L. Kent Smith

Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors.

Background. Although digoxin is effective in the treatment of patients with chronic heart failure who are receiving diuretic agents, it is not clear whether the drug has a role when patients are receiving angiotensin-converting-enzyme inhibitors, as is often the case in current practice. Methods. We studied 178 patients with New York Heart Association class II or III heart failure and left ventricular ejection fractions of 35 percent or less in normal sinus rhythm who were clinically stable while receiving digoxin, diuretics, and an angiotensin-converting-enzyme inhibitor (captopril or enalapril). The patients were randomly assigned in a double-blind fashion either to continue receiving digoxin (85 patients) or to be switched to placebo (93 patients) for 12 weeks

Comparison of three progressive exercise protocols in peripheral vascular occlusive disease.

Although claudication pain and hemodynamic responses to exercise are usually clinically assessed via graded treadmill walking, measuring these responses to other commonly performed tasks may yield a more nearly complete evaluation of peripheral vascular occlusive disease. Thus, the purpose of this study was twofold: (1) to determine the reliability of claudication and hemodynamic responses to level walking and stairclimbing and (2) to compare these responses with those obtained with graded walking at similar oxygen consumption. Ten patients with stable claudication symptoms performed graded walking, level walking, and stairclimbing progressive protocols with respective increases in grade, walking speed, and stepping rate on a modified stairclimbing device every two minutes. Similar peak oxygen consumption (13.60 to 14.18 mL/kg/min) was attained with the three protocols (P = NS). Reliability coefficients for the times to onset and to maximal claudication pain during level walking (R = 0.95 and 0.95, respectively) and during stairclimbing (R = 0.92 and 0.82, respectively) were similar to those previously obtained during graded walking. Reliability coefficients for foot transcutaneous oxygen tension during and following level walking (R = 0.78 to 0.96) and stairclimbing (R = 0.65 to 0.98) and for ankle systolic blood pressure following level walking (R = 0.95 to 0.97) and stairclimbing (R = 0.90 to 0.98) were also similar to those previously found with graded walking. Additionally, claudication and hemodynamic measurements were similar among the three exercise protocols. Thus, because graded walking, level walking, and stairclimbing progressive exercise protocols yield reliable and similar information about the hemodynamic severity of peripheral vascular occlusive disease, only one is needed for evaluation.

Relation of coronary artery calcium identified by electron beam tomography to serum lipoprotein levels and implications for treatment.

This study was designed to determine whether the National Cholesterol Education Program (NCEP) lipid guidelines accurately identify subclinical atherosclerosis and whether low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) levels are related to the extent and prematurity of coronary artery disease (CAD) as determined by electron beam tomography (EBT). Out of personal concern for CAD risk, 930 consecutive asymptomatic subjects, without clinical CAD and on no lipid-lowering agents, underwent EBT. Calcium score and percentile were correlated with total cholesterol (TC), LDL-C, HDL-C, triglycerides, and demographic parameters. A calcium score of > 0 (EBT+) was found in 55% of patients; 45% of patients had a 0 score (EBT-). Mean age (58.0 +/- 10.5 vs 49.3 +/- 9.7 years, p = 0.0001), TC (218 +/- 39 vs 211 +/- 41 mg/dl, p = 0.006), LDL-C (136 +/- 36 vs 127 +/- 27 mg/dl, p = 0.005), and TC/HDL-C (4.6 +/- 1.4 vs 4.2 +/- 1.5, p = 0.0001) were significantly higher and HDL-C (52.2 +/- 17.6 vs 55.4 +/- 19.3 mg/dl, p = 0.008) lower in the EBT+ compared with EBT- group. In the EBT+ group, 75.1% of subjects had LDL-C < 160 mg/dl and would not be advised to use lipid-lowering medications according to NCEP guidelines. In subjects with LDL-C < 160 mg/dl, 51.8% of subjects were EBT+, as were 46.1% of those with LDL-C < 100 mg/dl. There were no significant differences in the calcium scores throughout the entire range of all lipid parameters; calcium percentiles were virtually identical within lipid value subgroups. We conclude that asymptomatic patients with EBT-defined subclinical atherosclerosis are not reliably identified by NCEP guidelines, and TC, LDL-C, HDL-C, TC/HDL-C, and triglyceride levels do not correlate with either the extent or prematurity of calcified plaque burden.

Comparison of Treadmill Walking and Stair Climbing Over a Range of Exercise Intensities in Peripheral Vascular Occlusive Disease

Although claudication pain and hemodynamic responses to exercise are related to the degree of arterial narrowing in the lower extremities, the nature of these responses to different exercise tasks and intensities is less clear. Thus, the purpose of this study was to compare claudication and hemodynamic responses to graded walking, level walking, and stair climbing over a range of exercise intensities. Ten patients with peripheral vascular occlusive disease performed five tests within each of the three exercise tasks. Similar values of oxygen consumption were obtained among exercise tasks at each intensity (p = ns). Time to onset of claudication pain and to maximal pain were similar among exercise tasks (p = ns), and both demonstrated a curvilinear decrease as intensity increased (p < 0.05). Foot transcutaneous oxygen tension, ankle systolic blood pressure, and ankle/brachial systolic pressure index were also similar among the three exercise tasks (p = ns); however, each decreased linearly as exercise intensity increased (p < 0.05). Thus, in peripheral vascular occlusive disease, the imbalance between oxygen delivery to the exercising lower extremity musculature and the local metabolic demand is similar during different weight-bearing activities. Second, even though the peripheral circulation is progressively impaired with increased exercise intensity, anaerobic metabolism in the ischemic lower extremity musculature may prevent a continual decline in claudication times. The clinical implication is that a more thorough assessment of the functional limitations imposed by claudication pain is not obtained by using different types of weight-bearing exercise tests as opposed to using only one type.

Relationship Between Foot Transcutaneous Oxygen Tension and Ankle Systolic Blood Pressure at Rest and Following Exercise

To determine whether foot transcutaneous oxygen tension (TcPO2) and ankle systolic blood pressure (SBP) measure similar aspects of peripheral vascular occlusive disease (PVOD), the authors examined their relationship at rest and following treadmill exercise. Thirty-seven PVOD patients (mean age 69.2 ± 0.8 years) rested supine for twenty minutes, followed by a progressive treadmill walking test at a constant speed of 2 mph. The initial grade was 0 % ; this increased 2 % every two minutes until maximal claudication pain (n = 19) or until the occurrence of such limiting symptoms as volitional fatigue (n = 6), ST segment depression (n = 4), dyspnea (n = 3), multiple premature ventricular contractions (n = 2), and angina (n = 2). Patients then rested supine for fifteen minutes. Foot TcPO2 was recorded before, during, and after exercise, whereas ankle SBP was measured before and after exercise. At rest, a curvilinear relationship was found between foot TcPO2 and ankle SBP (foot TcPO2 = 41.89 + 0.22(ankle SBP) + 0.0005 (ankle SBP2); SEE = 9.2, R = 0.64, R2 = 0.41, p < 0.001). In contrast, the relationship was stronger and more linear during recovery, particularly at the sixth minute (foot TcPO 2) = 8.33 + 0.35 (ankle SBP); SEE = 13.6, R = 0.86, R2 = 0.73, p < 0.001). At rest, foot TcPO2 and ankle SBP charac terized different aspects of PVOD because they shared only 41 % common vari ance. During recovery, they provided similar information because up to 73 % of the variance was shared. It is concluded that foot TcPO 2 should also be used to assess PVOD patients because unique information is obtained at rest and values can be recorded during exercise.

Exercise training in patients with impaired left ventricular function.

Advances in the understanding of the pathophysiology of congestive heart failure have guided efforts in formulating effective treatment strategies. The epidemiology, etiology, and medical management of congestive failure are reviewed. The changing approaches to exercise and exercise training in patients with heart failure are discussed. Recent studies of the impact of exercise training in this important patient group are presented.Advances in the understanding of the pathophysiology of congestive heart failure have guided efforts in formulating effective treatment strategies. The epidemiology, etiology, and medical management of congestive failure are reviewed. The changing approaches to exercise and exercise training in patients with heart failure are discussed. Recent studies of the impact of exercise training in this important patient group are presented.

Outpatient cardiac rehabilitation: initial experiences of the first Hungarian multicentric study

INTRODUCTION This paper assesses the first controlled multicentric investigation of outpatient cardiac rehabilitation in Hungary. Framing and starting of the program was carried out beside the Hungarian experts by the United States Department of Health and Human Services. AIMS To prove the extreme importance of cardiac rehabilitation, both inpatient and outpatient, after the hospital treatment of cardiac emergencies. METHODS 531 patients were collected at the beginning of the study from three Hungarian cardiological centers having cardiac surgery and cardiac rehabilitation ward. 167 patients were ranked into the outpatients group (Group A), 311 were rehabilitated in hospital (Group B) and 53 served as control (group C). After physical, ergometric and echocardiographic examinations and psychometric evaluation (Beck and WHOBREF questionnaires) the patients of Group A and B performed a conducted training three times weekly for 3 months. All the patients were examined 3 and 12 months later. RESULTS Significant improvement of ergometric data was observed in both groups of patients who underwent rehabilitation training, but this was not the case with control patients. This improvement could not be observed after one year. The number of anginal attacks and the need of hospital treatment also showed a significant reduction in Groups A and B. CONCLUSIONS The data have proved that cardiac rehabilitation has an extremely important role in the stabilisation of heart functions and general health of patients after acute myocardial infarction or heart surgery. It was also proved, that 12-week rehabilitation training is not sufficient to achieve long-term stabilization. Sufficient data have accumulated during the study about the effectiveness and safety of outpatient cardiac rehabilitation as an alternative to inpatient service.

Járóbetegformában végzett kardiológiai rehabilitáció: az elsô hazai kontrollált multicentrikus tanulmány néhány eredménye

INTRODUCTION This paper assesses the first controlled multicentric investigation of outpatient cardiac rehabilitation in Hungary. Framing and starting of the program was carried out beside the Hungarian experts by the United States Department of Health and Human Services. AIMS To prove the extreme importance of cardiac rehabilitation, both inpatient and outpatient, after the hospital treatment of cardiac emergencies. METHODS 531 patients were collected at the beginning of the study from three Hungarian cardiological centers having cardiac surgery and cardiac rehabilitation ward. 167 patients were ranked into the outpatients group (Group A), 311 were rehabilitated in hospital (Group B) and 53 served as control (group C). After physical, ergometric and echocardiographic examinations and psychometric evaluation (Beck and WHOBREF questionnaires) the patients of Group A and B performed a conducted training three times weekly for 3 months. All the patients were examined 3 and 12 months later. RESULTS Significant improvement of ergometric data was observed in both groups of patients who underwent rehabilitation training, but this was not the case with control patients. This improvement could not be observed after one year. The number of anginal attacks and the need of hospital treatment also showed a significant reduction in Groups A and B. CONCLUSIONS The data have proved that cardiac rehabilitation has an extremely important role in the stabilisation of heart functions and general health of patients after acute myocardial infarction or heart surgery. It was also proved, that 12-week rehabilitation training is not sufficient to achieve long-term stabilization. Sufficient data have accumulated during the study about the effectiveness and safety of outpatient cardiac rehabilitation as an alternative to inpatient service.