Reciprocal ST change in acute myocardial infarction: assessment by electrocardiography and echocardiography.

To evaluate the incidence, time course and significance of reciprocal change, 25 consecutive patients admitted with their first acute transmural myocardial infarction were studied with serial electrocardiography and two-dimensional echocardiography. Reciprocal change was noted in all patients with inferior infarction (mean maximal ST segment depression 3.53 +/- 1.97 mm) and 70% of patients with anterior infarction (mean maximal ST depression 1.45 +/- 0.8 mm, p = 0.001). When initially present, reciprocal change had resolved within 24 hours in 59% of patients. The sum of reciprocal ST depression correlated with the sum of ST elevation in anterior (r = 0.92, p less than 0.001) and inferior (r = 0.55, p = 0.035) infarction, and this relation persisted when maximal ST depression and elevation were considered. Echocardiographic evidence of contraction abnormalities in areas of the left ventricle remote from the infarction was seen in 45% of patients. However, its presence did not correlate with the presence of reciprocal change. Although reciprocal change progressively diminished on serial electrocardiograms (maximal ST depression 2.73 +/- 1.77 mm at 19 hours after onset of symptoms; 1.0 +/- 0.92 mm at 2 to 3 days; and 0.22 +/- 0.26 mm at 7 to 10 days; p less than 0.05), the corresponding serial echocardiograms showed no change in the function of the remote wall (remote wall motion index 1.87 +/- 0.65, 1.81 +/- 0.62, 1.86 +/- 0.47, respectively, p = NS). These data, therefore, do not support the hypothesis that reciprocal ST depressions during early acute transmural myocardial infarction reflect remote ischemia. Rather, these changes are influenced by factors determining the degree of acute ST elevation, previously shown to include infarct size, shape, location, transmurality and duration.

Pulmonary findings in patients with chagasic megaesophagus. Study of autopsied cases.

We studied retrospectively 69 cases of chagasic megaesophagus (group 1) and 207 cases of chronic chagasic myocardiopathy (CCM) without megaesophagus (group 2) by autopsy in the Pathology Department of the Federal University of Bahia, Brazil, from 1953 to 1975. It was shown that pulmonary tuberculosis was significantly more frequent in group 1 (21.7 percent) than in group 2 (3.4 percent). The patients of group 1, who had megaesophagus without associated cardiomyopathy (n = 36), had a much higher rate of pulmonary tuberculosis (36.1 percent) than those with associated CCM (6.0 percent), and they also had the most severe forms of the pulmonary disease. Other pulmonary complications of infectious origin occurred more frequently in group 1. The prevalence of pneumonia was 34.7 percent in group 1 and 10 percent in group 2. Six cases were considered to be aspiration pneumonia. Long abscess occurred in two cases in each group. We suggest that megaesophagus should be carefully investigated for pulmonary complications, especially for tuberculosis in populations with a high rate of this infection.

Intracavitary thrombi in the right heart associated with multiple pulmonary emboli. Report of two patients.

Two-dimensional echocardiography identified intracavitary masses in the right heart in two patients presenting with extensive pulmonary embolism. In one, a right ventricular mass was identified which was confirmed at subsequent autopsy to be an organizing thromboembolus. In the second patient, a right atrial mass was identified; it disappeared with thrombolytic therapy which was accompanied by clinical improvement. We demonstrate that intracardiac thrombi associated with pulmonary embolism may be identified noninvasively by two-dimensional echocardiography. We suggest the presence of thrombi may represent a large intravascular thrombus. This recognition may influence therapeutic decisions.

Muscle magnesium content and cardiac arrhythmias during treatment of congestive heart failure due to chronic chagasic cardiomyopathy.

Magnesium (Mg2+) plays a significant role in the electrical stability of the heart and hypomagnesemia may predispose patients to arrhythmias and digitalis toxicity. We measured the serum and skeletal muscle Mg2+ content of patients with chronic Chagasic cardiomyopathy (CCC) during treatment for congestive heart failure and compared it to 15 normal patients who were used to establish the normal values of our population. There is a high frequency of muscle Mg2+ deficiency (66%) in patients with CCC during treatment for heart failure. However, serum Mg2+ is not a sensitive index of deficiency, since hypomagnesemia occurred in only 50% of the patients whose muscle Mg2+ was low. Digitalis toxicity was observed in all muscle Mg2+-deficient patients (100%) and in 25% of patients with normal Mg2+ levels (P less than or equal to 0.05). Ventricular tachycardia (VT) occurred in 75% of muscle Mg2+-deficient patients and in none of the patients with normal magnesium levels (P less than or equal to 0.05). The frequency and severity of premature ventricular contractions (PVC) were higher in muscle Mg2+-deficient patients. We conclude that muscle Mg2+ deficiency is very common in patients with CCC being treated for congestive heart failure and that muscle Mg2+ deficiency defines a higher risk CCC group in terms of digitalis toxicity and severe ventricular arrhythmias such as ventricular tachycardia.

[Segmental changes in contractility of the left heart ventricle in Chagas cardiomyopathy with and without ventricular dilatation]. / Alterações segmentares da contratilidade do ventrículo esquerdo na cardiopatia chagásica com e sem dilatação ventricular.

PURPOSE: To evaluate left ventricular (LV) segmental wall motion abnormalities in dilated and nondilated chronic chagasic myocarditis (CCM), to better understand the myocardial dysfunction progression in this pathology. METHODS: Sixty nine patients with the CCM, 39 had normal end-diastolic left ventricular dimension (LVEDD) and normal cardio-thoracic ratio (CTR) (group A), and 30 had increased LVEDD and CTR (group B), all of them with abnormal EKG, had the LV global and segmental contractility analysed by two-dimensional echocardiogram (Echo). A point score system to the LV contractility was applied. RESULTS: Segmental wall motion abnormalities were seen in 68% of the patients: apical 64%, postero-inferior 30%, septal 17%, anterior 6% and lateral 0. Apical aneurysm was observed in 42% of the patients, postero-inferior in 6% and basal septal in 3%. There was a statistically significant correlation between the LVDD and the LV score of contractility (r = 0.66; p = 0.0000). The LV contractility was normal in 28% of the patients, 47% in group A and 3% in group B. While in group A the abnormal pattern of contractility was segmental in all, but one patient, in group B it was diffuse in the large majority (93%). CONCLUSION: Initially LV abnormality in CCM is segmental. Beyond the apex, other regions of the LV are involved, the postero-inferior wall and basal septum for instance, even with aneurysm morphology. The CCM seems to evolve from an stage with essentially segmental wall motion abnormalities and normal LVDD to LV dilatation and diffuse hypocontractility.

[Evaluation of endomyocardial fibrosis by two-dimensional echocardiogram. Analysis of the severity and correlation with angiocardiography]. / Avaliação da endomiocardiofibrose pelo ecocardiograma bidimensional. Análise da gravidade e correlação com a angiocardiografia.

PURPOSE: To evaluate the capacity of two-dimensional echocardiogram (2D-Echo) to establish the severity of endomyocardial fibrosis (EMF) in comparison with angiography (Angio). METHODS: Twelve patients with EMF were prospectively studied by both: 2D-Echo and Angio. The mean age was 24.6 +/- 6.6 years (14 to 35), with 8 women and 4 men. To compare the severity by the 2 methods the obliterative process was graded according to its extension relative to the long axis of the respective, in diastole, as follows: 1 + only apical: 2 + less than 50% and 3 + greater than or equal to 50% from the apex to the atrioventricular valve level. RESULTS: All patients (100%) had biventricular disease by Angio, with right ventricle (RV) predominance in 5 (42%), left ventricle (LV) predominance in 1 (8%) and balanced in 6 (50%). By 2D-Echo the se numbers were: 11 (92%), 5 (42%), 1 (8%) and 5 (42%), respectively. The degree of concordance between 2D-Echo and Angio was 100% for the RV and 75% for the LV (p less than 0.005). In only 1 patient the LV apical involvement (+) was not identified by 2D-Echo. Mitral insufficiency (MI) was detected in 7 (58%) and tricuspid (TI) in 11 (92%) patients by Angio. These patients, expect one, had the corresponding atrial area greater than 18 cm2 by 2D-Echo. It was observed a statistically significant correlation between the atrial area and the degree of AV valve insufficiency (MI p less than 0.005; TI p less than 0.05). Paradoxical movement of the interventricular septum (IVS) was noted in 6 (50%) patients, associated with predominant RV disease, severe TI and mild or absent MI. CONCLUSION: The 2D-Echo, a valuable non-invasive method to diagnose and to grade severity of the fibrotic involvement of the ventricles by EMF, has a good correlation with Angio.