Vaskar Mukerji

Relation of Duration of Morbid Obesity to Left Ventricular Mass, Systolic Function, and Diastolic Filling, and Effect of Weight loss

Longer duration of morbid obesity is associated with higher LV mass, poorer LV systolic function, and greater impairment of LV diastolic filling. Weight loss-induced decreases in LV mass and improvements in LV systolic function and diastolic filling are due in part to favorable alterations in LV loading conditions.

Cardiac Morphology and Left Ventricular Function in Normotensive Morbidly Obese Patients With and Without Congestive Heart Failure, and Effect of Weight Loss

To assess cardiac morphology and left ventricular (LV) function in normotensive morbidly obese patients with and without congestive heart failure (CHF) we performed a physical examination and obtained a transthoracic echocardiogram and cardiac Doppler studies before and after substantial weight loss in patients whose actual body weight was initially equal to or more than twice their ideal body weight and who were free from systemic hypertension and underlying organic heart disease. There were 24 patients with CHF, 14 of whom were studied after weight loss. There were 50 patients without CHF, 39 of whom were studied after weight loss. Compared to patients without CHF, those with CHF had significantly greater mean LV internal dimension in diastole, LV end-systolic wall stress, LV mass/height index values, left atrial dimension and right ventricular internal dimension values, significantly lower mean LV fractional shortening, and transmitral Doppler E/A ratio values, and significantly longer mean transmitral E-wave deceleration time and duration of morbid obesity than patients without CHF. Substantial weight loss in those with and without CHF produced comparable reductions in mean LV internal dimension in diastole, LV end-systolic wall stress, LV mass/height index, transmitral Doppler E-wave deceleration time, and left atrial dimension, and comparable increases in LV fractional shortening and transmitral Doppler E/A ratio. Linear regression analysis identified duration of morbid obesity as the strongest predictor of CHF (p <0.00000002). Thus, LV mass is greater and LV systolic function and diastolic filling are more impaired in normotensive morbidly obese subjects with CHF than in those without CHF. Duration of morbid obesity is the strongest predictor of CHF among the variables studied. Substantial weight loss produces comparable changes in cardiac morphology and function in those with and without CHF.

Panic disorder in patients with chest pain and angiographically normal coronary arteries

Although patients with angiographically normal or near normal coronary arteries are at low risk for cardiac disease, several follow-up studies have shown that many continue to report recurrent chest pain associated with social and work dysfunction. Three diagnostic entities have been proposed to explain the morbidity of this group: microvascular angina, esophageal motility disorders and panic disorder. The purpose of this study was to test the hypothesis that panic disorder is found frequently in patients with chest pain who have normal epicardial vessels. Ninety-four subjects with angiographically normal coronary arteries were interviewed according to a structured psychiatric protocol within 24 hours of their catheterizations. Thirty-two (34%) fit Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria for current panic disorder. Because panic disorder can be effectively treated, physicians should consider this diagnosis in this group of patients. Current research findings suggest that panic disorder, microvascular angina and esophageal disorders may each form the basis for chest pain in approximately 25% of these patients. Miscellaneous problems account for the other 25%.

Comparative survival after permanent ventricular and dual chamber pacing for patients with chronic high degree atrioventricular block with and without preexistent congestive heart failure

To determine whether survival after permanent ventricular demand (VVI) pacing differs from survival after permanent dual chamber (DVI or DDD) pacing in patients with chronic high degree atrioventricular (AV) block (Mobitz type II or trifascicular block), 132 patients who received a VVI pacemaker (Group 1) and 48 patients who received a DVI or DDD pacemaker (Group 2) were followed up for 1 to 5 years. There was no significant difference in sex distribution, mean age or incidence of coronary heart disease, hypertension, valvular heart disease, diabetes mellitus, stroke or renal failure between Groups 1 and 2. Overall, the predicted cumulative survival rate at 1, 3 and 5 years was 89, 76 and 73%, respectively, for Group 1 and 95, 82 and 70%, respectively, for Group 2. In patients with preexistent congestive heart failure, the predicted cumulative survival rate at 1, 3 and 5 years was 85, 66 and 47%, respectively, for Group 1 (n = 53) and 94, 81 and 69%, respectively, for Group 2 (n = 20). The 5 year predicted cumulative survival rate was significantly lower in Group 1 patients with preexistent congestive heart failure than in Group 2 patients with the same condition (p less than 0.02). There was no significant difference in 5 year cumulative survival rate between Groups 1 and 2 for patients without preexistent congestive heart failure. The results suggest that permanent dual chamber pacing enhances survival to a greater extent than does permanent ventricular demand pacing in patients with high degree AV block and preexistent congestive heart failure.

Comparative survival following permanent ventricular and dual-chamber pacing for patients with chronic symptomatic sinus node dysfunction with and without congestive heart failure

To determine whether survival following permanent ventricular demand pacing differs from survival following permanent dual-chamber pacing in patients with symptomatic sinus node dysfunction (unexplained sinus bradycardia, subsidiary rhythms, sinus arrest, sinoatrial block, or the bradycardia/tachycardia syndrome), we followed 79 patients who received a VVI pacemaker (group 1) and 49 patients who received a DVI or DDD pacemaker (group 2) for 1 to 5 years. There was no significant difference in sex distribution, mean age, or the incidence of coronary heart disease, hypertension, valvular heart disease, diabetes mellitus, stroke, or renal failure between groups 1 and 2. Overall, the predicted cumulative survival rates at 1, 3, and 5 years were 89%, 82%, and 74%, respectively, for group 1 and 94%, 86%, and 78%, respectively, for group 2. In patients with preexistent congestive heart failure (CHF), predicted cumulative survival rates at 1, 3, and 5 years were 78%, 69%, and 57%, respectively, for group 1 (n = 23) and 90%, 83%, and 75%, respectively, for group 2 (n = 16). Five-year predicted cumulative survival was significantly lower in group 1 patients with CHF than in group 2 patients with CHF (p less than 0.03). There was no significant difference in 5-year cumulative survival rates between groups 1 and 2 in patients without CHF. The results suggest that permanent dual-chamber pacing enhances survival to a greater extent than permanent ventricular demand pacing in patients with chronic symptomatic sinus node dysfunction and CHF.

Factors influencing left ventricular systolic function in nonhypertensive morbidly obese patients, and effect of weight loss induced by gastroplasty

Heart rate and blood pressure were measured, and echocardiography was performed in 39 patients whose actual body weight was greater than twice their ideal body weight to identify factors influencing left ventricular (LV) systolic function in morbidly obese patients and assess the effect of weight loss on LV systolic function. Patients were studied before and after weight loss induced by gastroplasty. The study cohort was 133 +/- 8% overweight before weight loss and 39 +/- 7% overweight at the nadir of weight loss. Before weight loss, LV fractional shortening varied inversely with LV internal dimension in diastole (an indirect index of preload), LV end-systolic wall stress and systolic blood pressure (indexes of afterload). The weight loss-induced change in LV fractional shortening varied directly with the pre-weight loss LV internal dimension in diastole, LV end-systolic wall stress and systolic blood pressure, and inversely with the pre-weight loss LV fractional shortening. The weight loss-induced change in LV fractional shortening varied inversely with the weight loss-induced changes in LV end-systolic stress and systolic blood pressure. In patients with reduced LV fractional shortening (n = 14), weight loss produced a significant increase in LV fractional shortening that was accompanied by a significant decrease in LV internal dimension in diastole, LV end-systolic stress and systolic blood pressure. The results suggest that LV loading conditions have an important role in determining LV systolic function in morbidly obese patients. Improvement in LV systolic function in these patients is closely related to weight loss-induced alterations in LV loading conditions.

Effect of weight loss on left ventricular mass in nonhypertensive morbidly obese patients

Extreme obesity produces increases in circulating blood volume and cardiac output, which are proportional to the excess in adipose accumulation.1-20 In the absence of systemic hypertension, systemic vascular resistance decreases to accommodate the increase in cardiac output.l-‘o Left ventricular enlargement results from the increases in circulating blood volume and cardiac output, and in turn, predisposes the left ventricle to increased wall stress, in accordance with the law of LaPlace.‘-” Eccentric left ventricular hypertrophy is thought to develop in response to, and as a mechanism for, reducing left ventricular wall stress.” Prior postmortem and echocardiographic studies showed that left ventricular hypertrophy frequently occurs in extremely obese subjects, even in the absence of systemic hypertension.4-10 There has been no systematic assessment of factors influencing left ventricular mass in extremely obese subjects or of the effect of weight loss on left ventricular mass in these cases. The present study examines these issues.

Acute and long-term effects of nifedipine on pulmonary and systemic hemodynamics in patients with pulmonary hypertension associated with diffuse systemic sclerosis, the CREST syndrome and mixed connective tissue disease.

Ten patients with pulmonary hypertension associated with diffuse systemic sclerosis (1 patient), the CREST syndrome (calcinosis cutis, Reynauds phenomenon, esophageal dysmotility, sclerodactyl, telangiectasia) (6 patients) and mixed connective tissue disease (3 patients) were studied to assess the effect of oral nifedipine on pulmonary and systemic hemodynamics. Each patient underwent right-sided cardiac catheterization just before nifedipine administration. Thereafter, oral nifedipine was administered in 10 mg increments every 90 minutes until pulmonary vascular resistance normalized or a total dose of 30 mg was achieved. Hemodynamic measurements were obtained at 30-minute intervals for 3 hours, then hourly for 9 hours (acute study). Hemodynamic studies were repeated 3 to 6 months after the initial catheterization with the minimum dose of oral nifedipine (administered every 8 hours) required to achieve maximal reduction of pulmonary vascular resistance in the acute study (long-term study). In the acute study, oral nifedipine produced a significant decrease in mean pulmonary vascular resistance from 6.3 +/- 3.8 to 4.3 +/- 3.6 U (p less than 0.001). Similar changes in pulmonary vascular resistance were noted in the long-term study (n = 6). The results indicate that oral nifedipine is capable of producing an acute and sustained reduction in pulmonary vascular resistance in patients with pulmonary hypertension associated with diffuse systemic sclerosis, the CREST syndrome and mixed connective tissue disease.

Effect of weight loss on left ventricular diastolic filling in morbid obesity.

Abstract Substantial weight loss in morbidly obese subjects produces improvement in LV diastolic filling that is associated with weight loss-related decreases in LV mass and favorable alterations in LV loading conditions.

Non-fearful panic disorder: panic attacks without fear.

Abstract Twelve of 38 cardiology patients with chest pain and current panic disorder reported that during their last major panic attack they did not experience intense fear, nor did they experience fear of dying, fear of loss of control or fear of going crazy. Using the DSM-III(R) criteria, they were diagnosed as non-fearful panic disorder (NFPD), and contrasted with the other 26 S s on several descriptive and self-report measures. The NFPD group reported significantly fewer phobias but was no different on reports of depression and several panic attack variables. The NFPD group scored lower on only three of 18 self-report scales. These results suggest that the DSM-III(R) defined NFPD S s resemble those who report the subjective experience of anxiety during their attacks.