Effects of uncomplicated acute myocardial infarction on biochemical parameters of stress and sexual function.

The blood levels of several "stress indicators" (prolactin [PRL], growth hormone [hGH], total catecholamines, and adenosine 3',5'-cyclic monophosphate [cAMP]) were measured in men during the first 2 weeks of uncomplicated acute myocardial infarction (AMI) and during a 3-month follow-up period. PRL levels were significantly elevated during the first day, and hGH was elevated during the week after the AMI. The levels returned to the control baseline values thereafter. The levels of the total catecholamines and cAMP in blood remained normal throughout the study period. Sexual function during the 3-month follow-up was measured in 29 patients, using a specially designed questionnaire. Impotence was found in five patients and decreased libido in four. No correlation was noted between PRL values, the other stress indicators, and sexual dysfunction. A trend toward increased incidence of sexual dysfunction was found among patients with recurrent AMI.

Hypothermia and exsanguination in emergency cardiovascular surgery in children.

Emergency cardiac surgery in children can be successfully carried out even when cardiopulmonary bypass is either not feasible or not available quickly enough. Hypothermia induced with ice-water bags, complete circulatory arrest, near-total body exsanguination, and rewarming with a heating blanket and heating lamps, were used twice successfully in the repair of a ruptured aneurysm of the ascending aorta.

[Suspected acute coronary events in emergency room patients].

Identification of patients in whom chest pain is due to an acute coronary event is among the most challenging problems in emergency medicine. Because of the dangers of missing the diagnosis in patients with a possibly fatal condition, emergency room (ER) physicians often admit patients for 'observation' or 'to rule out MI.' As a result of such a policy, only 30-50% of such patients admitted to the CCU may finally be diagnosed as having an acute myocardial infarction (AMI), resulting in deleterious medical, psychological and economic consequences for the others. A series of 2280 patients who were referred to the ER was followed for 2 weeks. 1362 (59.7%) of those admitted were discharged; 16.1% were hospitalized in the CCU and 83.9% in medical wards. 95 (64.6%) of those hospitalized in the CCU and 97 (12.7%) of those admitted to medical wards had an AMI. The proportion of cases in which hospitalization was unnecessary was 10.2% in the CCU and 29.8% in the medical wards. Unjustified discharges from the ER were 4.3% of referrals. These data are similar to those reported from the USA and from our first study in 1969. It is hoped that by using a triage algorithm in the ER, differentiation between chest pain due to coronary heart disease and that due to other causes will be more accurate and therefore the demand on scarce resources due to unnecessary admissions will be substantially reduced.

Hour-glass deformity of the pulmonary valve: a third type of pulmonary valve stenosis.

In the 12 years from 1975 to 1987, 55 patients had open pulmonary valve surgery for isolated congenital stenosis of the pulmonary valve. Three types of pulmonary stenosis were seen: (a) dome-shaped pulmonary stenosis (34 patients); (b) dysplastic pulmonary valves with thick cauliflower-like cusps (12 patients), and (c) hour-glass deformity of the pulmonary valve, with "bottle-shaped" sinuses (nine patients). This third type has not been described before. Preoperative identification of the valve structure is important because the choice of treatment (balloon dilatation for some dome-shaped valves and excision for dysplastic and hour-glass valves) depends on the type of stenosis.

Haemodynamic effects of intravenous isosorbide-5-mononitrate in acute and chronic left heart failure of ischaemic aetiology.

Isosorbide-5-mononitrate was administered in a continuous intravenous infusion, according to the haemodynamic response, to 19 patients with left heart failure of ischaemic aetiology; 12 with acute heart failure complicating an acute myocardial infarction and 7 with chronic ischaemic failure. In both groups, the following statistically significant haemodynamic changes were observed: a decrease in PCWP from 25.4 +/- 4.6 to 17.2 +/- 4.6 mmHg; an increase in SWI from 19.1 +/- 10 to 23.6 +/- 13.1 gm m-2; a slight increase in cardiac index with no change in arterial pressure and only minimal decrease in vascular resistance. There were two major differences in the haemodynamic response between the patients with acute heart failure and those with chronic disease: (a) the duration of the effect of isosorbide-5-mononitrate on the PCWP was longer in the first group (mean, 8 hours, compared to 1.5 hours in the chronic group), and (b) the effect on afterload was more pronounced in the group with chronic ischaemic failure than in the first group. Thus, isosorbide-5-mononitrate administered by intravenous infusion under careful monitoring appears to have a beneficial role in the treatment of acute as well as chronic ischaemic heart failure.

Hemodynamics, circulating catecholamines and response to intravenous nitrate therapy in a specific subset of acute myocardial infarction: the hypertensive-hyperkinetic-coronary-active group.

A specific subset of acute myocardial infarction was defined and named 'the hypertensive-hyperkinetic-coronary-active' subgroup. This subgroup included patients with acute myocardial infarction without pump failure or hypovolemia who continued to have hypertension and tachycardia, after relief of pain and who also had at least two recurrent ischemic episodes in the first days after a transmural event. Fifteen patients belonging to this group (group A) were studied in comparison with 15 other patients with acute myocardial infarction complicated by pump failure (group B). The alterations in hemodynamics, in circulating catecholamine levels and the clinical course during an intravenous infusion of isosorbide dinitrate were evaluated and the data obtained in the two groups were compared. The patients in group A had tachycardia, hypertension and upper normal filling pressures (pulmonary capillary wedge pressures: 15.8 +/- 1.8 mm Hg). They had high levels of circulating catecholamines (1,343 +/- 407 ng/l), a cardiac output of 5.9 +/- 0.6 liters/min and stroke work index of 78 +/- 11 (mean +/- SD). The effect of intravenous nitrates on the left ventricular function curves of the two groups was the following: a marked shift downward and slight shift to the left in group A, as opposed to a moderate but significant shift upward and marked shift to the left in group B. The episodes of recurrent ischemia subsided in 13 out of 15 patients from group A. It appears therefore that the hyperkinetic patients with acute infarction are characterized by a hypersympathetic response, a typical hemodynamic profile and a particular response to nitrate therapy directionally opposite to the changes obtained in patients with acute infarction complicated with failure.

Carbon dioxide laser effect on platelet function and surface ultrastructure in vitro.

Platelet aggregation may be an important factor in the feasibility of transcatheter laser angioplasty. The in vitro effects of increasing doses of CO2 laser irradiation on platelet number, function, and surface ultrastructure were examined. Results indicated a progressive dose-response reduction of both platelet number and function following laser irradiation. By scanning electron microscopy the irradiated platelets showed dose-related changes in pseudopods as well as progressive damage of the cell membrane.

Calcium antagonists--adverse drug interactions.

In the clinical management of heart disease, calcium channel blockers are generally prescribed in combination with one or more anti-angina, antiarrhythmic, or antihypertensive agents. Two different mechanisms are involved in drug interactions: pharmacokinetic and pharmacodynamic. In the former, the disposition of one drug is altered by the action of another, causing an increase or decrease in its absorption or its modified distribution, metabolism, or excretion. In pharmacodynamic interactions, the physiologic effects of one drug interfere either directly or indirectly with those of another, for instance, by alterations in fluid or electrolyte balance. This effect may be antagonistic or additive. The present work outlines the possible adverse interactions between the three main calcium antagonists and other therapeutic agents, including digoxin, beta blockers and antiarrhythmic, anesthetic, antihypertensive, antiasthmatic, and antidiabetic drugs and contrast media. Knowledge of these effects is of major clinical importance in the treatment of cardiac patients.

Hemodynamic effects of oral isosorbide-5-mononitrate and dinitrate in ischemic heart failure.

Isosorbide-5-mononitrate (ISMN), the main metabolite of isosorbide dinitrate (ISDN) was recently introduced in clinical use. The hemodynamic effects of oral ISMN and ISDN, administered in equal doses, were studied in a randomized, crossover fashion in 20 patients with pump failure of ischemic etiology. Baseline hemodynamic criteria for admission into the study were: pulmonary capillary wedge pressure (PCW) of at least 20 mmHg and systolic arterial pressure (AP) above 90 mmHg. Hemodynamic parameters were serially measured and systemic vascular resistance was calculated up to 6 h postadministration of either ISMN or ISDN single dose (40 mg). Maximal effects obtained were statistically significantly different from baseline. While ISMN and ISDN appeared to be equipotent in reducing the filling pressure, with a maximum effect reached in 60-120 min, the mononitrate maintained its effects for a longer period.

Alpha-tocopherol: effect on plasma lipoproteins in hypercholesterolemic patients.

This study was designed to examine the hypothesis that dl-alpha-tocopheryl acetate (vitamin E) increases the level of high-density lipoprotein cholesterol (HDLC) with a concomitant decrease of the ratio of total cholesterol/HDLC and a resultant amelioration of the coronary risk profile. Vitamin E (500 IU/day) or placebo were administered under double-blind randomized allocation to 69 hypercholesterolemic patients for 3 months. Sixty patients completed the study (30 in the active treatment group and 30 in the placebo group). Vitamin E raised the mean level of HDLC from 1.39 +/- 0.38 (SD) to 1.58 +/- 0.41 mmol, a 13.6% increase. This increase significantly (P less than 0.05) exceeded a parallel smaller increase of only 0.05 mmol (3.8%) in the placebo group. As total cholesterol (TC) declined by similar proportions in the vitamin E (7.8%) and placebo (9.4%) groups, a concomitant reduction of 23% in the TC/HDLC ratio was achieved in the vitamin E group, significantly exceeding a 9.1% reduction under placebo. Significant beneficial effects were noted on apolipoprotein (Apo) A (which rose) and Apo B (which declined). An increase of Apo A/Apo B ratio by 17.9% was observed only in the vitamin E group. These results suggest that the oral administration of vitamin E (500 IU/day) is beneficial in hyperlipoproteinemia and offers a potential tool for treating the increased coronary heart disease risk.

Enhanced risk of coronary heart disease mortality in lean hypertensive men.

A recently presented hypothesis contends that the excess coronary heart disease mortality associated with hypertension is more prominent in lean men than in overweight men. This hypothesis was addressed using data collected in the Israeli Ischemic Heart Disease Study (n = 10,059). The ratios of age-adjusted 15-year death rates in hypertensive and normotensive men were 4.7, 2.8, 2.0, and 1.9 in the Quetelet index groups of less than 2.29, 2.29 to 2.56, 2.56 to 2.83 and greater than 2.83 g/cm2, respectively. The corresponding ratios for all-cause mortality were 2.2, 2.1, 2.0, and 1.7, respectively. The group with the highest all-cause age-adjusted mortality, at 33.6%, was that of the leanest (less than 2.29 g/cm2, bottom 20% of the Quetelet index distribution) hypertensive subjects. The same group also displayed the highest coronary heart disease mortality (age-adjusted rate, 18.2%). The findings persisted for both smokers and nonsmokers and after exclusion of men with coronary heart disease or diabetics at intake, men on antihypertensive medication, or those who died in the first 2 years of follow-up (1963-1965). A multivariate risk score for developing myocardial infarction was calculated, based on levels of age, systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, cigarette smoking, diabetes mellitus, and Quetelet index. This score varied little across the four Quetelet index groups in hypertensive men: 5-year mean estimated risks of myocardial infarction were between 70 and 74/1000. In normotensive men the scores increased from 19/1000 in the leanest subjects to 29/1000 in the overweight ones.(ABSTRACT TRUNCATED AT 250 WORDS)

Distributions of total cholesterol, triglycerides, and high-density lipoprotein cholesterol in Israeli Jewish children of different geographic-ethnic origins, ages 9-17 years.

To determine age and ethnic patterns of blood lipid levels in childhood and adolescence and to extend previous adult and late adolescent Israeli data to prepubertal ages, the levels of plasma total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) were determined among 1,153 schoolchildren in the area of Petah-Tikva. Half of the children were born to immigrants from Yemen. Among boys, TC levels progressively decreased as age increased from 10-11 to 14-15 years (159 to 142 mg/dl). The age-specific TC and HDL-C means among boys are compatible with an initial swift fall with age, followed by a rise restricted to TC during puberty. Among girls, progressively lower means through ages 12-13 and increasingly higher ones for older age groups are also compatible with puberty-determined changes, previously observed in American cohorts. The differences in TC were only partly accounted for by lower HDL-C means at higher ages (52 mg/dl in the youngest and 45 mg/dl in the oldest age group, respectively, among boys, compared with 53 mg/dl for girls at both ages 9 and 16-17). TG levels in boys, but not in girls, showed age differences paralleling those found for HDL-C, but in an inverse direction. TC means were lower as age increased only among female offspring of European-born Jews (159 to 148 mg/dl, ages 9-12 compared with ages 13-17), a phenomenon that requires further study. Overall, TC and HDL-C were clearly higher among girls than boys beginning at ages 12-13, with little or no sex differences in TG. The sex differences in TC, contrary to previous studies, were not fully accounted for by HDL-C sex differences. The ethnic variability paralleled previous findings in Israeli adults and adolescents, showing low TC levels among male offspring of Yemenite and other Asian-born fathers. The ethnic differences among girls were small. No specific pattern of age-related lipid changes was found in the group of Yemenite origin, who represented offspring of parents with notoriously low levels of coronary heart disease incidence.

High-density lipoprotein cholesterol: correlation with biochemical, anthropometric, behavioral, and clinical parameters in 6,500 Israeli men.

Correlations of high-density lipoprotein cholesterol (HDL-C), expressed in either absolute or relative terms, with a series of coronary risk factors and other variables were examined in the Israeli Ischemic Heart Disease Study sample. The Quetelet overweight index showed the highest correlations with HDL-C (r = -0.21) as well as with HDL-C as a percentage of total cholesterol (TC) (HDL/TC; r = -0.28). Additional negative inverse associations were statistically different from zero but small. High-density lipoprotein cholesterol and HDL/TC were significantly reduced in cigarette smokers, and HDL/TC was significantly reduced in men with myocardial infarction or angina pectoris and (albeit marginally) in diabetes mellitus as well. The presence of these diseases correlated poorly with HDL-C (absolute values). The associations of HDL-C and HDL/TC with the Quetelet index persisted after adjustment for cigarette smoking and vice versa. Reported dietary intake failed to explain HDL-C or HDL/TC variability among individuals. The "net" relationship of HDL-C to several variables was examined in a multiple regression analysis. The Quetelet index accounted for 0.21 of a multiple correlation coefficient of 0.28 (i.e., a very small proportion of explained variability). This magnitude is of an order similar to multiple correlations found in our study for total cholesterol, systolic blood pressure, and serum uric acid. It indicates that our knowledge of the determinants of HDL-C in adults is insufficient. The possible roles of several anthropometric and behavioral variables in determining HDL-C levels are considered, as is the possible genetic factor in dictating interindividual HDL-C variability.

Two-dimensional echocardiographic analysis of proximal left main coronary artery in humans.

The left main coronary artery (LMCA) was evaluated in 100 consecutive patients (88 men and 12 women; mean age 63 years) with anginal syndrome, all in New York Heart Association classes II and III. Each patient underwent two-dimensional echocardiography (2DE) from the parasternal short-axis and apical four-chamber views. Coronary angiography was subsequently performed within 24 hours. The LMCA was directly measured by 2DE and coronary angiography at its widest point. Each echocardiogram was blindly evaluated for LMCA aneurysm or obstruction. Eight patients (8%) were excluded because of inadequate visualization of the LMCA. The mean 2DE measurement was 4.4 +/- 0.9 mm vs 4.2 +/- 0.8 mm on coronary angiography (r = 0.86). Atherosclerotic aneurysms of the LMCA were correctly diagnosed in two patients by 2DE. LMCA stenosis (greater than 50%) was found in 11 patients on coronary angiography; three of them had ostial or proximal lesions, three had middle lesions, and five had distal lesions. 2DE correctly diagnosed all three ostial lesions, two of three middle lesions, but only two of five distal lesions. In four patients, dense echoes in the LMCA caused a false positive diagnosis. It was concluded that: the LMCA can be visualized and correctly measured by 2DE; atherosclerotic aneurysms can be detected; and 2DE is yet unable to screen patients for LMCA lesions; however, 2DE is a promising method for evaluating proximal and especially ostial LMCA stenosis.

Myectomy versus myotomy as an adjunct to membranectomy in the surgical repair of discrete and tunnel subaortic stenosis.

The results of membranectomy and deep myectomy in the left ventricular outflow tract were compared to those of membranectomy and myotomy in 42 patients who underwent surgical repair of discrete and tunnel subaortic stenosis. Fifteen consecutive patients (Group A) underwent membranectomy and myotomy, and 27 consecutive patients (Group B) underwent membranectomy and myectomy. Two patients of Group A and nine of Group B had tunnel subaortic stenosis. The preoperative mean (+/- standard deviation) peak systolic gradients across the left ventricular outflow tract in patients with discrete subaortic stenosis types I and II were 64 +/- 29 mm Hg in Group A and 52 +/- 3 mm Hg in Group B (p = not significant). In the patients with tunnel subaortic stenosis the preoperative mean gradients were 97 +/- 74 mm Hg in Group A and 73 +/- 26 mm Hg in Group B (p = not significant). In patients with discrete subaortic stenosis types I and II, postoperative catheterization at a mean follow-up of 21 months revealed residual mean gradients of 29 +/- 24 mm Hg in Group A and 10 +/- 13 mm Hg in Group B (p less than 0.01). In the patients with tunnel subaortic stenosis, the postoperative mean gradients were 25 +/- 7 and 30 +/- 30 mm Hg in Groups A and B, respectively (p = not significant). We conclude that in the surgical management of discrete subaortic stenosis types I and II, deep myectomy (in addition to membranectomy) produces better relief of the left ventricular outflow obstruction than do membranectomy and myotomy. In patients with tunnel subaortic stenosis myectomy is less effective than in the non-tunnel type but still produces acceptable results and may delay radical procedures to a later age.

Changes in systemic vascular resistance detected by the arterial resistometer: preliminary report of a new method tested during percutaneous transluminal coronary angioplasty.

A recently developed apparatus provides on-line continuous monitoring of systemic vascular resistance (SVR) by means of simple computer analysis of the peripheral arterial waveform. The fundamental equation of this method is Ri = P'/(dP/dt), where dP/dt is the peak dP/dt of the peripheral arterial waveform, P' is the pressure at time of peak dP/dt, and Ri is a resistance index that bears a direct relation to SVR. Eleven patients undergoing percutaneous transluminal coronary angioplasty (PTCA) were studied to evaluate the changes in SVR associated with myocardial ischemia (angina detection). There were 49 balloon inflations, all of which were associated with an increase in Ri (from 38.4 +/- 12 to 81.2 +/- 36 X 10(-3) sec; p less than .01) and a decrease in dP/dt (from 2076 +/- 257 to 1327 +/- 326 mm Hg/sec; p less than .01). In 42 of the balloon inflations these changes were associated with electrocardiographic ST-T changes and in 23 it was also associated with anginal pain. When angina was present, a further increase in Ri (to 97.5 +/- 43 X 10(-3) sec; p less than .01) and a decrease in dP/dt (to 1218 +/- 338 mm Hg/sec; p less than .01) was observed. It was found that myocardial ischemia is associated with an increase in the resistance index and a decrease in dP/dt and can be detected by the resistometer.