Edward S. Orgain

Graded Exercise Stress Tests in Angiographically Documented Coronary Artery Disease

Graded exercise stress tests performed on 650 consecutive patients with proven or suspected coronary disease undergoing evaluation by cardiac catheterization were correlated with clinical, hemodynamic, and angiographic findings. Among 451 patients with significant coronary stenosis, 332 (74%) had interpretable stress tests and 65% of these were positive (sensitivity). The rate of “false positives’ was 8%.The clinical syndrome of typical angina identified significant coronary disease in 89% of the patients, and 58% of that group had a positive exercise test defined by objective electrocardiographic criteria.Patients were not eliminated from this study because of recent digitalis ingestion. Although a higher frequency of uninterpretable exercise tests was found in this group (40%), the test results reflected more severe coronary disease. None of the patients with “false positive’ tests were taking digitalis. It is concluded that recent digitalis ingestion should not be considered a contraindication for exercise stress testing.Among the patients with interpretable exercise tests, the angiographic severity of coronary artery disease correlates strongly with the frequency of positive tests (40%, 66%, and 76%, with 70% or greater occlusion of one, two or three vessels respectively). Left main coronary stenosis of 70% or greater was associated with more severe ST segment changes, inability to achieve target heart rate during stress, and a lower maximum heart rate during exercise. The angiographic occurrence of collateral vessels was related to the extent of coronary disease and was associated with a higher percentage of positive exercise tests; no protective effect of collateral circulation could be demonstrated. Patients with abnormal resting hemodynamics or left ventricular asynergy had no significant difference in the frequency of positive tests after adjustment for the angiographic severity of disease.

Exercise Stress Testing in Evaluation of Aortocoronary Bypass Surgery: Report of 123 Patients

Graded exercise treadmill tests (ET) were performed on 123 patients who had undergone aortocoronary bypass surgery. All had angina preoperatively (preop) and 77% were in Class III or IV for angina. Postoperatively (postop), 68% were free of angina. Eighty-three patients had ST-segment changes of 0.1 mV or greater during stress preop (positive), 38 of which (46%) converted to electrocardiographically negative postop. Among the 30 patients (36%) remaining positive during stress postop, 19 (63%) were angina free despite ST-segment depression during stress. Among the 17 patients with negative ET preop, there were no conversions to positive postop. Twenty-three patients had undetermined ET preop; 13 remained undetermined postop, 4 were positive and 6 were negative. Patients experiencing a perioperative myocardial infarction more frequently had a negative postop ET. Among 27 selected patients undergoing postop angiography, there was good correlation between relief of symptoms and successful myocardial revascularization.This study demonstrates that dramatic improvement in angina after aortocoronary bypass surgery can be objectively substantiated in most patients. Subjective symptoms of angina are frequently absent during myocardial ischemia postop, emphasizing the importance of exercise testing in objective evaluation of surgical results.

Primary Pulmonary Hypertension Review of Clinical Features and Pathologic Physiology with a Report of Pulmonary Hemodynamics Derived from Repeated Catheterization

The clinical features of 16 patients with primary pulmonary hypertension are reviewed. Repeated cardiac catheterizations at intervals of 1 to 4 years during the course of the disease were performed in five patients. In three of the five patients there was a progressive increase in pulmonary artery pressure, total pulmonary resistance, and a decline in cardiac output. In two patients the pulmonary hemodynamics remained unchanged between studies at intervals of 2 and 4 years. Arterial oxygen saturation decreased with progression of the disease, presumably reflecting the appearance of an uneven distribution of pulmonary capillary flow. The course of the illness was variable and unaffected by any mode of therapy, including long-term anticoagulation.

Paroxysmal ventricular tachycardia in the absence of demonstrable heart disease

Abstract Three cases of paroxysmal ventricular tachycardia in the absence of demonstrable heart disease are presented. Its occurrence and favorable prognosis in patients without other signs of heart disease are not well appreciated. Diagnosis of this condition becomes certain only after its demonstration by the electrocardiogram. The identification of P waves during the paroxysm, at a slower rate than the ventricular complexes; the presence of a paroxysm of abnormal ventricular complexes occurring during auricular fibrillation; the onset of tachycardia with an abnormal ventricular complex or a close resemblance, in the same lead, of isolated ectopic QRS complexes to the complexes of the tachycardia are the established criteria for diagnosis. The esophagcal lead may be of great help. Therapy is directed toward removal of precipitating factors and use of procaine amide or quinidine to suppress the ectopic factors. Established bouts require vigorous attention, i.e., parenterally administered procaine amide or quinidine.

The mimetic nature of left atrial myxomas. Report of a case presenting as a severe systemic illness and simulating massive mitral insufficiency at cardiac catheterization.

Abstract A case of left atrial myxoma presenting the features of a severe systemic disease is described. Transseptal catheterization revealed left atrial hypertension and an enormous V peak. These hemodynamic alterations are ascribed in part to a mechanically inefficient atrial diastole produced by the huge myxomatous mass but more importantly to massive mitral insufficiency which may be created by herniation of the tumor through the mitral valve orifice. It is emphasized that left atrial myxomas may produce the signs of a multisystemic disease in the absence of embolic phenomena. The etiology of this diffuse response is unknown. A systemic reaction to the degenerative changes in the tumor is an attractive hypothesis. Recognition of the varied clinical manifestations of left atrial myxomas and greater suspicion of the presence of this lesion will indicate the need for more immediate and definitive angiocardiographic study in cases of obscure heart disease.

Congenital familial nodal rhythm.

An unusual family group covering 3 generations is presented, all of whose members manifest a characteristic arrhythmia that appears to be an inherited trait. Each of the 9 known descendants exhibits a nodal bradycardia and each of the 4 descendants who have entered the fourth decade of life have also experienced paroxysms of atrial fibrillation. These paroxysms almost invariably terminate with the re-establishment of nodal rhythm. By history, the majority of these individuals are asymptomatic, and detailed examination of 2 adult members has failed to uncover evidence of specific cardiac disease. The problem of familial arrhythmia is briefly reviewed.

The precordial honk

Abstract Seven patients with a loud, intermittent, precordial sound have been described. The quality of the sound suggested the honking noise of a goose, and we have elected to call it the “precordial honk.” This sound may well be the same sound that McKusick 5 and Levine and Harvey 11 have called a “systolic whoop.” The patients had extensive cardiac evaluations which included complete right and left heart catheterizations with cineangiocardiography. The clinical and cardiac catheterization findings are presented, and the various mechanisms for the production of the “precordial honk” are discussed.

Postpericardiotomy syndrome as a complication of percutaneous left ventricular puncture

Abstract Two cases of postpericardiotomy syndrome following percutaneous left ventricular puncture have been reported. Both had symptoms identical with the other “cardiotomy” syndromes and responded promptly to adrenal steroid therapy. The fact that one of the patients had a second episode of pericarditis four weeks following open heart surgery may mean that the development of this syndrome following left ventricular puncture may be associated with the development of the postpericardiotomy syndrome following cardiac surgery.

Percutaneous technic for cardiac pacing with a platinum-tipped electrode catheter☆

Abstract We have reported a rapid and simple percutaneous technic for initiating intracardiac pacing at the bedside utilizing a small platinum-tipped wire electrode catheter. The method is valuable and potentially life-saving, both pro-phylactically and therapeutically, in the management of Stokes-Adams disease, complete heart block and asystole, particularly when drugs prove ineffective.

Differentiation of benign from pathologic T waves in the electrocardiogram

Abstract In a series of 29 patients whose electrocardiograms exhibited nonspecific T wave changes, electrocardiograms during various physiologic manipulations were obtained to evaluate which procedures might be most useful clinically in differentiating functional from organic T wave changes. Electrocardiograms were obtained during the following maneuvers: (1) fasting; (2) standing; (3) deep inspiration; (4) hyperventilation; (5) exercise; (6) nitroglycerin; (7) glucose ingestion; (8) atropine intravenously; (9) postprandially; (10) postprandial exercise; (11) epinephrine intravenously and (12) potassium chloride intravenously (in 6 patients). Although improvement in the nonspecific T wave pattern followed some maneuver in all patients, normalization occurred with hyperventilation in 29 per cent of the patients, fasting in 28 per cent, and less regularly with the other procedures. Accentuation of the T wave changes occurred in over 50 per cent of the patients after glucose ingestion, standing, nitroglycerin and epinephrine. Normalization of the nonspecific T wave changes occurred in 69 per cent of the patients with the combination of fasting, deep inspiration, hyperventilation and exercise. In the 6 patients with organic heart disease similarly investigated, the T wave changes were less labile in response to the various maneuvers. It is concluded that the combination of procedures that is most useful as an aid in the differentiation of benign from ischemic T wave changes includes fasting, deep inspiration, hyperventilation and exercise.