Combined supravalvular aortic stenosis and hypertrophic subaortic stenosis: coexistence or association?

A 19-year-old male was found to have combined supravalvular aortic stenosis and hypertrophic subaortic stenosis. Two possible hypotheses with supportive evidence in the literature may explain this association: (1) long-standing fixed supravalvular aortic stenosis may result in secondary hypertrophic subaortic stenosis, and (2) infantile hypercalcemia, a condition closely related to supravalvular aortic stenosis, may also be involved by continuous inotropic stimulation in the pathogenesis of muscular hypertrophy and subaortic stenosis of the left ventricle. We tend to favor the second theory in light of recent evidence in the literature.

Single dose administration of propranolol in hypertension: a comparison of two formulations using clinic and home blood pressure measurements

The effect of once daily conventional or long acting propranolol on blood pressure was examined in a double-blind crossover trial in 15 patients with moderate hypertension previously responsive to beta-blocking drugs. After a washout period, patients were randomly allocated to receive either conventional or long acting propranolol (160 or 320 mg once daily) and matching placebo for four weeks. Each treatment period was followed by two weeks during which only placebo was given. Clinic and home blood pressure measurements, taken 24 hours after dosing, indicated adequate and similar control during the two treatment periods. The onset of the antihypertensive action was of similar duration and no "rebound" effect was observed after withdrawing treatment. There was a similar reduction in exercise tachycardia 24 hours after dosing. No difference in the incidence of side effects was detected. These results demonstrate satisfactory blood pressure control with propranolol administered once daily, but do not support any therapeutic advantage of long acting over the conventional formulation of the drug.

[Drug lowering of the HDL concentration in the serum of cardiologically treated patients]

The connection between decreased concentration of HDL-cholesterol in the serum and increased risk of arteriosclerosis has attracted the attention to such sizes of influence which are able to decrease the HDL-cholesterol-concentration. In these cases the question is asked, whether the analytic reliability of the techniques which are at the disposal for the estimation of HDL-cholesterol is sufficient for the recognition of the changes of the concentration to be expected. To the sizes of influence belong medicaments which cannot be fancied away in the therapy of cardiovascular diseases; thus the beta-receptor blockers talinolol and propranolol. The examination of 118 cardiologically treated patients yields the result that there is no particular risk of the patients treated by means of these medicaments, since an essential decrease of the HDL-cholesterol-concentration could not be proved.

Surgical control of chronic migrainous neuralgia by trigeminal ganglio-rhizolysis

Chronic migrainous neuralgia is not diagnosed as often as the periodic or "cluster" form of Horton's syndrome. The distinguishing features of chronic migrainous neuralgia, compared with the periodic variety, are the frequency and persistence of the attacks of hemicraniofacial pain and the intractability to medical management. Eight male patients ranging in age from 22 to 45 years received prompt, although transient, pain relief by blockade of the Gasserian ganglion on the side of their hemifacial pain with a local anesthetic. Prolonged relief was subsequently achieved by percutaneous radiofrequency trigeminal ganglio-rhizolysis. There were no significant complications from this procedure. Review of the literature indicated that other ablative neurosurgical procedures, such as alcohol injection of the Gasserian ganglion and trigeminal rhizotomy by the subtemporal craniectomy approach, have relieved migrainous neuralgia, but with a greater risk and incidence of complications. The characteristic clinical features of migrainous neuralgia and the medical and surgical approaches to therapy are discussed.

Clinical management of acute and chronic cocaine poisoning

At the Haight-Ashbury Free Medical Clinics in San Francisco, the recreational use of cocaine is on a precipitous incline of popularity. Intensified symptoms of intoxication and the possibility of overdose parallel the current fad of smoking "freebase." We examined the "cocaine reaction," an adrenergic storm affecting CNS, respiratory and cardiovascular systems, which may proceed to generalized collapse and death within minutes. The physiologic and pharmacologic mechanisms of the reaction are elaborated, and a logical algorithm of treatment is outlined. The psychodynamics of the "armed" cocaine personality is discussed, as is the proper psychological approach to these patients. A specific indicated technical and pharmacologic approach, as well as several caveats of therapy that have been clinically developed in the treatment of several hundred cases of cocaine overdose, are presented.

Arrhythmia prophylaxis using propranolol after coronary artery surgery

Sixty patients undergoing coronary artery bypass grafting operations with cold potassium cardioplegia as the method of myocardial preservation either received low-dose oral propranolol (10 mg every 6 hours; 28 patients) or served as controls (32 patients). The study period began after extubation and ended at the time of hospital discharge. On the fourth postoperative day, 24-hour Holter monitoring was performed to assess additional subtle differences in arrhythmias. The overall incidence of symptomatic postoperative arrhythmias was 31% in the control group: 6 patients (19%) had atrial fibrillation or flutter and 4 patients (12%), ventricular arrhythmias. By contrast, 1 patient (4%) in the propranolol group had atrial fibrillation, and no patient had ventricular arrhythmias. The difference in overall arrhythmia rates between the two groups is significant (p less than 0.025). Twenty-four-hour Holter monitoring demonstrated no additional differences in the frequency of simple or complex atrial or ventricular ectopy between the two groups. We conclude that the incidence of postoperative arrhythmias following coronary artery bypass operation is diminished by the oral administration of prophylactic low-dose propranolol. When compared with our previous study [1], in which the method of myocardial preservation was intermittent aortic cross-clamping and moderate hypothermia, there is no difference in the overall incidence of postoperative arrhythmias.

The additive antianginal action of oral nifedipine in patients receiving propranolol: magnitude and duration of effect

Ten men with stable angina not completely relieved by full doses of propranolol (mean 218 mg/day) were administered an oral dose of 10 mg of nifedipine or placebo on alternate mornings in a double-blind fashion. Patients had been trained in a protocol that precipitated angina after 3-6 minutes of bicycle exercise. On test days, with propranolol continued, bicycle exercise to angina or fatigue was performed before nifedipine or placebo administration, and hourly thereafter for 8 hours. Mean exercise duration was greater 1 hour after nifedipine than after placebo by 123 seconds (372 +/- 21 vs 249 +/- 16 seconds, p less than 0.001). By the fifth hour, the increase in exercise time was reduced to 93 seconds (p less than 0.001), and a significant, though further diminished, difference of 57 seconds was still present at 8 hours (p less than 0.01). Nifedipine lowered resting systolic blood pressure by 20 mm Hg (p less than 0.001) without appreciably changing heart rate. We conclude that nifedipine is a very effective and reasonably long-acting antianginal supplement to propranolol.

Propranolol-induced dyspnea in a nonasthmatic male

The authors report the onset of wheezing and dyspnea in a 32-year-old, nonasthmatic male who was receiving propranolol for chronic migraine headaches of 20 years' duration. The symptoms first appeared during the "cold season"; the diagnosis was bronchitis. After three months without propranolol, the patient, prompted by continuing migraine headaches, again took the drug (40 mg bid). Within 48 hours he complained of rhinitis that rapidly progressed to wheezing, resembling bronchitis. Other reports in the literature are discussed.

Controlled study of metoprolol and propranolol during prolonged administration in patients with essential tremor

The efficacy of propranolol and metoprolol in the treatment of essential tremor was compared in a double blind crossover placebo-controlled study in 16 patients. Each treatment was given for a period of 4 weeks at two different dosage regimens (150 and 300 mg daily for metoprolol, 120 and 240 mg daily for propranolol). Each dosage regimen lasted for 2 weeks. Tremor assessment was carried out by accelerometry, clinical evaluation, patient's self-rating and a battery of performance tests. At the lower dosage, propranolol was found to be superior to placebo on the basis of performance tests and patient's self-assessment. At the higher dosage, propranolol was superior to placebo on all methods of assessment. By contrast, the tremorolytic effect of metoprolol was not significantly different from that of placebo, irrespective of the dosage or of the method of assessment used. Propranolol (120 mg daily) was better than metoprolol (150 mg daily) on the basis of clinical evaluation and patient's self-assessment. Propranolol (240 mg daily) was superior to metoprolol (300 mg daily) on the basis of patient's self-assessment. Both drugs antagonised standing tachycardia to a similar extent. These results indicate that the effectiveness of metoprolol, previously demonstrated in a single-dose study in the same patients, is not fully maintained during prolonged administration. In the absence of specific contraindications, propranolol represents a better choice in the treatment of patients with essential tremor.

[Effect of hypotensive preparations on humoral factors in blood circulation regulation]

A total of 178 patients with labile arterial hypertension were examined for the effect of propranolol and clonidine on the central hemodynamics, plasma renin, dopamine- beta-hydroxylase, urine kallikrein, and blood prekallikrein and kallikrein. The results suggest that basic to changes in the hemodynamics produced by a single administration of propranolol is its beta-adrenoblocking effect proper. The decrease in the general peripheral resistance due to prolonged propranolol therapy may be determined by activation of the blood kallikrein-kinin system and enhancement of the descending inhibition of the sympathetic nervous system because of activation of the central alpha-adrenoreceptors under long-term blockade of beta-adrenoreceptors of the central nervous system. The changes in the hemodynamics produced by low doses of clonidine may be accounted for by its central alpha-adrenomimetic effect.

Effects of acute and long-term beta-adrenoceptor blockade with propranolol on haemodynamics, plasma catecholamines and renin in essential hypertension

The effect of an acute intravenous and repeated oral doses of propranolol on haemodynamics, plasma and urinary catecholamines and plasma renin activity was studied in patients with essential hypertension. Intravenous injection of propranolol 5 mg produced a fall in cardiac output but had no consistent effect on blood pressure. Treatment with oral propranolol for 24 weeks lowered cardiac output and blood pressure; total peripheral resistance did not differ from the pretreatment values. Neither acute intravenous nor chronic oral administration of the beta-blocker affected the resting plasma levels of noradrenaline and adrenaline. Long-term treatment with propranolol reduced urinary excretion of vanilmandelic acid without affecting urinary catecholamine excretion. Acute intravenous injection of propranolol decreased plasma renin activity less than did chronic oral treatment with the drug. The observed time course of plasma renin activity was compatible with the view that suppression of this enzyme contributed to the antihypertensive effect of propranolol.

Comparative effects of alinidine and propranolol in ischaemic heart disease

The effects of single oral doses of alinidine 40 mg, propranolol 40 mg or placebo during a maximal exercise test on a bicycle ergometer in patients with angina pectoris were studied in a randomised, double blind study. 2 and 5 h after drug intake a small fall in resting heart rate and systolic blood pressure was observed both after alinidine and propranolol. At a fixed work load both drugs decreased heart rate, systolic blood pressure, double product and the extent of ST segment depression. Total work performed and time to appearance of angina pectoris were increased 2 h alinidine and propranolol. The same effects were still apparent 5 h after propranolol but not after alinidine. At peak exercise neither drug had any effect on the extent of ischaemic ST segment depression.

Chronic stable angina: comparison of verapamil and propranolol

The effect of verapamil 120 mg t.d.s. was compared with propranolol 160 mg b.d. in the treatment of stable angina pectoris. Nineteen patients were studied in a randomized, double-blind, crossover trial, using patient diaries, exercise-testing and ambulatory electrocardiographic monitoring. Both drugs were given for 1 month. On average the number of attacks of angina was reduced equally by verapamil and propranolol. The degree of electrocardiographic evidence of myocardial ischaemia was decreased by the same amount, but verapamil was significantly more effective in prolonging the exercise time. Both drugs reduced the number of episodes of ST-segment depression during 24 hours of ambulatory electrocardiographic monitoring, which was analyzed in nine patients. It is concluded that verapamil compares very favourably with propranolol in the treatment of stable angina, and is more beneficial in improving exercise capacity.