Rolf M. Gunnar

Improvement in symptoms and exercise tolerance by metoprolol in patients with dilated cardiomyopathy: a double-blind, randomized, placebo-controlled trial.

It has been suspected that the increased sympathetic activity seen in patients with chronic congestive heart failure from dilated cardiomyopathy may be harmful. We therefore tested the long-term effect of metoprolol on eight patients in a double-blind, randomized protocol and 12 patients in an unblinded, crossover protocol who were treated for 12 months (range 10 to 24), and compared them with 16 similar subjects who were treated with placebo for 10 months (range 6 to 12) in a double-blind, randomized protocol. Patients were followed by serial clinical assessment, treadmill testing, radionuclide ventriculography, and echocardiography. Metoprolol-treated patients had an improvement in mean exercise capacity by 3 mets (p less than .0001) while experiencing a significant improvement in functional classification (p less than .001) during both the double-blind and open-label crossover studies and had an improved ejection fraction during the double-blind study (p less than .02). These improvements were not seen in matched control subjects receiving placebo. Seven of 20 patients receiving long-term metoprolol therapy had resolution of nearly all symptoms of heart failure, doubled their exercise capacity, and had progressive improvement in resting radionuclide left ventricular ejection fraction (12.6 +/- 3% to 26.9 +/- 6%) and echocardiographic left ventricular end-diastolic dimension (7.7 +/- 0.5 to 6.5 +/- 0.5 cm). Only one of 21 patients treated was intolerant of metoprolol. We conclude that metoprolol can be given safely to a select group of patients with dilated cardiomyopathy in doses that substantially reduce both resting and exercise heart rates. Long-term beta-blockade improved functional class and exercise capacity in 14 of 20 patients while producing an exceptional clinical response in seven that was accompanied by improved resting parameters of left ventricular function.

Natural Course of Peripartum Cardiomyopathy

Twenty-seven patients presented in the puerperium with cardiomegaly, abnormal `ECG, and congestive cardiac failure and were considered to have peripartum cardiomyopathy (PPCM). The incidence of PPCM was significantly higher in women over 30 years of age, in women in their third or subsequent pregnancy, and in the presence of twins or toxemia. Within 6 months, 14 patients had normal sized hearts (group A), and 13 patients maintained cardiomegaly (group B).The 14 patients in group A have been followed for 3 to 21 years (average 10.7 years). Two have died of unrelated causes. Of the remaining 12, eight are functional class I and four are functional class II. Eight patients had 21 subsequent pregnancies, with no permanent deterioration of cardiac function. Of 13 patients in group B, 11 (85%) have died of congestive cardiac failure. Their average survival was 4.7 years; six of 11 were dead in 3 years. Their clinical course was punctuated by repeated admissions for congestive cardiac failure. Six had pulmonary emboli, one had a systemic embolus, and three of six patients with subsequent pregnancies deteriorated in the puerperium. Of the two surviving patients, one is functional class I and the other is functional class II.Therefore, in those patients in whom cardiomegaly persisted, the prognosis was poor, and subsequent pregnancies were likely to lead to permanent deterioration. In those in whom the heart size returned to normal the prognosis was excellent.

Treadmill Exercise in Assessment of the Functional Capacity of Patients with Cardiac Disease

Abstract The effort tolerance of 43 patients with cardiac disease was evaluated with use of an intermittent multistage treadmill exercise test. The results were compared with independently made clinical estimates of functional classification using the criteria of the New York Heart Association. The 43 adult patients were classified into 4 groups on the basis of peak oxygen consumption (VO 2 ) achieved during treadmill exercise; 11 patients (26 percent) achieved a plateau in VO 2 , and 32 (74 percent) had a symptom-limited capacity. Subjects in Group 1 had a VO 2 of 23 ml/kg per min or greater; Group 2, 16 to 22 ml/kg per min; Group 3, 10 to 16 ml/kg per min; and Group 4, 10 ml/kg per min or less. Although the correlation between treadmill exercise and the physicians assessment of functional classification was significant (r = 0.84, P These results indicate that patients with cardiac disease begin to experience limiting symptoms when peak oxygen consumption is less than 22 ml/kg per min and usually consider themselves severely limited when peak oxygen consumption is 16 ml/kg per min or less. The determination of a patients performance capacity affords an objective measurement of the degree of cardiac impairment and may be useful in the planning of patient management.

Hemodynamic studies and results of therapy in 50 patients with bacteremic shock

Abstract Hemodynamic studies are reported in 50 patients with bacteremic shock. Differences between gram-positive and gram-negative infection and factors relating to survival in shock are examined. Failure of cardiac output to improve following plasma volume expansion suggests impaired cardiac function in some patients. Responses to norepinephrine, dopamine, isoproterenol and corticosteroids are reported, and use of these agents in patients with bacteremic shock is discussed.

The natural course of alcoholic cardiomyopathy.

Abstract Fifty-seven patients with cardiomyopathy associated with alcoholism were followed for an average of 40.5 months (range, 4 months to 8 years). None of the patients were treated with prolong...

Peripartum cardiomyopathy: Clinical, hemodynamic, histologic and prognostic characteristics

Peripartum cardiomyopathy is defined as left ventricular dilation and failure, first developing during the third trimester of pregnancy or in the first 6 months postpartum. In an effort to characterize this syndrome in a middle class population, 14 consecutive patients with peripartum cardiomyopathy underwent a detailed history and physical examination, right heart catheterization, M-mode and two-dimensional echocardiography, radionuclide ventriculography and right ventricular endomyocardial biopsy. These patients were then observed with sequential noninvasive studies to determine prognostic indicators. Eight (57%) of these 14 patients were primiparous and an equal number first presented with heart failure concomitant with or immediately before the onset of labor. When these women were compared with 55 patients with idopathic dilated cardiomyopathy, only mean age at onset of symptoms (28.7 ± 5.7 versus 48.2 ± 13.6 years, p Seven (50%) of the patients with peripartum cardiomyopathy had dramatic improvement within 6 weeks of follow-up, and 6 (43%) died. Survivors had a higher ejection fraction (22.8 ± 11.7 versus 10.6 ± 1.5%, p

Gallium-67 imaging in patients with dilated cardiomyopathy and biopsy-proven myocarditis.

Current standards for detection of myocarditis in a clinical setting rely on endomyocardial biopsy for accurate diagnosis. With this technique a subset of patients with dilated cardiomyopathy show unsuspected myocarditis histologically. Endomyocardial biopsy, despite its specificity, may lack sensitivity due to sampling error if the inflammation is patchy or focal. Therefore, inflammation-sensitive radioisotopic imaging may be a useful adjunct in the diagnosis of myocarditis. This study was designed to evaluate the applicability of gallium-67 (67Ga) myocardial imaging as an adjunct to endomyocardial biopsy in the diagnosis of myocarditis. Sixty-eight consecutive patients referred for evaluation of dilated cardiomyopathy underwent 71 parallel studies with 67Ga imaging and biopsies that served as the basis of comparison for this study. Histologic myocarditis was identified in 8% of biopsy specimens. Clinical and hemodynamic parameters could not be used to predict the presence of myocarditis. Five of six biopsy samples (87%) with myocarditis showed dense 67Ga uptake, whereas only nine of 65 negative biopsy samples (14%) were paired with equivocally positive 67Ga scans (p less than .001). The single patient with myocarditis and no myocardial 67Ga uptake had dense mediastinal lymph node uptake that may have obscured cardiac uptake. The incidence of myocarditis on biopsy with a positive 67Ga scan was 36% (5/14); however, the incidence of myocarditis with a negative 67Ga scan was only 1.8% (1/57). Follow-up scans for three patients showed close correlation of 67Ga uptake with myocarditis on biopsy. In conclusion 67Ga may be a useful screening test for identifying patients with a high yield of myocarditis on biopsy, and serial scans may eliminate the need for frequent biopsies in patients with proven myocarditis.

Endocarditis in the drug addict

Abstract The English literature is reviewed for reports of endocarditis in the drug addict, and 16 additional patients are described. Our series reveals a high incidence of Streptococcus viridans infections. In reviewing the previously recorded cases, we conclude that heroin addicts are not more likely to have endocarditis on the right side of the heart, but if this lesion does develop, the organism most likely responsible is the Staphylococcus. The mortality for this disease is high, and vigorous diagnostic and therapeutic measures are required.

Endotoxin, prekallikrein, complement and systemic vascular resistance: Sequential measurements in man

Eighteen patients were studied prior to and again within 6 hours after transurethral resection or cystoscopy. In addition to hemodynamic measurements, detection of endotoxin by limulus assay and bacteriologic sampling; prekallikrein, C3, C3 proactivator and lysosomal enzyme levels were measured. In five patients limulus assays were positive, and in one, gram-positive bacteremia developed but limulus assay remained negative. All six had significant decreases in prekallikrein, C3 or C3 proactivator. Systemic vascular resistance fell in all six. Four additional patients who had a decrease in systemic vascular resistance were not endotoxemic or bacteremic; one of these had a decrease in prekallikrein only. In the remaining eight patients with neither bacteremia nor endotoxemia, systemic vascular resistance did not change or increase after instrumentation. One had a decrease in C3 proactivator, another in prekallikrein. There was no significant difference in age, disease, antibiotic therapy or bactermia in the two groups of patients. Four of the five resectional procedures were performed in the group that showed decreases in systemic vascular resistance. The data suggest that acute endotoxemia or gram-positive bacteremia in man is associated with depletion of prekallikrein, decreased peripheral resistance and, in some instances, activation of the complement system.

Immunosuppressive therapy in patients with congestive cardiomyopathy and myocardial uptake of gallium-67.

Thirty-nine patients with idiopathic congestive cardiomyopathy underwent gallium-67 scintigraphy. Twenty had no evidence of myocardial uptake (group I) and 19 had demonstrable myocardial gallium-67 activity (group II). There was no significant difference in age, sex, duration of symptoms, antecedent viral illness, left ventricular end-diastolic pressure, pulmonary artery systolic pressure, or ejection fraction between the two groups. Fifteen patients in group II were treated with prednisone and azathioprine for a minimum of 8 months. Nine of 15 patients were clinically unchanged and gallium-67 scans remained positive (group IIa). Six patients had significant improvement and resolution of myocardial gallium-67 uptake (group IIb). The mean change in ejection fraction was +0.2% in group I, -4.8% in Group IIa, and +13.8% in group IIb. There were five deaths in group I (25% mortality), three in group IIa (33% mortality), and no deaths in group IIb. The only significant difference between patients in group IIa and those in group IIb was a greater left ventricular posterior wall thickness in group IIa patients. Twenty control patients without cardiac disease had negative gallium-67 scans. We conclude that gallium-67 myocardial scintigraphy may be a useful test for predicting the response to prednisone and azathioprine therapy.