Importance of immediate and very early postprocedural angiographic and thallium-201 single photon emission computed tomographic perfusion measurements in predicting late results after coronary intervention.

We examined prospectively the hypothesis that the adequacy of initial dilatation may be a major determinant of the late result of coronary angioplasty and that a better assessment of initial dilatation can be made from a combined angiographic and perfusion study than from angiography alone. Angiographic and perfusion (thallium-201 single-photon-emission computed tomography) measurements were made very early (18 to 24 hours) after coronary angioplasty in 59 patients (67 lesions) and also immediately (37 +/- 16 minutes) after the procedures in 19 of them (23 lesions). The early measurements, singly, in combination, and as a restenosis index (restenosis index = thallium-201 ischemic score (units) - minimal luminal area (squared millimeters) were examined as predictors of the late angiographic result. At late angiography (5.5 +/- 2.2 months after angioplasty), residual stenosis was related to the immediate and very early postangioplasty minimal luminal dimension, thallium-201 ischemic score, and restenosis index, and also to day-1 loss and lesion length. The combination of a normal result in the immediate or early thallium-201 perfusion study with a large ( > or = 2 mm) angiographic luminal dimension stratified a group of patients with better long-term results after angioplasty and a lower incidence of late restenosis (p = 0.03). The findings emphasize the importance of the initial procedure as a determinant of the late result of angioplasty.

Effect of age and training on aerobic capacity and body composition of master athletes.

Maximum oxygen uptake (VO2max) and body composition have been shown to deteriorate with age. How much of the decline is attributable to aging and how much is affected by reduced physical activity is not known. The purpose of this investigation was to determine the aerobic capacity and body composition of 24 master track athletes and to evaluate the relationship to age and maintenance of training over a 10-yr period. The subjects (50-82 yr of age) were retested after a 10.1-yr follow-up (T2). All continued their aerobic training, but only 11 were still highly competitive (COMP) and continued to train at the same intensity. The other 13 athletes studied became noncompetitive (post-COMP) and reduced their training intensity. The results showed the COMP group to maintain its VO2max and maximum O2 pulse while the post-COMP group showed a significant decline (54.2-53.3 vs. 52.5-45.9 ml X kg-1 X min-1; 20.7-20.8 vs. 22.4-20.0 ml/beat from test one (T1) to T2 for the COMP vs. post-COMP groups, respectively). Maximum heart rate declined 7 beats/min for both groups. Body composition showed no difference between groups from T1 to T2. For both groups body weight declined slightly (70.0-68.9 kg), percent fat increased significantly (13.1-15.1%), and fat-free weight decreased significantly (61.0-59.0 kg). Thus, when training was maintained, aerobic capacity remained unchanged over the follow-up period. Body composition changed for both groups and may have been related to aging and/or the type of training performed.

Work capacity and left ventricular function during rehabilitation after myocardial revascularization surgery.

A prospective randomized trial was conducted to evaluate the effects of exercise-based cardiac rehabilitation after myocardial revascularization surgery (MRS) on work capacity (measured in mets) and left ventricular function as determined from ejection fraction (LVEF). Twenty-eight patients undergoing MRS were randomly assigned to experimental (aerobic exercise, n = 19) or control (muscle relaxation and low-level exercise, n = 9) groups. Patients were studied before surgery (T1) and 2 (T2), 8 (T3), and 24 (T4) weeks after surgery with first-pass radionuclide angiography both while they were at rest and during maximal upright cycle ergometric exercise. Subsets of patients were also studied at T2, T3, and T4 at a standard workload of 75 W, and during maximal exercise 1 year after surgery (T5). Work capacity improved in both groups although significantly more so in the experimental group (3.9, 3.8, 6.0, and 7.3 mets and 3.7, 3.7, 4.9, and 5.7 mets at T1, T2, T3, and T4 in the experimental and control groups, respectively). The differences between groups were significant by T3. Peak exercise LVEF increased significantly in both groups from T1 to T2 then decreased at T3 and remained unchanged through T5. Peak exercise LVEF at T3 to T5 remained significantly above that observed at T1. LVEF responses were not related to the exercise program. During a standard workload, heart rate decreased, blood pressure increased, and LVEF did not change in either group. After conclusion of the formal protocol (T4), work capacity and LVEF did not change for either group throughout an additional 6 months (T5).(ABSTRACT TRUNCATED AT 250 WORDS)

Functional significance of chronotropic response during chronic amiodarone therapy.

Amiodarone, a potent antiarrhythmic agent, has been shown to depress sinus node function. Therefore, this study was undertaken to assess the effect of chronic amiodarone therapy on heart rate during graded exercise testing. 13 patients treated with amiodarone for ventricular arrhythmias were administered symptom-limited graded exercise testing before and 12 weeks after drug therapy. None of the patients had prior evidence of sinus node dysfunction. The mean resting heart rate (beats per minute; bpm) before and after amiodarone therapy was 75 +/- (SD) 13 versus 60 +/- 7 bpm, respectively (p less than 0.005), and the maximal heart rate was 135 +/- 30 versus 109 +/- 24 bpm (p less than 0.005). However, the change in heart rate from rest to maximum exercise (heart rate reserve) was not affected by the drug. Heart rate measured at comparable exercise levels before and during amiodarone therapy was 124 +/- 25 versus 104 +/- 31 (p less than 0.025). There was no change in the systolic blood pressure readings at these respective measured heart rates. Estimated maximal functional capacity before and after drug therapy was 4.9 +/- 1.8 versus 4.7 +/- 2.2 METs (p = NS). In conclusion, chronic amiodarone therapy significantly decreases heart rate at rest and during exercise without altering systolic blood pressure and functional capacity.

Evaluation of functional capacity during exercise radionuclide angiography.

This study compared functional capacity during treadmill exercise testing and during bicycle exercise radionuclide angiography. 262 patients performed maximal upright bicycle exercise and also performed maximal graded exercise testing using either the Bruce (n = 158) or Naughton (n = 104) treadmill protocols. The functional capacity was well correlated between bicycle and treadmill for Bruce (r = 0.89), Naughton (r = 0.93), or combined treadmill (r = 0.90) protocols. However, the functional capacity was significantly lower during bicycle than during treadmill testing for Bruce (8.3 vs. 10.5 METs), Naughton (7.8 vs. 8.7 METs), or combined treadmill (8.1 vs. 9.8 METs) protocols. Treadmill functional capacity could be predicted from bicycle functional capacity using the following equations: Bruce METs = 1.00 X (bike METs) + 2.23, Naughton METs = 0.94 X (bike METs) + 1.40, and combined treadmill METs = 0.98 X (bike METs) + 1.85.

Verapamil in effort-induced angina pectoris in patients with normal coronary arteries.

Two patients with classical effort-induced angina pectoris associated with abnormal ST-segment depression on graded exercise testing and normal coronary arteriograms are described. Both patients deteriorated during treatment with propranolol, and became asymptomatic during treatment with verapamil with normal graded exercise tests. Verapamil may thus improve an inadequate vasodilatatory response of the coronary vascular bed to effort.

Effects of propranolol on perceived exertion soon after myocardial revascularization surgery.

Effect of propranolol on perceived exertion soon after myocardial revascularization surgery. Med. Sci. Sports Exercise. Vol. 14, No. 4, pp. 276-280, 1982. This study evaluated the effects of propranolol on ratings of perceived exertion (RPE), heart rate (HR), and systolic blood pressure (SBP) during graded exercise testing of myocardial revascularization surgery patients before hospital discharge. Eighty-six men performed a symptom-limited, graded exercise test on a treadmill an average of 11 d after surgery. Patients were assigned to three groups: those not taking propranolol (no-propranolol group, N = 54), those taking propranolol (propranolol group, N = 22), and those exhibiting exertional hypotension during testing (hypotensive group, N = 10). Test results showed that estimated METs during peak exercise were similar for the three groups. The propranolol group demonstrated a lower HR for submaximal and peak exercise when compared with the no-propranolol group, but RPE was the same for matched exercise intensities. The hypotensive group failed to increase SBP during exercise, but perceived the matched exercise intensities to be the same as the other two groups. The HR response of the hypotensive group was similar to that of the no-propranolol group. Thus, an abnormal SBP response during exercise was not reflected in a changed RPE when compared with patients who increased SBP appropriately. It was concluded that propranolol does not affect RPE during graded exercise testing soon after cardiac surgery.

Diagnostic capabilities of exercise testing soon after myocardial revascularization surgery.

The purpose of this investigation was to compare data on early exercise testing for variables known to be of diagnostic/prognostic value following myocardial infarction in post-myocardial revascularization surgery patients. 70 patients were evaluated soon after surgery, by cardiac catheterization, moderate-intensity treadmill exercise testing, and rest and exercise radionuclide angiography. The results indicated no significant differences among groups with satisfactory and unsatisfactory results by catheterization compared for METs, peak heart rate, double product, ST-segment change, angina pectoris, and dysrhythmias. Significant differences were found among groups when rest and exercise ejection fraction and exercise-induced regional wall motion abnormality were taken into account. It was concluded that the moderate-intensity treadmill exercise test was ineffective in differentiating current cardiac function and arterial/graft status among postmyocardial revascularization surgery patients. Exercise radionuclide angiographic studies were able to identify groups of patients with adequate or inadequate postoperative cardiac catheterization results.

Cardiac rupture and ventricular septal defect in isolated right coronary artery disease.

A patient is described who had both ventricular septal defect and then cardiac rupture with death within 24 hours of the onset of acute posteroinferior myocardial infarction. At autopsy he was found to have single-vessel disease involving the right coronary artery. Isolated disease of the right coronary artery can produce unexpected, fatal mechanical complications.

Hydralazine in the management of symptomatic sinus bradycardia.

Hydralazine (Apresoline) was used to increase heart rate in 21 patients (14 hypertensive and 7 normotensive) suffering from symptomatic sinus bradycardia (SSB). Patients were assessed clinically and by 24-h ECG analysis before and after tailored increasing doses of the drug. Heart rates measured were resting (basal) rate, minimum rate during sleep, maximal rate during the day, and mean rate during the 24-h period (from hourly strips). The longest sinus pause or period of sinus arrest (when present) was also measured. Hydralazine ameliorated symptoms and produced a 20% or greater increase in heart rate in just under two-thirds of the hypertensive and half of the normotensive patients. Blood pressure decreased slightly in hypertensive but not in normotensive patients, and there were no important side-effects. Hydralazine appears to be a useful and effective drug to increase heart rate in patients with SSB.

Early calcification and obstruction of a mitral porcine bioprosthesis.

A patient is described in whom severe prosthetic valvular stenosis developed ten months after mitral valve replacement with an Angell-Shiley porcine heterograft. At emergency operation, calcification of the prosthesis was revealed. Early calcification and stenosis of a porcine heterograft valve is a life-threatening complication that must be recognized promptly and treated by emergency valve replacement.

Isolated circumflex coronary artery obstruction.

Isolated obstruction of the circumflex branch of the left coronary artery was present in 10 of 1,000 patients undergoing selective coronary angiography for suspected coronary artery disease. The clinical syndrome consisted of typical angina pectoris (six patients), atypical chest pain (three patients) and episodes of myocardial infarction (three patients). Left ventricular damage was mild, never involving more than 20% of the left ventricular circumference as measured during angiography. Left axis deviation was very common on the ECG. In eight patients, the ECG showed a mean frontal QRS axis of 0 degrees or less and in two, an axis of less than -30 degrees. The circumflex lesion typically occurred toward the end of the proximal third of the artery, often immediately after its major anterolateral marginal branch. Two patients had complete obstruction and eight had subtotal circumflex narrowing: the clinical picture was not differnet in these two subgroups. Overall left ventricular function, as measured by ejection fraction and left ventricular diastolic pressure, was normal in most of the patients. End-diastolic pressure was slightly increased in five patients, two of whom also had systemic hypertension.

Evaluation of the beta-blocking drug acebutolol in angina pectoris.

The effects of the beta-adernergic blocking drug acebutolol were studied in 23 patients with angina pectoris and angiographically documented coronary artery disease. Patients were evaluated clinically, by graded treadmill testing and by 24-hour Holter monitoring in the control state, after 2 weeks treatment with placebo, and after 2 weeks treatment with 600 mg. and then 1,200 mg. of acebutolol. Acebutolol (in a daily dose of 600 mg.) was an effective antianginal drug: the number of clinical attacks of angina pectoris (p less than 0.001) and the consumption of sublingual nitrate decreased (p less than 0.01), there was a significant increase in the treadmill effort tolerance as measured by the time to appearance of ischemic ECG changes (p less than 0.001) and the total work performed (p less than 0.001), and there was also a significant decrease in ischemic ST segment depression on 24-hour Holter monitoring. Treatment with 1,200 mg. acebutolol was associated with a further decrease in heart rate and a further improvement in effort tolerance on treadmill testing (p less than 0.05). On the large dose of the drug, however, there was no further clinical improvement, and no further improvement on 24-hour ECG monitoring; several patients complained of weakness and fatigue. Graded treadmill testing was an excellent objective method for assessing physical effort tolerance and its improvement after treatment with the beta-blocking drug. Twenty-four-hour Holter monitoring was a useful and complementary test, especially in patients who stopped exercising on the treadmill because of fatigue or weakness, and especially for assessing the efficacy of beta-blockade in controlling emotionally induced tachycardia and ischemia in the patient's own daily environment.

Co-existing aortic stenosis and secondary hypertrophic cardiomyopathy manifested by an hourglass left ventricle. Successful treatment with verapamil.

A patient with moderate aortic stenosis had severe hypertrophy and a typical hourglass appearance of the left ventricle. His effort-induced angina and dyspnea responded to treatment with verapamil. We suggest that the aortic stenosis resulted in secondary hypertrophic cardiomyopathy which may be treated by calcium antagonists.