Precipitation of heart failure following sudden withdrawal of hydralazine

Sudden withdrawal of oral therapy with hydralazine for reduction of afterload in a patient precipitated severe congestive heart failure. Signs of metabolic encephalopathy evolved due to low cardiac output. Reinstitution of therapy with hydralazine resulted in prompt improvement in cardiac and neurologic status. This case underscores the need for careful follow-up of such patients and argues against sudden withdrawal of vasodilator therapy.

Platelet function studies in coronary artery disease. V. Evidence for enhanced platelet microthrombus formation activity in acute myocardial infarction

Circulating platelet microthrombi were evaluated during the acute and convalescent phases of illness in 44 patients admitted to the hospital for chest pain. Similar studies were performed in 10 healthy volunteers and 6 patients with infection. Circulating platelet microthrombi were significantly increased during the acute phase in 22 patients with transmural myocardial infarction compared with values in the other 22 patients without myocardial infarction, the healthy volunteers and the patients with infection alone. This increase in circulating platelet microthrombi declined to normal levels by the 7th hospital day in all but two patients who had evidence of extension of myocardial infarction and died. In contrast, circulating platelet microthrombi were similar in acute and convalescent phases of patients with chest pain but without myocardial infarction and were comparable with values in healthy volunteers. This study suggests that increased circulating platelet microthrombi may be related to tissue necrosis associated with transmural myocardial infarction.

Demonstration of a specific neutrophil receptor for a cell-derived chemotactic factor

The crystal-induced chemotactic factor, a cell-derived chemoattractant for neutrophils, binds specifically to a site on human neutrophils but not to erythrocytes or lymphocytes, suggesting a relationship between the presence of specific binding sites on the neutrophils and the ability to be chemotactically activated. The Scatchard analysis revealed an equilibrium dissociation constant at 37 degrees C of 0.446 micrometer and the presence of approximately equal to 6.44 x 10(5) binding sites for 125I-crystal-induced chemotactic factor per cell. Binding was not displaced by the synthetic chemotactic factors F-Met-Leu-Phe and Gly-His-Gly or by complement-activated plasma providing evidence of the specificity of the receptor.

Effect of sublingual nitroglycerin on regional flow in patients with and without coronary disease

We evaluated the effects of sublingual nitroglycerin on indices of regional coronary flow and coronary resistance (CR) in 12 selected patients with coronary artery disease (CAD) and eight with normal coronary arteries (NCA), using continuous thermodilution. Resting total left ventricular flow, reflected by coronary sinus flow (CSF), and anterior regional flow, reflected by great cardiac vein flow (GCVF), in NCA and CAD patient groups, were similar. However, in a subgroup of six patients, with CAD limited to the anterior descending artery, GCVF was lower and anterior regional CR (CRANT) higher than the NCA subjects. Nitroglycerin reduced the systolic pressure-heart rate product similarly in both patient groups. CSF and GCVF in NCA subjects declined 15% and 17%, respectively, as total CR (CRT) and CRANT increased. In the CAD subgroup, consisting of patients with CAD limited to the anterior descending, GCVF increased 48% as CRANT declined 50%, and CSF was unchanged. In the other CAD subgroup of patients with CAD in the right and/or circumflex arteries, GCVF declined 32% and CRANT increased 46% as CSF was minimally increased. These data imply that sublingual nitroglycerin reduces both CSF and GCVF in NCA patients as oxygen demands decrease. In certain CAD patients, however, nitroglycerin alters regional coronary venous blood flow, suggesting a redistribution of flow from normally perfused to hypoperfused regions.

In vivo validation of a thermodilution method to determine regional left ventricular blood flow in patients with coronary disease

Several methods have been used to measure left ventricular regional blood flow in humans. However, limitations and lack of validation in patients are major problems. A continuous thermodilution technique to measure regional left ventricular blood flow in patients with coronary disease was validated in vivo. This technique permits simultaneous assessment of venous blood flow draining predominantly from the anterior wall and of the total left ventricular effluent. Thermodilution measurements with simultaneous electromagnetic flowmeter recordings from anterior descending vein grafts were compared in patients with occluded or subtotally occluded anterior descending coronary arteries. The thermodilution method yielded values for both absolute anterior regional blood flow and changes in anterior regional flow that compared closely to anterior descending bypass graft flow measured independently. The multithermistor technique may be useful in monitoring flow effects of regional coronary disease over time, as well as in studies of agents purported to alter regional blood flow.

Platelet aggregation in aortic and coronary venous blood in patients with and without coronary disease. 3. Role of tachycardia stress and propranolol

We studied 16 patients with coronary artery disease (CAD) to evaluate platelet aggregation in blood samples withdrawn simultaneously from the aorta and coronary sinus. At rest, mean platelet aggregation in coronary venous blood was significantly lower than that in aortic blood. Platelet counts in coronary venous blood were also lower than in the aortic blood in each of the six CAD patients in whom counts were done. Platelet aggregation was lower in seven patients who were taking propranolol than in the remaining nine who were not taking propranolol. During tachycardia stress, platelet aggregation increased in all patients, but the magnitude of increase was greater in patients not taking propranolol. In four other patients without CAD, platelet aggregation and counts were also studied in the same fashion and were similar in both the aortic and coronary venous blood. These data suggest that in certain CAD patients, platelet consumption or destruction within atherosclerotic vasculature may occur. Propranolol may reduce platelet aggregation at rest and modify excessive aggregation during tachycardia stress in certain CAD patients.

Platelet aggregation studies in coronary artery disease. Past 4. Effect of aspirin

We evaluated platelet aggregation in vitro in blood samples drawn simultaneously from aorta and coronary sinus. Platelet aggregation was significantly lower in the coronary venous blood than in the aortic blood in patients with coronary artery disease. Lower platelet counts were also observed in coronary venous blood. No such differences were seen in subjects with normal coronary arteries. Oral administration of aspirin eliminated the differences in platelet aggregation and counts across the myocardial vascular bed. These observations suggest that platelet sequestration in the myocardial vasculature may be related to the presence of disease in the coronary arteries.

Differences in platelet aggregation in coronary sinus and aortic blood in patients with coronary artery disease: effect of propranolol

Platelet aggregation was studied in aortic and coronary sinus blood samples obtained from 18 patients with coronary artery disease (CAD). Using epinephrine and ADP as aggregating agents, platelet aggregation was lower in coronary venous blood than in aortic blood. In nine patients on long-term propranolol therapy, platelet aggregation was lower in both aortic and coronary venous blood compared to the nine patients not taking propranolol. Four other subjects without angiographic evidence of coronary disease exhibited no difference in platelet aggregation in aortic and coronary sinus blood. These data suggest that platelet aggregation is lower in the coronary venous blood of certain patients with coronary disease and chronic propranolol treatment may reduce aggregation in both aortic and coronary sinus blood.

Haemodynamic effects of hydrallazine and of hydrallazine plus glyceryl trinitrate paste in heart failure

In a study designed to investigate potential non-parenteral treatment for chronic heart failure, hydrallazine, 225 to 300 mg per day, was given orally to 9 patients. There was no significant change in heart rate or mean arterial pressure as cardiac output increased. Left ventricular stroke work increased significantly and pulmonary artery wedge pressure fell. Systemic and pulmonary vascular resistances fell. With the addition of 2 per cent glyceryl trinitrate paste, there was a further decline in mean pulmonary arterial and wedge pressures, without a significant change in heart rate, arterial pressures, cardiac output, or systemic or pulmonary vascular resistance. There were no untoward effects from either form of treatment. All patients reported relief of shortness of breath and other symptoms related to ventricular dysfunction. This study supports the suggestion that oral hydrallazine is effective in increasing cardiac output and decreasing pulmonary congestion. Furthermore, the addition of topical glyceryl trinitrate provides a greater reduction of pulmonary pressures, probably through its predominant venodilator action. In some selected patients with heart failure, oral hydrallazine and topical glyceryl trinitrate in combination produce beneficial clinical and haemodynamic effects, probably through afterload and preload reduction, respectively.

Non-parenteral combined afterload and preload reduction therapy in congestive heart failure

It has been shown that hydralazine is beneficial in chronic heart failure by virtue of its afterload reducing effect. Nitroglycerin paste results in venodilation and fall in left ventricular filling pressure (LVFP). Thirteen patients with chronic heart failure were given a combination of oral hydralazine and nitroglycerin paste. With oral hydralazine (75 to 100 mg every 8 h), left ventricular stroke work increased and LVFP slightly fell. Following addition of 2% nitroglycerin paste, an additional decline in mean pulmonary artery and LVFP was observed without significant changes in heart rate and arterial pressure. There were no untoward side effects from either therapy. Eight patients followed for three to eight months (mean five months) reported subjective improvement in shortness of breath and other symptoms related to ventricular dysfunction. This study shows that in certain patients with chronic heart failure, hydralazine and nitroglycerin paste combination produces salutary clinical effects on long term probably through afterload and preload reduction, respectively.

Effect of altered lymphocyte function on immunologic disorders in NZB/NZW mice. III. Acceleration of disease by thymosin

Administration of thymosin fraction V to NZB/NZW F1 mice, an animal model for human SLE, accelerated the appearance of proteinuria and anti-nDNA antibodies, increased deposition of immunoglobulins in kidneys, and significantly shortened survivals. Although the addition of thymosin to in vitro cultures of spleen and lymph node cells from thymosin-treated mice increased DNA synthesis in response to stimulation with Con A, in vivo treatment with thymosin did not affect the Con A response. There was no effect on in vitro responses to PHA or LPS, or on IgM antibody formation to SRBC (T cell dependent) or SSS III (T cell independent) immunizations. Antibodies to thymosin or contamination of our thymosin preparations with nucleic acids could not be demonstrated. The acceleration of autoimmune disease produced by thymosin treatment could not be explained by alteration of the T and B cell functions studied.

Myocardial damage after repetitive direct current shock in the dog: correlation between left ventricular end-diastolic pressure and extent of myocardial necrosis

Acute myocardial necrosis was produced in 27 anesthetized dogs by repetitive DC 75 joule shock delivered with one electrode in the left ventricular cavity and the other on the left chest wall. A total of 1 shock/kg body weight delivered at 10 sec intervals resulted in discrete anterior wall necrosis of 7% to 31% (mean, 17.6%) of the mass of left ventricular myocardium. After some transient bradycardia, normal sinus rhythm was restored. Depression of left ventricular function 15 min after shock (rise in LVEDP from 4.0 +/- 1.5 to 17 +/- 2 mm Hg and fall in cardiac output from 2.29 +/- 0.24 to 1.82 +/- 0.12 L/min) recovered only slightly during the ensuing 2 hr. A significant correlation (r=0.85) was observed between the LVEDP at 2 hr after shock and the extent of necrosis determined histochemically and histologically at the time of sacrifice 3 hr after shock. Thus, in this form of acute myocardial damage, pump dysfunction is closely related to the area of necrosis.

Electrocardiographic and vectorcardiographic abnormalities in Fabry's disease

Fabry's disease has been reported to be associated with ECG abnormalities. Thirty-two patients with this disease followed in the University of Minnesota had ECG's and 15 had VCG's. An abonrmal rhythm was observed in two patients on initial examination and four more developed abnormal rhythm on follow-up examinations. A short PR interval (120 msec. or less) was seen in five patients. Thirteen others had a PR interval that was less than 140 msec. Conduction abnormalities involving the A-V node or His bundle or its branches were present in 22 per cent of the patients, most frequently the intraventricular conduction defects progressing to the right bundle branch block. Atrial or ventricular enlargement was seen in 60 per cent of the patients, left ventricular hypertrophy being the most common. ST-T changes with or without chamber enlargement were seen in 10 patients. One patient had an anterior myocardial infarction pattern on his ECG. Hemizygosity was found to be associated with significantly more abnormalities than heterozygosity. The severity of conduction defects also increased with the duration of the disease process. Vectorcardiography in this study did not provide significant additional information other than that observed on the ECG alone. Since the pathology usually reveals myocardial fibers, conduction system, and blood vessels infiltrated with glycosphingolipid, it is believed that lipid infiltration is responsible for conduction defects, chanber enlargement, and other abnormalities. Although Fabry's disease is rate, it may be amenable to therapy; therefore, recognition of cardiac involvement is important.

Aortic regurgitation associated with ventricular septal defect. Echocardiographic and hemodynamic observations

Ventricular septal defect is sometimes associated with aortic regurgitation. In this report, an echocardiogram demonstrating dramatic prolapse of the noncoronary cusp into the left ventricular outflow tract and ventricular septal defect in a patient with Down's syndrome and ventricular septal defect, confirmed by angiographic studies, is presented. The echocardiogram supports the concept of anatomic lack of support of the aortic ring due to a deficient septum and hemodynamically significant flow of blood to the right ventricle through the ventricular septal defect, resulting in trauma to aortic cusps and prolapse.

Hemodynamic effects of labetalol, an alpha and beta adrenergic blocking agent, in hypertensive subjects

Labetalol was administered to six hypertensive subjects in increasing doses for seven days. A decrease in both supine and standing arterial pressure and heart rate was observed with no change in cardiac output and few side effects. Exercise tolerance was unaltered by the drug, but the heart rate and arterial pressure response to exercise were significantly blunted. The infusion rate of isoproterenol required to produce tachycardia was increased sevenfold by 800 mg/day labetalol and tenfold by 1600 mg/day. More than twice the control dose of phenylephrine was required during labetalol therapy to produce a rise in diastolic arterial pressure reflex tachycardia to amyl nitrite-induced hypotension was attenuated. These studies indingina pectoris.

Effect of altered lymphocyte function on immunologic disorders in NZB/NZW mice

NZB/NZW F1 female mice were treated with the immunosuppresive enzyme L-asparaginar antibodies, diminished deposition of gamma-globulins in kidneys, significantly delayed the onset of proteinuria, and reduced deaths from nephritis. These effects were associated with reduction of cellular IgM antibody synthesis to both T-dependent and T-independent antigens, but the graft-versus-host reaction was not affected. After several weeks of therapy, antibodies against Asnase appeared in the circulation, the effect on antibody synthesis was lost, ANA and anti-DNA appeared, followed by proteinuria and deaths from nephritis. Therefore Asnase proved to be an effective therapy in NZB/NZW mice, but its usefulness was limited by the appearance of inactivating antibodies.

Reappraisal of the role of the diabetic state in coronary artery disease

Clinical and coronary arteriographic findings were evaluated in patients with angina pectoris who were considered not to have diabetes mellitus or to have chemical or clinical diabetes. Each of the three groups consisted of 100 consecutive referred patients. Neither the age of the patients nor duration of symptoms differed significantly among the groups. Hypertension, gout, and peripheral vascular disease were more frequent in the patients with clinical diabetes. There was no difference in serum cholesterol concentration among the groups, but plasma triglyceride levels and the frequency of type 4 hyperlipoproteinemia were significantly higher (p less than 0.01) in the chemical and clinical diabetic groups than in the nondiabetic patients. Coronary arteriographic observations indicated that the severity of the coronary arterial disease was greater in both diabetic groups than in nondiabetic patients. The difference in the coronary scores among the three groups of patients interacts to some extent with the triglyceride level, since a high score in the diabetic groups was noted only in the presence of an elevated tryglyceride concentration. The results indicate that the increased severity of coronary arterial disease in diabetic patients is not attributable to age, duration of symptoms, hypertension, type -4 hyperlipoproteinemia, or apparent severity of the glucose intolerance.

Fluorimetric method for the detection of anti-DNA antibodies in serum

A method for the detection of native anti-DNA antibodies in serum is described. The method is based on the reactivity of fluorescein isothiocyanate with DNA, forming a complex capable of combining with anti-DNA antibodies. The fluorescein content of the precipitated fluorescein-DNA anti-DNA complex is then measured in a fluorometer. The assay is accurate, highly reproducible, and inexpensive to perform. Comparative studies performed with the Farr assay show the fluorimetric method to be more sensitive in detecting anti-DNA antibodies in the serum of SLE patients.

Vectorcardiographic, electrocardiographic, and angiographic correlations in apparently isolated inferior wall myocardial infarction

Twenty-six patients with ECG evidence of localized inferior myocardial infarction and poor ejection fraction (less than 50 per cent) were compared with 26 patients with similar ECG's, but with normal ejection fraction (over 50 per cent). The poor ejection fraction group had significantly more frequent and more severe disease in left anterior descending artery and a higher incidence of triple coronary obstruction than the normal ejection fraction group. The poor ejection fraction group had a significantly greater incidence of ventricular asynergy in the anterior and apical segments of left ventricle. Vectorcardiography was available in 35 of the 52 patients studied and frequently supplied diagnostic information not available in the scalar ECG's. Of 18 patients with scalar ECG patterns of isols, vectorcardiography identified five cases with anterior infarction, three with left ventricular hypertrophy, and one with left anterior hemiblock. Vectorcardiography is a valuable supplementary tool in the clinical assessment of patients with apparently isolated inferior infarction. When extensive coronary and poor ventricular function exist, VCG clues may be expected in about half the patients.

Pituitary-testicular axis in patients on lithium therapy

Plasma follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone levels were studied in 10 patients undergoing lithium therapy. Testosterone levels were below the normal range in 7 of the 10 patients. FSH levels were high in two patients and LH levels were high in one. The effects of lithium on the pituitary-testicular axis are discussed.

Medical-surgical aspects of left main coronary artery disease

Disease of the left main coronary artery compromises circulation to the major part of the left ventricle and thus threatens massive myocardial infarction and sudden death. Cardiac catheterization and coronary bypass surgery, in previous reports, have been associated with high mortality and morbidity rates. We report 50 patients with over 50 per cent narrowing of the left main coronary artery. The clinical pattern in these patients was variable and a left main coronary artery lesion could not be predicted before coronary angiography. There was only one death during cardiac catheterization. One patient died while waiting for elective surgery. Coronary bypass surgery was performed in 42 patients; one died during surgery. Forty-one patients are alive at 2 to 39 months follow-up (mean, 19 months). Thirty-six patients are asymptomatic or have minimal symptoms. Compared to the prognosis in patients with left main coronary artery stenosis treated medically, coronary bypass surgery performed on urgent basis offers a much better prognosis. Both coronary angiography and bypass surgery can be performed in these patients with a very low risk.

Pacemaker Wenckebach phenomenon due to antiarrhythmic drug toxicity

Two patients with intractable ventricular arrhythmia were managed with ventricular pacing and antiarrhythmic drugs. Toxic levels of these drugs results in unusual conduction disturbances at the level of Purkinje ventricular junction which caused pacemaker Wenckebach phenomenon and marked QRS prolongation. Sodium bicarbonate and sodium lactate infusion improved the conduction velocity probably by hyperpolarizing the membrane and reversed the conduction disturbance.

Anterior conduction delay: a possible cause for prominent anterior QRS forces

Prominently anterior QRS forces often present a diagnostic dilemma. Frequently, right ventricular forces may be eliminated on clinical grounds and dorsal infarction is therefore suspected, especially in a clinical setting of coronary artery disease. In five such patients studied angiographically, the coronary disease was concentrated in the left anterior descending artery and the ventricular dysfunction confined to the anterior wall of the left ventricle. In a sixth case, the prominent anterior forces were observed intermittently together with left anterior hemiblock. These observations, in addition to serial studies following surgery, strongly suggest that the mechanism for prominent anterior QRS forces in these cases is conduction delay in an anterior division of the left bundle branch system.

A new catheter for percutaneous transfemoral right heart catheterization

A new catheter for percutaneous transfemoral right heart catheterization is described. The catheter can also be used for pulmonary angiography and pulmonary wedgepressure recording. Because of the speed and efficiency with which this catheter may be used, we suggested a trial by physicians involved in right heart catheterization pulmonary angiography.

Congenital aneurysm of the left ventricle associated with supravalvular aortic stenosis and aneurysm of the left main coronary artery: case report and review of the literature

We report a unique case of a 33 year old female with congenital aneurysm of the left ventricular apex associated with an aneurysm of the left main coronary artery and surgically repaired supravalvular aortic stenosis. The congenital aneurysm of the left ventricular apex was not associated with a midline thoraco-abdominal defect, as reported in the medical literature. The patient survived two episodes of thrombo-embolism and is well after 10 years of medical follow-up.

Preoperative coronary angiographic prediction of bypass flow and short-term patency

A quantitative preoperative coronary angiographic index was defined in 148 patients undergoing coronary revascularization. Each diseased vessel was scored 0-3, for both diameter and quality of run-off. The sum of the scores for diameter and run-off constituted the numerical index for the diseased vessel. Correlations between the index and graft flow measured by electromagnetic flow meter at surgery were established in 259 bypassed vessels. The highest scores (5-6) were associated with higher flows, and the lower scores (0-4) with the lower flows (P less than 0.005). Repeat angiography performed 2 wk postoperatively in 110 patients demonstrated 174 graft patencies and 15 graft closures. Mean flow in open grafts was 82 +/- 41 ml/mn vs. 60 +/- 23ml/mn in closed grafts (P less than 0.005). It is concluded that graft flow is predictable from preoperative Coronary Angiographic Index and that higher flow and index scores are more likely to be associated with graft patency than low flows and index scores.