or patients with phaeochromocytoma. 3. The responses of noradrenaline and adrenaline concentrations were similar after mental and isometric stress in primary hypertensive and normotensive subjects. 4. However, after mental stress and isometric exercise there were increased responses of plasma noradrenaline and systolic blood pressure respectively, in patients with high anxiety and anger compared with those below the 50th percentile (P less than 0.05). 5. Increased central and peripheral neurogenic tone at rest and after stress in association with increased anxiety and suppressed anger appear to be pathogenic factors in some patients with primary hypertension and may not be a result of the blood pressure elevation.