V. Eric Kemp

Anticoagulants in acute myocardial infarction. The failure of anticoagulants to alter mortality in a randomized series.

Abstract 1. 1. The effect of anticoagulation therapy on mortality and morbidity in 147 consecutive male patients with acute myocardial infarction was evaluated. 2. 2. The patients were divided into three groups: those adequately anticoagulated, those inadequately anticoagulated, and those not anticoagulated. The patients were randomly assigned, and the groups were shown to be comparable, except for an increased incidence of a history of previous heart failure in the untreated group. 3. 3. There was no significant reduction in mortality in the anticoagulated groups when compared to the control group. 4. 4. The incidence of thromboemboli was too low to be of significance in assessing the effects of anticoagulants as antithrombotic agents. 5. 5. We conclude from this study that routine anticoagulation therapy is not indicated in acute myocardial infarction, and that factors other than those affected by anticoagulants determine the prognosis in this disease.

Clinical communicationAnticoagulants in acute myocardial infarction: The failure of anticoagulants to alter mortality in a randomized series☆

Abstract 1. 1. The effect of anticoagulation therapy on mortality and morbidity in 147 consecutive male patients with acute myocardial infarction was evaluated. 2. 2. The patients were divided into three groups: those adequately anticoagulated, those inadequately anticoagulated, and those not anticoagulated. The patients were randomly assigned, and the groups were shown to be comparable, except for an increased incidence of a history of previous heart failure in the untreated group. 3. 3. There was no significant reduction in mortality in the anticoagulated groups when compared to the control group. 4. 4. The incidence of thromboemboli was too low to be of significance in assessing the effects of anticoagulants as antithrombotic agents. 5. 5. We conclude from this study that routine anticoagulation therapy is not indicated in acute myocardial infarction, and that factors other than those affected by anticoagulants determine the prognosis in this disease.

Multiple lead ECG submaximal treadmill exercise tests in angiographically documented coronary heart disease.

One hundred patients underwent submaximal exercise tolerance testing and coronary cineangiography. Sixty-six percent of the exercise tests were diagnostic including 48 positive and 18 negative tests; 34 patients had indeterminate test results. The occurrence of exercise induced ventricular premature beats was not related to significant coronary artery disease. Ventricular asynergy was significantly more frequent in patients with positive exercise tests (p less than .0001). Application of the age-adjusted target heart rate criterion recommended from Scandinavia and Myrtle Beach to patients with indeterminate results due to failure to reach target heart rate resulted in six false negative tests and lowered sensitivity. The number of positive diagnostic responses achieved using a multiple electrocardiographic lead system was compared with positive diagnostic responses detected in a single lead (V5) and the number of positive tests identified by the additional leads was highly significant (p less than .0001). A high incidence of indeterminate test results due to failure to achieve target heart rate is noted.

Rejection of the cardiac transplant

Abstract This report deals with the primary problem in cardiac transplantation, homograft rejection, in its acute and chronic forms. Experience is drawn from 125 orthotopic cardiac transplants in dogs and from 4 human cases. The electrocardiogram is the most reliable indicator of an impending rejection crisis; elevation of lactic dehydrogenase (LDH) isozymes may add confirmation. Treatment of the rejection crisis requires transiently high doses of prednisone in addition to maintenance doses of azathioprine. Experimental data suggest the additional value of graft irradiation. The acute pathologic process is characterized early by infiltration with mononuclear cells. These cells are associated with injury to vascular endothelium which results in interstitial hemorrhage and edema and anoxic injury to the muscle fibers. The chronic form of rejection is manifested by coronary arterial narrowing due to intimai proliferation or thrombus formation, which results presumably from immunologic damage to the endothelium.

Observations on the Atrial Sound in Hypertension

Recovery from heart failure in hypertensive patients having an audible atrial sound was associated with decrease in the intensity of this sound and lengthening of the P-G interval. In most patients the atrial sound disappeared entirely. The rapid intravenous infusion of saline was invariably associated with the appearance of an audible atrial sound in 10 hypertensive patients with left ventricular disease. This procedure was ineffective in producing an audible atrial sound in nine normal subjects and in eight of nine hypertensive patients without left ventricular disease. In four hypertensive patients with left ventricular disease and an audible atrial sound, the infusion of saline resulted in increase in the intensity of the sound and shortening of the P-G interval. An audible atrial sound was most frequently found in association with left ventricular disease and elevation of atrial and ventricular diastolic pressures. The findings suggest that an audible atrial sound is frequently a manifestation of cardiac dysfunction.

Apparent coexistent valvular and subvalvular left ventricular outflow tract obstruction.

A patient is presented in whom coexisting bicuspid valvular aortic stenosis and asymmetrical septal hypertrophy were suggested by echocardiography. A focal area of hypertrophy noted at operation was excised. Subsequent histological examination did not reveal evidence to support the echographic and surgical observations. The necessity for careful intraoperative assessment of the degree and nature of subvalvular muscular hypertrophy is stressed. The absence of classic echographic findings in these patients is noted.

Chest roentgenographic findings in the acute rejection crisis in human cardiac transplants.

FOUR CARDIAC transplantations were performed at the Medical College of Virginia during 1968. Of these, one patient is alive and has recovered from two rejection crises and a third episode of suspected rejection. The cause of death in the other patients was acute irreversible rejection of the cardiac homograft at seven, seven, and eighteen days, respectively. The purpose of this paper is to review the chest radiographic findings in these 4 patients in order to assess the value of the chest roentgenogram in the diagnosis of acute rejection. Preparation for the clinical trials of cardiac transplantation was obtained through extensive laboratory experimentation. Surgical technics (1, 2) were developed which resulted in complete recovery of dogs after orthotopic transplantation. Physiological studies (3–6) revealed that the denervated heart could generate a normal cardiac output and could respond normally to various forms of stress; moreover, autonomic reinnervation usually became functionally significant with...

Five Unusual Cases of Ventricular Aneurysm

Abstract Five patients with ventricular aneurysm exhibiting unusual etiological or anatomical features are presented. Resection of large portions of the ventricular myocardium, which may at times include the papillary muscle, is compatible with an excellent recovery despite diminution in the size of the left ventricular cavity and concomitant mitral valve replacement. Intentional fibrillation of the heart is recommended after the institution of bypass and prior to manipulation of the aneurysm in order to minimize the risk of intraoperative thromboembolism.