[Internal medicine and cardiology, internists and cardiologists]. / Interna a kardiologie, internisté a kardiologové.

A retrospective on the development of internal medicine as a base from which other specific fields of medicine, including cardiology as one of the largest, branched as consequence of technological progress and transformation from an empirical to a scientific discipline. Similar to the internal medicine tree, cardiology also branches into a number of subspecialities. This is because no one human brain has a capacity to remember and know everything. This has also resulted in a segregation of the operational curricula of internal medicine physicians and cardiologists. However, a close collaboration of all the disciplines is essential as it is the very same patient who is the focus of them all.

[Pathways in the development of electrocardiography]. / Odkud kam krácís, elektrokardiografie?

Electrocardiography celebrates hundred years of its existence. The historical article on the cornerstones of its development was written on request of the editorial board of Vnitrní lékarství (Internal Medicine) and the Czech Society of Internal Medicine. After summarizing the beginnings of the discovery of bioelectric current and attempts of its registration the author describes the construction of the string galvanometer by Willem Einthoven. In 1901 and 1903 he published the first findings on the application of electrocardiography in man. Therefore that years are considered the years when clinical electrocardiography was born. Next we deal with the development of lead systems and modern electrocardiographs, incl. the discovery of the Braun tube, the construction of monitors, vectorcardiography and spatiocardiography. The author summarizes the principles of rational interpretation of the surface electrocardiogram and analyzes further modifications such as the use of leads from the right hemithorax, oesophageal leads, stress electrocardiography. Classical surface electrocardiography is probably a completed discipline. It will remain also in future a basic auxiliary examination method in internal medicine and allied disciplines. Due to its importance however classical electrocardiographic examination should be shifted into primary care where it may be a great enrichment and acceleration of the diagnostic process. Further development of electrocardiology is focused on non-invasive and invasive examinations and in particular treatment of arrhythmias where surface electrocardiography will be also in future important as a reference signal for the time localization of electric potentials of the intracardial electrocardiogram and programmed electrical stimulation.

[Physical training in patients with chornic heart failure: haemodynamics, effects]. / Telesný trénink u pacientu s chronickým srdecním selháním: hemodynamika, pusobky.

UNLABELLED: The objective of the investigation is to assess the safety and contribution of physical training in patients with chronic heart failure and to assess the effect of training on central haemodynamics, left ventricular function evaluated by echocardiography and humoral substances. PATIENTS AND METHODS: Patients with cardiac failure NYHA II and III incl. 17 on t he background of IHD and 21 on the background of dilatation cardiomyopathy. All patients had the ejection fraction below 40% and pVO2 below 20 ml/kg/min. They were divided into groups enagaged in training (T) and controls (K). Before training and after its termination the patients were subjected to clinical examination, basic laboratory tests, echocardiography amd dextrolateral catheterization at rest and during ergometry and levels of humoral agents were assessed. The training was pursued three times per week for a period of two months on a bicycle ergometer. RESULTS: Before training there were no statistically significant differences between the groups. After training the groups did not differ in echocardiographic and haemodynamic parameters. In the training group there was as compared with the onset of the experiment a decline of the maximal median pressure (123.6 +/- 11.9 vs. 113 +/- 10.2 mm Hg, p < 0.04) the maximal pulse rate (112.5 +/- 18.7 vs. 108.4 +/- 20.1 p <0.02). In the control group, on the other hand there was an increase of big endothelin (52.2 +/- 4 9.1 vs. 88.0 +/- 76.7 pg/ml, p < 0.04) and an increase of pulmonary vascular resistance (102.8 +/- 71.7 vs. 149.2 +/- 69.5 dyn.s/cm5, p < 0.002). CONCLUSION: Physical training was well tolertaed by patients, it led to a subjective improvement of their conditionn, to a reduction of the chronotropic response to a load and thus to more economical cardiac activity.

[Lipids and acute coronary syndromes]. / Lipidy a akutní koronární syndrom.

Eccentric atherogenic plaques which cause only insignificant narrowing of the diameter of coronary arteries are the cause of 60-80% of all acute coronary syndromes. The plaque becomes unstable (vulnerable) due to cytokines released by macrophages in the lipid rich core. Weakening of the fibrous capsule of the core then leads to rupture of the plaque and subsequently to intracoronary thrombosis with a wide spectrum of ischaemia or even necrosis of the myocardium. Secondary preventive studies (4S, LIPID, CARE), morphological non-mortality studies (e.g. AVERT, REGRESS, LCAS) and primary preventive studies (WOSCOPS, AFCAPS/TexCAPS) revealed that statins reduce significantly, as compared with placebo, total and LDL-cholesterol by 20-35% and lead in subsequent years to a significant decline of the relative risk of the general and coronary mortality and morbidiy by 20-40%. They prevent progression and may lead to regression of coronary sclerosis. They do not act by mere reduction of the cholesterol level but also by their extralipid effects which stabilize the plaque. 80% of patients with coronary syndrome have cholesterol levels between 6.0 and 7.5 mmol/l, similarly as ca 40% of healthy middle aged persons. The difference is in the risk caused either by the presence of ischaemic heart disease or in healthy subjects by the cumulation of several coronary risk factors. A special risk group are the remaining 20% patients. They include subjects with a cholesterol level above 8 mmol/l who must be treated more aggressively, similarly as patients after a venous aortocoronary bypass. Subjects with slightly elevated LDL-cholesterol values but high triacylglycerol levels and lower HDL-cholesterol levels have also an atherogenic risk. This applies not only to postmenopausal women, elderly people, obese and diabetic subjects, hypertensive subjects with insulin resistance but also to young subjects. In the latter reduction of triacylglycerols is indicated. In coronary patients a combination of statins and fibrates may be used. Basic hypolipidaemic treatment for reduction of the atherothrombotic risk are statins. Despite statin treatment the prospective mortality and morbidity of coronary patients is still high and it is necessary to make an effort to achieve target lipid levels. Recent studies provide new findings, further progress and stricter therapy are foreseen.

Regression of left ventricular hypertrophy in hypertensive patients after 1 year of treatment with rilmenidine: a double-blind, randomized, controlled (versus nifedipine) study.

OBJECTIVE: To assess the effect of 1-year treatment with rilmenidine, an oxazoline compound that exerts its antihypertensive effects through binding to imidazoline receptors in the brainstem, on left ventricular hypertrophy (LVH) secondary to essential, mild-to-moderate hypertension [supine diastolic blood pressure (DBP)95-115 mmHg]. METHODS: We performed a double-blind, randomized, controlled (versus slow-release nifedipine) trial. Adjustment of treatment took place every month (M) between inclusion (MO) and an evaluation after 6 months (M6), then during M9 and after 1 year (M12) to achieve supine DBP values < or = 90 mmHg. Patients were dropped from our study if they had DBP> 95mmHg during two consecutive visits or DBP>115 mmHg on one occasion. The daily dosage of rilmenidine was 1 mg, and could be increased to 2 mg/day. The daily dosage of slow-release nifedipine was started from the beginning at the maximum dosage of 40 mg/day, so that there was no true adjustment of treatment despite the allocation of patients to a different unit in the case of DBP> 95 mmHg. The primary criterion was the change in left ventricular mass index (LVMI, g/m2), assessed by echocardiography, between MO and M12 for patients who completed the trial. RESULTS: After a 1-month placebo run-in period, 76 patients were selected and 73 were included (35 treated with rilmenidine and 38 treated with nifedipine). Fifteen patients withdrew from the study and two completed the study with a major deviation from protocol, leaving 56 patients (24 treated with rilmenidine and 32 treated with nifedipine) for a per-protocol analysis. Baseline demographic characteristics and history of arterial hypertension for the rilmenidine and nifedipine groups were similar, for included patients and for those taken into account for the per-protocol analysis. Between MO and M12, DBP in members of the per-protocol population was adequately controlled for those in the rilmenidine group (102.7+/-4.6 versus 88.5+/-7.1 mmHg, respectively) and for those in the nifedipine group (102.7+/-5.1 versus 85.6+/-79 mmHg, respectively). During MO, LVMI of patients in the rilmenidine group (176.9+/-41.3 g/m2) was slightly higher than that of patients in the nifedipine group (172.6+/-35.1 g/m2). During M12, LVMI was observed to have decreased both for patients in the rilmenidine group (to 154.8+/-40.2 g/m2, a decrease of 22.1+/-23.3 g/m2, P< 0.001) and for those in the nifedipine group (to 145.6+/-36.4 g/m2, a decrease of 26.9+/-29.5 g/m2, P< 0.001) but the difference between these two groups was not significant (P= 0.5). CONCLUSION: One-year treatment with a daily dosage of 1 or 2 mg rilmenidine achieves a significant reduction of left ventricular mass, which is not statistically different than that occurring with a daily dosage of 40 mg of slow-release nifedipine.

Humoral response in patients with chronic heart failure.

AIM: Correlation of five humoral markers with laboratory, echocardiographic and right heart catheterization parameters in patients with chronic heart failure. STUDY POPULATION: 29 patients, heart failure NYHA II and III, ejection fraction below 40% with coronary artery disease or dilated cardiomyopathy. METHODS: evaluation of thromboxane, prostaglandin F (PGF), tumor necrosis factor (TNF) alpha, endothelin-1 and big endothelin rest levels and their correlation with: (1) laboratory parameters: Sodium, urea, creatinine, fibrinogen, (2) chest X-ray: cardiothoracic index (CTI), pulmonary congestion, (3) right heart catheterization parameters at rest, hand-grip and bicycle ergometry: mean pulmonary artery pressure (AP), wedge pressure (WP), systemic and pulmonary vascular resistance (SVR, PVR) and cardiac index (CI), (4) echocardiographic parameters at rest, hand-grip and bicycle ergometry: end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), mitral flow E/A, filling period of left ventricle and time of duration of mitral regurgitation. RESULTS: No correlation was found between thromboxane, prostaglandin F and tumor necrosis factor alpha with the above mentioned parameters. Endothelin-1 level correlated with E/A, PVR and MPA at rest and at hand-grip. Big endothelin level correlated with EDV and ESV, AP, WP and SVR at rest and at both types of exercise. The highest correlation was between big endothelin and rest AP (r=0.79), rest WP (r=0.78) and CTI (r=0.58), all P<0.01. CONCLUSIONS: Big endothelin and partly endothelin-1 levels showed a close correlation with some parameters used for the evaluation of chronic heart failure severity.

Systolic and diastolic function in patients with chronic heart failure at rest and during exercise.

In our study we tried to evaluate systolic and diastolic function in patients with chronic heart failure (CHF) by using some echocardiographic parameters and invasively measured pulmonary capillary wedge pressure (PCWP). We studied 19 patients with CHF NYHA II-III at rest, at the end of isometric exercise (handgrip) and during a bicycle stress test. Right heart catheterization and echocardiography were simultaneously performed. We measured exchange of blood gases, end diastolic volume (EDV), end systolic volume (ESV), ejection fraction (EF), peak E velocity, peak A velocity, E/A ratio, deceleration time of E wave (DT), time of mitral regurgitation (MR) and effective filling period of left ventricle (FP). We divided patients according to the median of PCWP at rest into two groups: group A with PCWP< or =11 mmHg (10 pts), group B with PCWP>11 mmHg (9 pts). In group A mean PCWP at rest was 6+/-2 mmHg, during handgrip 12+/-4 mmHg and during bicycle exercise 18+/-6 mmHg. In group B mean values of PCWP were 19+/-6 mmHg, 26+/-11 mmHg and 33+/-5 mmHg, respectively. All values were significantly higher in group B (P<0.01). There was a significant difference in pVO2: in group A 18.8+/-3.5 vs. 14.7+/-3.3 ml/kg per min in group B (P<0.03). No differences between the groups were noticed in EDV, ESV and EF. The E/A ratio in group A was less than 1, in group B greater than 1 with the restrictive pattern. No differences between the groups were observed in MR and FP at rest. During bicycle exercise, MR was significantly longer (284+/-98 vs. 164+/-79 ms; P<0.05) and FP shorter (322+/-99 vs. 421+/-74 ms; P<0.05) in group B than in group A. The functional capacity of patients with CHF is influenced not only by EF and other systolic variables, but also by filling conditions. The duration of effective diastole may be one of the most important of them.

[Acute and chronic heart failure]. / Akutní a chronické srdecní selhání.

Cardiac failure is a syndrome which comprises ventricular dysfunction (confirmed by echocardiography) and compensating mechanisms (immediate activation of the sympathetic nerve and functioning of Starling's mechanism, within hours or days activation of RAAS within days or weeks hypertrophy of the heart). Cardiac failure develops rapidly either in a previously healthy subject (first extensive IM, diffuse myocarditis, acute aortic or mitral regurgitation) or in a damaged heart (IHD, KMP, defect) as a result of sudden excessive burdening (ischaemia, arrythmia, infection, surgery etc.) or spontaneously (end-stage). It is manifested above all by "backward" failure (pulmonary oedema). The pulmonary pressure must be rapidly reduced: i.v. nitrovasodilators act immediately, i.v. furosemide acts within 10-15 min. (in can, however, reduce the circulating volume which has not increased during the first failure). Also O2, anodynes. In the subacute stage (without any precise time limits) which may develop in serious cases from acute failure, or develop as a result of deterioration of chronic failure, in addition to congestion, symptoms caused by "forward" failure are in the foreground. These are symptoms caused by a reduced minute output and hyperfusion of tissue. It is indicated to administer substances which improve work tolerance, i.e. positive inotropics (digitalis, beta-agonist or phosphodiesterase inhibitors). If the blood pressure drops, a combination of dopamine and dobutamine should be administered; if the respiratory volume drops, artificial pulmonary ventilation, in case of persisting oedema continuous arteriovenous haemofiltration, in severe failure intraaorrtic balloon contrapulsation etc. In an irreversible state urgent or elective orthoptic transplantation of the heart should be considered. In chronic heart failure an important component of comprehensive treatment is in addition to treatment of congestion and hypoperfusion, prevention of "cardiovascular remodelling" by means of angiotensin convertase inhibitors etc. Which improve the quality of life and survival. Arrhythmias are an independent prognostic factor.

[Antianginal therapy '95]. / Antianginózní lécba '95.

The submitted review deals with contemporary possibilities of antianginal treatment. After a brief account of pathophysiological and morphological data in different types of cardiac ischaemia and angina pectoris the author submits algorithms which should be the basis for therapeutic decisions. It is a question of proper timing of invasive examinations leading to revascularization operations in relation to medicamentous treatment. The latter is supplementary treatment before or after revascularization, or is the main approach in case of minimal complaints, in case of contraindicated invasive treatment or in case of an inoperable finding. The author discusses the action, indications, contraindications, undesirable effects, and average dosage of nitrates, beta-blockers, calcium channel inhibitors and antithrombotics. The author mentions also the use of angiotensin converting enzyme inhibitors. View on treatment will change with advancing knowledge.

[Betaxolol hydrochloride in the treatment of mild and medium hypertension--long-term effects]. / Betaxolol hydrochlorid v lécbe mírné a stredne tezké hypertenze--jeho dlouhodobý úcinek.

All available beta-blockers are effective in the treatment of high blood pressure. Differences in the pharmacokinetics are important as they can have an impact on their clinical use. Betaxolol, a beta-1-selective blocker has a long biological half-life which can control the blood pressure and pulse rate for 24 hours. The authors investigated 20 patients with mild and medium severe hypertension by out-patient monitoring of the blood pressure. Treatment was focused on influencing the morning rise of blood pressure and pulse rate. The results confirm the effectiveness of betaxolol (Lokren) in the administered dose of 10-20 mg once per day. A favourable response was obtained in 75% when checked by a sphygmomanometer. The morning readings of blood pressure at 5, 6 and 7 o'clock following treatment did not exceed 90 mmHg diastolic pressure. It was also found that there is a statistically significant difference in the effect exerted on pressure and pulse rate in daytime, while the difference at nighttime is not significant. This mild reduction on blood pressure and pulse rate during the night is an advantage in particular in elderly patients. Lokren treatment did not have any serious side-effects it did not affect laboratory values or ECG with the exception of the pulse rate.

[Development of internal medicine as a discipline at the Medical School of Masaryk University]. / Vývoj interních oboru na Lékarské fakulté Masarykovy univerzity.

The lecture presented in extenso at the Conference held to commemorate the 75th anniversary of the Medical Faculty, Masaryk University in the assembly hall of the New Townhall in Brno on November 11, 1994 deals with the development of medical disciplines at the Medical Faculty, Masaryk University since the opening of the first general hospital in 1786, where after the foundation of Masaryk University in 1919 the clinics of the Medical Faculty were established. The author mentions the difficult beginnings when the discipline was gradually established, the destruction of equipment during the Second World War after the universities were closed down, the difficult postwar restoration, changes after 1948 and in particular during the "normalization period" in the seventies and subsequent changes after 1989. The author mentions the foundation of different disciplines which are part of internal medicine and the foundation of clinics, as well as the profiles of their leading personalities. Not all the names are given, the main reason being, as Goncourt said, there were too many.

[Stress tests in chronic heart failure]. / Zátezové vysetrení u chronického srdecního selhání.

The authors compared two types of spiroergometric tests in 14 patients with chronic heart failure (NYHA II-III, ejection fraction < 40%). Test A: 0.25 W/kg 3 minutes, 1 minute break, increase by 0.25 W/kg á 3 minutes. Test B: 25 W 2 minutes without break, increase by 10 W á 2 minutes. The two tests did not differ as to the achieved heart rate, blood pressure reading, oxygen consumption and biochemical parameters at the end of the load, even at the level of the anaerobic threshold. There was a significant statistical difference in the duration of the load: test A lasted 16.4 minutes, test B 9.7 minutes (p < 0.001). The length of the test B correlated with the peak oxygen consumption per 1 kg body weight (p < 0.001, r 0.9866). The authors recommend for common practice test B with a defined period of the load as sufficient.

[Are central hemodynamics the decisive factor in the manifestation of chronic heart failure?]. / Je centrální hemodynamika rozhodující pro projevy chronického srdecního selhání?

In the past some authors revealed that data assembled during examinations of the central haemodynamics, echocardiography, subjective complaints, physical findings and load tolerance in patients with chronic heart failure are not mutually consistent. The authors examined therefore comprehensively 40 patients with different grades of cardiac failure. They revealed very loose relations between the grade of functional classification, echocardiographic and invasive haemodynamic parameters at rest on the one hand and spiroergometric indicators on the other hand. Closer relations with spiroergometric findings were obtained with values of invasive haemodynamic parameters after a load, in particular values of the cardiac index, and systemic vascular resistance. The authors conclude that for clinical manifestations of chronic cardiac failure the peripheral circulation and tissue metabolism is at least equally important as changes of central haemodynamics. Moreover, the importance of the right ventricular function and diastolic cardiac function is not sufficiently appreciated.

[Tiracizine in the treatment of ventricular arrhythmia (preliminary study)]. / Tiracizin v lécbe komorových arytmií (predbezná studie).

Tiracizine a new antiarrhythmic drug class Ia was tested in a open crossover study in a group of 46 patients with more than 2500 ventricular extrasystoles per 24 hours or with ventricular arrhythmias III or a higher Lown class. The authors revealed a statistically significant drop of ventricular extrasystoles and a significant reduction of arrhythmias class IV of Lown's classification with a general shift of arrhythmias to lower classes. Improvement by at least one class occurred in 63%, deterioration without clinical impact in 11%. The drug does not have a clinical effect on haemodynamics. Side-effects of an anticholinergic type were recorded in 13% and a toxic allergic exanthema was observed in 6.5%. Tiracizine extends the spectrum of membrane antiarrhythmic drugs. Its effectiveness is similar as that of propafenon.

[The effect of creatine phosphate (Neoton) in acute myocardial infarct (a prospective multicenter pilot study]. / Ucinek kreatinfosfátu (Neoton) u akutního srdecního infarktu (pilotní multicentrická prospektivní studie).

The authors investigated in a group of 106 patients with a first myocardial infarction treated by thrombolysis the effect of i.v. administration of creatine phosphate (a new drug with cardioprotective action--Neoton Alfa Schiapparelli Wassermann Co). In the course of treatment electrocardiographic changes were recorded and the presence of arrhythmias examined by the Holter technique. The Neoton group displayed a statistically insignificant but nevertheless obvious trend of electrocardiographically less serious forms of infarction and a lower incidence of infarctions, as compared with the control group.

[The present status of nitrates in the treatment of ischemic heart disease]. / Soucasné postavení nitrátu v lécbe ischemické choroby srdecní.

The authors describe the development of nitrates from substances of the first generation (nitroglycerin and isosorbit dinitrate) to the second generation (isosorbit-5-mononitrate). They explain the mechanism of their action, haemodynamic effects and the problem of nitrate tolerance. Indications of their rational use are given.

Amlodipine in patients with stable angina pectoris treated with nitrates and beta-blockers. The influence on exercise tolerance, systolic and diastolic functions of the left ventricle.

The effects of 5 and 10 mg of amlodipine and of placebo were compared in 21 patients with stable angina pectoris and multivessel coronary artery disease. The blind comparison was performed by means of bicycle ergometry and stress echocardiography using esophageal stimulation of the left heart atrium. All patients subsequently received placebo, amlodipine 5 mg and 10 mg for 2 weeks. In bicycle ergometry both doses of amlodipine in comparison with placebo significantly lowered the ST segment depression in lead V5 and prolonged the time to onset of angina. The exercise duration was significantly prolonged only after 10 mg of amlodipine. In stress echocardiography 10 mg of amlodipine significantly improved ejection fraction and reduced wall motion score during stimulation and increased peak velocity of relaxation of left ventricular posterior wall at rest and immediately after stimulation. In the patients with left ventricular end-diastolic pressure < or = 20 mmHg, amlodipine reduced the ratio of peak transmitral flow velocity in atrial contraction to that in early diastole (A/E) at rest and shortened deceleration time at rest and immediately after stimulation. Amlodipine in patients with stable angina pectoris significantly improved the exercise tolerance and the function of the left ventricle in a dose-dependent way. Amlodipine was well tolerated.

Cardiac arrhythmias in chronic heart failure.

It has been proven that treatment of chronic heart failure (CHF) with some modern drugs is able to reduce mortality in groups of patients with the severest grades of this disease. The risk of sudden death has been unchanged, however. Out of 49 patients on long-term follow-up, 28 patients are surviving (group A) and 21 died (group B). 52.3% of the dead patients died suddenly. Eight patients in NYHA classes I-II died, all of them suddenly. Contrary to this, sudden death was the cause of death only in three of 13 patients in NYHA classes III-IV (p < 0.001). More severe heart failure was present in group B (NYHA class 2.95 +/- 0.96 vs. 2.18 +/- 0.48 in group A--p < 0.1). Antiarrhythmic drugs were given more frequently in group B (in 47.6% of pts vs. 17.9% in group A--p < 0.05). It is concluded that the occurrence of sudden death is higher in patients with less severe forms of CHF and has not been reduced by the means employed. Use of antiarrhythmic drugs may be dangerous and their indication should be based on results of a comprehensive examination. Use of the implantable cardioverter-defibrillator seems to be the most promising approach in indicated cases.

Radiologic changes in chronic heart failure.

The relationship between chest X-ray findings and NYHA classification or haemodynamic parameters (ejection fraction, end-diastolic and end-systolic volumes by echocardiography, right atrial pressure--RAP, pulmonary artery pressure--PAP and pulmonary wedge pressure--PAWP by right heart catheterization) was evaluated in 44 and 22 patients with chronic congestive heart failure, respectively. In chest X-ray, the cardiothoracic index (CTI) and authors' own classification of pulmonary congestion (PCG) of classes 0, 1 and 2 were used. A significant correlation was found between CTI and NYHA classification or haemodynamic parameters, and between PCG (classes 0 and 2) and echocardiographic parameters or right heart pressures (EDV, ESV, RAP, PAP, PAWP), but there was no significant relationship between X-ray and left ventricular ejection fraction. For a PAWP higher than 18 mmHg and PCG class 2, the sensitivity of X-ray was 86% and specificity 80%. The authors conclude that chest X-ray provides reliable information about the haemodynamic parametres, comparable to echocardiographic and catheterization data.