Primary culture of rat gastric epithelial cells as an in vitro model to evaluate antiulcer agents

Primary rat gastric cell cultures were investigated as an in vitro model for evaluating antiulcer agents. Following exposure to concentrations of up to 5 mg/mL of an antiulcer agent sucralfate, an aluminum hydroxide complex of sucrose octasulfate, cultured cells were treated with either pH 3.5 medium or 3.5 mM indomethacin. Cytoprotection was evaluated by colony forming efficiency, neutral red uptake, and 3-(4,5-dimethyl-2-thiazoyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) hydrolysis. By each measure, and depending on damaging agent, 2 and 5 mg/mL sucralfate provided partial (50% of untreated control) to near-complete (90% of untreated control) cytoprotection, respectively. Aluminum hydroxide also provided partial (55% of untreated control) to near-complete (more than 90% of untreated control) cytoprotection at 2 and 5 mg/mL, respectively, for the pH 3.5 medium-induced damage. Over a concentration range of 0.05 to 5 mg/mL, the potassium salt of sucrose octasulfate, KSOS, stimulated cell growth up to 40-60% over untreated controls but had little or no cytoprotective action in the presence of either 3.5 mM indomethacin or pH 3.5 medium. Overall results suggested that sucralfate may have at least two roles in influencing gastric epithelial cell function, cytoprotection and stimulation of cell growth in vitro. These observations serve as a basis for further study of in vitro models in evaluating the cytoprotective activity of antiulcer agents and their respective mechanisms of action.

Effect of percutaneous transluminal coronary angioplasty on circulating endothelin levels

Percutaneous transluminal coronary angioplasty (PTCA) is frequently associated with vasoconstriction involving large vessels as well as microcirculation, but the potential mechanisms remain poorly defined. In this study, we tested the hypothesis that endothelial disruption during PTCA is associated with an increase in circulating levels of endothelin, a potent endothelium-derived vasoconstrictor peptide. Circulating levels of endothelin and other potential vasoactive mediators such as atrial natriuretic factor, epinephrine and norepinephrine were measured immediately before and after PTCA in 23 patients with coronary artery disease. Although there was no change in the endothelin levels after angiography alone (43 +/- 5 vs 44 +/- 7 pg/ml, p = 0.5), there was a significant increase after PTCA (32 +/- 8 to 37 +/- 10 pg/ml, p < 0.005). The increase in endothelin was associated with a significant increase in atrial natriuretic factor (78 +/- 57 to 129 +/- 131 ng/ml, p = 0.01) and a decrease in epinephrine and norepinephrine levels (111 +/- 64 to 59 +/- 36 pg/ml, p = 0.005, and 1,131 +/- 500 to 811 +/- 311 pg/ml, p = 0.003, respectively). Circulating levels of endothelin did not correlate with the percent coronary stenosis before or after PTCA or the presence or absence of angiographically visible thrombus. These findings suggest that endothelial injury during PTCA may be associated with increased circulating levels of endothelin and its counter-regulatory hormone, atrial natriuretic factor, and also with a reciprocal decrease in epinephrine and norepinephrine levels. Thus, these humoral changes may modulate changes in coronary vascular tone after PTCA.

Utilization of a human intestinal epithelial cell culture system (Caco-2) for evaluating cytoprotective agents

Human intestinal epithelial cells (Caco-2) were cultured as confluent monolayers on polycarbonate membranes in Transwells for investigating their applicability in evaluating the cytoprotective activity of sucralfate. The control experiments established a reproducible chemical method (using 0.5 mM indomethacin in Hanks' balanced salt solution) for inducing damage to the Caco-2 cell monolayers. Damage was determined by measuring changes in transepithelial electrical resistance (TEER). Twenty-day-old Caco-2 cell monolayers were significantly and reproducibly damaged (compared to buffer alone) (P < 0.001) by application of 0.5 mM indomethacin to the apical side for 1 hr. While sucralfate, at a 0.5, 2, or 5 mg/mL concentration in the buffer, was shown not to reverse (treat) the damage caused by indomethacin in this cellular model, it was able to protect (prevent) the cells from indomethacin-induced damage (P < 0.001). We observed that indomethacin-induced damage to the Caco-2 cell monolayers greatly affected the paracellular pathway since the percentage transport of [3H]methoxyinulin was significantly elevated. In contrast, protection of the Caco-2 cells with 5 mg/mL sucralfate in the presence of the damaging agent resulted in transport of the paracellular marker similar to that in the control (HBSS-treated) cell monolayers. This direct cytoprotective effect was thus independent of vascular factors at neutral pH and was observed to be dose dependent (0.5 to 5 mg/mL) when sucralfate was applied to the cells in the presence of the damaging agent.(ABSTRACT TRUNCATED AT 250 WORDS)

Modification in sucrose tolerance test with acarbose, guargum and their combination in patients with non-insulin dependent diabetes

The study was undertaken to assess the efficacy guargum, Acarbose and their combination in modifying the sucrose absorption in patients of non Insulin dependent diabetes mellitus (NIDDM). Fifty patients of NIDDM were randomly distributed in three groups. Group A had 20 patients who received 20 grams of guargum, Group B had 10 patients who received 100 mg of Acrabose, Group C had 20 patients who received 10 grams of guargum and 50 grams of Acrabose. All the patients underwent 50 grams sucrose tolerance test with and without the trial drugs. Blood glucose levels were determined at 0, 30, 60, 90 and 120 minutes after sucrose loading. With the drugs, there was a significant decrease in the blood glucose levels at all time intervals (p < 001) in all the three groups. In all the three groups the blood glucose levels with the trial drugs was significantly lower (p < 001) than without the drug. It was seen that acarbose alone and guargum alone did not differ significantly in reducing the blood sugar level whereas combination of two produced significantly greater reduction in blood glucose levels than either of the drug used alone. Thus both guargum and acarbose are equally effective in modifying the absorption of sucrose. When combined in half the dosage they have synergistic effect and the reduction in blood glucose level is greater than either of the drug used alone.

The technique of inserting a Swan-Ganz catheter. Selecting the equipment; positioning the catheter properly

Before hemodynamic monitoring, carefully select and test the appropriate equipment and calibrate all monitors. To insert the catheter, use strict aseptic technique and, whenever possible, fluoroscopic guidance. The internal jugular vein is generally preferred for cannulation, but cutdown of an antecubital vein may be better for patients receiving anticoagulants or thrombolytics. The balloon remains deflated until the catheter tip is in the right atrium. Characteristic pressure wave forms signal the catheter's passage through each heart chamber. In most patients, advancement from the right atrium to wedge position is completed within 20 to 30 seconds.

Deciding when hemodynamic monitoring is appropriate. How will the data affect your diagnostic or therapeutic approach?

Hemodynamic data can be used to differentiate a variety of cardiopulmonary disorders, including right ventricular dysfunction, massive pulmonary embolism, and precapillary pulmonary hypertension. In patients with acute pulmonary edema, low-output states, or shock, hemodynamic measurements can help guide therapy; they also provide a precise estimate of a patient's response to vasoactive or inotropic drugs. Consider a flotation catheter for patients with complicated MIs, critically ill patients with multiorgan or major organ dysfunction, and high-risk cardiac patients undergoing surgery.

Effect of beta-blockers on ventilatory function in smokers and non smokers

Twenty healthy nonsmokers, 20 asymptomatic mild smokers and 20 asymptomatic moderate smokers were assessed for ventilatory functions, before and after equipotent dosages of atenolol, propranolol and oxprenolol in a single blind longitudinal study. The basal spirometric values were significantly lower in smokers than non smokers. After propranolol significant reduction was seen from basal values in FEV1, FEF 75%, MMFR, FEF 200-1200 in all the three groups. After oxprenolol significant difference was seen only with MMFR in the moderate smokers. With atenolol the variation was not significant in any group. Intercomparison of values after the drugs in each group was done. The values after propranolol was significantly lower than values after atenolol or oxprenolol for FEF 75%, MMFR and FEF 200-1200 in both the smoker groups whereas values after oxprenolol and Atenolol did not differ significantly from each other. Thus, in smokers atenolol offers a safe choice. If propranolol is to be used, the possibility of significant bronchospasm should be considered.

Angiographic validation of bedside markers of reperfusion

OBJECTIVES

We sought to validate with coronary angiography several primary and ancillary markers of reperfusion.

BACKGROUND

The availability of bedside markers of reperfusion is of major importance in the thrombolytic therapy of acute myocardial infarction. However, the reliability of current markers is still controversial.

METHODS

Changes in chest pain, ST segment elevation and heart rate and rhythm were assessed every 5 to 10 min for up to 3 h after initiation of recombinant tissue-type plasminogen activator therapy in 82 patients with acute myocardial infarction. Coronary angiography was performed within 24 h.

RESULTS

At angiography, 69 of the 82 patients had a patent infarct-related artery with Thrombolysis in Myocardial Infarction trial (TIMI) grade 3 flow and a rapid and progressive decrease in chest pain and ST elevation. The pain resolved in 24 +/- 23 min (range 3 to 50). The ST elevation decreased by > or = 50% within 16 +/- 14 min (range 5 to 41). Accelerated idioventricular rhythm developed in 49% of patients and sinus bradycardia in 23%; conduction abnormalities and atrial fibrillation resolved. All markers appeared in close temporal proximity to the onset of an abrupt increase in plasma creatine kinase (CK) and CK-MB isoenzyme activity, a previously validated marker of the time of reperfusion. Before its final resolution, ST elevation transiently decreased and increased in 58% of patients. Comparison of one pretreatment and one posttreatment electrocardiogram significantly reduced the reliability of ST segment change as a marker of reperfusion. In 13 of 82 patients, the infarct-related artery demonstrated TIMI grade < or = 2 flow; in 9, pain and ST elevation did not lessen and CK and CK-MB activity showed no abrupt increase. The remaining four patients initially demonstrated a decrease in pain and ST elevation; however, within 3 h and before angiography, the recurrence of pain and ST elevation suggested reocclusion.

CONCLUSIONS

A rapid and progressive decrease in pain and ST elevation is a reliable marker of reperfusion with TIMI grade 3 flow. Because ST elevation and pain often fluctuate before undergoing final resolution with reperfusion, frequent or continuous monitoring of ST elevation is essential for reliable recognition of the fact and time of reperfusion. Accelerated idioventricular rhythm and episodes of sudden sinus bradycardia, although specific to reperfusion, do not occur in all patients with reperfusion.

Effect of nasal continuous positive airway pressure on cardiac output and oxygen delivery in patients with congestive heart failure

We studied the acute hemodynamic effects of increasing nasal continuous positive airway pressure (CPAP) in 13 patients with acute decompensation of congestive heart failure. Heart rate, respiratory rate, pulmonary capillary wedge pressure, right atrial pressure, systemic blood pressure, and thermodilution cardiac outputs were measured at baseline, during, and after application of nasal CPAP at increasing pressures of 5, 10, and 15 cm H2O. Cardiac index, stroke volume, and oxygen delivery were calculated. Based on a significant change in cardiac output greater than or equal to 400 ml, seven patients were classified as responders, whereas six patients were considered to be nonresponders. In responders, significant increases were noted in cardiac index (2.5 +/- 0.7 to 2.9 +/- 0.9 L/min/m2), stroke volume (49 +/- 15 to 57 +/- 16 ml), and oxygen delivery (10.3 +/- 5.1 to 12.3 +/- 6.0 ml/min/kg) without a change in pulmonary capillary wedge pressure. In contrast, the nonresponders showed no significant change in any of the hemodynamic parameters. Improvement in cardiac output could not be predicted by any of the baseline hemodynamic or clinical variables, nor was it related to random variations since all variables returned to baseline after cessation of CPAP. Increase in stroke volume without a change in pulmonary capillary wedge pressure (preload) suggests either improved inotropic function of the left ventricle or reduced left ventricular afterload with CPAP. Thus, CPAP may offer a new noninvasive adjunct to improving left ventricular function and augmenting cardiac performance in a subset of patients with congestive heart failure.

Anistreplase versus alteplase in acute myocardial infarction: comparative effects on left ventricular function, morbidity and 1-day coronary artery patency. The TEAM-3 Investigators

OBJECTIVES

This double-blind, randomized, multicenter trial was designed to compare the effects of treatment with anistreplase (APSAC) and alteplase (rt-PA) on convalescent left ventricular function, morbidity and coronary artery patency at 1 day in patients with acute myocardial infarction.

BACKGROUND

Anistreplase (APSAC) is a new, easily administered thrombolytic agent recently approved for treatment of acute myocardial infarction. Alteplase (rt-PA) is a rapidly acting, relatively fibrin-specific thrombolytic agent that is currently the most widely used agent in the United States.

METHODS

Study entry requirements were age less than or equal to 75 years, symptom duration less than or equal to 4 h, ST segment elevation and no contraindications. The two study drugs, APSAC, 30 U/2 to 5 min, and rt-PA, 100 mg/3 h, were each given with aspirin (160 mg/day) and intravenous heparin. Prespecified end points were convalescent left ventricular function (rest/exercise), clinical morbidity and coronary artery patency at 1 day. A total of 325 patients were entered, stratified into groups with anterior (37%) or inferior or other (63%) acute myocardial infarction, randomized to receive APSAC or rt-PA and followed up for 1 month.

RESULTS

At entry, patient characteristics in the two groups were balanced. Convalescent ejection fraction at the predischarge study averaged 51.3% in the APSAC group and 54.2% in the rt-PA group (p less than 0.05); at 1 month, ejection fraction averaged 50.2% versus 54.8%, respectively (p less than 0.01). In contrast, ejection fraction showed similar augmentation with exercise at 1 month after APSAC (+4.3% points) and rt-PA (+4.6% points), and exercise times were comparable. Coronary artery patency at 1 day was high and similar in both groups (APSAC 89%, rt-PA 86%). Mortality (APSAC 6.2%, rt-PA 7.9%) and the incidence of other serious clinical events, including stroke, ventricular tachycardia, ventricular fibrillation, heart failure within 1 month, recurrent ischemia and reinfarction were comparable in the two groups; and mechanical interventions were applied with equal frequency. A combined clinical morbidity index was determined and showed a comparable overall outcome for the two treatments.

CONCLUSIONS

Convalescent rest ejection fraction was high after both therapies but higher after rt-PA; other clinical outcomes, including exercise function, morbidity index, and 1-day coronary artery patency, were favorable and comparable after APSAC and rt-PA.

Functional hypothalamic amenorrhoea-isolated gonadotropin deficiency

A 21 year old female patient with primary amenorrhoea was diagnosed to have isolated gonadotropin deficiency with probable functional hypothalamic amenorrhoea. The evaluation included buccal smear for sex chromatin, trial of medroxy-progesterone acetate, trial of oestrogen-progesterone preparation and estimation of serum prolactin, gonadotrophin and oestrogen levels. When diagnosed as isolated gonadotropin deficiency, treatment with gonadotropin is rewarding.

Low high density lipoprotein level is associated with increased restenosis rate after coronary angioplasty

BACKGROUND

To determine the relation of post-percutaneous transluminal coronary angioplasty (PTCA) restenosis to serum lipid fractions and to circulating levels of endogenous tissue plasminogen activator (t-PA) and its rapid inhibitor (PAI-1), 68 patients with coronary artery disease who underwent a successful PTCA were studied.

METHODS AND RESULTS

During a mean follow-up of 9 months (range, 7-11 months), 28 (41%) patients developed restenosis. A low high density lipoprotein (HDL) cholesterol level was independently and strongly related to both the risk of restenosis (p less than 0.001) and to the time of restenosis (p = 0.03). The mean HDL cholesterol level was 33 +/- 12 mg% in the restenosis group compared with 45 +/- 12 mg% in the nonrestenosis group (p less than 0.001). Restenosis developed in 22 of 34 (64%) patients with an HDL cholesterol less than or equal to 40 mg% compared with six of 34 (17%) patients with an HDL cholesterol greater than 40 mg% (p less than 0.002). The only other variable that was significantly related to restenosis was a low PAI-1 level (p = 0.04).

CONCLUSIONS

The strong relation between a low HDL cholesterol level and the risk of restenosis suggests that lipid fractions could be important in the pathogenesis and prevention of restenosis.

The Sion test

Endosonography as a tool for checking the patency of Fallopian tubes was an expected development in the progress the field of gynaecology was taking. We at Sion Hospital have used transvaginal sonography in evaluating the patency of Fallopian tubes with a technique which encompasses a thorough pelvic scan as well. We offer The Sion Test not as a substitute for hysterosalpingography, laparoscopy or hysteroscopy but as a screening technique in infertility investigation. The Sion Test can be performed in the gynaecologists' office at the same time as the pelvic examination. A series of 50 infertile patients had a diagnostic laparoscopy and hysterosalpingography after our test was done. We have compared the accuracy of the 3 methods of evaluating tubal patency and have found our test an excellent screening technique for investigations in infertility.

A human immunodeficiency virus-resistant airway for cardiopulmonary resuscitation

Due to fear of transmitted disease, mouth-to-mouth cardiopulmonary resuscitation (CPR) is now rare, even though early CPR is associated with a fivefold to 30-fold increase in survival. The authors have devised a one-piece silicone mask (Kiss of Life [KOL], Brunswick Biomedical Technologies, Inc, Warehom, MA) with a one-way valve and circular recess to form a no-contact lip seal, enabling mouth-to-mouth CPR to be given. The ventilatory volume during mannequin CPR using the KOL mask was 0.75 +/- 0.235 L. This volume was significantly (P less than .05) greater than that generated by alternate widely used airways (range, 0.195 +/- 0.147 to 0.617 +/- 0.208 L). To assess mask performance in vivo, the authors measured exhaled volumes in 10 apneic anesthetized patients under three conditions: with the KOL mask, a standard anesthetic mask and bag, and an anesthetic mask with an endotracheal tube. The results were: anesthetic mask and tube, 1.5 L (range, 1.2 to 1.7 L); KOL mask, 1.1 L (range, 1.0 to 1.3 L); anesthetic mask alone, 0.7 L (range, 0.5 to 0.8 L). To test permeability, we exposed two KOL masks to a high titer of human immunodeficiency virus (HIV)-1 soup (10(6) culture infection doses/mL) for 10 and eight masks for 60 minutes, respectively, and cultured swabs of the interior of the valve for 1 month. There was no growth in any culture. These data suggest that the KOL mask has excellent ventilating characteristics, is practical (pocket-portable, disposable), experimentally impermeable to HIV-1, and inexpensive.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiology of acute coronary syndromes

The natural history of coronary artery disease is punctuated by clinical manifestations of unstable angina, acute myocardial infarction, and ischemic sudden death. These acute coronary syndromes share common pathophysiologic mechanisms that include fissuring of a plaque followed by varying degrees of dynamic coronary obstruction, which is due to vasoconstriction and coronary thrombosis. The response to plaque fissure is likely to be modulated by local and/or systemic procoagulant and anticoagulant-fibrinolytic activities. The key role of coronary thrombosis in acute coronary syndromes has substantial implications for prevention and treatment of complications of coronary atherosclerosis.

The role of thrombolytic therapy in patients with acute myocardial infarction presenting later than six hours after the onset of symptoms

Thrombolytic therapy clearly reduces mortality in patients with acute myocardial infarction, especially when initiated within 6 hours of onset of symptoms. Some studies have also suggested that thrombolytic therapy may improve survival even when initiated 6-24 hours after the onset of symptoms by mechanisms other than infarct size limitation, such as reduced expansion, reduced electrical instability, and improved healing of the infarct. However, in view of the possibility that late thrombolytic therapy may also be associated with an increased risk of cardiac rupture, the risk-benefit ratio needs to be more clearly defined. Ongoing randomized trials are expected to clarify the situation in the near future. In the meantime, efforts to initiate reperfusion as soon after the onset of myocardial infarction as possible should continue, since early treatment is still the best treatment.

Cardiac tamponade. Pathophysiology, diagnosis, and management

Cardiac tamponade is a clinical syndrome that results from an increased intrapericardial pressure and leads to impaired cardiocirculatory function. The spectrum of cardiac tamponade is relatively wide, ranging from an asymptomatic elevation of intrapericardial pressure recognized during objective evaluation, to extreme hemodynamic compromise in the form of severe hypotension or electromechanical dissociation, and many variations between these extremes. This article discusses the causes, pathophysiology, clinical manifestations, diagnosis, and management of cardiac tamponade.

Nuclear imaging in acute cardiac care

Various noninvasive nuclear imaging techniques provide powerful information regarding infarct site and size, regional and global ventricular function, myocardial perfusion, metabolic function and viability, as well as myocardial salvage after reperfusion in patients with acute coronary syndromes. This information is valuable to clinicians in streamlining diagnostic and therapeutic decision-making for critically ill cardiac patients.

Complicated acute myocardial infarction. Heart failure, shock, mechanical complications

In-hospital mortality in patients with acute myocardial infarction is predominantly related to heart failure or shock and mechanical complications (acute mitral regurgitation, ventricular septal rupture, and free wall rupture). Heart failure and shock are primarily the consequences of contractile dysfunction of the left ventricle. Use of inotropic agents and assist devices are temporizing measures; early reperfusion with salvage of ischemic interventricular septum or free wall, resulting in severe mitral insufficiency, left to right shunt, and acute tamponade, respectively, necessitates immediate diagnosis and surgical intervention.

Incremental prognostic accuracy of clinical, radionuclide and hemodynamic data in acute myocardial infarction

A logical sequence of testing in evaluating prognosis early in acute myocardial infarction (AMI) would be to use clinical data first, then add noninvasive data and finally add invasive data. The incremental prognostic information concerning 1-year survival obtained from such a sequence in 107 patients with AMI was studied using logistic regression and receiver-operating characteristic curves. Cardiac mortality was 24% at 1 year. Clinical data obtained soon after admission (prior myocardial infarction, heart rate, blood pressure, age) were 78 +/- 5% accurate in the prediction of 1-year survival. The addition of radionuclide-estimated left ventricular ejection fraction or invasive hemodynamic data to the clinical model at this time improved prognostic accuracy to 84 +/- 5% (p = 0.05) and 87 +/- 4% (p = 0.007), respectively. The further addition of invasive data to the model containing clinical and left ventricular ejection fraction data provided a further increment in prognostic accuracy to 89 +/- 4%, whereas no significant increase in accuracy was seen on addition of left ventricular ejection fraction to the model containing clinical and invasive data. It is concluded that clinical data provide important prognostic information concerning late survival early in the course of AMI. This may be improved by the logical application of noninvasive and invasive studies at this time.

Incremental prognostic value of exercise hemodynamic variables in chronic congestive heart failure secondary to coronary artery disease or to dilated cardiomyopathy

To determine the prognostic value of hemodynamic variables at rest and during exercise, 49 patients with chronic congestive heart failure undergoing hemodynamic evaluation at rest and during symptom-limited exercise were followed for 1 year. One-year mortality rate was 33%. On univariate analysis, nonsurvivors differed significantly from survivors in pulmonary arterial wedge pressure at rest (22 +/- 10 vs 15 +/- 10 mm Hg; p = 0.01) and during exercise (32 +/- 9 vs 24 +/- 9 mm Hg; p = 0.003), stroke work index at rest (19 +/- 6 vs 25 +/- 9 g-m/m2; p = 0.03) and during exercise (20 +/- 7 vs 32 +/- 14 g-m/m2; p = 0.001) and exercise-induced increment in stroke work index (0.5 +/- 0.4 vs 7 +/- 8 g-m/m2; p = 0.004), but not with respect to left ventricular ejection fraction, exercise duration, peak oxygen consumption or peak left ventricular hydraulic power. Patients with a peak exercise stroke work index less than 20 g-m/m2 had a 66% mortality rate compared with a mortality rate of 13% in patients with a peak exercise stroke work index greater than 20 g-m/m2 (p = 0.0001). Multiple logistic regression analysis identified pulmonary arterial wedge pressure at rest and peak exercise stroke work index as the only independent predictors of mortality. A receiver-operating characteristic curve analysis revealed that peak exercise stroke work index provided significant incremental prognostic information over the resting hemodynamic variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiology of unstable angina

This article discusses the heterogeneous clinical spectrum of atherosclerotic coronary artery disease. The clinical manifestations and pathophysiology of unstable angina as well as atherosclerotic coronary stenosis, mechanisms of plaque fissure, factors that contribute to coronary artery obstruction, and mechanisms of platelet aggregation and thrombosis are discussed.

Prevalence of unsuspected mitral regurgitation and left ventricular diastolic dysfunction in patients with coronary artery disease and acute pulmonary edema associated with normal or depressed left ventricular systolic function

To define the prevalence and role of left ventricular (LV) systolic dysfunction, LV diastolic dysfunction and mitral regurgitation (MR) in patients with acute pulmonary edema, 40 patients with coronary artery disease and acute pulmonary edema were prospectively evaluated within 36 hours of presentation. LV ejection fraction and 3 parameters of LV diastolic function were measured with radionuclide ventriculography, whereas MR was assessed with Doppler echocardiography. LV ejection fraction was normal in 11 (27%) and depressed in 29 (73%) patients. Moderate or severe MR without LV diastolic dysfunction was common and equally prevalent in patients with and without LV systolic dysfunction (33 vs 38%; difference not significant). Diastolic dysfunction without MR was less frequent but equally prevalent in patients with and without systolic dysfunction (17 vs 27%; difference not significant). Two (18%) of 11 patients without and 12 (33%) of 36 patients with LV systolic dysfunction had both MR and LV diastolic dysfunction. Furthermore, MR was clinically silent and unsuspected in two-thirds of all patients with MR, regardless of a normal or depressed systolic function. These data show that there is a high prevalence of unrecognized moderate to severe MR in patients with acute pulmonary edema, regardless of the presence or absence of LV systolic dysfunction. Furthermore, the prevalence of LV diastolic dysfunction without MR is relatively low even in patients with normal LV systolic function and pulmonary edema. Thus, unrecognized MR may be an important contributor to the syndrome of acute pulmonary edema in patients with normal or depressed LV systolic function.