George Dennish

Serial noninvasive assessment of left ventricular hypertrophy and function after surgical correction of aortic regurgitation

Serial echocardiographic analyses of left ventricular hypertrophy and function, with validation of extent of shortening by first pass radionuclide angiography, was performed in 16 patients before and after surgical correction of severe aortic valve regurgitation. All patients were symptomatic (predominantly in New York Heart Association functional class III or IV) before operation but were in class I or II after operation. The preoperative pattern of eccentric hypertrophy (increased mass with normal ratio of left ventricular cross-sectional wall area to cavity area) changed immediately after operation to a pattern of concentric hypertrophy (increased mass with increased ratio of left ventricular cross-sectional wall area to cavity area) because of a significant reduction in chamber size and increase in wall thickness. On late follow-up (9 to 35 months, average 15 months after operation), the hypertrophy lessened significantly, the cross-sectional area of the ventricular wall decreasing to 21.1 ± 5.4 (mean ± standard deviation) cm2 from a preoperative average of 31.6 ± 4.8 cm2 (P < 0.01), and the ratio of wall area to cavity area was once again normal. In the same period, left ventricular enddiastolic diameter decreased from 6.52 ± 0.68 to 4.64 ± 0.52 cm (P < 0.01). Preoperatively, ejection phase indexes were normal or only marginally depressed in 12 of 16 patients but were moderately depressed in the remaining 4. At early follow-up (average 4 months) ventricular shortening tended to increase; and at late follow-up the fractional shortening of the minor axis, the ejection fraction and the mean velocity of circumferential fiber shortening increased to 0.39 ± 0.07, 0.68 ± 0.10 and 1.26 ± 0.22 circumference/sec, respectively, from preoperative values of 0.33 ± 0.09, 0.60 ± 0.14 and 1.05 ± 0.31 circumferences/sec (P < 0.05 for each index). In the four subjects with preoperative depression of left ventricular function, the extent and speed of myocardial shortening at late follow-up became normal in three subjects and remained moderately depressed in one patient. Paradoxical septal motion was observed immediately postoperatively and in the early follow-up studies, but it was noted in only 3 of 16 cases by the late follow-up period. Provided septal dyskinesia was not present, echocardiographic and first pass radionuclide determinations of ejection fraction correlated highly (r = 0.92). It is concluded that when aortic valve replacement for symptomatic aortic regurgitation is undertaken prior to severe myocardial decompensation, improvement in clinical status is associated with significant regression of myocardial hypertrophy, reduction in left ventricular size, evolution of a normal massvolume ratio, recovery of septal dyskinesia as revealed on echocardiography, and improvement in left ventricular function. These data do not define the type and degree of left ventricular dysfunction which is irreversible.

A comparative trial of zolmitriptan and sumatriptan for the acute oral treatment of migraine.

Objective.–This randomized, double‐blind, parallel group multicenter study compared response rates and tolerability of zolmitriptan with sumatriptan in the acute treatment of migraine.

Effectiveness of three different doses of carvedilol for exertional angina

Carvedilol is a nonselective beta-receptor antagonist with vasodilating properties primarily due to selective alpha-1 antagonism. This 4-treatment, 5-period, double-blind, crossover study evaluated the efficacy and safety of 3 doses of carvedilol (12.5, 25, and 50 mg given twice daily) versus placebo in 122 patients with chronic stable angina. Carvedilol in doses of 25 mg twice daily and 50 mg twice daily was statistically superior to placebo with respect to time to angina (placebo: 316 seconds; 25 mg carvedilol: 337 seconds, p = 0.0039; 50 mg: 345 seconds, p <0.0001) and time to 1-mm ST-segment depression (placebo: 301 seconds; 25 mg: 313 seconds; 50 mg: 323 seconds; p <0.0001). The percentage of patients reporting any adverse experience was slightly less in those receiving placebo (placebo: 28.4%; 12.5 mg: 33.1%; 25 mg: 34.5%; 50 mg: 31.9%). Carvedilol is effective and safe in treating patients with chronic stable angina.

Semiautomated Method for Evaluation of Left Ventricular Regional Wall Motion in Coronary Artery Disease

Regional left ventricular wall motion was independently assessed in 436 patients using both subjective visual inspection of ventriculograms and objective computer-determined percent change in the square root of the area between systolic and diastolic outlines. Agreement between subjective and objective techniques was greatest at the ventricular apex and least at the base and partly dependent on the number of abnormal segments present. Objective analysis of regional wall motion provides a permanent quantitative record of wall motion and shows good agreement with meticulous subjective inspection of ventriculograms. As such, it has potential as an adjunct to ventriculography.

Distribution and severity of left ventricular wall motion abnormalities according to age and coronary arterial pattern in 500 patients with coronary artery disease and angina pectoris

Abstract Left ventriculograms of 500 patients with coronary artery disease and angina pectoris were compared with respect to coronary arterial pattern, left ventricular dyssynergy, and the patients age. The coronary arterial patterns were separated into Right, Mixed, and Left systems depending upon the blood supply to the inferior surface of the left ventricle. The left ventriculograms were divided into two regions and five areas. The anterior region consisted of the anterobasal area, anterolateral area, and the apical area. The posterior region consisted of the diaphragmatic area and the posterobasal area. Areas were scored as normal, hypokinetic, akinetic, or dyskinetic. The following relationships were noted: 1. 1. Forty percent of patients with coronary artery disease and angina pectoris have normal left ventricular wall motion. In the 60% of patients with left ventricular dyssynergy, wall motion abnormalities are divided evenly into three categories: anterior dyssynergy alone, posterior dyssynergy alone, and combined anterior and posterior dyssynergy. The mean age of patients with normal and dyssynergic wall motion is strikingly similar. 2. 2. Coronary arterial patterns of Right, Mixed, and Left systems have little, if any, influence on left ventricular wall motion abnormalities. 3. 3. Hypokinesis is the most common wall motion abnormality found in patients with coronary artery disease regardless of coronary arterial distribution or region of the left ventricle affected, with the exception of the apical area, where dyskinesis is found most commonly. Dyssynergy occurs most commonly in adjacent areas. In the anterior wall dyssynergy, the anterolateral and apical areas of the left ventricle are involved together most commonly. In posterior wall dyssynergy, the diaphragmatic and posterobasal areas of the left ventricle are involved most commonly. 4. 4. In patients with coronary artery disease and angina pectoris, left ventricular dyssynergy is similar from the third to the eighth decade of life.

Usefulness of nicardipine as monotherapy for chronic, stable angina

Using a double-blind, Latin square protocol designed to detect dose response, nicardipine hydrochloride, a new calcium antagonist, was studied as monotherapy for stable exertional angina. Eighty-one patients were enrolled in the trial and 62 patients were included in greater than or equal to 1 primary efficacy analyses. Patients received 1 to 2 weeks of placebo run-in, then 5 weeks of treatment with placebo and with 10, 20 and 30 mg of nicardipine given 3 times daily. Patients completed symptom diaries, were monitored with 24-hour electrocardiographic Holter monitors and underwent serial exercise treadmill tests. By 1 hour, 10, 20 and 30 mg of nicardipine administered 3 times daily produced statistically significant, dose-related improvements in all key exercise parameters, which persisted at the 4-hour evaluation. The systolic blood pressure at rest and during exercise decreased, but the pulse slightly increased. The peak rate-pressure product was unchanged. The side effects were not severe. Nicardipine hydrochloride is an effective, well-tolerated medication for the treatment of stable exertional angina, and is a good alternative to currently available calcium antagonists.