Eliezer Klainman

Multiform accelerated idioventricular rhythm in acute myocardial infarction: Electrocardiographic characteristics and response to verapamil

Thirteen patients with acute myocardial infarction with multiform accelerated idioventricular rhythm (AIVR) occurring during the first 12 hours of monitoring in the coronary care unit are described. This arrhythmia, similar to the more common uniform AIVR, was intermittent, did not cause hemodynamic compromise, and was not related to more serious ventricular arrhythmias. There was no correlation between the bundle branch block pattern of the multiform AIVR and the electrocardiographic location of the myocardial infarction, but there was a perfect correlation between the frontal plane electrical axis of the multiform AIVR and the electrocardiographic location of the myocardial infarction. The presence of fusion beats between the different forms of AIVR suggests multifocality rather than multiformity. Intravenous verapamil (3 to 5 mg bolus) was administered to 6 patients with multiform AIVR in whom the arrhythmias were persistent enough to allow the evaluation of the effect of verapamil on the arrhythmia. Verapamil caused no change in the rate of AIVR in 1 patient, but in a second patient it decreased the rate by 20 beats/min. In 4 patients, verapamil abolished the arrhythmia: in 2 patients carotid sinus pressure (induced sinus slowing) allowed the emergence of the AIVR at a lower rate, and in the remaining 2 patients the arrhythmia was not observed.

Functional evaluation in patients with chronic obstructive pulmonary disease : pulmonary function test versus cardiopulmonary exercise test

The pulmonary function test (PFT) alone may be inadequate for predicting work-related exercise capacity in patients who file workers’ compensation claims for respiratory limitation and compensation. Two hundred sixteen ambulatory patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second = 54.1 ± 16.8% predicted) were administered the PFT and cardiopulmonary exercise test, and the results were analyzed by categorical statistical comparison, based on standard medical impairment classifications. Sixty-five patients (30.1%) were similarly classified by the two methods. Of the remaining patients, 132 (61.1%) were found to be less impaired according to the cardiopulmonary exercise test than according to the PFT, and 19 (8.8%) were more impaired according to the PFT. The results favor the use of the cardiopulmonary exercise test for the routine evaluation of respiratory impairment in patients with chronic obstructive pulmonary disease, particularly for patients with mild or moderate impairment revealed by the PFT. The large discrepancy between the two procedures emphasizes the need for a novel approach.

Contribution of cardiopulmonary indices in the assessment of patients with silent and symptomatic ischemia during exercise testing

Cardiopulmonary and radionuclear indices were used to evaluate and compare cardiac function during exercise testing in patients with symptomatic and silent ischemia. The study comprised 58 patients aged 35-74 years, divided into three groups: Group I-20 patients (controls) with neither ST depression nor chest pain; Group II-22 patients with ST depression > 1 mm and no chest pain; Group III-16 patients with both ST depression and chest pain. All patients in Groups II and III demonstrated significant coronary artery disease. No antianginal medication was taken at least 24 h before testing. All patients underwent a cardiopulmonary exercise test and a multigated acquisition radionuclear study. The following variables were measured: oxygen consumption (VO2), CO2 output (VCO2), minute ventilation (VE), O2-pulse, ventilatory anaerobic threshold (VAT), left ventricular ejection fraction (LVEF) at rest (r) and at maximal effort (ex). Probability values were significant for all variables (P < 0.01-0.0001) except left ventricular ejection fraction-rest (P not significant between the three groups). No significant differences in extent of coronary artery disease were noted between Groups II and III. These findings suggest that during exercise testing patients with silent ischemia have better overall cardiac function than patients with symptomatic ischemia. Their value for both cardiopulmonary and radionuclear indices are closer to those of the control group than to the symptomatic group, regardless of the severity of the coronary artery disease Summary of results: (mean +/- 1 S.D.) Group VO2-max O2-Pulse max VAT (%) VAT (ml/min) LVEF-rest delta LVEF (ex-r) I 25.2 +/- 6.3 15.7 +/- 3.4 51.2 +/- 6.6 1075 +/- 289 54.7 +/- 7 5.4 +/- 4.85 II 22.4 +/- 2.8 14.5 +/- 2 47.0 +/- 5.3 854 +/- 136 52 +/- 10 1.2 +/- 6.7 III 16.0 +/- 2.5 11.4 +/- 2 41.6 +/- 7.7 683 +/- 105 51 +/- 8.5 -5.87 +/- 6.3

Natural course of electrocardiographic components and stages in the first twelve hours of acute myocardial infarction

Time course evolution of R, Q, T and ST components of the electrocardiogram during the first 12 hours of an acute myocardial infarction was studied. A comparison between anterior-extensive and anteroseptal wall infarctions (anterior group), and inferior-extensive and inferior wall infarction (inferior group) showed appearance of significant Q waves within two hours in both groups. R wave loss was nearly a mirror image of Q wave development in both groups. T waves became negative and ST more isoelectric earlier in the inferior than in the anterior group. When combined variations of the four electrocardiographic components were analyzed, four stages of acute infarction were delineated. Stage I--tall R, no Q, ST elevation and positive T; Stage II--significant Q wave appearance; Stage III--negativity of T waves; and Stage IV--ST isoelectric. The inferior group reached stages III-IV within 12 hours; the anterior group remained mostly in stage II. An early appearance of Q waves correlated well with rapid progression to stages III-IV within 12 hours in both infarction groups.

Unstable angina with tachycardia: Clinical and therapeutic implications

We prospectively evaluated 19 patients with prolonged chest pain not evolving to myocardial infarction and accompanied with reversible ST-T changes and tachycardia (heart rate greater than 100 beats/min) in order to correlate heart rate reduction with ischemic electrocardiographic (ECG) changes. Fourteen patients (74%) received previous long-term combined treatment with nifedipine and nitrates. Continuous ECG monitoring was carried out until heart rate reduction and at least one of the following occurred: (1) relief of pain or (2) resolution of ischemic ECG changes. the study protocol consisted of carotid massage in three patients (16%), intravenous propranolol in seven patients (37%), slow intravenous amiodarone infusion in two patients (10%), and intravenous verapamil in four patients (21%) with atrial fibrillation. In three patients (16%) we observed a spontaneous heart rate reduction on admission. Patients responded with heart rate reduction from a mean of 125 +/- 10.4 beats/min to 84 +/- 7.5 beats/min (p less than 0.005) and an ST segment shift of 4.3 +/- 2.13 mm to 0.89 +/- 0.74 mm (p less than 0.005) within a mean interval of 13.2 +/- 12.7 minutes. Fifteen (79%) had complete response and the other four (21%) had partial relief of pain. A significant direct correlation was observed for heart rate reduction and ST segment deviation (depression or elevation) (r = 0.7527 and 0.8739, respectively). These patients represent a unique subgroup of unstable angina, in which the mechanism responsible for ischemia is excessive increase in heart rate. Conventional vasodilator therapy may be deleterious, and heart rate reduction in mandatory.

Assessment of Functional Results after Percutaneous Transluminal Coronary Angioplasty by Cardiopulmonary Exercise Test

Twenty-nine patients with documented coronary artery disease underwent cardiopulmonary exercise tests before and following a percutaneous transluminal coronary angioplasty (PTCA). The patients medication regimen and exercise protocols remained the same in both cases. Following PTCA, significant improvement (p < 0.001–0.0001) was noted in oxygen consumption (1,526.8 ± 470.0 vs. 1,686.2 ± 390 ml/min), oxygen pulse (12.40 ± 2.73 vs. 13.44 ± 2.9 ml/beat), oxygen pulse score (7.62 ± 1.29 vs. 8.85 ± 1.26 points) and in the ventilatory anaerobic threshold (993.1 ± 177.6 vs. 1,089.8 ± 150.9 ml/min) but not (p > 0.05) in maximal heart rate (128.7 ± 16.9 vs. 132.0 ± 17.2 beats/min). Thus, a cardiopulmonary exercise test is an effective method to assess functional results following PTCA.

Effects of isosorbide dinitrates intravenously in high doses over a short period in anterior acute myocardial infarction.

The effects of intravenous isosorbide dinitrate administered in high doses over a short period of time in 17 patients (14 men, 3 women, mean age 67 years) with anterior wall acute myocardial infarction were evaluated. Patients were classified into 2 groups based on the electrocardiographic pattern of acute ischemia. Patients presented with anterior acute myocardial infarction; an electrocardiographic pattern of third-degree ischemia demonstrated a more favorable electrocardiographic and radionuclear angiographic evolution than similar patients who presented with an electrocardiographic pattern of second-degree ischemia.

Behçet’ Disease (‘Silk Route Disease’) and Mitral Valve Prolapse

Dear Sir, I read with interest the article on cardiac involvement in Behçet’s disease by Morelli et al. [1]. The finding of a high incidence of mitral valve prolapse in 50% of their patients is not surprising. The association of mitral valve prolapse and Behçet’s disease was first reported from China [2]. Shen et al. [3] from Shanghai reported in 1985 also a 50% incidence of mitral valve prolapse in their patients with Behçet’s disease. Behçet’s disease occurs most frequently in Japan and the Mediterranean countries but also in the population linking these two areas to each other [4]. It occurs most frequently between latitudes 30° and 45° north, in Asian and Eurasian populations. This area coincides with the old Silk Route. Thus, Behçet’s disease is sometimes also called ‘Silk Route disease’ [2, 4]. OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

Pulmonary function threshold for distinguishing ventilatory- and nonventilatory-limited patients with airflow obstruction

Patients with chronic obstructive pulmonary disease (COPD) may demonstrate great variability between results on the pulmonary function test (PFT) compared to those on the cardiopulmonary exercise test (CPXT). The purpose of this study was to correlate PFT and CPXT indices and to identify PFT threshold values for predicting exercise capacity in patients with airflow limitation. Fifty-seven patients (48 men and 9 women) of mean age 66.4 +/- 4.8 years with COPD and 40 age-matched control patients underwent PFT and CPXT. Based on the CPXT results, the patients were divided into ventilatory-limited (VL) and nonventilatory-limited (NVL), and the findings were correlated with the PFT indices. Linear regression analysis was used to determine the relationship between dyspnea index (VEmax/MVV) and forced expiratory volume in one second (FEV1). The cutoff value for VL was FEV1 < 38% and for NVL FEV1 > 68%. The prominent limiting symptom (61%) in the VL group was dyspnea sensation, with leg discomfort presenting in only 14%; corresponding rates in the NVL group were 38% and 31%. We conclude that the FEV1 is a reliable index for distinguishing VL from NVL COPD patients during CPXT at two extremes: below 38% of the predicted value (VL) and above 68% of the predicted value (NVL).

Effect of Controlled Exercise Training in Coronary Artery Disease Patients with and without Left Ventricular Dysfunction Assessed by Cardiopulmonary Indices

Cardiopulmonary indices were used to evaluate the effect of controlled exercise training prescribed on the basis of the heart rate at the ventilatory anaerobic threshold in coronary artery disease patients with and without impaired left ventricular function. Fifty-two patients aged 38-75 years were divided into four groups. The first three groups included patients with a left ventricular ejection fraction of > 45% at rest, as follows: group 1, 10 patients with single-vessel disease; group 2, 12 patients with two-vessel disease; group 3, 10 patients with three-vessel disease. Group 4 comprised 20 patients with left ventricular dysfunction (ejection fraction < 35%). The left ventricular ejection fraction was assessed by multigated acquisition radionuclear study. All patients underwent a cardiopulmonary exercise test before and after the program which lasted 6-9 months. The variables measured were oxygen consumption (VO2), CO2 output, minute ventilation, O2 pulse, and ventilatory anaerobic threshold. Significant improvements in maximal VO2, maximal O2 pulse, and ventilatory anaerobic threshold level were observed in groups 1, 2, and 4 (p < 0.1-0.0001), but not in group 3. These findings indicate that the overall cardiac function, as evaluated by cardiopulmonary indices, improves in patients with one- or two-vessel disease with good left ventricular function and in patients with impaired left ventricular function following an exercise training program. Severe coronary disease seems to limit improvement, even in the presence of a good left ventricular function. The results validate the heart rate at the ventilatory anaerobic threshold as the optimal training heart rate in coronary artery disease patients and the cardiopulmonary exercise test as a sensitive tool for evaluating exercise training results.