Gerald M. Breneman

Ruptured papillary muscle following myocardial infarction with long survival. Report of two cases.

Two cases of rupture of a papillary muscle of the left ventricle are presented. We believe that these are the two longest recorded survivals of this complication of acute myocardial infarction. A presumptive clinical diagnosis is possible from the characteristic history of sudden deterioration together with the development of a loud apical systolic murmur. The differential diagnosis and the possibility of corrective surgery in a patient who survives the acute event are discussed.

Atrial Tachycardia with Block Treated with Digitalis

Fifteen cases of atrial tachycardia with block were seen at the Henry Ford Hospital in 1 year. In nine cases the arrhythmia was not a result of digitalis excess. One of these nine patients has had the arrhythmia for 5 years, and two others had not received prior digitalis. In four cases, stopping digitalis and adding potassium did not affect the arrhythmia. Two patients experienced a brief episode of the arrhythmia while continuing digitalis. The addition of digitalis or a continued maintenance dose was necessary to control congestive heart failure or a rapid ventricular rate in all nine patients. The six remaining patients with atrial tachycardia with block had digitalis intoxication. When one first encounters this arrhythmia, the possibility of digitalis intoxication should immediately be considered. Digitalis and diuretics should be stopped and potassium added. If the arrhythmia persists despite this therapy, digitalis intoxication becomes less likely and the administration of the drug may be indicated.

Recurrent Stenosis of the Mitral Valve

Forty-three patients with suspected restenosis of the mitral valve are reported. Forty of these occurred in a series of 672 mitral commissurotomies. A significant degree of recurrent stenosis was found in 40 of the 43 cases at the time of the second operation. The clinical features and findings in these patients are discussed, as well as the probable etiologic factors. Left heart catheterization is indicated in many of these cases to define precisely the hemodynamic status, particularly in those individuals with suspected concomitant mitral incompetency or myocardial disease. Open-heart surgery should significantly improve the results of a repeat mitral commissurotomy.

Experience with phenylindanedione in the management of acute myocardial infarction.

Abstract A series of 251 cases of acute myocardial infarction treated during the acute phase with phenylindanedione is reported. All cases treated for less than 48 hours are excluded. The over-all recovery rate was 90 per cent. The incidence of thromboembolic complications was 3.5 per cent. Major hemorrhagic complications occurred in only 1.6 per cent of the total cases. Two cases of skin eruption requiring the immediate discontinuation of the drug were observed. It is our belief that, at present, this is the oral anticoagulant of choice.

THE USE OF THE NEWER DIURETICS IN THE TREATMENT OF CARDIAC DISEASE

The introduction of chlorothiazide in 1957 was rapidly followed by that of several analogues of the benzothiadiazine series. Slight changes in basic structure have been noted to alter markedly the potency of the drug, while less marked but definite changes occur in the electrolyte excretion pattern. One of the most significant of these changes has been the reduction in potassium excretion with the trifluoromethyl derivatives. Hydrochlorothiazide, flumethiazide, hydroflumethiazide, and benzydroflumethiazide, in addition to benzothiadiazine, are all potent oral diuretics, approaching the parenteral mercurial diuretics in effectiveness. While they are not as potent in single-dose administration as mercurials, they are superior to the mercurials for diuretic practice in many ways. The practical and economic advantages of oral therapy are obvious. The drugs have been extremely well tolerated, have a low incidence of toxicity, remain effective on repetitive or continuous administration, produce increased sodium excretion and water loss, and tend to stabilize a patient who is accumulating edema fluid more readily than might the sporadic intermittent mercurial program. More recent derivatives are currently being evaluated in our clinical practice. All of these agents inhibit primarily the renal tubular reabsorption of sodium and chloride, with water loss occurring secondarily: an action similar to that of the mercurials. Increased potassium excretion caused by these agents has important clinical implications. Diuresis is initiated approximately 2 hours after an effective oral dose, and continues for 6 to 12 hours thereafter. These important advances in the field of diuretic therapy have not supplanted the basic indications in the treatment of congestive heart failure, which continue to be digitalis, rest, and a reasonable reduction in the dietary intake of sodium. These first measures suffice in many instances of early cardiac decompensation. I t also follows that when diuretics become necessary the choice of drug and dosage must be tailored to the needs of the individual patient. The use of the minimal effective dose will lessen the likelihood of undesired effects and, possibly, toxicity. A schedule of diuretic administration on one or two days of each week may keep a patient free of edema, while more advanced cases may necessitate a daily diuretic regimen. An additive effect may be observed by the concomitant use of one of these agents plus a mercurial diuretic. This has been useful in some cases of resistant congestive failure and in patients approaching the refractory phase of their disease. A few instances of gratifying results in these advanced cases have also been seen when a benmthiadiazine has been combined with adrenocortical steroids or the spirolactones. The effective dose of chlorothiazide or flumethiazide is 1 to 2 gm. daily in two divided doses. This results in a significantly greater diuresis than that produced by a large single dose given once a day. If the second dose is given