Haemostatic variables in patients with unstable angina

To assess the contribution of thrombus formation in the pathogenesis of unstable angina, we employed the recently developed assays of small fragments which reflect the degree of activation of various components of the haemostatic system. Such haemostatic measurements were undertaken in patients with unstable angina (n = 47) from the time of their admission to the coronary care unit (CCU) at 8-h intervals in the first 24 h and then daily for a total of 5 days. The results obtained were compared with healthy control values. Patients exhibited lower ATIII, prolongation of the APTT and TT, but not PT or the reptilase time, which is a consequence of heparinization. There was significant elevation of fibrinogen, factor VIII:C, von Willebrand factor:antigen and von Willebrand factor:ristocetin cofactor throughout the study period. There was also evidence of thrombin generation as indicated by the elevated levels of fibrinopeptide A (FPA) and thrombin-antithrombin complexes. The platelet release proteins, beta-thromboglobulin (BTG) and platelet factor 4 (PF4), were markedly elevated in the first 2 days and dropped gradually thereafter. The fibrinolytic inhibitor, plasminogen activator inhibitor (PAI), levels were elevated throughout. Proteins C and S, plasminogen and alpha 2-antiplasmin remained unchanged. It was concluded that in patients with unstable angina, there is significant activation of the clotting system and inhibition of fibrinolysis which confirms the existence of a tendency towards thrombus formation in patients with unstable angina.

Residency training in graduate medical education (nine-year view)

Assessment of the progress of residency training in graduate education after 9 years shows that the original goals established for various specialties are being effectively met. There are now 7 approved residency programmes for diplomas and 10 approved residency programmes for fellowships with 324 residents trained and in training, out of whom (32%) were females, and 222 (68%) were male residents. Student interest in these programmes has remained at a high level. Only 15 candidates (4.64%) had withdrawn from the residency training programmes. Heavy emphasis has been placed upon curriculum design, selection criteria of students and quality control mechanisms through residency committees in specialty departments and the residency board embracing residency coordinators. This paper outlines some concerns regarding the present status of various residencies and suggests some recommendations for future development of these programmes.

Electrocardiographic abnormalities in patients with heat stroke

Serial electrocardiograms were taken in 46 Hajj Pilgrims suffering from heat stroke immediately after cooling 12 and 24 h later. The collected data were analyzed and revealed that a statistically significant number of patients with heat stroke had sinus tachycardia (43 percent, p < 0.05), conduction defect (22 percent, p < 0.046), prolonged Q-T interval (61 percent, p < 0.007), diffuse nonspecific ST-T changes (26 percent, p < 0.036), and ST-T changes (localized to the ECG leads confirming to a territory of coronary artery) consistent with myocardial ischemia (21 percent, p < 0.02). Although adverse effects of heat stroke on the heart are multifactorial, the above data indicate that heat stroke predisposes to certain risk of myocardial ischemia and conduction disturbances. This may reflect the true cardiovascular status of these heat stroke victims.

Relationship of atrial fibrillation to significant pericardial effusion in valve-replacement patients

Rhythm change was observed in 21 of 242 (8.7%) patients during the first four weeks of open heart surgery (OHS). In the valve-replacement group of 148 patients the rhythm change was found to be associated with significant pericardial effusion (PE). Seven patients had rhythm changes during the first three days of OHS unrelated to PE. Two patients who were in atrial fibrillation (AF) developed fast ventricular rate and twelve patients showed rhythm change from sinus to supraventricular tachyarrhythmia (AF in ten and supraventricular tachycardia in two) and all these fourteen patients had significant PE. With pericardiocentesis or open drainage or withdrawal of anticoagulation, AF reverted to sinus rhythm in nine patients and five patients remained in AF but with a slow ventricular rate. Significant PE was related to a high anticoagulation ratio. We conclude from this study that within the first four weeks of OHS, high anticoagulation ratio contributes to the development of significant PE, and tachyarrhythmia (particularly AF) is a forerunner of significant PE or cardiac tamponade: the aim of management should be to rule out or show evidence of significant PE once tachyarrhythmia develops, and if significant PE is present then the pressure in the pericardial cavity should be reduced.

Aneurysmal dilatation of the coronary arteries: diagnostic patterns and clinical significance

In order to define the clinical features, clinical patterns and significance of aneurysmal dilatation of the coronary arteries, five cases are presented which were diagnosed by coronary angiography. Three cases presented with left ventricular dysfunction secondary to coronary arterial occlusive disease and the fourth patient presented with thromboembolic cerebrovascular disease. The fifth case presented with manifestations of acute myocardial infarction.

Cerebral infarction and left ventricular mass: a clinical and echocardiographic study

One hundred and two stroke patients were studied. Thirty-three (32 per cent) were hypertensive by the WHO criteria. Eighty-three (83 per cent) had cerebral infarction and three patients suffered from spontaneous intracerebral haemorrhage. The mean left ventricular mass was calculated from echocardiographic measurements and compared with that of controls. Neither cases nor controls had valvular or congenital heart disease, or disease processes that may be associated with myocardial infiltration. Mean left ventricular mass of all cases was significantly greater than that of controls (p less than 0.025) and that of the cases over the age of 50 years was also significantly greater than that of controls of the same age (p less than 0.02). The clinically normotensive cases had greater left ventricular mass than the normotensive controls (p less than 0.02). Meanwhile left ventricular mass in patients aged 50 and under was not significantly different from the appropriate control group (p greater than 0.2). These data indicate that the frequency of arterial hypertension among victims of cerebral infarction is greater than may be ascertained clinically particularly in those over 50.

Serum IgE levels in adults with asthma

Serum total immunoglobulin E (IgE) was measured in 88 normal adults and 100 adults with asthma using Phadebas IgE PRIST kits. The geometric mean IgE in our normal subjects was found to be higher than that reported by some investigators but was similar to or lower than that reported by others without showing any geographic pattern. It increased progressively from 92 kU/L in normal controls through 205 kU/L in cases of asthma with low atopic scores to 464 kU/L in asthma cases with high atopic scores. There was wide variation in IgE levels among individuals, making it difficult to use it to classify any subject into one of these groups. However, as a group, female asthmatics had lower mean IgE levels (182 kU/L) than did men (577 kU/L), and a higher proportion of them had low atopic scores (60% of the women versus 47% of the men). This suggests that probably more women had intrinsic asthma, while extrinsic asthma was more common among men in the population studied.