Joseph V. Messer

Significance of ventricular tachycardia in idiopathic dilated cardiomyopathy: Observations in 35 patients

To evaluate the significance of ventricular tachycardia (VT) in idiopathic dilated cardiomyopathy (IDC), 35 consecutive patients seen between 1976 and 1980 were studied. The criteria for diagnosis of IDC were based on clinical, laboratory, and cardiac catheterization findings. All patients had right and left heart catheterization, left ventriculography, and coronary cineangiography. Long-term ambulatory electrocardiograms (Holter) were obtained in all patients at the time of diagnosis. There were 24 male and 11 female patients aged 22 to 72 years (mean +/- standard deviation [SD]51 +/- 12). Frequent ventricular premature beats (VPB) (30/h) were observed in 29 patients (83%): complex VPB (Lown grades 3, 4, and 5) in 93% and simple VPB in 7%. Twenty-one patients (60%) had nonsustained VT consisting of 3 to 46 beats (8 +/- 5) with rates from 75 to 210/min. No difference between patients with and those without VT was observed in regard to the presenting symptoms, functional classification, electrocardiographic findings, heart size on chest X-ray, and the hemodynamic measurements including cardiac index, left ventricular end-diastolic pressure, and ejection fraction. Patients with VT were older (p less than 0.05). Follow-up observation from 4 to 74 months (34 +/- 17) showed that 2 patients died suddenly (1 with and 1 without previous VT), a third patient died from intractable congestive heart failure, and the fourth from sepsis. It is concluded that (1) the incidence of ventricular arrhythmias in IDC is high, (2) VT is frequent and tends to occur in the nonsustained form, and (3) there is no correlation between VT and the clinical and hemodynamic findings. VT does not appear to predict prognosis during a relatively short follow-up period in patients with IDC.

History and physical examination in acute pulmonary embolism in patients without preexisting cardiac or pulmonary disease

The history and physical examination were assessed in 215 patients with acute pulmonary embolism uncomplicated by preexisting cardiac or pulmonary disease. The patients had been included in the Urokinase Pulmonary Embolism Trial or the Urokinase-Streptokinase Embolism Trial. Presenting syndromes were (1) circulatory collapse with shock (10 percent) or syncope (9 percent); (2) pulmonary infarction with hemoptysis (25 percent) or pleuritic pain and no hemoptysis (41 percent); (3) uncomplicated embolism characterized by dyspnea (12 percent) or nonpleuritic pain usually with tachypnea (3 percent) or deep venous thrombosis with tachypnea (0.5 percent). The most frequent symptoms were dyspnea (84 percent), pleuritic pain (74 percent), apprehension (63 percent) and cough (50 percent). Hemoptysis occurred in only 28 percent. Dyspnea, hemoptysis or pleuritic pain occurred separately or in combination in 94 percent. All three occurred in only 22 percent. The most frequent signs were tachypnea (respiration ate 20/min or more) (85 percent), tachycardia (heart rate 100 beats/min or more) (58 percent), accentuated pulmonary component of the second heart sound (57 percent) and rales (56 percent). Signs of deep venous thrombosis were present in only 41 percent and a pleural friction rub was present in only 18 percent. Either dyspnea or tachypnea occurred in 96 percent. Dyspnea, tachypnea or deep venous thrombosis occurred in 99 percent. As a group, the identified clinical manifestations, although nonspecific, are strongly suggestive of acute pulmonary embolism. Conversely, acute pulmonary embolism was rarely identified in the absence of dyspnea, tachypnea or deep venous thrombosis.

2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: A joint report of the American college of radiology appropriateness criteria committee and the American college of cardiology foundation appropriate use criteria task force

Peter Alagona, MD[⁎][1]nnGerard Aurigemma, MD[‡][2]nnJaved Butler, MD, MPH[§][3]nnDon Casey, MD, MPH, MBA[∥][4]nnRicardo Cury, MD[#][5]nnScott Flamm, MD[¶][6]nnTim Gardner, MD[⁎⁎][7]nnRajesh Krishnamurthy, MD[††][8]nnJoseph Messer, MD[⁎][1]nnMichael W. Rich, MD[‡‡][9]nnHenry

Clinical assessment of external pressure circulatory assistance in acute myocardial infarction. Report of a cooperative clinical trial.

Abstract The clinical effects of early application of external pressure circulatory assistance (EPCA) in acute myocardial infarction were evaluated in a prospective, randomized trial involving 258 patients in 25 institutions. All patients had mild left ventricular failure and received circulatory assistance within the first 24 hours after the onset of symptoms. There were no significant differences between the treatment and control groups, consisting of 142 patients and 116 patients, respectively, with regard to age, sex, race, previous cardiac history, electrocardiographic location of myocardial infarction, Norris prognostic index, admission heart rate, blood pressure and chest roentgenogram, and time from onset of symptoms to hospital admission. There were also no differences between the treatment and control groups with regard to antiarrhythmic, positive inotropic, diuretic and vasodilator therapy. Hospital mortality was significantly decreased, compared with that of control patients, in the group receiving 4 or more hours of external pressure circulatory assistance within the first 24 hours after admission (mortality rate 6.5 percent [7 of 108] in treatment group versus 14.7 percent [17 of 116] in control group, p

Determination of cardiac output in critically ill patients by dual beam doppler echocardiography

Recent technology in Doppler echocardiography has produced a dual beam Doppler instrument that is capable of insonating the total cross-sectional area of the ascending aorta. The purpose of this study was to evaluate the accuracy of this instrument in measuring cardiac output in critically ill patients by comparing results with those of the thermodilution-derived cardiac output. A technically adequate Doppler cardiac output measurement was attained in 71 (91%) of 78 patients. The range of thermodilution-derived cardiac output measurements was from 1.58 to 11.70 liters/min. To maximize thermodilution cardiac output reliability, several measurements were made for each patient. Those patients in whom the difference between the highest and lowest measurement varied by less than 10% from the averaged results were accepted into the 50 patient study. There was significant correlation between dual beam Doppler- and thermodilution-derived cardiac output (r = 0.96, SEE = 0.55 liters/min, p less than 0.0001). This study demonstrates that dual beam Doppler ultrasound is a promising noninvasive method of measuring cardiac output in the critically ill patient.

Effects of altering carbohydrate metabolism on energy status and contractile function of vascular smooth muscle.

Substrate-dependent changes in vascular smooth muscle energy metabolism and contractile function were investigated in isolated porcine carotid arteries. In media containing glucose glycogen catabolism accounted for all the estimated high-energy phosphate turnover that occurred in conjunction with contraction induced by 80 mM KCl. However, in glucose-free media glycogen catabolism accounted for only a portion of the estimated ATP utilization in resting and contracting arteries, even though glycogen stores were not depleted. The glycogenolysis and lactate production that ordinarily accompanies contraction was completely inhibited by 5 mM 2-deoxyglucose (2-DG). However, there was no decrease in the high-energy phosphate levels when compared to control resting arteries similarly treated with 2-DG. The results suggest that an endogenous non-carbohydrate source may be an important substrate for energy metabolism. Treatment of arteries with 50 microM iodoacetate (IA) in media containing glucose resulted in a marked reduction of high energy phosphate levels and an accumulation of phosphorylated glycolytic intermediates, as demonstrated by 31P-NMR spectroscopy. In glucose-free media, 50 microM IA had only a slight effect on high-energy phosphate levels, while glycogenolysis proceeded unhindered. With 1 mM IA in glucose-free media, the oxidative metabolism of glycogen was inhibited as evidenced by the depletion of high-energy phosphates and the appearance of sugar phosphates in the 31P-NMR spectra. Thus, the titration of enzyme systems with IA reveals a structural partitioning of carbohydrate metabolism, as suggested by previous studies.

Value and limitations of technetium-99m stannous pyrophosphate in the detection of acute myocardial infarction☆

Technetium-99m stannous pyrophosphate (99mTc-PYP) myocardial imaging was performed in 436 consecutive patients for the evaluation of chest pain and suspected acute myocardial infarction (AMI). Scintigrams were assessed independently by three observers with a 90% interobserver agreement. In 134 patients with documented AMI (97 TRANSMURAL, 37 NONTRANSMURAL), THE SENSITIVITY OF 99MTc-PYP imaging was significantly lower in patients with nontransmural AMI (41%) than in patients with transmural AMI (78%), 99mTc-PYP imaging correctly localized the site of transmural infarction in 53 patients (70%). A diffuse 99mTc-PYP uptake was found in nine (10%) of 91 patients with positive scintigrams: six of these had a transmural AMI and three nontransmural AMI. In 226 patients without AMI, the specificity of infarct imaging was 95%. A false-positive scintigram was found in 0%, 8%, 9%, and 2% of patients with unstable angina, progressive angina, stable angina, and noncardiac chest pain, respectively. A diffuse uptake was found in six (54%) of 11 patients with false-positive scintigrams. No patient with the clinical diagnosis of noncardiac chest pain showed discrete uptake. In 76 patients with uncertain diagnosis for AMI, 99Tc-PYP imaging was considered of value in 11 patients with ventricular conduction defects (two patients with WPW syndrome, nine patients with LBBB). These data suggest that: 1. 99mTc-PYP imaging is moderately sensitive in detecting and localizing transmural AMI and is insensitive in detecting nontransmural AMI; 2. A discrete 99mTc-PYP uptake is highly specific for AMI; 3. a diffuse uptake is neither sensitive to, nor specific for AMI. Myocardial imaging with 99m-Tc-PYP is of clinical value when the standard electrocardiographic and enzymatic techniques are inadequate for an accurate diagnosis of AMI.

Relation of ventricular premature beats to underlying heart disease

The relation between ventricular premature beats (VPBs) and physiologic disease was investigated in 305 patients who had 24-hour Holter monitoring tests, cardiac catheterization and angiography. Both frequency and Lown class of VPBs were measured. Analyses showed that occurrence of VPBs at an average frequency of more than 2 per hour or occurrence of complex VPBs (Lown class greater than 2) have the highest association with the presence and severity of cardiac disease. Using these criteria, VPB severity was then compared with extent of ventricular wall motion abnormality (right anterior oblique projection segments), ejection fraction, end-diastolic pressure, category of disease (normal, coronary artery disease [CAD], valvular heart disease, dilated cardiomyopathy), age and severity of CAD (major coronary arteries with greater than 75% diameter reduction). Severe VPBs defined either by complexity or frequency were significantly correlated with extent of wall motion abnormality, ejection fraction, category of disease and age. Severe VPBs were not significantly correlated with end-diastolic pressure or severity of CAD. Discriminant analysis then showed that in addition to wall motion abnormality and ejection fraction, category of disease and age are independently correlated with VPB severity.

The effect of exercise on cardiac performance in human subjects with congestive heart failure

Abstract Cardiac performance and myocardial energetics were studied during physical exercise in 19 subjects with congestive heart failure. Mechanical efficiency of the left ventricle was subnormal at rest and failed to rise normally during effort. The oxygen consumed by a unit weight of muscle at rest was not significantly different in the patients with failure than in the control subjects. With physical effort the oxygen consumption rose out of proportion to both the new work performed and the new pressure generated by the left ventricle. Changes in pressure-time/qO 2 ratio suggest that, unlike the normal ventricle, the failing ventricle is unable to effect a decrease in mean chamber volume during exercise and may actually become larger. No consistent evidence for myocardial hypoxia or anaerobiosis during stress was found. The low mechanical efficiency of the failing heart may be explained by (1) the large chamber volume (and tensile forces required); (2) organic failure or after-load inhibition of change in fiber shortening rate; and (3) further increase in heart size on effort. The fixed pressure-time per minute per oxygen consumption is probably related to an increase in heart size on effort and is a resultant of the above-mentioned factors.

Ethical considerations in CT angiography

The rapid development and clinical deployment of CT angiography raises several important issues, including assurance of professional competence and technical quality, self-referral, the relative role of radiologists and cardiologists, appropriateness and proper indications, the detection and disposition of unexpected or incidental findings and the concern for the rapidly increasing costs of health care and imaging. These questions are properly addressed within the framework of medical ethics, including principles of beneficence, autonomy and justice.