Albert A. Kattus

Angina Pectoris at Rest with Preservation of Exercise Capacity Prinzmetal's Variant Angina

Twenty patients with Prinzmetals variant of angina are described and the literature on the subject is reviewed. This syndrome is characterized by anginal attacks at rest with S-T segment elevation, while exercise capacity is well preserved. Coronary arteriography usually demonstrates significant, focal, obstuctive disease of the major coronary artery predicted from the distribution of S-T elevation seen in the ECG during attacks. Occasionally the coronary disease is minimal or absent. The cause of attacks is believed to be transient, spastic occlusion of a major coronary artery, which was actually observed during surgery in one case. Because of this unusual pathophysiology, these patients may not make ideal candidates for isolated saphenous vein bypass surgery. Other diagnostic, therapeutic, and prognostic implications of this interesting anginal syndrome are discussed.

Ischemic Response to Sudden Strenuous Exercise in Healthy Men

In ten healthy, asymptomatic men, intra-arterial pressure and electrocardiograms were recorded during various types of exercise. Potential subendocardial blood flow was estimated from a diastolic pressure time index (DPTI) and myocardial oxygen requirements estimated from the tension time index (TTI). The ratio DPTI/TTI provided an estimate of the supply/demand relationship With sudden vigorous exercise without warm-up, the DPTI/TTI was below 0.35 in three men who had ischemic electrocardiograms, below 0.44 in three men with minor ST abnormalities, and above 0.44 in four men with normal ST segments. With a prior warm-up exercise, sudden exercise caused no ischemic changes, but DPTI/TTI was below 0.44 in two subjects who had minor ST abnormalities. Maximum treadmill testing produced higher heart rates and TTI than did sudden exercise, but DPTI/TTI was above 0.44 in all cases and no ST abnormalities occurred.Abnormal electrocardiographic responses produced by sudden, vigorous exercise in normal men may represent subendocardial ischemia caused by a transient, unfavorable alteration in the subendocardial oxygen supply/demand relationship which is predictable from arterial pressure measurements.

Adaptation to exercise in angina pectoris. The electrocardiogram during treadmill walking and coronary angiographic findings.

Twelve patients with angina pectoris manifested an ability to adapt to exercise during treadmill stress testing with electrocardiographic monitoring. Three patterns of adaptation were seen. Nine subjects had the ability to continue walking after the onset of angina with eventual disappearance or lessening of anginal pain and the associated ischemic ST-segment depression; anginal pain and ST depression began to diminish during a steady state of blood pressure and heart rate in those cases in which these factors were measured. Four subjects were able to continue walking for long periods of time during a state of angina and ischemic ST depression. Three subjects demonstrated an increase in exercise capacity after being warmed up by a preceding bout of exercise-induced angina; blood pressures and heart rates during the initial, “warming-up” effort tended to be higher than those during the early stages of the second effort. In three subjects more than one of these patterns of adaptation were demonstrated. Five of the subjects showed striking subjective and objective improvement in exercise tolerance while on a program of regular walking exercise.Selective coronary cineangiography was performed in eight of these patients and two patterns of coronary disease were seen: (1) occlusion of a major coronary vessel with good collateral channels circumventing the obstruction; (2) strategically placed, proximal, stenotic lesions in major coronary vessels without frank occlusion and without discernible collateral development.Some diagnostic and therapeutic implications of these findings are discussed.

Paradoxical Motion of Interventricular Septum in Left Bundle Branch Block

Abnormal interventricular septal motion, with pre-ejection posterior motion and anterior motion away from the posterior left ventricular wall during ejection, was demonstrated by echocardiography in 14 out of 17 cases with complete left bundle branch block (LBBB). Two of 14 cases had intermittent LBBB and showed abnormal septal motion only during LBBB. Of the control group of 49 patients without LBBB but with cardiac disorders similar to the cases with LBBB, only two showed abnormal septal motion. However, pre-ejection motion was not seen in these two cases. During right ventricular pacing abnormal septal motion was observed in three out of ten cases. It is suggested that conduction abnormalities are responsible for abnormal septal motion in LBBB; normal septal motion in most cases with right ventricular pacing may be due to different conduction pathways not affecting the septum.

Exercise electrocardiography: Recognition of the ischemic response, false positive and negative patterns

Abstract The ischemic electrocardiographic response is characterized by S-T segment depression in the left ventricular leads. When this response is elicited by exercise and is accompanied by anginal discomfort, it constitutes powerful diagnostic evidence of the presence of coronary arterial obstructive disease. The amount of exercise required to elicit the response is closely related to the extent of the obstruction. S-T segment elevation provoked by exercise rarely occurs with proximal severe stenosis in the left anterior descending coronary artery or in leads exploring the region of healed myocardial infarcts. Depression of the J point may be an ischemic manifestation reversible by administration of nitroglycerin. The ischemic electrocardiographic response may be obscured by conduction defects as in bundle branch block and healed myocardial infarcts. False positive ischemic responses may be encountered in patients taking digitalis glycosides or potassium-depleting drugs, or in patients with hyperadrenergic states, pectus excavatum or short P-R Intervals.

Electrocardiographic Changes During Selective Coronary Cineangiography

Examination was made of standard lead III of the electrocardiogram recorded during selective right and left coronary artery injections of Hypaque-M 75% in 107 patients. Left coronary artery injection caused the mean frontal plane QRS vector to shift transiently to the left and T wave vector to shift toward the right. Right coronary artery injection caused shifts of the QRS and T wave vectors in the opposite directions. Occlusion of one main coronary artery caused these ECG changes to be minimal or absent. Transient sinus bradycardia was common with injection of either coronary artery. Serious arrhythmias were rare. The electrocardiogram recorded during selective coronary arteriography can give information useful to the angiographer during the procedure itself as well as during the subsequent interpretation of the angiogram.

Echocardiographic Study of the Abnormal Motion of the Posterior Left Ventricular Wall during Angina Pectoris

Echocardiographic waves from the posterior left ventricular endocardium were recorded in 30 normal subjects and in nine patients during 13 anginal episodes. At rest the normal maximal systolic endocardial velocity (SEVM) was 6.2 ± 1.4 cm/sec, the mean systolic endocardial velocity (SEV) was 4.1 ± 0.7 cm/sec, and the systolic endocardial excursion (SEE) was 1.4 ± 0.3 cm. The maximal diastolic endocardial velocity (DEVM) was 18 ± 3 cm/sec, and the mean early diastolic endocardial velocity (DEV) was 9.4 ± 1.7 cm/sec. Exercise in 20 normals caused a significant increase in SEVM, SEV, DEVM, and DEV, but not SEE. In no instance did any of these values fall below the resting levels. The angina patients differed significantly from the normals having at rest a slower DEVM (15 ± 4 cm/sec) (P < 0.025) and DEV (8.4 ± 0.8 cm/sec) (P < 0.025). During exercise, but before angina, there was a significant increase in SEVM and SEV but not SEE, DEVM, or DEV. In no instance did any of these values fall below the resting levels. During angina SEVM and SEV reacted variably and together with SEE were not significantly different from the resting values. In contrast, there was a remarkable slowing of DEVM (8.2 ± 3.2 cm/sec) (P < 0.001) and DEV (5.7 ± 2.2 cm/sec) (P < 0.001). Five minutes after the pain and S-T-segment depression disappeared, the endocardium moved as it did before exercise.

Primary intraluminal tumor of the aorta producing malignant hypertension: successful surgical removal.

PRIMARY intraluminal tumors of the aorta must be exceedingly rare. There is, to our knowledge, only 1 other case in the literature that resembles to any degree the case reported below.1 Our patient...

The Effect of a β-Adrenergic-Blocking Agent (Nethalide) and Nitroglycerin on Exercise Tolerance in Angina Pectoris

A study was made of the acute effects of orally administered nethalide on the subjective and electrocardiographic responses to treadmill exercise in 11 patients with angina pectoris. Nethalide lowered the standing heart rate at rest and the maximum heart rate attained with exercise whether or not nitroglycerin was used concurrently. No consistent change in exercise capacity or time of onset of anginal pain and electrocardiographic abnormalities was noted after nethalide administration in the doses used in this study. However, the combination of nethalide and nitroglycerin in most subjects caused a strikingly greater exercise tolerance and delay in the onset of pain and electrocardiographic changes than did nitroglycerin alone.

Exercise testing in the diagnosis of coronary heart disease: A perspective

The methods of assessing the diagnostic usefulness of exercise testing in detecting coronary obstructive disease are examined. The limitations of long-term clinical follow-up and coronary angiography as standards for the determination of disease are described as are the effects of test methodology, criteria for positivity, prevalence of disease in the study population, reliability of the standard and recognition of false positive and false negative results in determining reliability of such testing. High values were found for sensitivity and specificity for exercise testing of patients with coronary artery disease referred for consultation to medical center cardiology services. Maximal exercise testing and consideration of symptomatic and hemodynamic as well as electrocardiographic criteria for identification of myocardial ischemia are helpful in improving reliability. Diagnostic accuracy is greatly enhanced by recognition of known causes for false positive and false negative results.