Samuel Butman

Relationship between age, body size, gender, and blood pressure and Doppler flow measurements in the aorta and pulmonary artery

Previous studies have demonstrated a relationship between both age and body surface area (BSA) and M-mode echocardiographic measurements of left ventricular, left atrial, and aortic root dimensions and left ventricular wall thickness. We evaluated the relationships between age, BSA, gender and blood pressure, and Doppler aortic and pulmonary artery (PA) flow velocity measurements in 97 adults, aged 21 to 78 years, without clinical evidence of cardiac disease. No significant relationship was found between gender or blood pressure and aortic or PA flow velocity measurements. Aortic peak flow velocity, flow velocity integral, and average acceleration decreased with increasing age (all p less than 0.001), whereas ejection time (corrected for heart rate) increased, and acceleration time did not change. In contrast, there was no relationship between age and Doppler PA flow velocity measurements. Although there was no relationship between BSA and Doppler aortic flow measurements, PA peak flow velocity and average acceleration increased, while acceleration time decreased with increasing BSA (all p less than 0.02). Decreases in aortic peak flow velocity and flow velocity integral may be partly related to known increases in aortic root diameter with aging. The relationship between PA flow velocity measurements and BSA is not readily explained.

Early exercise testing after stabilization of unstable angina: Correlation with coronary angiographic findings and subsequent cardiac events

To evaluate the safety and diagnostic use of exercise testing in patients with unstable angina, 78 patients underwent submaximal exercise testing and diagnostic cardiac catheterization early after stabilization of their pain. Thirty-six patients (46%) had a positive exercise test manifested as angina or ST segment depression of greater than or equal to 0.1 mV during or immediately after exercise. Thirty-three of 36 patients (92%) with a positive exercise test had multivessel coronary disease compared to 18 of 42 patients (43%) with a negative exercise study (p less than 0.001). Twenty-two of 36 patients (61%) with a positive exercise test had three-vessel disease compared to 12 of 42 patients (29%) with a negative test (p = 0.004). The sensitivity of exercise testing in detecting multivessel disease was 65%, specificity 89%, predictive value of a positive test 92%, predictive value of a negative test 57%, and overall accuracy 73%. When the 42 patients taking beta blockers were examined, these values were essentially unchanged. Ventricular arrhythmias during exercise testing were associated with a lower ejection fraction, 61.1 +/- 12.5%, compared to 67.9 +/- 11.1% in patients without ventricular arrhythmias (p less than 0.05). Submaximal exercise testing after stabilization of patients with unstable angina is safe and useful in evaluating patients for the presence of multivessel coronary artery disease.

Echocardiographic and Doppler flow observations in obstructed and nonobstructed hypertrophic cardiomyopathy

Some investigators have suggested that left ventricular (LV) ejection is completed much earlier than normal in patients with hypertrophic cardiomyopathy (HC), whether or not a LV outflow gradient is present, and they have therefore concluded that LV ejection is not impeded in HC, but merely ends early because of early completion of LV emptying. This possibility was examined using pulsed Doppler echocardiography to record ascending aortic flow velocity patterns in 20 patients with HC, 12 with evidence of LV outflow gradient at rest (obstructed HC) and 8 without evidence of a significant resting gradient (nonobstructed HC). Peak aortic flow velocity was similar in patients with nonobstructed HC (92 +/- 26 cm/s) and those with obstructed HC (94 +/- 26 cm/s) and in 20 normal subjects (92 +/- 11 cm/s). However, mean ejection time measured from the aortic flow velocity tracing or aortic echogram was longer in those with obstructed HC (345 +/- 30 ms) than in those with nonobstructed HC (296 +/- 24 ms, p less than 0.02) and in normal subjects (294 +/- 19 ms, p less than 0.01). Furthermore, a rapid decrease in aortic flow velocity in midsystole was seen in 11 of 12 patients with obstructed HC, but in none of the patients with nonobstructed HC or normal subjects. Doppler left atrial flow velocity recordings, obtained in 11 patients, demonstrated mitral regurgitation in 4 of 5 patients with obstructed HC but in none of 6 patients with nonobstructed HC.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of coffee on exercise-induced angina pectoris due to coronary artery disease in habitual coffee drinkers

The acute effects of coffee on exercise-induced angina were studied in 17 men with coronary artery disease using a double-blind treadmill protocol. Ingestion of either 1 or 2 cups of caffeinated coffee increased the exercise duration until onset of angina (8 and 12%, respectively, p less than 0.05), whereas decaffeinated coffee had no effect. The extent of ST-segment depression and the heart rate-blood pressure product at angina were similar after drinking caffeinated and decaffeinated coffee. Exercise duration until 0.1 mV of ST-segment depression, as well as the heart rate, blood pressure and double product at angina and at 0.1 mV of ST-segment depression were similar after drinking caffeinated or decaffeinated coffee. The mean serum caffeine levels (+/- standard deviation) after ingestion of 1 and 2 cups of caffeinated coffee were 1.97 +/- 1.0 and 3.89 +/- 1.6 micrograms/ml, respectively. The acute ingestion of 1 to 2 cups of caffeinated coffee had no deleterious effect on exercise-induced angina pectoris in patients with coronary artery disease.

Prognostic implications of complicated ventricular arrhythmias early after hospital discharge in acute myocardial infarction: A serial ambulatory electrocardiography study

To assess the prevalence and prognostic implications of complicated ventricular ectopic depolarizations (VEDs) after hospital discharge in patients with acute myocardial infarction (AMI), we obtained serial 24-hour Holter recordings in 85 patients during the first 6 weeks after AMI. Recordings were obtained during two coronary care unit time intervals, two hospital ward time intervals, and during four weekly time intervals after discharge. Complicated VEDs were defined as unifocal VEDs greater than or equal to 10/1000 beats for 24 hours, multiform VEDs, pairs, or ventricular tachycardia. At 1 year follow-up, there were nine cardiac deaths (six sudden deaths and three deaths from recurrent AMI). The mean left ventricular ejection fraction at discharge in the cardiac death patients was 29 +/- 12% (sudden death patients 24 +/- 11% and AMI death patients 40 +/- 6%) compared to 49 +/- 13% in the survivors (p less than 0.001). Patients with complicated VEDs at discharge (2 weeks after AMI) or during the first 4 weeks after discharge (3 to 6 weeks after AMI) were significantly more likely to have sudden death at follow-up compared to patients without complicated VEDs. Of the six sudden death patients, four (66%) had complicated VEDs at discharge compared to 18 of 68 survivors (26%) (p less than 0.05). One of three patients who died of recurrent AMI had complicated VEDs. No Holter data were obtained at hospital discharge in eight of the survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of ethmozine to propranolol and the combination for ventricular arrhythmias

A randomized, double-blind, crossover study was performed to evaluate the efficacy and tolerance of ethmozine, propranolol and a combination of ethmozine and propranolol for treatment of ventricular arrhythmias. Twenty-six patients received propranolol, 40 mg, or matching placebo 3 times daily, alone or in combination with ethmozine, 600 to 900 mg/day in 3 equally divided doses, for 1-week periods separated by matching placebo. As determined by 48-hour weekly Holter monitoring, the mean reduction in ventricular premature complex (VPC) frequency was significantly greater with ethmozine (86%) and with ethmozine plus propranolol (90%) than with propranolol (41%) (p less than 0.05). Seventy-five percent of patients had more than a 70% reduction in VPCs with ethmozine plus propranolol, although 70% of patients had an equal degree of suppression with ethmozine alone. Only 2 patients (10%) had the same degree of VPC suppression with propranolol. The results were similar for reductions in pairs of VPCs and VT runs. Two patients discontinued propranolol because of adverse effects, but no patient discontinued ethmozine or combination therapy. Adverse effects were not more frequent with combination therapy. Ventricular function as assessed by echocardiography during drug dosing showed no significant changes from placebo. Ethmozine alone or in combination with propranolol was effective in suppressing VPCs for as long as 1 year in patients who responded. It is concluded that ethmozine alone or in combination with propranolol is well tolerated. Propranolol does not appear to enhance the efficacy of ethmozine.

Hemodynamic effects of verapamil in left ventricular valvular volume overload

The hemodynamic consequences of aortic and mitral insufficiency may be influenced by the high systemic vascular resistance often seen in these patients. Since the calcium antagonists have been shown to reduce systemic vascular resistance, we evaluated the effects of intravenous verapamil in 23 patients. In 11 patients with aortic insufficiency, verapamil resulted in a 20% increase in cardiac index (p less than 0.001), 18% increase in forward stroke volume index (p less than 0.001), and a 24% decrease in regurgitant fraction (p less than 0.005). In the 12 patients with mitral insufficiency, verapamil resulted in a 19% increase in both cardiac index (p = 0.004), and forward stroke volume index (p less than 0.001), while there was a 19% decrease in regurgitant fraction (p less than 0.02). Left ventricular end-systolic stress decreased significantly in both groups as did end-diastolic stress in the mitral insufficiency group. There was no significant change in several measures of contractile performance, though the end-systolic stress-to-volume index ratio fell significantly (p less than 0.04) in the mitral insufficiency group. Our findings suggest that the vasodilatory effects of intravenous verapamil predominate over the negative inotropic effects in patients with aortic and mitral insufficiency. Verapamil may be of use in patients intolerant to other vasodilators, patients with concomitant ischemic heart disease, or those with supraventricular arrhythmias.

Acquired atherosclerotic aortopulmonary fistula presenting as new-onset congestive heart failure

A middle-aged patient with new-onset congestive heart failure, a loud precordial systolic murmur, and a widened mediastinum on chest radiography is described. Noninvasive studies in addition to the clinical examination suggested an unusual complication of atherosclerotic aortic disease, which was demonstrated at aortography and confirmed at surgery. This case stresses the importance of a careful bedside examination in addition to selective noninvasive studies in patients with new-onset or atypical congestive heart failure.