A. Carlton Ernstene

Differentiation of the changes in the Q-T interval in hypocalcemia and hypopotassemia☆

Abstract 1. 1. The electrocardiographic findings have been described in a typical case of hypocalcemia and in five cases of hypopotassemia due to various causes. 2. 2. Hypopotassemia is characteristically attended by rounded T waves of increased duration and usually of low amplitude. When the widening of the T waves attains a sufficient degree, prolongation of the Q-T interval results. The RS-T segments are not lengthened but often are slightly depressed. Prominent U waves are commonly present and by partial fusion with the descending limb of the T waves may cause further apparent lengthening of the Q-T interval. The duration of the QRS complexes is occasionally increased. 3. 3. In contrast to the findings in hypopotassemia, the electrocardiographic pattern of hypocalcemia is of a simple nature and consists entirely of prolongation of the Q-T interval due to lengthening of the RS-T segment.

Myxoma of the left atrium simulating mitral stenosis.

A case of myxoma of the left atrium originally diagnosed as mitral stenosis has been presented. Analysis of the clinical and roentgenologic features and the data obtained from cardiac catheterization indicate that a correct diagnosis probably could have been made. Certain of the findings suggest that although prolapse of the tumor into the orifice of the mitral valve was responsible for striking changes in the patients condition, the site of the chronic obstruction responsible for the pulmonary hypertension and the changes in the pulmonary arterioles may have been at the atrial orifices of the pulmonary veins.

Observations on arterial blood pressure during attacks of angina pectoris

Abstract Blood pressure readings were obtained during spontaneous attacks of angina pectoris in twenty-three patients. In seven, the previous blood pressure readings were known. In three, the attacks were allowed to end spontaneously, and in twenty relief was obtained by administering nitroglycerin. In every instance the level of the systolic pressure was distinctly higher during pain than when the patient was free from pain. Although this may not be an invariable relationship, this study and a survey of the cases recently reported leads one to the conclusion that a failure of the blood pressure to rise in anginal attacks is rare. Evidence is presented to show that in patients with angina pectoris, pain alone, e. g., that of renal colic, neither produces an elevation in blood pressure nor brings on an attack of angina. Although we suspect that a temporary elevation in blood pressure is an important factor in the production of anginal attacks and may even be a necessary immediate cause of the attack, a final decision as to this relationship will require further investigation.

The Management of Cardiac Patients in Relation to Surgery

Skillful anesthesia and surgical operations do not significantly increase the demands upon the heart for work. Patients who have organic heart disease but who have been able to carry on normal daily activities without symptoms referable to the heart tolerate anesthesia and operation without difficulty provided that anoxia, hemorrhage and shock are avoided. Hypertension, cardiac enlargement, valvular disease other than advanced aortic stenosis, and electrocardiographic abnormalities, per se, do not increase surgical mortality or postoperative morbidity. When symptomatic myocardial insufficiency or evidence of congestive heart failure is present, a period of preoperativre treatment with rest, digitalis, sodium restriction and mercurial diuretics is advisable. Treatment should be as thorough as possible during the interval in which the operation can be safely delayed. With adequate management, patients who have had myocardial failure can be expected to tolerate aniesthesia and surgery satisfactorily. Postoperative complications, such as pneumonia, atelectasis, thromboembolic accidents and abdominal distention, are not well borne, however, and may be responsible for a return of cardiac decompensation. Patients who have auricular fibrillation or auricular flutter should be digitalized before operation even though there have been no symptoms of impaired myocardial reserve and regardless of the ventricular rate. Surgery should be avoided if possible in persons who have severe coronary disease, aortic stenosis, coronary ostial steniosis due to syphilitic aortitis, and high grade or complete auriculoventricular block complicated by the Stokes-Adams syndrome. Spinal anesthesia should not be employed in the presence of these conditions. The decision as to the exact type of operation to be performed is seldom influenced by the existence of organic heart disease. The presence of organic heart disease is only occasionally of more than secondary importance in determining the choice of the anesthetic agent to be given by inhalation. Cyclopropane, however, should not be used. Although unimportant disturbances of cardiac rhythm occur frequently during anesthesia and operation, serious complications such as ventricular tachycardia, standstill of the heart and ventricular fibrillation are uncommon. The treatment of these conditions has been discussed. Postoperative cardiac complications are not common and are seldom responsible for death of the patient. The greatest incidence occurs in patientswhohaveseverecoronaryarterydisease. The intravenous administration of fluids which contain sodium should be avoided during operation and the postoperative period unless their use is specifically indicated.

Extensive Calcification of the Myocardium Report of a Case

An unusual case of extensive calcification of the myocardium in a 25 year old woman is presented. Presumably it was the result of an earlier severe toxic or septic myocarditis.

Cardiac asthma due to occluding thrombus of the left auricle

Abstract Clinical and post-mortem observations are presented on a patient with advanced mitral stenosis, regular heart rhythm, subacute bacterial endocarditis, and an occluding thrombus of the left auricle. The striking clinical feature was the occurrence of an attack of typical cardiac asthma accompained by tachycardia and signs of greatly impaired peripheral circulation. The latter signs persisted after subsidence of the paroxysmal dyspnea and tachycardia.

PANEL DISCUSSION ON THE CLINICAL MANAGEMENT OF MYOCARDIAL INFARCTION

Moderator: IRVING 8. WRIGHT, M.D., Professor of Clinical Medicine, Cornell University Medical College, New York, N. Y. Panelists: A. CARLTON ERNSTENE, M.D., Chief of Staff, Division of Medicine, Cleveland Clinic, Cleveland, Ohio; CHARLES K. FRIEDBERG, M.D., Associate Clinical Professor of Medicine, Columbia University, College of Physicians and Surgeons, and Attending Physician and Cardiologist, The Mount Sinai Hospital, New York, N. Y.; HOWARD B. SPRAGUE, M.D., Lecturer on Medicine, Harvard Medical School, Boston, Massachusetts; and JEREMIAH STAMLER, M.D., Established Investigator, American Heart Association, and Assistant Director, Cardiovascular Department, Medical Research Institute, Michael Reese Hospital, Chicago, Illinois.