Clive E. Handler

Congenital diverticulum of the left ventricle presenting as heart failure and diagnosed by magnetic resonance imaging

We report a 25-year-old man with a probable congenital diverticulum of the heart. The diverticulum was clearly shown using magnetic resonance imaging.

Comparison of isradipine and nifedipine in chronic stable angina

Isradipine, a new dihydropyridine calcium antagonist, was compared to nifedipine in the treatment of 11 male patients with angina and coronary artery disease in a randomised, double-blind cross-over study. Patients received 5 mg nifedipine three times a day rising to 20 mg three times a day in three dosage increments over six weeks or 2.5 mg isradipine three times a day rising to 7.5 mg three times a day in three dosage increments over six weeks, and then received the alternate preparation. There were no significant differences between the drugs in terms of the frequency and severity of angina attacks or the consumption of glyceryl trinitrate. The increases in systolic blood pressure and the double product during exercise were significantly less with isradipine than with nifedipine. There was a similar trend in heart rates. There was no difference between the treatments in respect of exercise induced ST-segment depression or diastolic blood pressure. We conclude that isradipine and nifedipine have similar anti-anginal effects and that isradipine may be a useful new anti-anginal agent.

Stress testing predischarge and six weeks after myocardial infarction to compare submaximal and maximal exercise predischarge and to assess the reproducibility of induced abnormalities

Submaximal and maximal treadmill exercise tests were performed predischarge in 64 patients after acute myocardial infarction to assess the relative yield of residual ischaemic abnormalities. The reproducibility of individual abnormalities resulting from maximal stress tests performed predischarge and 6 weeks after infarction was also assessed in 55 of these patients. Compared with predischarge submaximal exercise testing, a maximal exercise test identified a significantly greater number of patients with residual myocardial ischaemia (26 vs. 15, P less than 0.05) and this was associated with a significantly longer average maximal exercise duration (P less than 0.001), and a higher rate-pressure product (P less than 0.001). Among the 55 patients who had maximal stress tests both predischarge and 6 weeks after infarction, there was a significant lack of reproducibility in the occurrence of exercise induced angina (P less than 0.01) and an abnormal blood pressure response (P less than 0.02). In contrast, exercise induced ST segment depression and elevation and ventricular arrhythmias were relatively reproducible. More patients had an ischaemic test result (ST depression or angina) at the later test compared to the predischarge test (33 vs. 25 patients) but this increase was not statistically significant. There were, however, significant increases at the later test in mean maximal exercise duration (P less than 0.001). mean maximal heart rate (P less than 0.001) and heart rate-systolic blood pressure double product (P less than 0.001). The majority of patients who had a cardiac event in the period between the two tests had a predischarge test abnormality. We conclude that a significantly greater number of patients with residual reversible myocardial ischaemia after infarction will be identified by symptom limited exercise testing compared with a submaximal predischarge test. Because ST depression and elevation appear reproducible, patients who develop these abnormalities during a predischarge test do not, for prognostic reasons, need retesting 6 weeks after infarction. Exercise induced angina pectoris and an abnormal blood pressure response, however, are highly variable and in these patients a repeat test may be useful.

Double-blind randomised crossover trial comparing isosorbide dinitrate cream and oral sustained-release tablets in patients with angina pectoris

Percutaneous isosorbide dinitrate cream and sustained-release tablets were compared in a double-blind randomised crossover trial in 28 patients with coronary artery disease and chronic stable angina pectoris. Twenty-two patients completed the trial. Both preparations significantly increased the mean exercise time to the onset of angina (P less than 0.001) and to termination of exercise (P less than 0.001) compared to the pre-treatment period. There were no significant differences between the cream and tablets with respect to frequency of anginal attacks, glyceryl trinitrate consumption, heart rate and ST segment depression at the onset of angina, ST segment depression at maximal exercise and the double product of heart rate and systolic blood pressure at maximal exercise. Equal numbers of patients expressed preference for cream and tablets. We conclude that in this group of patients isosorbide dinitrate sustained-release tablets have no clinical advantage over isosorbide dinitrate cream which, may, therefore, be of particular value for those patients with angina pectoris who dislike taking tablets or who prefer this form of nitrate preparation.

Permanent Transvenous Pacing After a Mustard Procedure

HANDLER, C.E., et al.: Permanent Transvenous Pacing After a Mustard Procedure We report the case of a 20‐year‐old man born with transposition of the great vessels who underwent emergency balloon septostomy and subsequently a Mustard procedure. When aged 20 years, he had several syncopal attacks due to sinoatrial disease for which he was simply and successfully paced transvenously in VVI mode.

Effects of oral prajmaline bitartrate on exercise test responses in patients with coronary artery disease

SummaryThe safety, tolerability and haemodynamic effects of oral prajmaline bitartrate were assessed in a double-blind, randomized, placebo-controlled, crossover trial in 21 patients with stable angina pectoris and coronary artery disease. No serious side-effects occurred. Prajmaline bitartrate produced no statistically significant changes in resting heart rate or systolic blood pressure or in work capacity on the treadmill, or in heart rate or systolic blood pressure at maximum exercise compared to placebo values. No new arrhythmias or conduction abnormalities were produced in any patient.We conclude that oral prajmaline bitartrate is well tolerated and can be given safely to patients with coronary artery disease without producing deleterious haemodynamic effects or changes in exercise capacity.

Exercise testing early after myocardial infarction: discussion paper.

The management of patients recovering from myocardial infarction has undergone vast changes over the last three decades. Physicians should now not merely be content that their patients have survived the acute event but try to advise them on the most appropriate longterm management. Inherent in this is the concept of risk stratification which neccessitates knowledge of the natural history of the condition, identifying which patients are at greatest risk from recurrent infarction and subsequent angina, and assessing those most suitable for medical treatment or myocardial revascularization. The natural history of myocardial infarction has been studied in several longitudinal surveys of patients admitted to hospital (Beard et al. 1960), but accurate information is obscured by the variable indications for hospital admission. These include the age of the patient and the stage and clinical state when he was seen by the general practitioner, and importantly, the home circumstances. In spite of these drawbacks, accepted statistics for outcome after infarction are a 10% six-month mortality rate (5% in the first three weeks), with about 40% of patients developing angina, a second myocardial infarction, or dying within a year (Bland & White 1941, Cole et al. 1954, Granath et al. 1977, Theroux et al. 1979). Several clinical and haemodynamic methods have been used in an attempt to identify this high-risk group. Peel et al. (1962) and Norris et al. (1969) were among the first and suggested various demographic, historical and clinical factors as prognostic indices. Only features associated with severe left ventricular impairment, however, have been found to be reproducible, and this is currently considered to be the major determinant of prognosis. Patients with a prolonged tachycardia, heart failure and a third heart sound may, therefore, be in this poor prognostic group (Wolk et al. 1972, Weber et al. 1973, Scheidt et al. 1973). The relative mortality risk, deduced from a combination of factors, has also been studied. Bigger et al. (1978) found that the strongest factors associated with mortality in the first six weeks after infarction were raised blood urea and serum creatinine levels, persistent cardiac enlargement and ventricular tachycardia two weeks after myocardial infarction, peak creatine kinase level, and left ventricular failure. The presence of one of these factors increased the risk of dying up to II times, and if two or more were present the mortality risk increased up to 20 times. The incorporation of haemodynamic data including pulmonary capillary pressure and cardiac output increased the accuracy of assessment of left ventricular function (Weber et al. 1978). The introduction of exercise tests early after myocardial infarction and their use as a prognostic guide had to await confirmation of their safety. Thirty years ago, physicians were so concerned about the possibly lethal sequelae of stressing a recently infarcted myocardium that common practice was to keep patients bed-bound in hospital for six to eight weeks. In this way the risks of damage to a presumed electrically unstable and fragile myocardium Were thought to be decreased, albeit at the expense of deep vein thromboses and often fatal pUlmonary emboli ..Exercise earlier than the almost sacrosanct six weeks was thought to put the patient at risk from extension of the infarction with precipitation of serious arrhythmias, aneurysm formation or a catastrophic myocardial rupture. In 1952 Levine & Lown challenged these principles with their revolutionary ideas of