Henry I. Russek

Influence of Saline, Papaverine, Nitroglycerin and Ethyl Alcohol on Electrocardiographic Response to Standard Exercise in Coronary Disease

Much disagreement exists regarding the value of vasodilator agents in the treatment of coronary disease. Opinions have largely been based upon observations of pharmacologic action of drugs in animals, uncontrolled clinical studies and analyses of a purely subjective index, that of pain, in patients with angina pectoris. A technic was devised, therefore, to study the modifying action of various drugs upon the electrocardiographic response to standard exercise. To have validity, the procedure could be carried out only in a patient showing constant electrocardiographic changes with each performance of the standard test. The present communication records the findings in such a patient who was studied in this manner.

Cortisone in the immediate therapy of apoplectic stroke.

In recent years considerable progress has been made in the rehabilitation of the hemiplegic patient. The brilliant work of Rusk and associates (1) and others has clearly demonstrated that modern methods of rehabilitation and retraining can successfully restore such patients to lives of independence and productivity. The advances in the therapy of residual defects, however, have far exceeded the questionable gains in the treatment of the acute phase of the cerebrovascular accident. The immediate treatment of “stroke” is mainly devoted to measures for saving life and restoring physiologic balance. All authorities stress the importance of skillful nursing care, maintenance of hydration, attention to bladder and bowels and the prevention of hypostatic pneumonia. The current attitude toward therapy has been summarized by Alvarez (2) in a recent editorial as follows: “The best treatment for cerebral thrombosis is an expectant one. We all know that in many of these cases a weakness of the arm or leg clears up, and often aphasia disappears almost entirely. This recovery may be due to subsidence of edema of the brain or it‘may be due to rerouting of impulses around the destroyed area of the brain tissue.” Nevertheless, despite the recognition that return of function often occurs spontaneously due to a clearing of cerebral edema and improvement in cerebral blood flow, there is impatience with the necessity for awaiting “expectantly” the final and unalterable decree of nature. The hope of decreasing the degree of neurologic residua has stimulated interest in a more active treatment of cerebrovascular occlusions. Thus, attempts have been made to improve the cerebral circulation in such patients by the administration of vasodilator drugs, by the injection of procaine into the stellate ganglion, and by the administration of anticoagulants. Drugs of the vasodilator group have been found of little value for treatment of organic occlusion of the cerebral vessels: on theoretical grounds alone, there is little to suggest that any lasting benefit could result from a short period of vasodilation. When neurologic signs and symptoms are the result of transient cerebral vasospasm, however, large doses of papaverine (3 to 8 gtains, three or four times a day) do have great value in the prevention of recurrences (3). There is a divergence of opinion in the literature as to the efficacy of blocking the stellate ganglion. The difficulty in differentiating between clinical improvement resulting from therapy and that occurring spontaneously, indicated the need for carefully controlled studies. It has been argued that no logical basis exists for blockage of the stellate ganglion, since most observations on the circu-

Risk of thromboembolic complications from cortisone therapy

Abstract An increased coagulability of the blood has been reported in the hyperadrenal state induced by the therapeutic administration of corticotropin (ACTH) and cortisone. This finding, as well as a seemingly high incidence of thromboembolism in patients receiving such treatment, has led some authors to consider the use of anticoagulants when serious vascular disease or thrombophilic tendencies are present in patients requiring hormonal therapy. Without clear knowledge of the actual risk involved in the use of ACTH or cortisone, however, clinical judgement as to the selection of cases for treatment and the need for preventive measures must remain clouded. The present communication has recorded observations in eighty-six patients with advanced cardiovascular and/or cerebrovascular disease who received large dosages of cortisone in a course of therapy generally extending over a period of three weeks. In these patients no thromboembolic phenomena or other vascular complications were encountered during the administration of the drug or following its withdrawal. This experience seems to indicate that the theoretical danger of thrombotic complications from the use of cortisone is not clinically significant and that underlying disease of the heart or blood vessels need not preclude such therapy when proper supervision and simple precautions are instituted.

The Syndrome of Bernheim as a Clinical Entity

Can the right ventricle become partially obliterated by a bulging and hypertrophied interventricular septum so as to produce the clinical picture of isolated right heart failure? If so, the syndrome of Bernheim must be accepted as a distinct clinico-pathologic entity. The authors have previously reported 3 cases of right ventricular stenosis which appeared to originate in this manner. More recently, this evidence has been challenged and theoretic objections have been raised as to the possible existence of the syndrome. The present report attempts to answer these contrary assertions and records another instance in which the syndrome was diagnosed clinically and confirmed at autopsy.

EVALUATION OF DRUGS USED IN THE TREATMENT OF ANGINA PECTORIS BY MEANS OF EXERCISE‐ELECTROCARDIOGRAPHIC TESTS

In the entire field of therapeutics there is no area of greater conflict or confusion than that concerned with the use of drugs in the management of angina pectoris. No mystery exists, however, as to the major causes underlying this chaotic state. These causes stem primarily from the nature of the disease under investigation, the difficulties in estimating and interpreting drug-induced changes in subjective responses, and the lack of suitable means for determining, in man, coronary blood flow, cardiac metabolic rate, cardiac work, and cardiac efficiency. If the pain in angina pectoris provided a true reflection of the disparity between coronary flow and myocardial requirements, this subjective sensation might offer an acceptable index for assaying the potency of so-called vasodilator drugs. There is, however, no simple and direct relationship between coronary insufficiency per se and the pain experienced, and consequently a minute ischemic area in the myocardium may cause as severe discomfort as ischemia of a whole ventricle.’ This is because the distress experienced as angina is determined not only by the intensity of the stimulus evoked by myocardial hypoxia but also by the psychic reaction to its perception? I t has been pointed out that such states of feeling as anxiety, frustration, fear, and panic that may be aroused in this manner possess the power to intensify the total experience expressed as p a h 3 Discomfort in the chest, self-diagnosed as a coronary attack and connoting possible death, may be a totally unsettling experience, but it becomes a trivial annoyance easily disregarded when accurately labeled as myositis or neuralgia. Consequently, since marked variability in the psychic component of angina exists not only from day to day but from one attack to another, some device is necessary to neutralize or control reaction to pain perception if this subjective index is to be utilized for drug evaluation in angina pectoris. Most authorities believe that such control may be accomplished simply by alternating courses of placebo with similar courses of test drugs, and they consider that proper control is obtained, by the same manipulation, over spontaneous changes in the severity of angina occurring during the natural course of the disease, over seasonal changes, disturbances in other organ systems, emotional influences, and unknown factors. I t appears doubtful that valid results can be obtained in this manner from a study of small groups of subjects over a period of several weeks or months. Investigators who compare the action of a drug with that of an inert material frequently overlook the profound effects of emotion and other influences on bodily function, and they consequently treat the patient as a static apparatus whose performance can be modified only by the substances put into it. Indeed, the vagaries that influence the anginal state

Comparative Responses to Various Nitrates in the Treatment of Angina Pectoris

Three long-acting nitrates, namely, pentaerythritol tetranitrate, erythrol tetranitrate and isosorbide dinitrate, are available for reducing the severity and frequency of attacks of angina pectoris. The time of onset of the action of these drugs is an important consideration. The duration of the action of these drugs also must be considered in planning frequency of their administration in relation to the symptoms in each case.

Environmental factors in coronary artery disease.

Atherosclerosis arises as the result of a complex interaction between host and environment. The multiplicity of causes which may influence its initiation and progression tend to defy even academic classification under titles of agent, host and environment.’ Environmental factors suspected of influencing conditions within the host which promote atherogenesis include such variables as diet, exercise, occupation, stress, culture, climate and drugs. Considerable difference of opinion exists both as to the actual and relative significance of each of these factors in the genesis of the disease. Indeed, in many quarters so much emphasis has recently been placed on the role of diet that all other factors have been

The influence of insulin shock therapy on the electrocardiogram

Abstract A study before and after a series of insulin shock treatments in 259 patients with schizophrenia was undertaken to determine the incidence of significant electrocardiographic alterations. It was concluded that this form of therapy is not associated with any cumulative injury to the myocardium which could be detected in the electrocardiogram.

SUBACUTE BACTERIAL ENDOCARDITIS COMPLICATED BY AGRANULOCYTOSIS; REPORT OF CASE WITH RECOVERY

Excerpt The superiority of penicillin over all other agents thus far employed in the treatment of subacute bacterial endocarditis appears to be established.1, 2, 3, 4, 5, 6That penicillin may simil...

Prognosis in Severe Angina Pectoris with Medical Versus Surgical Therapy.

Excerpt The response of 100 patients with severe angina pectoris under long-term treatment with propranolol and isosorbide dinitrate has been determined by controlled objective evaluation and compa...