Shirley Rubler

New type of cardiomyopathy associated with diabetic glomerulosclerosis

Abstract The postmortem findings and clinical records of 27 patients with proved diabetic glomerulosclerosis were examined and reviewed for evidence of primary myocardial disease. Twenty-three cases were excluded because of complicating conditions such as hypertension, significant obstruction of the major coronary arteries or valvular disease. Four patients demonstrated cardiomegaly and congestive heart failure of no known cause. The autopsy findings consisted of left ventricular hypertrophy and, in 1 case, right ventricular hypertrophy as well, in the absence of major coronary artery disease. Histopathologic study revealed diffuse fibrotic strands extending between bundles of muscle fibers and myofibrillar hypertrophy. In 1 case, the small intramural coronary arterioles demonstrated thickening of the wall and narrowing of the lumen due primarily to the deposition of acid mucopolysaccharide material in the subendothelial layers and subsequent subintimal thickening and medial hypertrophy. It is postulated that the myocardial disease seen in these cases is probably secondary to diabetic mjcroangiopathy although the direct effects of the abnormal myocardial metabolism in diabetes could not be excluded.

Dose-related hemodynamic and renal effects of dopamine in congestive heart failure.

Summary The hemodynamic effects of dopamine were studied in nine patients with congestive heart failure. A dose-related increase in cardiac output and stroke volume was observed with infusion rates up to 5 μg per kilogram per minute in all patients; more rapid infusions resulted in a diminished response in many individuals. Tachycardia was significant only at an infusion rate of 10 μg per kilogram per minute. Dose-related increments in aortic dp/dt, urine flow, sodium excretion, and creatinine clearance were also observed. A correlation of invasive and noninvasive techniques for evaluating the hemodynamic effects of dopamine is presented and the potential clinical usefulness of dopamine discussed.

Duchenne's muscular dystrophy

DR. SHIRLEY RUBLER: The patient was a 23year-01d black male whose illness began in 1959 when, at age five years, his parents noticed leg weakness, difficulty i n climbing stairs, and increased size of calf muscles. He had two brothers, one of whom died at age 20 with a similar muscular disorder, and another with brain damage due to birth trauma. Six sisters were well. Genetic information regarding m a t e r n a l male relatives was not available. On admission to the Hospital of the UniversitY of Pennsylvania in 1964, the patient had a waddling gait but wa~ still able to play with his peers despite dyspnea on climbing a flight o f stairs. Symmetrical weakness primarily involved the shoulder and pelvic girdles and flexor and extensor muscles of the neck. The biceps, triceps, and thigh flexors were also affected; the muscles of the shoulder girdle were atrophic, but the calf muscles were enlarged {pseudo-hypertrophic): Cardiac examination disclosed a normal left ventricula r impulse and a short localized Grade I I /VI apical systolic murmur. There was sinus tachycardia at 120 beats per minute and a blood pressure of 105/75 mm. Hg. A right deltoid muscle biopsy demonstrated myopathy with regeneration. The SGOT was 168 units. A diagnosis of X-linked recessive: Duchennes Progressive muscular dystrophy was made. After discharge, there was progression of weakness resulting in confinement to a wheelchair in

Systolic time intervals in pregnancy and the postpartum period

Abstract Systolic time intervals in the supine and upright positions were obtained in 16 antepartum subjects at maximal expansion of blood volume (27 to 33 weeks) and six weeks postpartum. Isovolumic contraction time (IVCT) was determined by 2 methods: (1) first heart sound to carotid upstroke interval (I m -CAR u ) and minus pulse transmission time (I m -CAR u -PTT), and by (2) upstroke of apexcardiogram to upstroke of carotid (ACG u -CAR u ) and minus pulse transmission time (ACG u -CAR u -PTT). The IVCT was short in the antepartum supine subject (I m -CAR u was 60.5, SD 4.3 msec.) and 31.7 msec. when corrected for PTT) and became longer in the upright position (63.7 msec. [SD 6.1] and 35.6 msec., respectively). In the postpartum state the supine IVCT was significantly longer than in the antepartum state (72.2 msec. [SD 9.3] and 42.2 msec. when corrected for PTT) (P The left ventricular ejection time index was 425.1 msec. (SD 13.5) in the antepartum supine subject and demonstrated corresponding shortening in the erect position (412.8 msec., SD 14.2). In the postpartum period the LVETI was shorter (407.0 msec. [SD 17.4]) and shortest in the upright position (392.9 msec. [SD 11.6]).

Comparison of left atrial size and pulmonary capillary pressure with P wave of electrocardiogram

The amplitude and duration of P waves in Leads II (P II), P terminal force in V1, (PV1) and the sums of P II and PV1 were compared in 37 subjects with left atrial size obtained by echocardiographic technique in 36 instances and with hemodynamic estimates of pulmonary capillary wedge pressures in 16 cases. The 22 females and 15 males were subdivided into the following groups. Group I, four normal subjects, Group II, 11 patients with predominant aortic insufficiency (two of whom had a mild mitral insufficiency); Group III, 14 patients with mitral valve disease, seven of whom had mitral insufficiency (two with minimal aortic insufficiency) Group IIIa) and seven had mitral stenosis (Group IIIb); Group IV, eight patients with miscellaneous disorders, i.e., coronary artery disease (5), hypertension (2), and idiopathic hypertrophic subaortic stenosis (1). Good correlations were obtained between left atrial size and P in Lead II (P II) (r = 0.74; p less than 0.001) and between P terminal force in V1 (PV1) and left atrial size (r = -0.69; p less than 0.001). In Group IV good correlation between PV1 and atrial size was noted. Some correlation between the sum of P II and PV1 and left atrial size (r = 0.51; p less than 0.02) was noted, but a better correlation was obtained in the patients with aortic insufficiency (r = 0.80; p less than 0.01). Pulmonary capillary wedge pressures were not reflected in changes in P II or PV1, except for the group with mitral stenosis (Group IIIb). Adding P II to PV1 improved the correlation with wedge pressure for the entire group.

Exercise Testing in Young Asymptomatic Diabetic Patients

The cardiovascular response to submaximal bicycle exercise was studied in a group of 19 asymptomatic diabetic patients aged 18 to 39, including 11 males and 8 females and 18 control subjects (9 males and 9 females, aged 20 to 34 years). The maximum heart rate achieved by the control subjects (group I), 175.9 ± 8.9 beats/min, was greater than that achieved by the diabetic patients (group II), 159.4 ± 17.8 beats/min, (P < 0.01 ). The work load at which the maximum heart rate was reached was lower in diabetic males, 681 ± 155.4 kg m/min, than in healthy males, 866.7 ± 139.9 kg m/min, (P < 0.02). Although systolic blood pressure elevations were comparable during exercise and the postexercise period, the increase in diastolic blood pressure during exercise in the diabetic patients was greater than in control subjects (P < 0.001). This difference, however, was only observed in the males and not in the females. The difference in diastolic blood pressure was again noted between the groups in the postexercise period; that of group II was higher than that of group I (P < 0.01). This was particularly notable in the older diabetics (aged 31 to 40 years). One patient in group II developed ischemic ST segment changes, and 1 subject in each group was found to have J junction depression of 1.0 mm or more. The implications of these findings are discussed in relation to the possible pathophysiology of the diabetic patients.

Pulmonary Edema Associated With Pulmonary Embolism: a Clinicopathological Study

* From the Division of Cardiology, Department of Medicine, and the Department of Pathology, New York Medical College, Metropolitan Hospital, New York, New York. The relationship between pulmonary embolism and pulmonary edema has been mentioned previouslyl-9 but it has not been sufficiently emphasized nor has its significance been widely appreciated. This is, in part, due to the difficulty in differentiating the manifestations of such embolization from those of pulmonary edema. It has also been difficult for many clinicians to conceive of a failing left ventricle in a condition where the major problem would seem to be the imposition of a sudden increase in the work load presented to the right ventricle. The purpose of this study is to emphasize the importance of pulmonary embolism as a precipitating factor in the production of pulmonary edema in patients with underlying heart disease without clinical signs of heart failure before the incident. It is hoped that an increased awareness of this complication in such patients will facilitate the proper management of this potentially fatal illness.

Diastolic intervals in cardiomyopathy and abnormal thyroid states: alterations in isovolumic relaxation time and rapid filling time of depressed and enhanced myocardial contractility.

Diastolic and systolic time intervals were measured in 11 control subjects, 11 patients with cardiomyopathy, 7 hyperthyroid patients, and 5 hypothyroid patients. The isovolumic relaxation time (IVRT), rapid filling time (RFT), preejection period (PEP), left ventricular ejection time (LVET), and PEP/LVET ratio were found by simultaneously recording the ECG, phonocardiogram, external carotid pulse, and apexcardiogram. In cardiomyopathy the IVRT and RFT were prolonged (107.4 +/- 21.1 msec [P less than 0.01] and 111.0 +/- 10.0 [P less than 0.01] respectively) in comparison to the control subjects. (In the controls the IVRT was 85.7 +/- 18.4 msec and the RFT was 94.5 +/- 12.8 msec). In altered thyroid states the RFT was most affected; in hypothyroidism it increased to 123.9 +/- 25.2 (P less than 0.01) and in hyperthyroidism it decreased to 71.5 +/- 21.3 msec (P less than 0.01). In hyperthyroid patients the IVRT, although shorter than in control subjects, was not significantly altered, but it showed a significant increase after treatment. The RFT also returned toward normal after therapy in both groups (116.7 +/- 14.6 msec in hypothyroid patients and 89.0 +/- 23.1 msec in those with hyperthyroidism).

The T loop in right bundle branch block: A vectorcardiographic study of 82 cases☆

ectorcardiographic studies of QRS loops in right bundle branch block (RBBB) have been reported by many authors, and the classic abnormalities are discussed in texts and symposium proceedings.l-6 The T loop in RBBB has received scant attention thus far, except for Chou and associates’g who reported the incidence of abnormal T loop wideness in 10 per cent of RBBB cases. The rotational characteristics of T loops in RBBB, as encountered in ischemic heart disease, in right ventricular enlargement, and in healthy persons have not been explored. The purpose of this investigation was to survey T-loop characteristics in a series of patients whose RBBB was of diverse etiology.