John J. Gregory

Double-Blind, Placebo-Controlled Study of the Effects of Carvedilol in Patients With Moderate to Severe Heart Failure The PRECISE Trial

Background Carvedilol has improved the symptomatic status of patients with moderate to severe heart failure in single-center studies, but its clinical effects have not been evaluated in large, multicenter trials. Methods and Results We enrolled 278 patients with moderate to severe heart failure (6-minute walk distance, 150 to 450 m) and a left ventricular ejection fraction ≤0.35 at 31 centers. After an open-label, run-in period, each patient was randomly assigned (double-blind) to either placebo (n=145) or carvedilol (n=133; target dose, 25 to 50 mg BID) for 6 months, while background therapy with digoxin, diuretics, and an ACE inhibitor remained constant. Compared with placebo, patients in the carvedilol group had a greater frequency of symptomatic improvement and lower risk of clinical deterioration, as evaluated by changes in the NYHA functional class (P=.014) or by a global assessment of progress judged either by the patient (P=.002) or by the physician (P<.001). In addition, treatment with carvedilol...

Hemodynamics, coronary blood flow, and myocardial metabolism in coronary shock; response to l-norepinephrine and isoproterenol

Hemodynamics and myocardial metabolism were evaluated in 18 patients in cardiogenic shock following acute myocardial infarction. The response to l-norepinephrine was studied in seven cases and the response to isoproterenol in four cases. Cardiac index (CI) was markedly reduced, averaging 1.35 liters/min per m(2). Mean arterial pressure ranged from 40 to 65 mm Hg while systemic vascular resistance varied widely, averaging 1575 dyne-sec-cm(-5). Coronary blood flow (CBF) was decreased in all but three patients (range 60-95, mean 71 ml/100 g per min). Myocardial oxygen consumption (MV(O2)) was normal or increased ranging from 5.96 to 11.37 ml/100 g per min. Myocardial oxygen extraction was above 70% and coronary sinus oxygen tension was below 22 mm Hg in most of the patients. The detection of the abnormal oxygen pattern in spite of sampling of mixed coronary venous blood indicates the severity of myocardial hypoxia. In 15 studies myocardial lactate production was demonstrated; in the remaining three lactate extraction was below 10%. Excess lactate was present in 12 patients. During l-norepinephrine infusion CI increased insignificantly. Increased arterial pressure was associated in all patients by increases in CBF, averaging 28% (P < 0.01). Myocardial metabolism improved. Increases in MV(O2) mainly paralled increases in CBF. Myocardial lactate production shifted to extraction in three patients and extraction improved in three. During isoproterenol infusion CI increased uniformly, averaging 61%. Mean arterial pressure remained unchanged but diastolic arterial pressure fell. CBF increased in three patients, secondary to decrease in CVR. Myocardial lactate metabolism deteriorated uniformly; lactate production increased or extraction shifted to production. In the acute state of coronary shock the primary therapeutic concern should be directed towards the myocardium and not towards peripheral circulation. Since forward and collateral flow through the severely diseased coronary bed depends mainly on perfusion pressure, l-norepinephrine appears to be superior to isoproterenol; phase-shift balloon pumping may be considered early when pharmacologic therapy is unsuccessful.

Systemic and Myocardial Hemodynamic Responses to Relatively Small Concentrations of Carboxyhemoglobin (COHB)

1992 National Health and Medical Research Council Act 1992 National Health and Medical Research Council June 1991 Passive smoking and the risk of heart attack or coronary death Annette J Dobson, Hilary M Alexander, Richard F Heller, Deborah M Lloyd Article published in: The Medical Journal of Australia, vol.154 A retrospective cohort study of smoking habits in Australia Jilda Hyndman, Michael Hobbs, Konrad Jamrozik, Richard Hockey, Richard Parsons Unit of Clinical Epidemiology, University of Western Australia

Calcified Left Atrial Myxoma Simulating Mitral Insufficiency Hemodynamic and Phonocardiographic Effects of Tumor Movement

In the atypical case presented, a calcified myxoma of the left atrium simulated isolated mitral insufficiency. Unique hemodynamic and phonocardiographic events were recorded. A notch in the upstroke of the left ventricular pressure tracing during isometric contraction occurred simultaneously with an ejection sound, which fused with the first heart sound, and with an abrupt decrease in ventricular volume as the tumor was ejected from the ventricle. A similar notch in the downstroke of the ventricular pressure tracing was most likely due to the abrupt increase in ventricular volume as the tumor descended into the left ventricle. A third heart sound was present which was identified as a ventricular diastolic gallop and was differentiated from a mitral opening snap by simultaneous pressure tracings.

Use of the permanent transvenous pacemaker in 168 consecutive patients

Abstract One hundred and eighty-one implantations of permanent transvenous cardiac pacemakers have been performed in 168 patients at the St. Vincents Hospital, New York, N. Y., from April 1965, to March 1970. The chief indication for the implantations was complete heart block, although one-third of the patients were symptomatic from other bradyarrhythmias. Only ventricular triggered demand units have been used in the last two years. Cardiac output studies at varying rates indicated a rate of 60 beats per minute to be adequate in the group so studied, and all pacemakers are set at this rate. All patients have been relieved of symptoms. Complications have been minimal. The demand-type pacemaker has proved as reliable as the fixedrate unit, and appears preferable in all patients.

A survey of New Jersey hospital ethics committees

A mail survey in 1988 of all 108 hospitals in New Jersey, and telephone follow-up in 1990, investigated the extent and structure of ethics committees with attention to the distinctions between prognosis, infant care review committees (ICRC) and general ethics committees (HECs). It disclosed that as of August, 1990, 74 hospitals had prognosis committees, 16 had ICRCs, and 64 had HECs. All types of committees tend to cluster in teaching hospitals and in hospitals with 200-500 beds. HECs average 13 members which include 4-5 physicians, 2-3 nurses, administrators and clergy (1-2 each), and fewer than one each for any other single profession. The primary purpose of HECS is to develop hospital ethics policy (96%), followed by educating hospital staff (80%), and providing counsel and support to physicians (67%). Case review with recommendation is provided by 54% of the HECs and 21% are involved in confirmation of prognosis.

Use of the permanent subcutaneous transvenous pacemaker in Adams-Stokes syndrome

Abstract The technic and results of long term endocardial pacing with a subcutaneous power supply are discussed. Among 15 patients so treated during a 10 month period, 11 patients were discharged from the hospital with satisfactorily functioning transvenous units. One patient died suddenly one month after discharge. The other 10 have done well. Of the original group, 2 died suddenly in the hospital, and 2 had transthoracic epicardial pacemakers installed when transvenous units failed to function. The incidence of late failure of equipment has been small, and the ease and safety of installation under local anesthesia make it a satisfactory method for permanent pacemaking.

Resuscitation of the severely ill patient with acute myocardial infarction

Abstract Three certain cases and 1 questionable case of acute myocardial infarction complicated by acute pulmonary edema and cardiac arrest are presented. All patients survived. The implications of resuscitation in these severely ill patients with acute myocardial infarction are discussed.

Audible atrial sounds in a case of atrial flutter

Abstract A case of atrial flutter in which audible atrial sounds were heard and graphically recorded is added to the 15 previously reported cases. The mechanism of atrial flutter sounds is discussed and attributed to the rapid movement of a stiff, thickened, stenotic mitral valve after each atrial contraction. A high degree of atrioventricular block is usually necessary for recognition of these sounds.