Anne Jonathan

Patterns of disturbed myocardial perfusion in patients with coronary artery disease. Regional myocardial perfusion in angina pectoris.

Fifty patients who presented with angina pectoris were studied to examine the disturbances of regional myocardial perfusion during stress. Each patient underwent 16-point precordial mapping of the ECG during an exercise test, and coronary and left ventricular angiography. Regional myocardial perfusion was assessed using an atrial pacing test and a short-lived radionuclide, krypton-81m. Eleven patients had negative exercise tests and uniform increases in myocardial activity of krypton-81m of 98 +/- 18.0% during pacing. Ten patients performed 30,000-43,000 J in positive exercise tests. These patients showed abnormal coronary anatomy and increases in myocardial activity of krypton-81m to remote and jeopardized myocardium at the onset of pacing. However, further pacing produced a decrease in activity in the affected segment of 68.0 +/- 9.0% accompanied by ST-segment depression and angina. Twelve patients achieved 26,000-32,000 J in positive exercise tests and had significant coronary artery disease. Atrial pa...

Significance of exercise induced ST segment elevation in patients with previous myocardial infarction.

In order to determine the significance of exercise induced ST segment elevation in patients with previous myocardial infarction, we have studied 156 patients, 26 months (mean) after myocardial infarction. Each patient underwent 16 lead precordial electrocardiographic mapping before, during, and after exercise and in addition coronary arteriography was performed. There was no significant difference in the extent of coronary disease or abnormalities of left ventricular function between patients with exercise induced ST segment elevation that was noted to occur in leads with Q waves and those with ST segment elevation plus depression or those with ST segment depression alone. Patients without exercise induced ST segment changes had fewer coronary arteries involved than those who developed ST segment changes. Nineteen patients with exercise induced ST segment elevation alone underwent coronary artery bypass surgery; in 11 this resulted in complete abolition of the exercise induced ST segment elevation and was associated with symptomatic relief and patent grafts without alteration of left ventricular function. Thus, exercise induced ST segment elevation in patients with previous myocardial infarction should be considered as important as ST segment depression in terms of underlying myocardial ischaemia, coronary anatomy, and left ventricular function.

Inability of exercise-induced R wave changes to predict coronary artery disease.

To determine the value of exercise-induced R wave changes in diagnosing coronary disease 200 patients undergoing coronary angiography were studied with 16 lead precordial exercise mapping. R wave amplitude was calculated before and immediately after exercise as the sum of R in all 16 leads, the sum of the R waves in the left plus the S waves in the right precordial leads, as well as the sum of the R waves only in those leads that manifested S-T depression. Coronary artery disease was found in 154 patients, S-T depression developed in 122 (sensitivity 79 percent); the sum of R increased or remained unchanged in 61 and decreased in 93 (sensitivity 40 percent). Forty-six patients did not have coronary artery disease; S-T depression developed in 5 (specificity 89 percent); the sum of R increased or was unchanged in 30 and decreased in 16 (specificity 35 percent). Similar results were obtained using the other criteria for calculating R wave amplitude. Exercise-induced S-T depression was identified in 5. 1 +/- 2.6 (mean +/- standard deviation) of the 16 precordial leads and in 2.0 +/- 1. 1 of the chest leads of the standard electrocardiogram (p less than 0.01). Thus, electrocardiographic alterations found in the standard chest leads represent only a small variable proportion of the total projection. When the whole precordial area was analyzed, R wave changes were so unpredictable that they could not be used in the diagnosis of coronary disease.

Electrocardiographic precordial mapping in anterior myocardial infarction. The critical period for interventions as exemplified by methylprednisolone.

Serial 72-point precordial mapping of ECG has been recorded to describe the natural history of changes in the precordial areas of ST segment elevation and the development of Q waves in 51 patients with acute uncomplicated anterior myocardial infarction. Eight patients have been studied in the same way but received 25 mg/kg of methylprednisolone sodium succinate as a single intravenous injection within 6 hours from the onset of chest pain. There was a linear relationship between the stable precordial area of Q waves at 24 hours and the rapidly changing precordial areas of ST segment elevation at 2--3 hours, 5--6 hours and 12 hours after the onset of pain in the untreated patients. When methylprednisolone was given, the treated patients developed a smaller precordial area of Q waves at 24 hours than was predicted from the precordial area of ST elevation recorded before the drug was given. This study has introduced a technique that can provide a qualitative assessment of the relationship between ECG evidence of ischemia and infarction in each patient.

Interaction between cigarettes and propranolol in treatment of angina pectoris.

To determine whether cigarette smoking interferes with the medical management of angina pectoris, 10 patients with angina pectoris who smoked at least 10 cigarettes a day were studied before, during, and after a standardised maximal exercise test. This was done at the end of four randomly allocated one-week treatment periods during which the patients took glyceryl trinitrate while not smoking, took glyceryl trinitrate while smoking, took glycerly trinitrate and propranolol (380 mg/day) while not smoking, and took glyceryl trinitrate and propranolol while smoking. Carboxyhaemoglobin was measured to ensure compliance. Smoking was associated with a significantly higher heart rate, blood pressure, number of positions with ST-segment depression, and total ST-segment depression after exercise than non-smoking (p < 0.01) whether or not the patients were taking propranolol. These results suggest that smoking aggravates the simple haemodynamic variables used to assess myocardial oxygen requirements and the exercise-induced precordial electrocardiographic signs of myocardial ischaemia. These effects were still evident after treatment with propranolol and represent a hindrance to the effective medical treatment of angina pectoris.

Pericardial complications of endocardial and epicardial pacing.

A patient with complete atrioventricular block was fitted with a temporary endocardial pacing wire via a right subclavian percutaneous approach. The result was initially satisfactory, but within a few days radiography for left-sided chest pain showed pneumopericardium. A permanent epicardial pacing system was therefore substituted and she remained well for three months. She was then admitted for syncope: the pacemaker was failing to capture, and radiography showed pericardial and pleural effusion. A new permanent endocardial pacing system using a wedged electrode was inserted and she made an uncomplicated recovery. Pneumopericardium complicating endocardial pacing has apparently not been reported before. Presumably the electrode had penetrated both the right ventricle and the pericardium into the adjacent lung.

Electrocardiographic mapping after exercise for evaluation of coronary bypass graft surgery

Abstract Electrocardiographic mapping after exercise adds an extra dimension to the routine exercise test because a measure can be made of the area and severity of electrocardiographic changes that occur after exercise. The value of this technique in assessing coronary bypass graft surgery was investigated in 50 patients who had postoperative coronary angiography after undergoing such surgery. The patients were classified into three groups: The 35 patients in Group 1 were free of pain at follow-up and had no new precordial Q waves. Among these, 24 patients had patent grafts and no precordial area of S-T segment change after exercise. The remaining 11 patients had areas of exercise-induced S-T segment change postoperatively; 10 of the 11 had at least one blocked graft and 1 had a patent although poorly functioning graft. The 10 patients in Group 2 continued to have chest pain after operation. Eight of the 10 had an area of S-T segment change that persisted after exercise and at least one blocked graft; the 2 patients without precordial S-T segment changes after exercise had patent grafts. The five patients in Group 3 were in poorer condition after operation; three had greater areas of S-T segment change after exercise, and the remaining two had new areas of Q waves. All patients had at least one occluded graft. In 8 (16 percent) of the 50 patients studied before operation precordial areas of S-T segment change after exercise that were identified with electrocardiographic mapping were not identified using a modified 12 lead system. After operation, mapping revealed precordial areas of ischemia in 24 patients; In 4 (17 percent). These areas were not detected with the modified 12 lead electrocardiogram. Electrocardiographic mapping after exercise is a simple noninvasive test that objectively describes the effects of coronary bypass surgery on myocardial ischemia and aids in interpretation of a patients report of a change in the frequency of angina. Because it provides more information than a modified 12 lead system it may reduce the need for postoperative angiocardiography.

Treatment of Angina Pectoris with Propranolol: the Harmful Effects of Cigarette Smoking

The effects of smoking on the treatment of angina has been studied in 10 patients. Each patient underwent 4 randomized 1-week treatments consisting of on and off smoking, and on and off propranolol (360 mg/day). At the end of each treatment a maximal exercise test was performed using 16 praecordial leads. Smoking was associated with a significantly higher heart rate, blood pressure, area and severity of ST-segment depression. This was not abolished by propranolol. Thus, smoking aggravates the simple haemodynamic variables used to assess myocardial oxygen requirements and the electrocardiographic signs of ischaemia; this is true even after treatment with propranolol.

Precordial electrocardiographic mapping in the identification of patients with left main stem narrowing

This study was designed to determine if exercise testing using 16-lead precordial mapping can be used to identify patients with left main stem narrowing. In a group of 235 consecutive patients undergoing coronary angiography there were 35 patients with left main stem narrowing. The patients with left main stem disease differed from the others in that not only did they develop extensive S-T segment depression, but more specifically these changes occupied a characteristic position high on the precordium above the usual site of the precordial leads of the 12-lead electrocardiogram. This finding was then tested prospectively in a second group of 100 patients. Fourteen of the 100 patients had left main stem narrowing; the sensitivity and specificity of S- T segment changes high on the precordium in identifying patients with left main stem disease were 82 and 84% respectively. Thus precordial mapping and exercise testing is valuable in the diagnosis of patients with left main stem narrowing. The technique is simple and inexpensive and provides data not available using the conventional precordial leads of the 12-lead electrocardiogram.

The Dose-Response Effects of Nifedipine of ST-Segment Changes in Exercise Testing: Preliminary Studies

This study examines the effects of increasing doses of nifedipine on exercise-induced ST-segment depression in patients with severe typical stable angina pectoris. 10 patients underwent four 1-week treatment periods in a single-blind clinical trial. These were nifedipine 0, 30, 60, and 90 mg in divided doses daily. At the end of each week a maximum exercise test was performed using 16 precordial electrocardiographic leads and the ST-segment changes measured immediately after exercise. In 4 patients nifedipine produced no effects on these electrocardiographic parameters; 4 patients improved and 2 deteriorated. Thus, a dose of nifedipine, effective in 1 patient, can have opposite effects in another.