Ralph E. Spiekerman

The Spectrum of Coronary Heart Disease in a Community of 30,000 A Clinicopathologic Study

The high rate of necropsy in deaths among permanent residents of Rochester, Minnesota, provided a unique opportunity to study the prevalence of coronary heart disease and the frequency and mode of death resulting from this disease. In this community of approximately 30,000 population, necropsy was done in 73 per cent of all resident deaths during the years 1947 through 1952. Included in this group were 691 necropsies that represented 67 per cent of the 1,026 deaths of persons 20 years of age or older. Coronary heart disease caused death in 221 patients (23 per cent of all necropsies and 32 per cent of all necropsies on adults). These 221 coronary deaths in adults represented 41 per cent of the men and 22 per cent of the women. The coronary deaths were attributed to acute coronary failure (sudden death) in 94 patients (43 per cent), acute myocardial infarction in 87 patients (39 per cent), congestive heart failure in 32 patients (14 per cent) and thromboembolism in eight patients (4 per cent). The 87 patients dying during acute myocardial infarction died of congestive heart failure (30 per cent), myocardial rupture (24 per cent), acute coronary failure (23 per cent), and thromboembolism (14 per cent), with the remaining 9 per cent dyingof a combination of acute myocardial infarction and additional serious systemic disease. The greatest number of deaths from coronary heart disease occurred during the seventh decade of life in men and the eighth decade in women. At least one coronary artery exhibited from 25 to 100 per cent obstruction from atherosclerosis in 513 hearts (74 per cent of the adult necropsies). These necropsies, representing two thirds of all deaths in adults in this community, disclosed that significant coronary-artery disease was present in three of four adults and was the cause of death in four of 10 men and two of 10 women.

Verapamil and 24-hour ambulatory blood pressure monitoring in essential hypertension

The antihypertensive effects of oral regular and slow-release verapamil, a calcium-channel blocking agent, were evaluated in 22 patients with mild to moderate hypertension (sitting diastolic blood pressure [DBP] 95 to 112 mm Hg). The dose required to control blood pressure varied from 80 to 120 mg, 3 times a day. All patients received regular verapamil for a further 3 to 4 months, when systolic blood pressure (SBP) and DBP had risen from the end of the open-label phase. During a double-blind phase patients were randomly assigned to continue the same dose of regular verapamil, 3 times a day, or an equivalent daily dose of sustained-release verapamil (240 to 360 mg once a day). Seven of the 11 patients on regular and 3 of the 11 on sustained-release verapamil were also taking diuretics. This antihypertensive program was continued for at least 4 weeks. During the efficacy period, 24-hour ambulatory blood pressure monitoring was carried out. Mean 24-hour SBP and DBP were 133 +/- 20 and 89 +/- 13 mm Hg, respectively, on regular and 131 +/- 22 and 87 +/- 12 mm Hg, respectively, on sustained-release verapamil. There were no statistically significant differences noted between the 2 groups. Mean SBP and DBP varied similarly during awake and sleep hours with both formulations of verapamil. With regular verapamil, SBP was 139 +/- 18 and 124 +/- 20 mm Hg and DBP 92 +/- 11 and 84 +/- 13 mm Hg during awake and sleep hours, respectively; with sustained release, SBP was 138 +/- 21 and 122 +/- 22 mm Hg and DBP 92 +/- 10 and 80 +/- 10 mm Hg during awake and sleep hours, respectively. Heart rate fell during the entry period and continued during the entire study period. No other adverse effects were noted during the double-blind phase. In summary, verapamil is an effective antihypertensive medication and can be administered once a day as a sustained-release preparation; it is most useful in patients in whom adrenergic blocking drugs are indicated.

Potassium-Sparing Effects of Triamterene in the Treatment of Hypertension

Triamterene (2,4,7-triamino-6-phenylpteridine) was employed alone and in combination with hydrochlorothiazide in the treatment of patients with group 1 and 2 hypertension. In 21 patients, triamterene alone had an inconsistent antihypertensive effect on the systolic blood pressure, which was minimal in most patients. In 16 patients the combination of triamterene and hydrochlorothiazide (2:1 by weight) reduced the systolic blood pressure slightly more than did hydrochlorothiazide alone. Triamterene alone or in combination with hydrochlorothiazide produced an increase in the concentration of potassium in serum. Side effects due to triamterene were similar to those noted with thiazide diuretics. In addition, five patients had a decreasein blood hemoglobin concentration, and two patients had reversible alterations in liver function during triamterene therapy. Triamterene may be a useful adjunct for thiazidetreated hypertensive patients by decreasing the likelihood of complicating hypokalemia.

RE-EVALUATION OF THERAPY OF ACUTE MYOCARDIAL INFARCTION.

Abstract A review of results of therapy for acute myocardial infarction was undertaken because the decline in the rate of mortality from this disease has not been commensurate with the general advancement of medical technology. Conscientious general care and early chair rest are emphasized. A retrospective study of the use of anticoagulants revealed a slightly decreased incidence of thromboembolism and of mortality in the cases in which anticoagulants were used. Although anticoagulant drugs are probably of some benefit, their use should not detract from the search for better methods of salvaging life after myocardial infarction. Intensive-care units which utilize modern electronic monitoring, therapeutic devices, and medical personnel trained and drilled in the procedures for cardiac resuscitation are considered to be an urgent need. Intensive-care units are likely to be the best means now available to clinicians for decreasing the rate of mortality from acute myocardial infaction. The use of thrombolytic agents, now quite new, may become a widely employed and useful means of helping the patient who has acute myocardial infarction. At present, the need in this area is for further clarification of the biochemical effects of thrombolytic agents, the development of more practical means of administration and control of the agents, the search for improved agents, and the evaluation of thrombolytic agents in animals and in the various thromboembolic diseases of man under careful investigational conditions.

Evaluation of the posology of pindolol therapy of hypertension with automatic indirect ambulatory blood pressure monitoring

Pindolol, a nonselective β-adrenergic blocking drug, lowered systolic and diastolic blood pressure equally well during once daily and twice daily dosage. Absence of supine bradycardia likely was attributable to the intrinsic sympathomimetic activity of pindolol. Automatic ambulatory blood pressure monitoring reliably confirmed office blood pressure recordings and indicated good control throughout the day and night.