Samuel M. Butman

Bedside cardiovascular examination in patients with severe chronic heart failure: Importance of rest or inducible jugular venous distension

OBJECTIVES The aim of this study was to determine the sensitivity, specificity and utility of the cardiovascular examination in predicting cardiac hemodynamics in patients with advanced chronic congestive heart failure. BACKGROUND Although the physical signs of acute left heart failure have been shown to correlate relatively well with cardiac hemodynamics, their reliability in estimating hemodynamics in patients with chronic heart failure has recently been questioned. METHODS We prospectively recorded the history, cardiovascular physical signs present at bedside examination and the hemodynamic measurements obtained at right heart catheterization in 52 patients with chronic congestive heart failure undergoing in-hospital evaluation for possible heart transplantation. In addition, we obtained chest radiographs and multigated nuclear scans for the evaluation of left ventricular function. RESULTS Pulmonary rales, a left ventricular third heart sound, jugular venous distension and the abdominojugular test, when positive, indicated higher right heart pressures and lower measures of cardiac performance. The presence of jugular venous distension, at rest or inducible, had the best combination of sensitivity (81%), specificity (80%) and predictive accuracy (81%) for elevation of the pulmonary capillary wedge pressure (> or = 18 mm Hg). Furthermore, in this population sample, the probability of an elevated wedge pressure was 0.86 when either variable was present. CONCLUSIONS The bedside cardiovascular examination in the patient with chronic heart failure is extremely useful in identifying patients with elevation of right and left heart pressures. Examination for jugular venous distension at rest or by the abdominojugular test is simple and highly sensitive and specific in assessing left heart pressures in these patients.

Submaximal exercise testing after stabilization of unstable angina pectoris

To determine the prognostic value of exercise testing in patients with unstable angina pectoris, 125 hospitalized patients were prospectively evaluated soon after stabilization of their pain. Exercise testing was performed after exclusion of acute myocardial infarction and a pain-free period of at least 3 days (mean +/- SD 3.9 +/- 1.4). No complications were noted during or immediately after exercise testing. A positive test (angina or greater than or equal to 1 mm ST segment depression, or both) was noted in 60 patients (48%). During a 1 year follow-up period, 52 (87%) of these 60 patients had an unfavorable outcome (American Heart Association class III or IV angina, recurrent unstable angina, coronary artery bypass surgery, acute myocardial infarction or cardiac death) compared with 19 (29%) of the 65 patients with a negative test (p less than 0.001). The sensitivity and specificity of exercise testing in predicting outcome were 73 and 85%, respectively. The predictive value of a positive test was 87% and that of a negative test was 71%. Angina by itself during the exercise test was a reliable predictor of severe angina (class III or IV angina) at follow-up (sensitivity 92%, specificity 89%, positive predictive value 83% and negative predictive value 95%; p less than 0.001). The findings were not significantly affected by beta-adrenergic blocking agents or digitalis in the study sample. Thus, in patients with unstable angina which has been stabilized, the results of early submaximal exercise testing may be useful in predicting outcome in the first year after hospital discharge. Patients with a positive test result should be considered for further diagnostic studies.

Safety and Efficacy of Epoprostenol in Patients with Severe Congestive Heart Failure

Patients with advanced heart failure often remain severely symptomatic and have a high mortality rate despite currently available therapy. We studied the safety and efficacy of a new approach to the patient with refractory heart failure: continuous intravenous treatment via a portable infusion pump with epoprostenol (prostacyclin), a potent pulmonary and systemic vasodilator. A group of 33 patients with severe heart failure (64% New York Heart Association class IV and 36% class III) and profound ventricular dysfunction (median left ventricular ejection fraction, 0.15)--despite prior treatment with diuretics (100%), digitalis (91%), angiotensin-converting enzyme inhibitors (85%), and dobutamine (30%)--underwent a baseline 6-minute walk test prior to dose titration with epoprostenol during invasive hemodynamic monitoring. Subjects responding during the dose titration were randomized, on an open basis, to receive either continuous epoprostenol infusion via an indwelling central venous catheter plus conventional therapy or conventional therapy alone for 12 weeks. The initial dose-ranging study with epoprostenol produced a significant decline in systemic and pulmonary vascular resistance and a substantial increase in cardiac index despite a fall in pulmonary capillary wedge pressure. Symptoms related to vasodilation were noted within the first week after randomization to epoprostenol in 9 of 16 patients but resolved with adjustment of the infusion and concomitant medications in all but one subject. Dose adjustments during the chronic epoprostenol infusion were infrequent after the first week and complications related to the drug delivery system were rare. The change in distance walked from baseline to the last available 6-minute walk test was significantly greater in patients who received epoprostenol compared with patients assigned to standard therapy (72 +/- 40 vs -39 +/- 32 m, mean +/- SEM; p = 0.033). Our study suggests that long-term intravenous infusion of epoprostenol is feasible in patients with severe heart failure and our hemodynamic and functional results suggest clinical benefit as well. However, until recent results indicating an adverse effect of epoprostenol on survival are fully evaluated, the role of this drug in the treatment of advanced heart failure will remain uncertain.

Successful Coronary Artery Bypass Grafting for High-Risk Left Main Coronary Artery Atherosclerosis After Cardiac Transplantation

Severe stenosis of the left main coronary artery developed in a 58-year-old woman 9 years after orthotopic heart transplantation. Because of serious reversible myocardial ischemia and the high-risk nature of the coronary disease, coronary artery bypass grafting was performed, with no complications. Possible risk factors for the development of coronary arterial disease and its management in the transplant population are discussed.

The pathogenesis and treatment of no-reflow occurring during percutaneous coronary intervention

No-reflow is one of the major causes of postinterventional rise of cardiac enzyme and myocardial infarction (MI). This complication is associated with substantial morbidity and mortality after percutaneous coronary intervention (PCI). During and after a no-reflow episode, the patient can suffer from severe chest pain, hypotension, bradycardia, hemodynamic collapse, MI, congestive heart failure, and death. Every effort should be taken to reduce the incidence of this complication. The distal embolic protection device has been shown to decrease this risk in saphenous vein graft (SVG) interventions but not in native coronaries. On the other hand, the use of glycoprotein IIb/IIIa receptor antagonists have been effective in reducing the occurrence of no-reflow during PCI of native coronaries but not during SVG interventions. The treatment of no-reflow is based on the intracoronary administrations of medications that induce maximal vasodilatation in small distal coronary vasculature. The most commonly used drugs in this setting are adenosine, nitroprusside, and verapamil. The goal of this study was to review the pathogenesis and treatment of no-reflow in patients undergoing PCI.

A randomized controlled trial of intravenous streptokinase in evolving acute myocardial infarction

To determine the efficacy of intravenous streptokinase in acute myocardial infarction, 52 patients were randomized to intravenous streptokinase or control groups. Time from onset of infarction to randomization was similar in the streptokinase group and control group, 4.9 +/- 2.1 hours vs 5.4 +/- 2.4 hours, respectively. The 28 streptokinase patients received an intravenous infusion of 700,000 units of streptokinase followed by full-dose anticoagulation. The 24 control patients received normal saline solution followed by full-dose anticoagulation. Of 28 streptokinase patients, 12 (43%) had noninvasive evidence of reperfusion by early peaking of serum creatine kinase (peak creatine kinase less than 16 hours after onset of infarction) vs 3 of 24 control patients (13%), p less than 0.02. Two streptokinase patients (7%) had reperfusion arrhythmias during streptokinase infusion. One streptokinase patient (4%) and two control patients (8%) died during hospitalization. At angiography (16 +/- 5 days after infarction) 22 of 26 streptokinase patients (85%) had a patent infarct-related coronary artery compared to 8 of 20 control patients (40%), p less than 0.01. Comparison of radionuclide left ventricular ejection fraction assessed acutely (28 +/- 10 hours after infarction) with left ventricular ejection fraction at hospital discharge (15 +/- 3 days after infarction) showed no significant improvement in either the streptokinase or control group, 0% and +1%, respectively. At follow-up 13 +/- 7 months after infarction, total mortality rate was similar in the streptokinase group and control group, 17.8% (5 of 28 streptokinase patients) and 20.8% (5 of 24 control patients), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

One heart, two bodies: Insight from the transplanted heart and its new electrocardiogram

Cardiac transplantation provides a unique opportunity to record the electric field generated by a human heart in a new somatic environment. By examining pre- and posttransplantation electrocardiograms (ECGs), it is possible to address questions on the effect of rotation of the heart on its long axis on the surface ECG, the effect of thoracic anatomy on ECG voltage and predisposing factors for conduction defects observed after transplant surgery. To examine these questions, we reviewed a series of 35 matched donor and recipient ECGs. There were no differences in the mean height of the donors and recipients, but age, weight and body surface area were higher in the recipients (p less than 0.025). We found no significant differences in the mean heart rate or precordial voltage but the PR and QT intervals were shorter (p less than 0.025), and the precordial transitional zone was more to the left after transplantation (p less than 0.0005). New evidence of right bundle branch delay was found in 11 recipients and this was not related to pretransplantation hemodynamic factors or the period of ischemic arrest. Thus, there is indeed an anatomic basis for the ECG determination of clockwise rotation of the heart when the precordial transition zone is to the left. Age and body habitus, per se, do not appear to affect precordial voltage and evidence of right bundle delay in the transplant recipient appears to be related to the altered position of the heart and not to injury or changes in right ventricular hemodynamics.

Syncope with ST-Segment Abnormalities Resembling Brugada Syndrome Due to Reversible Myocardial Ischemia

INDIK, J. H., et al.: Syncope with ST‐Segment Abnormalities Resembling Brugada Syndrome Due to Reversible Myocardial Ischemia. This report describes a case of syncope with an initial ECG that showed ST‐segment elevation in the right precordial leads suggestive of Brugada syndrome. Procainamide infusion induced a significant increase in the ST‐segment abnormalities, further increasing the suspicion for this syndrome. Cardiac catheterization showed lesions in the proximal left anterior descending artery and distal right coronary artery. Following percutaneous coronary intervention at these sites, the ST‐segment abnormalities resolved and a repeat procainamide challenge was negative. Electrophysiological study did not provoke any ventricular arrhythmias. Silent myocardial ischemia may result in ECG changes that resemble those seen in patients with Brugada syndrome.

Rapid resolution of a massive left ventricular thrombus by usual systemic anticoagulation

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Look before you close: atrial septal defect with undiagnosed partial anomalous pulmonary venous return.

The growing and continued success of percutaneous closure of atrial defects is related to its high benefit‐to‐risk ratio in appropriately selected patients. The following case illustrates a previously undocumented danger, namely, the potential for incomplete correction. A thorough transesophageal examination performed at the time of the planned atrial defect closure suggested the presence of a partial anomalous pulmonary vein insertion, which was then appropriately documented and the incomplete closure was averted.