John A. Mantle

Unstable angina pectoris: National cooperative study group to compare medical and surgical therapy

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.Abstract A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the ethical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Unstable angina pectoris: National cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.Abstract A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the ethical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Enhancement of left ventricular function by glucose-insulin-potassium infusion in acute myocardial infarction

Abstract Twenty-eight patients admitted to the hospital with suspected acute myocardial infarction underwent baseline studies within 12 hours of onset of symptoms. Patients were then randomized to receive control infusion (0.45 percent sodium chloride at 20 ml/hour) (15 patients) or glucoseinsulin-potassium infusion (300 g glucose, 50 units regular insulin, 80 mEq KCl/liter water at 1.5 ml/kg per hour) (13 patients) for 48 hours. All patients received 0.45 percent sodium chloride for 2 more days. Coronary arteriograms and left ventriculograms were obtained in 26 (93 percent) of 28 patients 2 to 3 weeks after infarction. Radionuclide ejection fraction improved during glucose-insulin-potassium infusion (49 ± 4 to 55 ± 5 percent, p During experimental infusion pulmonary arterial end-diastolic pressure decreased in the glucose-insulin-potassium group (17 ± 2 to 12 ± 2 mm Hg, p These data suggest that glucose-insulin-potassium infusion after acute myocardial infarction in human beings (1) increases global ejection fraction, (2) Increases ejection fraction in the “infarcted zone” without changing ejection fraction in the “noninfarcted zone”, and (3) decreases pulmonary arterial end-diastolic pressure and end-diastolic and end-systolic volumes.

Clinical effects of glucose-insulin-potassium on left ventricular function in acute myocardial infarction: Results from a randomized clinical trial

Abstract The effects of glucose-insulin-potassium (GIK) on hemodynamics and left ventricular (LV) function in patients with acute myocardial infarction (AMI) were investigated in a prospective randomized study. Patients who presented with suspected AMI were candidates for this study if prerandomization evaluation was completed within 12 hours from onset of chest pain. Patients over 75 years of age, insulin-dependent diabetics, patients with renal insufficlency, and comatose patients were excluded. Following completion of baseline hemodynamic measurements, patients were randomly allocated to 48-hour infusion of 300 gm G, 500 units I, and 80 mEq KCl per liter at rate of 1.5 ml/kg/hr or to conventional therapy. In addition to serial hemodynamic measurements, dextran LV function curves (LVFC) were constructed during the second and third days to assess extent of LV injury. Eighty-five of 118 patients who were initially randomized into this study had AMI documented by diagnostic rise and fall of CK-MB isoenzyme. Baseline characteristics and hemodynamics were similar for GIK and control patients with AMI. GIK patients who presented with their initial AMI had significant reduction in pulmonary arterial end-diastolic pressure from prerandomization value of 16 ± 1 to 10 ± 1 by day 3, compared to 18 ± 1 to 16 ± 1 mm Hg for control patients ( p 2 for control patients ( p p p

Method for quantitative analysis of regional left ventricular function with first pass and gated blood pool scintigraphy

Abstract The ability of radionuclide angiocardiography to quantitatively assess regional left ventricular function was studied in 33 patients undergoing biplane left ventricular cineangiography (45 ° right anterior oblique projection, and 60 ° left anterior oblique projection with 25 ° caudocranial angulation), and first pass (30 ° right anterior oblique projection) and multiple gated equilibrium (35 ° to 45 ° left anterior oblique projection with 20 ° to 25 ° caudocranial angulation) left ventricular scintigraphy within 48 hours. End-diastolic and end-systolic silhouettes of contrast angiograms were superimposed, and five segments were defined in each plane by radial lines originating from the end-diastolic center of mass. Segmental angiographic ejection fraction (end-diastolic area — end-systolic area/ end-diastolic area) was calculated for each segment by computerized planimetry. Similar segments were defined in the end-diastolic and end-systolic regions of interest of the first pass and gated left ventricular scintigrams, and the segmental scintigraphic ejection fraction (back-ground-corrected end-diastolic counts — background-corrected end-systolic counts/background-corrected end-diastolic counts) was obtained for each. A good correlation was observed between segmentai angiographic and scintigraphic ejection fraction in the segments corresponding to the anterobasal (r = 0.74), anterolateral (r = 0.70), apical (r = 0.77), diaphragmatic (r = 0.71), distal septal (r = 0.66), posterolateral (r = 0.71) and inferolateral (r = 0.60) left ventricular regions. The poor correlation in the posterobasal (r = 0.39), basal septal (r = −0.02) and superolateral (r = 0.05) segments was probably related to difficulty in defining the aortic valve, overlap of the left atrium and the left ventricle, and inability to visualize the high septum with these scintigraphic techniques. The reproducibility of scintigraphic segmental ejection fraction was studied in 13 patients in whom a second gated scintigram was performed 2 hours after the initial one. Excellent agreement (r = 0.93) was observed for scintigraphic segmental ejection fraction in the distal septal, posterolateral and inferolateral segments. Segmental scintigraphic ejection fraction enables accurate quantitative evaluation of the function of the anterobasal, anterolateral, apical, diaphragmatic, distal septal, posterolateral and inferolateral left ventricular regions with high reproducibility.

Surgical versus medical therapy for treatment of unstable angina: Changes in work status and family income

Abstract Employment and income status of 96 patients randomized into the Alabama portion of the National Cooperative Unstable Angina Study were evaluated before the patients admission to the study and in 1977. All patients had at least 12 months of follow-up study (mean 38 months). The ratio of patients fully employed at the time of follow-up to those fully employed at entry into the study (baseline) was 0.68 for medically treated patients, 0.53 for surgically treated patients and 0.53 for patients in whom medical therapy failed and who later underwent operation. The changes in annual family income were +

Advantage of the cranial-right anterior oblique view in diagnosing mid left anterior descending and distal right coronary artery disease

1,111 for medical patients, −

Unstable angina pectoris: A comparison of the costs of medical and surgical treatment

2,447 for surgical and +

Cardiac catheterization and angiographic analysis computer applications.

875 for those later undergoing surgery. Regression analysis revealed that nonwork income, initial work status, initial income, severity of angina while the patient was in the unstable angina study and the procedural variable (that is, persistent medical, early surgical or late surgical treatment) were associated with return to full-time employment. Changes in family income were related to change in work status, the procedural variable, the patients education, initial work status, the spouses income, occurrence of a myocardial infarction after entry into the unstable angina study, duration of angina before entry into the unstable angina study, marital status and sex. Patients who underwent initial surgery had the largest reduction in family income, related to the change in nonworking status at the time of follow-up interview.

Measurement of effective renal plasma flow in congestive heart failure

The value of the cranial-right anterior oblique view in uncovering or improving the arteriographic visualization of lesions in the mid left anterior descending coronary artery, the origin of its diagonal and septal branches and the distal branches of the right coronary artery was analyzed in 300 consecutive patients. The cranial-right anterior oblique view was compared with standard and other angled views. In the mid left anterior descending artery the view provided improved visualization over the other views in 80 percent of cases and uncovered lesions in 7 percent. In the septal arteries, the view improved visualization in more than 90 percent of cases and uncovered lesions in 26 percent. In the diagonal branches, the view improved visualization in nearly 75 percent of cases. In the distal right coronary artery there was improved visualization of the posterior descending and posterolateral branch arteries in more than 80 percent of cases. The cranial-right anterior oblique view was also the most advantageous view from a technical standpoint, yielding satisfactory exposure factors in obese and extremely heavy patients.