Joel M. Felner

Cardiac abnormalities in cachectic patients before and during nutritional repletion

Abstract The effect of PCU and HA on heart dimensions and function was examined with non-invasive methods in 10 patients with severe undernutrition of diverse etiology. Control subjects were 10 normal men and women matched to their cachectic counterparts by height and sex. The study was conducted in two phases. In phase A, baseline studies of heart dimensions and function were completed. Phase B consisted of cardiovascular and metabolic monitoring during 4 to 6 weeks of enteral or parenteral HA. Phase A was characterized by a reduced radiographic total heart volume, echo EdV, LV mass, and CO. These reductions, however, were only one half to one eighth as great as the losses in BW. The patients therefore entered HA with an elevated LV mass index and cardiac index. Ejection phase indices of LV function (EF and Vcf) were normal or enhanced. Phase B studies in five subjects showed that decreased cardiac size and output were correctible by HA, but at differing rates. Ventricular volume and CO corrected more rapidly than LV mass under the conditions of rapid repletion where the daily sodium intake was 2 to 4 grams, and values for cardiac index reached 250 per cent of normal. Resting metabolic rate also increased during phase B. The combination of an elevated output, excessive sodium retention, and increased metabolic rate while LV mass was still reduced appeared to be responsible for cardiac decompensation in two of five repleted patients. To prevent cardiac decompensation during the HA of undernourished subjects, we propose the use of low salt regimens, a slower rate of HA and serial monitoring of cardiac dimensions and function by clinical examination and echo.

Symptomatic myocardial bridging of coronary artery

Abstract Two cases of symptomatic myocardial bridging of the left anterior descending coronary artery requiring surgery for relief are reported. One patient experienced the sudden onset of ventricular fibrillation, had evolving electrocardiographic evidence of an anterior myocardial infarction and subsequently continued to have chest pain. The second patient presented with a long-standing history of repeated episodes of paroxysmal supraventricular tachycardia accompanied by chest pain. During one such episode he had prolonged chest pain and a syncopal episode, but evidence for myocardial necrosis did not develop. On coronary arteriography the only abnormality noted was severe systolic narrowing of the left anterior descending coronary artery in the first patient and similar narrowing of both this artery and a large diagonal vessel in the second. Each patient successfully underwent coronary arterial debridging and, in addition, had a bypass graft to the distal left anterior descending artery. Both patients are In stable condition and show considerable improvement 46 and 9 months, respectively, after operation. Although in most cases of bridging detected on coronary arteriography there is no evidence of ischemic heart disease, the occurrence of symptoms with tachycardia and, in particular, the unusual length of the bridged segments and the severity of systolic narrowing may have played a significant role in the development of disease in these two patients.

Differentiation of hypertrophic cardiomyopathy and cardiac amyloidosis from other causes of ventricular wall thickening by two-dimensional strain imaging echocardiography.

Hypertension is the most common cause of left ventricular (LV) hypertrophy. However, multiple causes can lead to LV hypertrophy, each of which has different histological and mechanical properties. To assess the value of a novel speckle-tracking echocardiographic measurement of myocardial strain and strain rate in defining the mechanical properties of LV hypertrophy, 20 patients with asymmetric hypertrophic cardiomyopathy, 24 patients with secondary LV hypertrophy, 12 patients with biopsy-proved confirmed cardiac amyloidosis, and 22 age-matched healthy asymptomatic volunteers were studied. Patients with amyloidosis had severe diastolic dysfunction, and myocardial deformation was significantly decreased. The new technique allowed cardiac amyloid to be easily differentiated from the other categories. In patients with hypertrophic cardiomyopathy, there was segmental myocardium dysfunction as assessed by strain imaging. LV global systolic velocity and radial displacement were higher, and abnormal relaxation was more frequent, in the group with secondary LV hypertrophy than in normal controls. In conclusion, the observations from strain parameters derived from speckle tracking were consistent with the known underlying pathology of each condition, which speaks to the value of strain imaging. Cardiac amyloid profoundly alters all strain parameters, and analysis of these parameters could aid in the diagnosis.

Echocardiographic study of cardiac dimensions and function in the endurance-trained athlete

Adaptive cardiac responses to isotonic training were studied with echocardiographic measurement of cardiac dimensions and function in 20 endurance runners whose maximal aerobic capacity on the treadmill was 4.88 +/- 0.13 (mean standard error of mean) liters of oxygen/min. They were compared with 26 young sedentary control subjects whose capacity was 3.34 +/- 0.11 liters of oxygen/min (P less than 0.001). A modest degree of right and left ventricular chamber enlargement and left ventricular hypertrophy was observed in endurance runners (left ventricular mass index 140 +/- 6 g/m2 compared with 107 +/- 4 g/m2 in sedentary control subjects, (P less than 0.001). Resting heart rate was slower in endurance runners (51 +/- 2 versus 62 +/- 2 beats/min, P less than 0.001) and resting left ventricular function as evaluated with ejection fraction and maximal posterior wall shortening velocity and mean circumferential shortening velocity (VCF) was comparable or slightly depressed in endurance runners (0.98 +/- 0.03 versus 1.02 +/- 0.05 circumferences/sec [difference not significant]). This study suggests that isotonic training results in adaptive changes in ventricular volume and mass, slower heart rates that may be associated with more efficient pumping function (that is, increasing stroke volume) and insignificant alterations in resting ejection phase indexes of left ventricular function.

Time course of regression of left ventricular hypertrophy in treated hypertensive patients

Abstract In a prospective study, 32 hypertensive patients with echocardiographic evidence of left ventricular hypertrophy were treated with methyldopa, hydrochlorothiazide, or methyldopa and hydrochlorothiazide combined. Echocardiograms and electrocardiograms were obtained in each of the 32 patients before treatment, at the point of initial blood pressure control, and then one, three, and six months thereafter; in 27 patients these studies were also obtained after 12 and 18 months. Left ventricular end-diastolic posterior wall thickness decreased in seven patients whose blood pressure was controlled with methyldopa alone (p

Exercise testing and training in physically disabled men with clinical evidence of coronary artery disease

Abstract A prospective, randomized, controlled clinical trial in patients with coronary artery disease (CAD) and a concurrent physical disability evaluated the effects of a home exercise training program on cardiovascular function and blood lipids. Eighty-eight men between the ages of 42 and 72 years (mean 62) with documented CAD and a physical disability with functional use of ≥2 etremities including 1 arm were randomized to either a 6-month home exercise training program using wheelchair ergometry or to a control group that received usual and customary care. Both groups received dietary instructions and were requested to follow a fat-controlled diet. Exercise test variables with echocardiography and blood lipids were measured at baseline and at 6 months. The home exercise training group significantly improved both peak exercise left ventricular ejection fraction (p = 0.007) and fractional shortening (p = 0.01) between baseline to 6 months, whereas the control group showed no significant changes. Exercise training effects of decreased resting heart rate (p = 0.03) and decreased peak rate pressure product (p = 0.03) were also found in the treatment group. No exercise-related cardiac complications occurred. Both groups significantly (p ≤ 0.01) increased high-density lipoprotein cholesterol levels. These results indicate that physically disabled men with CAD can safely participate in a home exercise training program which may result in intrinsic cardiac benefits. The metabolic cost of activities of daily living imposed on this disabled popu lation may also have a positive effect on high-density lipoprotein cholesterol levels.

Sequence of cardiac changes in Duchenne muscular dystrophy

Boys with Duchenne muscular dystrophy (DMD) rarely have clinical evidence of myocardial dysfunction during life. Nevertheless, congestive heart failure is a frequent terminal event and autopsy invariably shows dystrophic myocardial involvement. Little is known regarding the progression of heart functional abnormalities in boys with DMD from birth to death. Therefore we have examined the hearts of 18 DMD boys aged 4 to 15 years with the following non-invasive methods: cardiovascular physical examination, electrocardiography, chest x-ray, serum enzymes, and echocardiography. Control subjects were 25 normal boys matched to their DMD counterparts by age and by body surface area. The dystrophic patients were divided into early (N = 9) and late (N = 9) DMD according to manual muscle testing of skeletal muscles. In early DMD, six of 23 cardiac indices differed from control boys; in the late stage, an additional five indices became abnormal. Early DMD was characterized by these abnormalities: tachycardia, large ECG R/S ratio in V1, augmented q wave voltages in Leads I, II, and V5 of the ECG, diminished contractile excursion of the left venticular posterior wall (LVPW) and interventricular septum, and decreased rate of relaxation of the LVPW. In late DMD additional cardiac abnormalities appeared: enlarged heart volume by x-ray, reduced cardiac ejection fraction, diminished change in left ventricular diameter from diastole to systole, reduced maximal systolic endocardial velocity, and decreased rate of circumferential fiber shortening as detected in the echocardiogram. Most of the cardiac abnormalities were revealed only by echocardiography, which is thus shown to be a sensitive method for monitoring the progression of cardiac dystrophy during the life span of the DMD child.

Sources of variability in echocardiographic measurements

Abstract Experienced echocardiographers performed and interpreted echocardiograms of 16 normal volunteers in an experiment designed to quantify the sources of variability in echocardiographic measurements. The experimental factors were 16 subjects, two echocardiographic technicians, replication between 2 successive days, replication between two echocardiograms taken approximately 20 minutes apart, two subject positions and subject gender. The experimental factors in echocardiographic interpretation were four interpreters each interpreting two copies of each echocardiogram. The major conclusions of this study are: (1) Relatively little of the variability in echocardiographic measurements can be attributed to the technicians if the latter are experienced. (2) There appears to be relatively little variability in measurement with respect to days of replication within days, except for heart rate and the right ventricular internal dimension measurements. (3) The variability that resulted when an interpreter read unidentified copies of the same echocardiogram on different occasions was as large or larger than the variability that occurred when different interpreters read the same echocardiogram. (4) There is significant extraneous variability in the measurement of the thickness of the ventricular septum and posterior wall in normal subjects. (5) The position of the subject systematically influences the value of the measurements of the right ventricular internal dimension, but has relatively little or no effect on other measurements. It is concluded that each echocardiogram should be read at least twice by each of at least two interpreters. Minimally, each echocardiogram should be read either by one interpreter on two separate occasions or by two interpreters. The reported result for a measurement should be the mean of the values. If possible, an interpreter reading the same echocardiogram more than once should be “blinded” to the identity of the echocardiograms so that bias on subsequent readings is minimized.

“Harvey,” the cardiology patient simulator: Pilot studies on teaching effectiveness

Abstract The final prototype of “Harvey,” a cardiology patient simulator, was completed in 1976. A review and critique of the simulators nonauscultatory and auscultatory physical findings by cardiologists indicated that the simulator was capable of faithfully reproducing the blood pressure, jugular venous pulsations, carotid and peripheral arterial pulsations, precordial impulses and auscultatory events of almost all cardiac diseases. Pilot studies using the simulator in a formal senior medical student elective program in cardiology showed an average gain in bedside examination skills of 32 percent ( p To assess the acceptability of the device, 770 undergraduate and graduate physicians, family practitioners, internists and cardiologists were exposed to the cardiology patient simulator. Their reaction was positive, 93 percent rating it excellent and 100 percent wishing to be taught with the device again in the future. Prolonged periods of use demonstrated the technical reliability of the simulator. Formal multicenter studies are now underway that will assess its effectiveness as a teaching and testing device. The long range goals of these efforts remain: (1) to produce better trained physicians in less time and at less cost; and (2) to provide an objective method to measure the clinical competency and skills of students and physicians in patient-oriented examinations, such as those for Board certification and recertification.

Cardiac evaluation of women distance runners by echocardiographic color Doppler flow mapping

Echocardiographic color Doppler flow mapping was performed in 46 normal women to determine the normal flow phenomena across each of the four heart valves. Three groups were studied: Group I consisted of 15 highly trained long distance runners, mean age 27 years, running an average of 105 km/week, with a mean rest heart rate of 45 beats/min; Group II consisted of 14 moderately trained long distance runners, mean age 28, running an average of 60 km/week, with a mean rest heart rate of 53 beats/min; Group III consisted of 17 sedentary control subjects, mean age 28, with a mean rest heart rate of 77 beats/min. Color Doppler flow mapping showed that the ventricular inflow and outflow patterns were the same for each of the groups and identified a regurgitant flow pattern across each of the valves. A tricuspid regurgitant flow pattern was present in 14 subjects (93%) in Group I, 8 (57%) in Group II and 4 (24%) in Group III. A pulmonary regurgitant flow pattern was present in 13 subjects (87%) in Group I, 8 (57%) in Group II and 3 (18%) in Group III. A mitral regurgitant flow pattern was present in 4 subjects (20%) in Group I, 5 (35%) in Group II and 1 (17%) in Group III and an aortic regurgitant flow pattern was present in 1 subject (6%) in Group I. Patients in Group I had significantly more tricuspid and pulmonary regurgitant flow patterns than did patients in Group III (p less than 0.001). Heart rate and distance training in women appear to correlate with the frequency of tricuspid and pulmonary regurgitant flow patterns.(ABSTRACT TRUNCATED AT 250 WORDS)