Charles P. Taliercio

A randomized comparison of the nephrotoxicity of iopamidol and diatrizoate in high risk patients undergoing cardiac angiography

Three hundred seven high risk patients with renal impairment (serum creatinine greater than or equal to 1.5 mg/dl) were randomized in a double-blind manner to either iopamidol (a nonionic, low osmolar radiocontrast agent) or diatrizoate (a conventional radiocontrast agent) at cardiac angiography with subsequent follow-up study of renal function. Baseline clinical and angiographic variables were similar in the iopamidol (n = 155) and diatrizoate (n = 152) groups. Change in renal function after angiography was less pronounced with iopamidol compared with diatrizoate as measured by mean ( +/- SD) increase in 24 h serum creatinine (0.11 +/- 0.2 versus 0.22 +/- 0.26 mg/dl, p less than 0.001), mean maximal increase in serum creatinine (0.2 +/- 0.44 versus 0.38 +/- 0.73 mg/dl, p less than 0.0001) and percent of patients with a maximal increase in serum creatinine greater than 0.5 mg/dl (8% versus 19%, p less than 0.01). Such differences could not be documented in diabetic patients using insulin. There was no significant difference between agents in the number of patients developing clinically severe acute renal dysfunction. It is concluded that iopamidol is less nephrotoxic than diatrizoate in high risk patients at cardiac angiography. However, the difference in nephrotoxicity is small, of no major clinical significance in the majority of high risk patients and could not be documented in insulin-using diabetic patients. Iopamidol may be the preferred agent in certain patients with advanced renal impairment, but further study is warranted.

Natural history of hypertrophic cardiomyopathy in the elderly.

The prognosis of patients diagnosed as having hypertrophic cardiomyopathy at advanced age has not been well defined. This study details follow-up information obtained for 95 patients initially diagnosed as having hypertrophic cardiomyopathy at age greater than or equal to 65 years. Seventy-five percent of patients were symptomatic, as defined by the presence of chest pain, dyspnea or syncope, and the mean ventricular septal thickness was 20 mm. The median duration of follow-up study was 4.2 years. The survival rate at 1 and 5 years was 95% and 76%, respectively, which was not significantly different from that an age- and gender-matched control group. Of patients presenting with New York Heart Association functional class I or II dyspnea, only 18% progressed to class III or IV during the follow-up period. However, patients presenting with class III dyspnea had a 1 year mortality rate of 36%, significantly higher than that of control subjects (p less than 0.003). Of the echocardiographic variables, indexed left atrial size was most strongly associated with reduced survival (p less than 0.008). These results suggest that the prognosis of elderly patients with hypertrophic cardiomyopathy is generally favorable. Certain clinical and echocardiographic variables appear to be of use in identifying patients with a less favorable prognosis.

Dilated Cardiomyopathy in Children

Dilated cardiomyopathy is a rare but serious disease in children. Clinical manifestations are primarily due to impaired systolic function of the left ventricle. Diagnostic evaluation is important to exclude masquerading cardiac abnormalities and to assess the degree of myocardial dysfunction. Treatment of dilated cardiomyopathy is not curative but directed at improving symptoms and long-term outcome.

Successful treatment of pulmonary embolism and associated mobile right atrial thrombus with use of a central thrombolytic infusion.

Patients with pulmonary embolism and two-dimensional echocardiographic evidence of right atrial thrombus have a high mortality rate despite standard anticoagulation therapy. We used a direct central infusion of streptokinase in three such patients, who subsequently had rapid and complete clinical improvement. In this setting, thrombolytic therapy should be considered an effective therapeutic option.

Prognosis in patients with an abnormal exercise radionuclide angiogram in the absence of significant coronary artery disease

To investigate the prognostic importance of abnormal exercise left ventricular function on radionuclide angiography in the absence of significant angiographic coronary artery disease, 79 consecutive patients with these findings were followed up for a mean of 25 months (range 12 to 55). All patients had 1) an ejection fraction at rest greater than or equal to 0.40, 2) an ejection fraction that decreased with exercise or peak exercise ejection fraction less than 0.60, and 3) no significant coronary artery disease. The mean change in ejection fraction was a decrease of 0.07. In 63 patients (80%), the ejection fraction decreased during exercise; in 45 patients, it decreased by greater than or equal to 0.05. Twenty patients (25%) had a peak exercise ejection fraction less than 0.50. All patients were alive at follow-up study. One patient had a nonfatal myocardial infarction, and three patients were hospitalized for recurrent chest pain. No patient underwent coronary angioplasty or bypass surgery. The calculated infarction-free survival rate at 4 years by life table analysis was 97%. Patients with an abnormal exercise radionuclide angiogram in the absence of significant angiographic coronary artery disease have an excellent short-term prognosis.