Effects of exposure to altitude on men with coronary artery disease and impaired left ventricular function.

The effects of altitude on coronary patients with impaired left ventricular function are virtually unknown and the question arises whether an exposure to altitude poses a risk to such patients. Twenty-three patients with coronary artery disease (mean age 51 +/- 9 years; group H) with a mean ejection fraction of 39 +/- 6% were compared with 23 normal subjects (mean age 53 +/- 6 years; group N). Both groups underwent a maximal symptom-limited bicycle stress test at 1,000 m and 2 days later at 2,500 m. In both groups, exercise capacity decreased significantly (group H, 1,000 m 162 +/- 28 W, 2,500 m 155 +/- 28 W, p = 0.02; group N, 1,000 m 205 +/- 28 W, 2,500 m 198 +/- 25 W, p = 0.02). Maximal heart rate and blood pressure did not differ between 1,000 and 2,500 m; oxygen saturation at rest and during exercise remained unchanged. At 2,500 m, the test was terminated more often because of dyspnea, but the level of perceived exertion (Borg) was similar to that at 1,000 m. There were no complications or signs of ischemia. Thus, patients with coronary artery disease with impaired left ventricular function without residual ischemia have good tolerance to exposure to altitude. The effects in patients are comparable to those in a group of normal subjects and the risk for an adverse event is not increased.

[Perioperative myocardial infarction and cardiac complications after noncardiac surgery in patients with prior myocardial infarction. II: Perioperative long-term ECG--clinical relevance practicability]. / II: Perioperatives Langzeit-EKG--Klinische Relevanz und Praktikabilität.

UNLABELLED: Perioperative, mostly silent ischaemia in patients with coronary heart disease is difficult to detect by clinical examinations. METHODS: During the clinical evaluation (part I of this study) we monitored patients with prior myocardial infarction (MI) by continuous electrocardiographic (ECG) recording from the evening before until the first 24 h after operation. Excluded from Holter ECG studies were patients with a bundle branch block, pacemaker, valvular heart disease, cardiomyopathy, severe hypokalaemia, and digitalis treatment. Data were recorded with a Holter 8500 recorder (Marquette Electronics) using modified V2, V4, and V5 leads (Fig. 1). Holter tapes were analysed twice with a Holter computing system (Software 5.8, Marquette Electronics), first by a blinded technician and then by the authors themselves. We defined the following criteria as pathological ST segment changes and as ischaemic episodes [7]: horizontal or down-sloping ST depression of at least 1 mm or elevation of 2 mm of at least 1 min duration measured at the J-point plus 60 ms. To quantify individual levels of ischaemia we used the definition "ischaemic load" [3]: ischaemic min/h monitored per patient. The statistic evaluation did not differ from that used in part I. RESULTS: Out of 160 patients, 100 could be examined by Holter monitoring. Because of technical problems we could not record a Holter ECG in 2 of 6 patients with reinfarction. We found one or more perioperative episodes of ST-segment depression in 25 patients (25%). Ischaemic episodes were detected in 15 patients preoperatively, in 12 intraoperatively, and in 10 postoperatively. Three patients had ischaemic episodes during all periods. Patients with pathological ST segments suffered significantly more reinfarctions (3 of 25 vs. 1 of 75 patients) and were older (mean age difference 7 years, P < 0.05). Patients with ischaemic episodes and a clinical diagnosis of reinfarction (n = 3) demonstrated a dramatic postoperative increase in ischaemic load. Preoperative use of beta-blocking agents did not influence the incidence of ischaemic events. The sensitivity of postoperative Holter ECG monitoring in the diagnosis of reinfarction was 50%, the specificity 92%. CONCLUSIONS: Perioperative Holter ECG monitoring is time-consuming, expensive, not very sensitive, and therefore not generally applicable for all patients with prior MI.

[Sports and rehabilitation in old age]. / Sport und Rehabilitation im Alter.

Cardiac rehabilitation of older patients aims at restoring physical aptitude as well as possible and at preserving independence. Prognostic aspects are less important than symptomatic relief. A formal rehabilitation program is indicated in adjunction to revascularization procedures and in cases, where a closer medical supervision is warranted. Exercise guidelines for persons older than 65 years should include prescriptions for endurance training of moderate intensity and an exercise program to enhance flexibility and coordination. Weight training at 40 to 60% of maximal voluntary contraction to support muscle-strength is feasible and useful even in frail persons, whereas sports with high impact of technical skills and speed are not advisable. Such training prescriptions will allow to maintain physiological and psychological function and will thus enhance the quality of life of older patients.

[Heart patient and sports]. / Herzpatient und Sport.

Patients with heart disease may benefit from scheduled exercising in different ways. Exercise tolerance is increased, risk factors are controlled, and even progression and regression of coronary artery disease can be influenced by training and diet. Psychological effects include lessened depression and reduced anxiety. Overall, regular physical activity is important for maintenance of health and may lead to a better quality of life. In order to minimize the risk of training, the patients should be provided with guidelines for exercising by the physician. Activities should include dynamic endurance exercises and properly selected calisthenics (without a need for high technical skills). Circuit weight training of moderate intensity is helpful for promoting muscle strength. Training has to be followed not less than 2 to 3 hours per week in at least three sessions at an intensity corresponding to 60 to 85% of the maximum heart rate achieved in a symptom-limited maximum exercise-test. Cardiac patients at high risk (decreased left ventricular function, persisting ischaemia, low exercise capacity, severe symptoms, older age) should exercise at lower intensities.

Psychosocial factors predict medical outcome following a first myocardial infarction. Working Group on Cardiac Rehabilitation of the Swiss Society of Cardiology.

BACKGROUND: The aim of this study was to identify psychosocial variables that, in addition to known medical factors, predict the long-term outcome after a first myocardial infarction. PATIENTS AND METHODS: The study population consisted of 222 men aged 30-60 years who entered an inpatient rehabilitation program a mean of 7 weeks after a first myocardial infarction. Medical data and completed questionnaires for psychosocial variables were obtained from the patients and their family physicians at entry to the rehabilitation center and 1 year later. Further data, including answers to a detailed questionnaire, were collected at the beginning of rehabilitation and after one year; this follow-up was 99% complete. RESULTS: The 1-year mortality was 2.2%, the reinfarction rate 1.8%, hospital readmissions for cardiac reasons occurred in 25%, and 13% of the patients underwent a subsequent revascularization procedure. At baseline and after 1 year, respectively, 84 and 83% of the patients were asymptomatic. A poor medical outcome, defined as death, reinfarction, severe symptoms or poor exercise capacity, was seen in 9% of the patients. The most important physiological predictors for an unfavourable medical outcome, found in bivariate and multivariate analyses, were age, severity of infarction, and major coronary risk factors. In addition, some of the psychosocial variables were significantly related to a poor medical outcome: lack of a stable partnership, high work load, poor general well-being with multiple chronic non-specific health complaints, and a low external locus of control (failure to identify disease-promoting factors within own surroundings or lifestyle). CONCLUSIONS: The medical course of coronary artery disease was predicted not only by medical variables but also by psychological and social variables. As well as being addressed directly, these factors may help to identify patients who need to be followed more closely, so that medical complications can be reduced by treating early signs of disease progression more aggressively.

Deletion of the structural gene for the NADH-dehydrogenase subunit 4 of Synechocystis 6803 alters respiratory properties.

Chloroplasts and cyanobacteria contain genes encoding polypeptides homologous to some subunits of the mitochondrial respiratory NADH-ubiquinol oxidoreductase complex (NADH dehydrogenase). Nothing is known of the role of the NADH dehydrogenase complex in photosynthesis, respiration, or other functions in chloroplasts, and little is known about the specific roles of the perhaps 42 subunits of this complex in the mitochondrion. Inactivation of a gene for subunit 4 (ndhD-2, ndh4) of this complex in the cyanobacterium Synechocystis 6803 has no effect on photosynthesis, judging from the rate of photoautotrophic growth of mutant cells, but the mutant's respiratory rate is about 6 times greater than that of wild-type cells. Respiratory electron transport activity in cyanobacteria is associated both with photosynthetic thylakoid membranes and with the outer cytoplasmic membrane of the cell. Cytoplasmic membranes of mutant cells have much greater NADH-dependent cytochrome reductase activity than preparations from wild-type cells; this activity remains at wild-type levels in isolated thylakoid membranes. It is suggested that the 56.6-kD product of ndhD-2 is not essential for the activity of a cytoplasmic membrane-bound NADH dehydrogenase but that it regulates the rate of electron flow through the complex, establishing a link between this ndh gene and respiration. The activity of the molecularly distinct thylakoid-bound NADH dehydrogenase is apparently unaffected by the loss of ndhD-2.

[Regression of coronary atherosclerosis: possible--and clinically relevant?]. / Regression der Koronaratheromatose: Möglich--und von praktischer Bedeutung?

Several recent clinical trials have shown that in male patients with stable coronary heart disease, progression of atherosclerosis can be delayed even in short time. The interventions to bring about less progression and even a regression of coronary artery lesions mainly consisted in lowering high lipid levels, either with drugs, partial ileal bypass surgery or comprehensive lifestyle changes. The results of trials using calcium antagonists were less consistent and failed to show clear-cut slowing or prevention of progression. Some questions, however, arise and are discussed: i.e. the shortcomings of quantitative angiography to assess the extent of atherosclerotic lesions and the clinical importance of the observed changes in luminal diameter, which tended to be small. Despite these intriguing issues, the reported studies provided the additional information that the angiographically demonstrated benefits were paralleled by a reduction of clinical vascular events and an improvement of the short-term clinical outcome.

[Intramural rehabilitation following infarction]. / Die stationäre Rehabilitation nach Infarkt.

Major objectives of a comprehensive cardiac rehabilitation include not only an increased functional capacity by physical training with aerobic exercise as a cornerstone, a reduction in morbidity and mortality by secondary preventive measures and a rapid return to work, but also an improvement in subsequent quality of life. Different forms of rehabilitation programs may be equally successful: a four-week institutional rehabilitation course or an outpatient rehabilitation program with 2 to 3 weekly training sessions for 3 to 6 months. If the guidelines for graduated activity are respected, the training bears a low risk. Patients with low exercise capacity for cardiac, vascular or other reasons, as those otherwise handicapped, should not join a formal rehabilitation program, but should be followed on an individual basis. In those patients as well as in many others the home physician plays a crucial role in the long-time supervision and counseling.

[Physical activity and coronary heart disease]. / Körperliche Aktivität und koronare Herzkrankheit.

Epidemiological data suggest that in middle aged men a regular physical activity, occupational or in leisure time, may protect against a first coronary event. Randomized clinical trial of cardiac rehabilitation after myocardial infarction, including physical training, has shown a positive trend for reduced rates of all-cause death and coronary death in the intervention group. Although not statistically significant, physical training in coronary patients is recommended because the benefits of training include an improved exercise tolerance and risk factor profile. Furthermore, supervised cardiac exercise programmes appear to be safe for the average patient, with the possible exception of some patients with large anterior wall infarctions who might deteriorate and have, therefore, to be closely controlled during rehabilitation.

[The alcoholic patient in rehabilitation]. / Der Alkoholkranke in der Rehabilitation.

Alcoholics are in general not the ideal candidates for a cardiac rehabilitation programme, mainly because the rehabilitation demands a high degree of cooperation and motivation by the patients to be successful. Therefore, only stable patients with some self-esteem and strong enough to withstand the temptation of the available alcohol, patients without symptoms and signs of neuro-psychiatric deficit and with a relative intact social network, have a chance to benefit from the therapy which is based mainly on a physical training programme beside the usual medical care, but without the possibility of intensive care.

Angiotensin converting enzyme in human seminal plasma is synthesized by the testis, epididymis and prostate.

The activity of angiotensin converting enzyme (ACE) was assessed in human body fluids (serum, seminal plasma, prostatic secretions), in tissue extracts of the testis, epididymis, prostate and skeletal muscle, in split ejaculates and in seminal plasma obtained from patients before and after vasectomy. To ensure the specificity of the results the dependence of ACE activity on specific inhibitors was evaluated. Enzyme activity found in tissues of the male genital tract was considerably higher than that in serum and other tissues. ACE in human seminal plasma is synthesized by the testis, epididymis and prostate in different amounts.

[Health aims of patients following myocardial infarct and heart surgery: are the goals realistic?]. / Untersuchungen zum Gesundheitsverhalten von Patienten nach Herzinfarkt und nach Herzoperation: werden die Ziele verwirklicht?

134 patients (11 females and 123 males, mean age 52 years) taking part in our rehabilitation program after myocardial infarction or bypass surgery were asked to say what they were aiming for as far as exercise, smoking habits and body weight are concerned. Follow-up was carried out by a questionnaire 6 months later. 120 patients (90%) were prepared to engage in some exercise on a regular basis. 112 (86%) of the 130 patients surviving actually met the criteria at follow-up. On admission 15 patients were smokers and at discharge still 12; 9 of whom intended to stop smoking. This would have left a smoking fraction of 2%. At the key date, however, 19% were either still smokers or had become smokers again. Only 43 patients were able to lose as much weight as they intended. Yet during the follow-up period the average weight of all patients remained constant. In short, the aims of our coronary patients are pitched extraordinarily high. Regular exercise is achieved easily, but with regard to smoking habits and required loss of weight the intentions are obviously somewhat too optimistic.

Investigations on the functional role of angiotensin converting enzyme (ACE) in human seminal plasma.

The investigations were carried out with partially purified angiotensin converting enzyme (E.C.3.4.15.1) from human seminal plasma and from human blood plasma. The Km-constants for angiotensin converting enzyme (ACE) from both sources, estimated by the use of synthetic substrates, were in the same order. The catalytic properties of the enzymes were characterized by a series of known peptidase inhibitors. The male antifertility drug gossypol (1,1',6,6',7,7'-hexahydroxy-3,3'-dimethyl-5,5'-bis-isopropyl-(2,2' -naphthalene)--8,8'-dicarboxaldehyde) was identified as a potent ACE-inhibitor. The inhibitory constants of several kinins and other biologically active peptides were determined. Any regulatory influence of the peptides investigated on the ACE-activity in vivo is not probably. The inhibitor of Zn-containing metalloproteases 2-(N-hydroxycarboxamido)-4-methylpentanoyl-L-alanylglycin e amide) (Zinkov) selectively inhibited ACE from blood plasma, whereas ACE from seminal plasma was not influenced. In seminal plasma the majority of the enzyme is associated with macromolecular structures, identified as membrane vesicles. These vesicles contain also other enzymatic activities usually detectable in seminal plasma. In the male genital tract ACE is synthesized in the prostate, epididymis and testis. As our data indicate ACE seems not to be involved in the regulation of sperm motility.

[Can factors of prognostic significance be identified during rehabilitation of cardiac infarct patients?]. / Lassen sich während der Rehabilitation von Herzinfarktpatienten prognostisch bedeutsame Faktoren erfassen?

In a follow-up study of myocardial infarction patients who had followed the rehabilitation program at this clinic, a cardiac mortality rate of 3.8% (35 out of 930 patients) and a reinfarction rate of 2.3% (21 out of 930 patients) were observed in the 16.6 months after infarction. The relationship between 15 variables and these cardiac events was examined by cross-tabulation and then by Fischer's test of independence. No prognostic factors for reinfarction were found. However, there were 4-risk-indicators which were predictive of early mortality: diabetes, severe complications during the hospital course, congestive heart failure and exercise-induced, complex ventricular arrhythmias. While a single risk-indicator was of little prognostic significance, a combination of two or more identified patients at high risk of subsequent mortality.

[Outcome after hospital rehabilitation of patients with myocardial infarct]. / Verlauf nach der stationären Rehabilitation von Herzinfarktpatienten.

A series of follow-ups were carried out in 947 patients who had 12 to 28 months previously (average 16.6 months) undergone a period of rehabilitation at this clinic in Gais . 17 patients were not traced, but from the remaining 930 patients, 35 (3.8%) had died of cardiac disorders, 21 had had nonfatal infarctions, and 51 patients had undergone aortocoronary bypass operation by the follow-up period. The prevalence and grade of angina pectoris (NYHA functional classification) in 816 patients from whom data was obtained remained unchanged. Even after exclusion of all patients with reinfarction or bypass surgery, there was no increase in the severity of angina pectoris in the remaining 752 patients. 705 patients had returned to work, 555 of whom were still in full employment and 118 part-time , while 32 remained active housewives. From the remaining 112 patients who were not working, 55 had retired. In conclusion, a stable course and high grade of employment were observed during the first year after infarction in patients who had undergone a course of rehabilitation at this clinic.

[Are swimming and sauna hazardous in the rehabilitation of heart patients?]. / Sind Schwimmen und Sauna bei der Rehabilitation von Herzpatienten gefährlich?

The incidence of cardiac arrhythmias and ischemic episodes (I) during swimming and sauna as compared to other types of physical exercise was studied in 18 patients with coronary disease and in 18 controls without heart disease (mean age 46 and 48 years respectively). Maximum achieved heart rates during swimming and sauna were lower by at least 10% than those achieved during bicycle ergometry. Angina and/or ST segment displacement greater than or equal to 1 mm and frequent (greater than 1/min), multiform or repetitive VPB's occurred more frequently in coronary patients than in controls (I: 50 vs 11%, VPB's: 72 vs 28%, both p less than 0.005). VPB's were observed in 13/18 coronary patients, 6 of whom had these VPB's during swimming or sauna. Repetitive VPB's did not occur during swimming, but occurred during sauna in 2 coronary patients in whom they were also present during rest and walking. Ischemic episodes were noted in 9/18 coronary patients in 5 of whom they occurred during swimming. No ischemias were noted during sauna. It is concluded that swimming and sauna may safely be recommended during rehabilitation of coronary patients provided a submaximal exercise test and possibly a 24-h Holter ECG are performed on entry to exclude patients at risk.