Herman K. Hellerstein

Anatomic Variations of the Orifice of the Human Coronary Sinus

Anatomic variations of the orifice of the human coronary sinus now have practical significance since the advent of catheterization of the coronary sinus. Six main types of variation of the valve of the coronary sinus of 150 hearts are described. The difficulties encountered in catheterization of the human coronary sinus are probably due to obstruction offered by large membranes, bars and networks, and less frequently due to the presence of a large eustachian ridge. On the basis of this study, catheterization of the human coronary sinus should be possible in a maximum of 75 per cent of the cases.

Two step exercise test as a test of cardiac function in chronic rheumatic heart disease and in arteriosclerotic heart disease with old myocardial infarction.

Abstract 1. 1. The electrocardiographic responses of ninety-two consecutive patients with rheumatic heart disease and 100 consecutive patients with arteriosclerotic heart disease who performed a standard two step Master exercise test were analyzed for changes in mechanism, conduction and repolarization and evaluated by five sets of criteria. 2. 2. The incidence of abnormal responses according to the various criteria ranged from 18 to 48 per cent. However, there was no significant difference in the incidence or types of abnormal electrocardiographic responses to exercise in rheumatic or arteriosclerotic heart disease when compared with the same criteria. 3. 3. The incidence of abnormal responses varied according to the severity of disease as measured by the functional and therapeutic classification, regardless of the cause. The incidence of abnormal responses of patients with rheumatic heart disease was not related to age, type of valvular lesion or digitalis medication, but was directly related to the functional status of the heart as determined by the therapeutic and functional classification, cardiac chamber enlargement, presence of atrial fibrillation and electrocardiographic response to the Valsalva maneuver. Abnormal electrocardiographic responses also occurred more commonly in patients with anterior myocardial infarction. 4. 4. We challenge the belief that abnormal electrocardiographic changes occurring after exercise are either diagnostic of coronary arteriosclerosis or caused solely by an insufficient blood supply to the myocardium. Reasons are presented why the interreaction of many facets of myocardial function should be considered in the understanding of the changes produced by exercise. 5. 5. The two step exercise test is a valuable test of cardiac function but is not specific for the diagnosis of cause. The test has proved to be of value as an objective measure of circulatory fitness for brief peak exercise and has been useful for prescribing work and daily activities for patients with all types of heart disease.

Evaluation of cardiac function in relation to specific physical activities following recovery from acute myocardial infarction.

Summary Prescription for physical activities in the hospital, home or world of work requires an evaluation of the whole person and his disease and an analysis of each activity and its physical and emotional requirements. The fitness of a patient recovering from an acute myocardial infarct varies with age, previous training, psyche and the disease process and should be related to the magnitude of the activities undertaken. The physician can approximate the caloric level of the patients fitness from the type of life activities performed without distress. The functional classification of the New York Heart Association should be used because of its excellent correlation with physical fitness, ability to perform at various levels of energy expenditure and prognosis. The physiologic costs of activity should be assessed in terms of heart rate, caloric expenditure, cardiac output, electrocardiogram, blood pressure and heart work. Clinical tests (amplified Masters tests, Valsalva maneuver or Bruces test) afford a good basis for evaluating circulatory function and fitness. The requirements of an activity should be considered in terms of kilogrammeters or foot pounds, environmental stresses, skills, dexterity and muscle groups required. The validity of work prescription can be tested by simple on-the-job measurements, such as blood pressure, recovery pulse and resting pulse rates during the working day and subjective reactions of the patient. When requirements of work and life activities, emotional and social pressures and mature clinical and laboratory evaluation are integrated, the physician has the information necessary for a comprehensive prescription for life activity. By prescription, and not proscription, the coronary patient is permitted to return to a life as full as his cardiovascular capabilities permit. This positive philosophy requires knowledge and application of ergonomics, physiology, vocational and social counseling, psychiatry and clinical medicine. It is hoped that physicians assume this comprehensive role in the treatment of patients with myocardial infarction.

Effect of Digitalis Glycosides on the Myocardial Sodium and Potassium Balance

Nontoxic and toxic doses of digitalis glycoside produced a rapid release of potassium from the myocardium and from extracardiac tissues of the dog. For approximately 25 minutes after the administration of a digitalis glycoside the myocardium was in negative potassium balance and within an hour returned to positive balance. The most serious electrocardiographic changes transpired when the myocardium approached or attained potassium balance. Pretreatment with potassium chloride protected the heart against arrhythmias by increasing Ko+. Pretreatment with glucose and insulin enhanced the arrhythmic action of the digitalis glycosides presumably by producing a low serum potassium (Ko+) and possibly by modifying the state of intracellular potassium (Ki+).

Limitations of marathon running in the rehabilitation of coronary patients: anatomic and physiologic determinants.

Prescribed, supervised exercise training has proved valuable in the rehabilitation of selected coronary patients. However, long distance (marathon) running has limited cardiovascular value in the rehabilitation of patients for a majority of occupations, which involve predominantly upper extremity effort. The age of patients with coronary heart disease and the severity of the lesions preclude the wide application of marathon running to the general coronary heart disease population. Less than 6/1000 subjects with coronary heart disease have been estimated as potentially being able to achieve by high-level training a maximum Vo2 sufficient to complete a marathon race in 5 hours. The hazards of high-level-activity-induced cardiac arrest that is reversible mandates the availability of CPR equipment and personnel in the immediate vicinity of all coronary patients and most coronary-prone patients who are undertaking such heroic activity. Over-publicized marathon running by a few subjects has aroused unrealistic expectations for the majority of coronary heart disease subjects and probably similarly for a considerable number of coronary-prone subjects, many of whom have silent coronary disease.

Work and Heart Disease: II. A Physiologic Study in a Steel Mill

Knowledge of the cardiovascular requirements of various types of work is essential in making work recommendations for cardiac patients. In a previous study the stresses of work in a light metal manufacturing plant were shown to be small. The present study is an evaluation of the physiologic requirement of a typical days work in an open-hearth furnace and other areas in a steel mill. The oxygen consumption, pulmonary ventilation, respiratory rate, and other physiologic responses in cardiac patients are compared to those of normal subjects performing the same tasks.

Electrocardiographic Studies during Cardiac Surgery

The electrocardiographic behavior of the heart was observed in 100 patients undergoing heart operations. Most of the arrhythmias were unrelated to the cardiac operative procedure, but as in other thoracic procedures, were related to hypoxia, level of anesthesia, vagal reflexes, and changes in blood pressure. TA and S-T displacements occurred in all groups and were thought to be related to altered dynamics of the right auricle and ventricle. Prevention, recognition and control of disturbances of cardiac mechanism are discussed.

Work and Heart Disease I. A Physiologic Study in the Factory

Sixty-two factory workers, 36 with heart disease, and 26 healthy control subjects, were studied during a typical days work. Observations of energy expenditure, pulmonary ventilation, pulse rate and electrocardiogram are reported and analyzed in relation to the type of work, the influence of heart disease, and possible objective evidence of fatigue.

Comprehensive care of the coronary patient; a challenge to the physician.

THE MODERN physician should be able to secure a competent evaluation of his patient as a member of society, as an individual, and as a person with a physiologic disorder, in order to recognize the true extent of the disability and to provide appropriate, comprehensive care. In treating patients with coronary disease the physicians attention in the past has been properly fixed on assessing the anatomic injury and restoring physiologic function. This has been so because coronary heart disease inflicts its most obvious and immediate damage on the heart and its action. Today, however, as the clinical picture of coronary disease has developed more clearly, it has become increasingly evident that prognosis for life and even for return to pre-infarction cardiovascular function is better than was previously thought. Most patients survive the acute attack into the stage of convalescence. Here, the impact of this event on the patients psychologic adjustment and on his place in the context of society thrusts itself on our attention. A man who has a heart attack is at least as likely to think of himself as a disabled breadwinner or as a frightened soul as to categorize himself as a coronary patient. The physician, on the other hand, is expected to have an intense preoccupation with his professional specialty and may, as a result, approach the patients problem primarily on the level of heart disease when in fact the patients major impairment may be recognizable only in the light of his social relationships, or of the psychic damage he has suffered. This paper deals, therefore, with the impact

Repetitive ventricular fibrillation in myocardial infarction refractory to bretylium tosylate subsequently controlled by ventricular pacing.

Abstract A 51 year old man began to have recurrent bouts of ventricular fibrillation 7 days after the occurrence of an extensive acute anteroseptal and lateral myocardial infarct. Lidocaine and quinidine were not effective therapeutically. Bretylium tosylate was given intravenously in increasing doses and frequency without suppressing the episodes of ventricular fibrillation. After 28 such episodes, ventricular pacing terminated the recurrences abruptly, and the patient made an uneventful and complete recovery.