Saktipada Mookherjee

Effects of sublingual nitroglycerin on resting pulmonary gas exchange and hemodynamics in man.

Simultaneous hemodynamic, ventilation and blood gas measurements were performed in 19 males during cardiac catheterization for evaluation of chest pain syndrome before and 3 to 5 min after 0.4 mg sublingual nitroglycerin. Pulmonary arterial pressures and total pulmonary vascular resistance fell (P < 0.001 for both), and mean systemic arterial pressure decreased (P < 0.05). However, peripheral vascular resistance, cardiac output, and mixed venous PG2 did not change. Total and tidal ventilation, PCO2, pH, and base excess remained unchanged. However, the arterial PO, decreased from a mean of 80 ± 3 (SEM) to 72 ± 2 mm Hg (P < 0.001) and mean venous admixture increased from 8.8 ± 1% to 12.6 ± 1.5% (P < 0.001). The alveolararterial P02 difference increased (P < 0.001) and the dead space tidal volume ratio rose (P < 0.05). We conclude that the decrease in arterial P02 following sublingual nitroglycerin is caused by redistribution of pulmonary blood flow with imbalance in ventilation-perfusion relationships or shunting.

Ultrasonic Measurement of Left Ventricular Wall Motion in Acute Myocardial Infarction

The time-motion representation of the echogram was used to evaluate the left ventricular posterior wall motion in myocardial infarction. The left ventricular posterior wall echo was obtained in 10 normal subjects and 26 patients with chest pain admitted to a coronary care unit, including 11 with acute myocardial infarction (group 1), nine with old myocardial infarction (group 2), and six with chest pain of miscellaneous origin (group 3). The total amplitude of posterior wall excursion, left ventricular isometric contraction time, left ventricular systolic ejection time, and mean posterior wall velocity (ratio of posterior wall excursion to ejection time) were measured. By using the measurements of posterior wall excursion, mean posterior wall velocity, and isometric contraction time, group 1 patients were differentiated from those of groups 2 and 3 and from the normal subjects (all P < 0.01). The data from patients in groups 2 and 3 were not statistically different from those of normal subjects. The measurements obtained by the time-motion curve of the left ventricular posterior wall echo appear to be of value in the bedside evaluation of acute myocardial infarction.

Improved electrocardiographic criteria for the diagnosis of inferior myocardial infarction.

New electrocardiographic (ECG) criteria for the diagnosis of inferior myocardial infarction (IMI) are proposed. The criteria are based upon the relationships between portions of the vectorcardiographic (VCG) QRS loop in the frontal plane and the corresponding portions of the ECG QRS complexes recorded in leads II and III. The application of the proposed criteria requires that the tracings be obtained with three‐channel ECG machines so that the temporal relationships between the QRS complexes in lead II and those in simultaneously recorded lead III can be inspected. This type of analysis of the ECG permits important features of the contour of the VCG QRS loop to be predicted. The proposed ECG criteria for the diagnosis of IMI are: in the absence of counterclockwise rotation in the frontal plane, (1) Q waves of 30 msec or longer in lead II or (2) regression of initial inferior forces from lead III to lead II. The proposed ECG criteria were evaluated in an initial series of 333 patients and, using a blind experimental design, in a confirmatory series of 94 patients. The performance of the proposed criteria was statistically superior to that of two sets of ECG Q‐wave criteria and comparable to that of the VCG criteria of Starr et al.

Systemic systolic hypertension in the elderly: Correlation of hemodynamics, plasma volume, renin, aldosterone, urinary metanephrines and response to thiazide therapy

Twenty-four men, mean age 63 +/- 1.7 years, with systemic systolic hypertension were studied before and after 1 month of therapy with oral hydrochlorothiazide, 50 mg/day. The control mean plasma volume was 2,664 +/- 96 ml, cardiac index 3.9 +/- 0.2 liters/min/m2, stroke volume index 52 +/- 2 ml/beat/m2, systemic vascular resistance 1,351 +/- 80 dynes s cm-5, plasma aldosterone 8.6 +/- 1.0 ng/dl and 24-hour urinary excretion of metanephrines 0.371 +/- 0.044 mg. On renin-sodium profiling in 23 patients, 12 were classified into a normal group and 11 into a low-renin group; none had high renin values. Based on multiple regression analysis, the 24-hour urinary excretion of total metanephrines appeared to be the single most important factor explaining 28% of the variability in systolic blood pressure (BP). After therapy with oral hydrochlorothiazide, the elevated systolic BP decreased (p less than 0.0001) and diastolic BP decreased (p less than 0.005), with concomitant reduction in systemic vascular resistance (p less than 0.03). Patients in both the normal- and low-renin groups had normal plasma volume and responded similarly to thiazide diuretic therapy, without symptomatic side effects.

Clinical utility and the predictors of outcome of overdrive transesophageal atrial pacing in the treatment of atrial flutter

Transesophageal atria pacing (TEAP) using a pill electrode was performed in 49 patients with atrial flutter. The responses observed were (1) immediate sinus rhythm in 17 (35%), (2) delayed sinus rhythm in 13 (27%), (3) atrial fibrillation in 11 (22%), and (4) no success in 8 (16%) patients. Sinus rhythm was thus restored in 30 patients (61%). In group A, 12 of 17 patients (p < 0.05) had coronary artery disease. The patients in group D had echocardiographic evidence of right atrial enlargement (2.56 +/- 0.29 cm, p = 0.007), left atrial enlargement (4.6 +/- 0.12 cm, p < 0.0001), right ventricular dilatation (3.41 +/- 0.45 cm, p < 0.05), left ventricular dilatation (6.39 +/- 0.66 cm, p < 0.05), and depressed left ventricular ejection fraction (32 +/- 7%, p < 0.05). Optimal pacing rate (375 +/- 54 beats/min) was 41% higher than the mean atrial flutter rate (266 +/- 37 beats/min) for cardioversion to immediate sinus rhythm. Pacing current strength and the pulse width had no influence on the final outcome. On the basis of the result of the initial attempt, patients undergoing TEAP repetitively had an almost predictably similar outcome on the subsequent attempts. Thus, normal sinus rhythm could be resumed in most patients with atrial flutter by TEAP. It does not require general anesthesia and can be performed even in patients who have undergone digitalization, when a direct-current countershock may be of some concern.

Fluid Therapy in Severe Systemic Reaction to Radiopaque Dye

Two patients developed severe vascular collapse after left ventriculography with organic iodides. Hemodynamic monitoring showed marked reduction in systemic pressures. In one patient there was no response to the standard therapeutic measures in anaphylactic reactions, and prompt response to fluid administration was obtained. In the second patient response was prompt to fluids, adrenalin, and hydrocortisone.

Factors encouraging research productivity in a division of general internal medicine [published erratum appears in Acad Med 1991 May;66(5):272]

The authors investigated two of the causes of and possible remedies for low research activity (as measured by rate of publication) of faculty members in a division of general internal medicine at a university hospital and its affiliated Veterans Administration medical center. They did this by analyzing information about the faculty in the health centers records spanning a 16-year period. This 1989 study suggests that the general medicine faculty members who are also involved in subspecialties and who have protected research time can improve their research productivity.