The effectiveness and tolerance of betablockers in elderly patients (> or = 70 years) with heart failure.

UNLABELLED: The beta blockers (BB) being less prescribed in elderly patients (P) with heart failure (HF), the aim of this study was to assess the effectiveness and tolerance of BB (meteoprolol, bisoprolol or carvedilol) given on the top of the conventional therapy in HF due to LV systolic dysfunction in P > or = 70 year (n=57, group 1) and < 70 year (n=101, group 2). Differences in baseline clinical characteristics between the 2 groups were not significant. The BB doses given in group 1 P was lower but the difference was significant for bisoprolol only. Intolerance to BB imposing withdrawal occurred in 12% of group 1 P and in 10% group 2 P (p>0.05). Symptomatic improvement expressed as a significant decreases in NYHA class was observed in both groups. Readmission for worsening HF was needed in 42% vs. 39% while 1 year mortality rate was 11.4% vs. 10.4% in group 1 and 2 P respectively (p>0.05). CONCLUSION: BB are tolerated and seem to be effective in most elderly P with HF. Therefore, BB should be tried in all HF P without contraindication irrespective of age.

[The treatment of hypertensive crisis with nifedipine as the basis]. / Tratamentul crizei hipertensive cu nifedipina în teren.

In 48 patients (p) with hypertensive crisis (HC) the effect of nifedipine (N) sublingual 10-20 mg alone (group I, n = 19, mean control AH +/- SD 232 +/- 15.3/132.5 +/- 4.9 mmHg) or associated with furosemide and clonidine (group II, n = 29, AT 249 +/- 21/131.8 +/- 13.6 mmHg). In both groups the AT fell significantly starting five minutes after the administration of N (except diastolic AT in group II); the values measured at 45 min. being 177 +/- 32/105.4 +/- 13 mmHg in group I and 164.6 +/- 44.4/100.1 +/- 16.3 mmHg in group II (the mean proportional difference at 45 min. for systolic AT was 24.6 +/- 11.4% in group I and 28.7 +/- 12.2% in group II; for diastolic AT 20.5 +/- 9.4% in group I, and 27 +/- 12.2% for group II). The good clinical results consisted of lowering of the AT values below critical levels and clinical improvement in 42 p (87.5%). Tolerance to N was good, in a single case was hypotension associated with fainting, both being promptly treated by simple means. CONCLUSIONS. 1. N administered sublingual, 10-20 mg, alone or associated with furosemide has in most patients a rapid hypotensive effect, lowering AT below critical limits within 45 min; 2. the drug is readily administered and without the risk of side effects and can be used in the field in the emergency treatment of hypertension.

[Echocardiographic parameters in the follow-up of left ventricular performance before and after the surgical correction of mitral and aortic regurgitation]. / Parametrii ecocardiografici de urmarire a performantei ventriculare stîngi, înainte si dupa corectia chirurgicala a regurgitarii mitrale si aortice.

The present study investigates 16 patients with aortic regurgitation (AR), and 10 patients with mitral regurgitation (MR). Before operation, all the 26 patients had increased telediastolic and telesystolic diameters. The patients were divided into two groups, as a function of the postoperative values of the telediastolic diameter: group A--with the telediastolic diameter within normal limits; group B--with the persistence of the increased values of the telediastolic diameter. In the case of the patients with AR, the following postoperative situation was noticed: in group A: the peak systolic stress (PSS) was increased, the shortening fraction (SF) in the telesystolic stress (TSS) within normal limits; in group B: PSS and TSS were increased, and ST depressed. 8 months after the valvular correction, in group A: PSS, TSS and SF were normal; in group B: the changes in PSS and TSS continued and was lowered. In the case of the patients with MR, before operation, in group A: PSS was slightly increased while TSS and SF were normal; in group B: PSS was slightly increased, TSS, increased and SF depressed. 8 months after the surgical correction: in group A: PSS and SF decreased; in group B: echocardiographic changes continued. Therefore, in the group B patients with MR and AR, the persistence of the increased values of PSS, TSS leads to the postoperative decrease of SF (post-charge in excess).

Clinical utility of plasma digoxin measurements.

The results of plasma digoxin concentration (PDC) measurements in 260 patients treated with digitalis lanata preparations (digoxin, lanatoside C, betamethyl-digoxin) allowed the following observations: 1. Owing to an important overlap between "toxic" and "nontoxic" PDC values, the method has a limited value in the diagnosis of digitalis toxicity. However, in patients with toxicity associated with PDC under 2 ng/ml, it allows identification digitalis sensitivity. 2. A dosage selection based on PDC assessment led to a decrease of digitalis toxicity under 4%. As the method is not widely available, it has to be used in patients with borderline renal function, in aged subjects and in patients with rapid atrial fibrillation who require higher digitalis doses for heart rate control.

The heart rate slowing effect of pindolol in patients with digitalis resistant atrial fibrillation and heart failure.

Heart rate (HR) slowing action and the possible negative inotropic effect of pindolol (P) (daily dose +/- standard error of the means (SEM): 14.7 +/- 1.6 mg) were studied in 12 patients with heart failure and with rapid atrial fibrillation (AF) resistant to effective beta-methyl dioxin (BMD) doses (mean plasma digoxin concentration +/- SEM: 2.05 +/- 0.17 ng/ml). Mild bicycle ergometer exercise test with the same work load was performed under both BMD and combined BMD--P therapy. Rest exercise and 5 minute recovery HR were significantly lower under combined BMD--P therapy than under BMD alone (80.8 +/- 3 vs. 101 +/- 4.5 beats/min, 123.8 +/- 3.9 vs. 155.8 +/- 7.6 beats/min and 84.9 +/- 2.6 vs. 105.1 +/- 4.5 beats min respectively, p less than 0.001, paired t test). Differences in cardiac volume were not significant (1.131 +/- 76 vs. 1.116 +/- 92 ml). Although all patients were clinically improved under combined BMD--P therapy the 13 to 14% increase in cardiac volume noted in 3 cases could be related to some negative inotropic effect of P. It is concluded that in patients with heart failure and with rapid AF resistant to digitalis, the association of P to digitalis is effective in rest- and mild-exercise HR control without a clinically expressed negative inotropic effect.

Exercise tests in labile hypertensive patients.

From a collectivity of 17,256 subjects below the age of 30 years, 80 subjects with labile hypertension (LH) were selected. The LH subjects were subjected to exercise test and the response of arterial blood pressure (BP) was followed up. The data obtained were compared with similar determinations carried out in a group of normotensive subjects. The mean value of systolic blood pressure (SBP) on exercise in the normal subjects was 171.0 +/- 2.9 mmHg and that of diastolic blood pressure (DBP) was 77.5 + 1.5 mmHg. The LH subjects presented, on exercise increases of both SBP and DBP in 35 cases (43.7%), increase of only SBP in 10 cases (12.5%) and "normal" type response in 35 cases (43.7%). In these subjects the mean value of SBP, on exercise, was 191.0 +/- 2.6 mmHg (p less than 0.001 as compared with the normal) and that of DBP was 90.0 +/- 1.9 mmHg (p less than 0.001 as compared with the normal). The above data proved that the LH subjects represented a group distinct from the normal subjects. The LH subjects presented a bimodal percent distribution of SBP and DBP on exercise, suggesting the existence of two subgroups one with "normal" type BP response the other with "hypertensive" type response. The BP response to exercise represents a simple test for the detection of abnormal BP increases. The authors consider as fully justified a longitudinal study of LH subjects. The exercise test might have a predictive value in detecting the early signs of essential hypertension.

Indication of cardiac surgery in infective endocarditis.

From the 33 patients with infective endocarditis (IE) hospitalized in the 1st Clinic of Internal Diseases, Timisoara between 1981 and 1984, in 5 (4 men and one woman) ranging in age from 21 to 52 years (mean 38) cardiac surgery was indicated and aortic (3) and mitral (2) valve replacements were performed. Valve replacement was performed for: 1) rapid/slow progressive hemodynamic deterioration with intractable congestive heart failure associated with ruptured chordae on posterior leaflet of mitral value (1 case); perforated aortic cusp (1 case); 2) prosthesis endocarditis (1 case); 3) precocious recurrence of IE (1 case); 4) uncontrollable infections (1 case). Echocardiography was helpful in all the cases by permitting recognition and evaluation of the preexistent lesions, and by the supplying of characteristic vegetations (all echocardiographic findings were confirmed by open heart surgery). Likewise it proved an accurate method in assessing pre- and post-operative left ventricular performance. In conclusion it is considered that early valve surgery in IE is indicated in hemodynamic deterioration, prosthetic endocarditis or impossibility to control septicemia. Echocardiography is the most useful noninvasive method for the pre- and postoperative evaluation of the patients investigated.

Clinical and echocardiographic spectrum of pericardial effusions in routine M-mode echocardiographic examinations of hospitalized patients.

In 123 (13.2%) out of 926 hospitalized patients pericardial effusions were diagnosed during routine M-mode echocardiographic examination. 53 (43.0%) presented a small (group 1), 31 (25.3%) a moderate (group 2) and 38 (31.7%) a great amount of fluid (group 3). Pericardial effusion could be diagnosed only by echocardiographic examination in 18 patients (34.0%) of the first group, in 8 (26.0%) of the second and in 7 (18.0%) of the third group. Routine M-mode echocardiographic examination in hospitalized patients allows the detection of small pericardial effusions often missed by conventional methods. This method also makes possible rapid diagnosis of pericardial effusion in cardiac patients in a critical condition or with haemodynamic disturbances sometimes difficult to identify.

M-mode echocardiography in hypertensive heart disease.

Left ventricular hypertrophy (LVH) is both a target organ response to hypertensive vascular disease and a factor that might be responsible for other cardiovascular events. Therefore we studied by means of echocardiography 41 patients with untreated hypertension classified into 4 groups according to electrocardiographic and chest X-ray LVH criteria. The patients in group IV had in addition a history of coronary disease. Thirty-seven patients (92%) presented concentric LVH and 4 patients combined LVH and dilatation. Five patients from group IV presented impairment of interventricular septum or posterior wall motion. Thirty-seven patients (92%) had increased left ventricular mass (p less than 0.01). Ejection fraction was normal in groups I, II and III but significantly decreased (p less than 0.001) in group IV. We conclude that LVH is part of the natural evolution of hypertensive vascular disease. Echocardiography proved to be the most indicated method for the assessment of cardiac dimensions and function in hypertensive heart disease.

Echocardiographic approach to the early diagnosis of congestive cardiomyopathies.

M-mode echocardiography was used to study left ventricular (LV) function in 25 patients with congestive cardiomyopathy (CC). Good discrimination of patients with CC from a control group of normal subjects was possible using echocardiographic parameters. Symptomatic patients (group II) with CC had a significantly larger LV end-diastolic diameter (LVED) than the asymptomatic ones (group 1) but the differences in the shortening fraction (SF), ejection fraction (EF), and mean velocity of circumferential fiber shortening (Vcf) were not statistically significant. Asymptomatic patients showed significant differences from normal in LVED, SF, EF and Vcf. End-systolic wall stress is a quantitative index of true myocardial afterload that can be plotted against LV end-systolic diameter to give an index of contractility independent of loading conditions. End-systolic wall stress in normal subjects (64.80 +/- 19.50 X 10(3) dyn/cm2) was significantly lower than in patients with CC (169.6 +/- 13.43 X 10(3) dyn/cm2). In conclusion the LV echocardiographic parameters can be conveniently combined to provide a good recognition and estimation of patients with CC, even in early stages.

Echocardiographic evaluation of left ventricular function before and after cardioversion of atrial fibrillation to normal sinus rhythm.

Echocardiographic measurements were obtained in 20 patients before cardioversion immediately after and two, four and six hours after cardioversion to normal sinus rhythm. At six hours after cardioversion there was no significant change in heart rate, left atrial diameters (LAD), left ventricular end-diastolic diameters (LVEDD) or left ventricular end-systolic diameters (LVESD). On follow-up one month to nine months after cardioversion, 14 of the 20 patients (70%) remained in normal sinus rhythm. Neither LAD, LVEDD, or LVESD, nor the presence or amplitude of the A-wave on the mitral valve echogram correlated with the persistence or normal sinus rhythm.