Autoantibodies in untreated and treated essential hypertension. I

Using the indirect immunofluorescence method, autoantibodies (AB) of IgG and IgM classes were investigated in sera from 161 consecutive patients with essential hypertension and compared with those from 78 healthy normotensive subjects of the same composition by age and sex, and without any family history of hypertension. The frequency of one or more AB was as high in 78 untreated (15.3%) as in 83 treated patients (13.0%) and was in the controls 9.0% (n.s.). In the treated patients, the AB were associated with heart involvement (p less than 0.02). In the untreated patients, antinuclear antibodies of IgG class were associated with BP (p less than 0.01) and fundus grading (p less than 0.005). A family history of hypertension was found in 23.5% of the hypertensive males with AB and in 9.0% of the normotensive males (p less than 0.10). These results are discussed in relation to reports of an association of AB with cardiovascular diseases. It is concluded that the presence of AB in essential hypertension is not necessarily due to drug induction.

Herpesvirus antibodies and vascular complications in essential hypertension

Antibodies against herpes simplex virus (HSV) and cytomegalovirus (CMV) were examined in sera from 132 patients with essential hypertension and 54 normotensive healthy subjects of the same age and sex. Prevalences of HSV and CMV antibodies (titre greater than or equal to 4) were equal in patients and controls. A HSV antibody tire greater than or equal to 64 was found in 39.5% (17/53) of patients with WHO stage III hypertension, in 26.2% (22/85) of patients with stage I-II hypertension, and in only 9.4% (5/54) of normotensive subjects (p less than 0.0005). The HSV antibodies were mainly of type 1. No association between CMV antibodies and vascular complications could be demonstrated.

Serum concentrations of immunoglobulins and free light chains before and after vascular events in essential hypertension

Serum concentrations of immunoglobulins (Ig) and free light chains (LC) of Ig have been determined at regular intervals during five years in patients with essential hypertension and correlated to development of vascular complications. In 6 cardiac event patients serum IgG increased by 11.9% (p less than 0.05) and LC by 19.8% (p less than 0.05). IgG levels correlated positively with LC levels (r = 0.59, p less than 0.001) and changes in IgG correlated positively with changes in LC (r = 0.46, p less than 0.01). The post-event increments in IgG persisted up to 21 months. No significant changes in serum concentrations of IgA, IgM, albumin and creatinine were found. In 10 cerebral event patients and in matched groups of 15 uncomplicated hypertensive patients, no significant changes in the above parameters could be demonstrated. It is concluded that heart tissue damage in essential hypertension induces a long-lasting stimulation of B-lymphocytes, and it is suggested that the high Ig levels found in as yet uncomplicated hypertensive patients may reflect an ongoing damage of the vascular bed.

Antihypertensive effect of atenolol (100 mg once a day) and methyldopa (250 mg thrice a day). A double-blind cross-over multicentre study

In a double-blind cross-over multicentre study lasting for 16 weeks, the antihypertensive effect of atenolol (100 mg once a day) was compared with that of methyldopa (250 mg thrice a day) in 48 patients with mild to moderately severe hypertension. At the end of the trial, atenolol was superior to methyldopa in achieving clinically relevant BP levels, less than 150/95 mmHg (p less than 0.001), and in respect to patients' drug preference (p less than 0.04). The BP levels after the first 2 weeks of treatment with either drug were identical but, in contrast to methyldopa, atenolol caused further significant reduction in BP during the following 4 weeks. This finding implies that one should hesitate to start additional therapy until after at least six weeks of atenolol treatment, whereas no further reduction in BP can be expected after the first 2 weeks of treatment with methyldopa. Two patients had to be withdrawn from the study during treatment with atenolol, as they developed severe bradycardia and dyspnoea, respectively. Other side-effects were few and of minor clinical importance.

Labetalol-induced Peyronie's disease? A case report

Peyronie's disease (induratio penis plastica) has been observed in a 58-year-old man 8 months after initiation of treatment with the new combined alpha- and beta-blocking agent, labetalol. During the last 2 months before onset of symptoms he had received 2400 mg labetalol daily. He showed no other signs of abnormal fibrous tissue production and the ANF test was negative. Cessation of the drug revealed no improvement. Peyronie's disease has also been observed in relation to treatment with propranolol, practolol and metoprolol and might be due to an impaired balance between alpha- and beta-receptors in connective tissue, but there may also be an immunological basis for the fibrosis. A possible coincidence is stressed, as the ages of the reported cases are within the range where this disease most often develops.

Increased serum levels of immunoglobulins in untreated and treated essential hypertension. I. Relation to blood pressure

In 164 consecutive patients with essential hypertension, serum immunoglobulin (Ig) levels of IgA, IgG, and IgM classes were determined, using single radial diffusion techniques, and compared with 80 healthy normotensive subjects without any family history of hypertension. Of 80 untreated and 84 treated patients, IgA and/or IgG were significantly increased in 40% and 37%, respectively. IgG correlated positively to BP in untreated patients (p less than 0.0008), as well as in insufficienctly treated males (p less than 0.004). No correlations were found between Ig and duration of hypertension. The increase in Ig was not associated with any particular drugs. A family history of hypertension was found in 19.6% of the patients with elevated Ig and in 9.7% of those with normal Ig (p less than 0.10). The study provides further evidence for involvement of immune mechanisms in essential hypertension, and suggests a possible genetic predisposition.

Time course of vascular remodeling, formation of neointima and formation of neoadventitia after angioplasty in a porcine model

BACKGROUND

Vascular remodeling is the major cause of restenosis after coronary balloon angioplasty but the pathophysiology of this process is not known.

OBJECTIVE

To examine the time courses of vascular remodeling, formation of neointima and adventitial changes after coronary angioplasty.

DESIGN

An experimental study on pigs using coronary angiography, intravascular ultrasound (IVUS), and histology.

METHODS

Deep vessel-wall injury was induced by conventional balloon angioplasty in the circumflex and right coronary arteries, and by retraction of a chain-encircled balloon in the left anterior descending artery. Angiography in all three arteries and IVUS measurements in circumflex and left anterior descending arteries were performed before and after angioplasty, and at follow-up on days 0, 1, 4, 7, 14, 28, and 56 (n = 5 in each group). Serial IVUS measurements were used to determine vascular remodeling. Formation of neointima and neoadventitia was measured by histomorphometry.

RESULTS

Angiographically evident loss of lumen and ultrasonographically detectable constrictive remodeling occurred between day 7 and day 28. IVUS measurements showed that late loss of lumen (days 28 and 56) was correlated to vascular remodeling but not to the increase in wall area (neointima plus media). Histomorphometry revealed that neointima was present from day 7 and that amount of neointima increased up to day 28. Area of adventitia increased during the first 4 days and remained unchanged thereafter. Adventitial neovascularization by vasa vasorum was observed from day 4 onward.

CONCLUSIONS

Formation of neoadventitia precedes late loss of lumen, constrictive remodeling, and formation of neointima. The time course of vascular remodeling coincides with growth of neointima rather than with changes in the adventitia.

Measurement of left ventricular volumes by 3-dimensional echocardiography with tissue harmonic imaging: a comparison with magnetic resonance imaging

We hypothesized that tissue harmonic imaging (THI) in comparison with fundamental imaging (FI) would improve endocardial border detection, and therefore in combination with 3-dimensional echocardiography (3D echo), it would be a precise method for left ventricular (LV) volume measurement. Ten healthy subjects and 18 consecutive patients with dilated hearts underwent estimation of LV volumes by magnetic resonance imaging (MRI) and transthoracic 3D echo with THI and FI. In patients, the agreement between MRI and 3D echo was closer with THI in comparison with FI for assessment of LV volumes. Thus the mean +/- 2 SD of differences between MRI and 3D echo with THI versus FI, respectively, was -6.4 +/- 40.0 mL versus -17.4 +/- 57.6 mL (P <.01) for the end-diastolic volume (EDV), and 0.0 +/- 26.6 mL versus -8.1 +/- 35.6 mL (P <.01) for the end-systolic volume (ESV). In patients, THI in comparison with FI approximately halved observer variation on EDV and ESV. In healthy subjects, only ESV showed significantly reduced observer variation by THI. In conclusion, because THI demonstrated a clinically relevant reduction in observer variation and a closer agreement to the MRI technique in patients with dilated hearts, it should replace FI in LV volume measurements.

Elevated endothelin concentrations are associated with reduced coronary vasomotor responses in patients with chest pain and normal coronary arteriograms

OBJECTIVES

The purpose of this study was to investigate the relationship between arterial and coronary sinus endothelin (ET) concentrations and coronary vasomotor responses during rapid atrial pacing in patients with chest pain and normal coronary arteriograms (CPNA).

BACKGROUND

Plasma ET concentrations are significantly higher in CPNA patients than in healthy control subjects.

METHODS

We investigated 19 carefully characterized CPNA patients (14 women; mean age 53 +/- 9 years) of whom 10 had positive electrocardiographic responses to exercise. The percentage fall in coronary vascular resistance (%d.CVR) after 10 min of rapid atrial pacing was determined using a thermodilution pacing catheter. Plasma ET concentrations were measured by radioimmunoassay on simultaneously drawn arterial and coronary sinus samples.

RESULTS

No significant differences in ET concentrations were observed between men and women, but a strong statistical trend suggested that %d.CVR was lower in women than men (27[23 to 31]% vs. 34[29 to 45]%--median[interquartile range]; p = 0.07). Simple regression analysis including only the women (n = 14) suggested a significant relationship between baseline arterial ET concentrations and %d.CVR (R2 = 0.34; p = 0.06). Furthermore, stepwise multivariate regression analysis of the group as a whole indicated that both gender (p = 0.03) and baseline arterial ET concentration (p = 0.02) were independently predictive of %d.CVR (R2 = 0.44; overall p = 0.02); this relationship predicts that women with high ET levels would have the lowest %d.CVR during pacing.

CONCLUSIONS

These data support the hypothesis that elevated ET activity may be associated with reduced coronary flow responses during rapid atrial pacing in CPNA patients.

Thrombus organization plays no major role in late neointimal formation after angioplasty in porcine coronary arteries

Thrombus organization has been suggested to play a major role in late neointimal formation after coronary angioplasty. We sought to describe the time sequence of lesion formation after angioplasty in porcine coronary arteries and to quantify the relation between early thrombosis and late neointimal formation. Deep vessel wall injury was induced by conventional balloon angioplasty in the circumflex (CX) and right coronary (RCA) arteries and by retraction of a chain-encircled balloon in the left anterior descendent artery (LAD). Lesions were assessed by histomorphometry at days 0, 1, 4, 7, 14, 28, and 56 after angioplasty. A response-to-injury index (lesion area/injury length) was determined for each artery. Angioplasty led to rupture/removal of media. Thrombus was present at the exposed adventitia at days 0, 1, and 4. From day 7, neointima was observed on the luminal side of the arterial wall. All thrombus had disappeared at day 28, at which only neointima was observed. Histomorphometry revealed that lesion formation after angioplasty was a gradually increasing process from day 0 to day 28 with no further growth from day 28 to day 56. Maximal thrombus size (day 4, RCA: 0.07+/-0.04 mm, CX: 0.23+/-0.16 mm, LAD: 0.15+/-0.11 mm) was significantly smaller than late neointimal formation (day 28, RCA: 0.68+/-0.18 mm, CX: 0.63+/-0.23 mm, LAD: 0.71+/-0.18 mm) in all three arteries (p < .03). Lesion formation after angioplasty is a gradually increasing process for 4 weeks. Maximal thrombus size is about four times smaller than late neointimal formation. Thus, thrombus organization plays no major role in late neointimal formation.

Echocardiographic mitral valve prolapse in cavalier King Charles spaniels: epidemiology and prognostic significance for regurgitation

This study investigated the epidemiology and prognostic significance of mitral valve prolapse, detected by ultrasonography, in 153 cavalier King Charles spaniels which were screened consecutively during a period of one year. Seventy-five of the dogs, which had either no murmur or a grade I murmur on screening, were reexamined three years later. The screening revealed that 82 per cent of the dogs aged one to three years and 97 per cent of the dogs over three years had various degrees of mitral valve prolapse. The presence and severity of the condition were independent of gender but correlated positively with age and negatively with bodyweight. The degree of mitral valve prolapse at screening correlated with the regurgitation status (murmur intensity and size of the regurgitant jets) at re-examination and with the percentage increase in the left ventricular end diastolic diameter over the three-year period. The presence of a grade I murmur was not a useful prognostic indicator.

[Hemicraniectomy in malignant mid-cerebral infarction. Further trials needed before its acceptance in clinical practice]

In cases of completed middle cerebral artery territory stroke, prognosis is very poor and the clinical course is characterised by a rapid decline in consciousness and signs of herniation 2-4 days after the onset of symptoms due to a space-occupying mass. Failure of conservative therapy is the rule, and herniation is the usual cause of death, occurring in almost 80 per cent of cases. Recently published results have suggested that hemicraniectomy may improve survival in patients with massive hemisphericstroke, decreasing mortality to less than 35 per cent. The article presents what is probably the first case to be reported in Sweden, where hemicraniectomy was performed on a 45-year-old woman with right hemispheric completed middle cerebral artery infarction.

[Chronic thromboembolic pulmonary hypertension]

Acute pulmonary hypertension has a high mortality at the onset. Patients surviving the first phase will usually recanalize the pulmonary arteries through intrinsic thrombolytic mechanisms and medical treatment. However, in some cases there is insufficient resolution of the emboli with subsequent thrombotic and fibrotic reorganization, leading to a worsening of the pulmonary obstruction. In the open pulmonary arteries the disease may lead to hypertrophy of the media and intimal proliferation, thus leading to a further increase in the pulmonary vascular resistance. This again leads to hypertrophy of the right ventricle and ultimately to right-sided heart failure. Untreated, chronic thromboembolic pulmonary hypertension has a five-year mortality approaching 100%, but extensive pulmonary thrombendarterectomy using extracorporeal circulation and deep hypothermia has been shown to lower the pulmonary vascular resistance and thereby improve the prognosis significantly. Operative treatment can now be offered in Denmark, and the purpose of this review is to draw attention to the disease, its symptoms, diagnosis and the surgical treatment.

[Thromboendarterectomy of chronic thromboembolic pulmonary hypertension]

Chronic thromboembolic pulmonary hypertension has a five year survival rate of less than 10% in patients with a systolic pulmonary artery pressure of 50 mmHg with no convincing effect of medical treatment. The operative mortality from pulmonary thrombendarterectomy in specialised centres has been reduced to 9%, suggesting this treatment as being an option. The results from thrombendarterectomy of two Danish patients are reported. The first patient, a 34 year-old woman was operated at the centre in San Diego with the assistance of a Danish thoracic surgeon. The second, a 60 year-old man was operated at our institution by this surgeon. Following removal of sufficient amount of embolic masses and intimal tissue, the patients were discharged from hospital with a substantial improvement in their clinical status and near normalisation of pulmonary artery pressure, which remained at the latest follow-up (3 to 22 months).

Heart function in patients with chronic glomerulonephritis and mildly to moderately impaired renal function. An echocardiographic study

Left ventricular hypertrophy and diastolic heart dysfunction have been reported in essential hypertension and in patients with chronic renal failure, treated with haemodialysis, but a close association with blood pressure (BP) level has not been uniformly documented. Thus, other factors could be involved in the pathogenesis of cardiac dysfunction. The aims of the present echocardiographic study were to investigate cardiac morphology and function in patients with chronic glomerulonephritis with mildly to moderately impaired renal function, and to study the relation between echocardiographic findings and glomerular filtration rate (GFR), BP and age. Twenty patients with chronic glomerulonephritis and 14 healthy controls, of the same age- and sex-distribution, were examined by 2D-, M-mode and pulsed-wave Doppler echocardiography. In patients, GFR was determined as plasma clearance of Cr-EDTA. The patients had significantly thicker left ventricular (LV) posterior walls in end diastole (8.7 vs 8.1 mm, p < 0.05), and a higher LV mass index (106.5 vs 93.8 g/m2, p < 0.05). Systolic functional indices, i.e. LV fractional shortening and LV ejection fraction, were statistically significantly lower in patients than in controls (p < 0.05). LV diastolic function in patients was characterized by a statistically significantly lower early peak flow velocity (E-Vmax) (0.66 compared with 0.8 m/s) and early to late peak flow velocity ratio (E/A ratio) (1.07 vs 1.41), as well as E/A ratio of time velocity indices (VTI-E/A) (1.45 vs 1.99) (p < 0.05). The right ventricular filling indices showed a tendency towards a lower E-Vmax in patients (0.55 compared with 0.62 m/s, p = 0.1). In patients, statistically significant negative correlations were found between age and mitral E/A ratio (r = -0.76, p < 0.0001), as well as LV VTI-E/A(r = -0.81, p < 0.0001). The same trend was seen for the tricuspid E/A ratio. No statistically significant correlations were found in patients between mitral or tricuspid E/A ratio and GFR, BP, LV mass or heart rate.

IN CONCLUSION

in a group of patients with chronic glomerulonephritis and mildly to moderately impaired renal function, it was found by means of echocardiography that there was a higher LV mass index and decreased systolic function, when compared with healthy controls. In addition, the patients had diastolic dysfunction of primarily the left ventricle. The echocardiographic findings were not correlated to BP level or renal function. This suggests that factors other than GFR or BP per se might be involved in the pathogenesis of cardiac dysfunction, at an early stage.

Doppler echocardiographic estimation of the pressure gradient in aortic stenosis. An updated assessment of the technique used in clinical practice in 249 patients

This study included 249 consecutive patients with suspected significant aortic valve stenosis. Using contemporary ultrasound equipment we reassessed the value of out-patient Doppler-derived maximum pressure gradients for the prediction of peak-to-peak pressure gradients measured later at heart catheterization. It was possible to record the pressure gradient in 97% of the patients by Doppler examination and in 86% at heart catheterization. There was a fair, statistically significant correlation between Doppler and invasive gradients (n = 201, r = 0.80, p < 0.05, SEE = 21 mm Hg), independent of coexistent aortic regurgitation, atrial fibrillation, left ventricular function, number of days between the examinations and other variables analysed. A Doppler gradient > 80 mm Hg was 98% (90-100%) predictive of critical aortic stenosis (gradient > 50 mm Hg as determined by heart catheterization). Similarly, a Doppler gradient of < or = 30 mm Hg was 98% (87-100%) predictive of non-critical stenosis. In the remaining patients (53% of the population) the Doppler gradient did not contribute decisively to clinical management.

[Diagnosis of suspected thoracic aortic dissection. Focused on transesophageal echocardiography]

Over a five-year period (1990-1994), 72 consecutive patients were referred to transoesophageal echocardiography (TEE) on suspicion of thoracic aortic dissection. TEE was performed as the only or last investigation in 42 patients (58%). In 44 patients one or more other investigations were carried out before final clinical decision making: aortography (n = 30), X-ray computer tomography (CT, n = 18), and magnetic resonance imaging (MRI, n = 12). The final diagnosis was based on the combination of clinical information, the available examination results, and findings at surgery or autopsy; 31 of the patients were diagnosed as having aortic dissection. One patient with aortic dissection died during TEE while none of the other patients suffered major complications. The sensitivity (demonstration of dissection including correct classification in type A or B) was 81%, 80%, 45%, and 83% for TEE, aortography. CT, and MRI, respectively. The specificities were 88%, 93%, 71%, and 100%, respectively. Dissection of the thoracic aorta is a life-threatening condition demanding prompt and accurate diagnosis. None of the four techniques employed in the present study is ideal. Although TEE is adequate for immediate bedside examination our results show that more time-consuming and resource demanding investigations are sometimes required. Proper training and improved equipment may, however, increase the usefulness of TEE in patients with suspected aortic dissection.

Mitral valve prolapse in 3-year-old healthy Cavalier King Charles Spaniels. An echocardiographic study

Clinical studies have shown that Cavalier King Charles Spaniels (CKCS) have a high prevalence of mitral valvular insufficiency (MVI). Echocardiography has the potential to disclose early valvular changes, and the present prospective study was designed to investigate the occurrence of mitral valve prolapse (MVP) in young CKCS without heart murmurs, and to correlate the degree of MVP with the clinical status of the dogs by including CKCS with MVI as well. The study was based on blinded evaluations of echocardiographic recordings of mitral valves from 34 CKCS and 30 control dogs. Thirteen (87%) of 15 three-year-old CKCS without heart murmurs had MVP (2 total and 11 partial), as compared with 1 (7%) of 15 three-year-old normal Beagle dogs (P < 0.0001), and none of 15 three-year-old normal Medium Size Poodles (P < 0.0001). Of 19 CKCS with MVI, MVP was found in 84% of the entire group and in 100% of dogs with pulmonary congestion or edema. The occurrence of total MVP tended to be higher in the group with MVI (47%, 9/19), when compared with the younger CKCS without heart murmurs (13%, 2/15, P = 0.06). MVP was positively associated with excessive heart rate variability (P = 0.003). The radius of curvature of the anterior mitral valve leaflet in systole was significantly reduced in dogs with MVP when compared with those without (P < 0.0001). In conclusion, this study shows that CKCS at an early age have a high occurrence of MVP. This suggests: 1) A genetic predisposition of CKCS to MVP; and 2) That MVP is a pathogenetic factor in the development of mitral valvular insufficiency. Follow up studies may add further support to these proposals, and clarify whether echocardiography may be an aid in selecting CKCS for future breeding.

Perivalvular cavities in endocarditis: abscesses versus pseudoaneurysms? A transesophageal Doppler echocardiographic study in 118 patients with endocarditis

The appearance of perivalvular cavities (PCs) in patients with infectious endocarditis (IE) was studied by transesophageal echocardiography (TEE) color Doppler examinations to determine whether the color Doppler TEE presentation was in keeping with the current concept of PCs representing abscesses. Two heart centers participated in the study. Videotape recordings of TEE examinations in patients with IE were analyzed retrospectively for 18 months in both centers, and one center included patients prospectively for an additional 18 months. A total of 118 patients with a diagnosis of IE based on TEE and clinical and laboratory findings were seen during the study period. TEE showed PCs in 34 patients. In 3 patients who died, no autopsy was performed; the PCs were proved at autopsy or surgery in the remaining 31 patients, who constituted the study population. All PCs were echo free at TEE. Apart from one technically inadequate examination, all PCs contained color Doppler signals indicating intracavitary blood flow; the PCs communicated through a narrow channel with high-pressure regions (the left ventricle or the ascending aorta). At surgery or autopsy, only 2 of the 31 patients had pus accumulations besides the blood-filled PCs. At TEE the pus accumulations presented as echo-rich, shaggy tissue thickening. It is concluded that well-delineated, echo-free PCs with intracavitary color Doppler signals at TEE appear to be pseudoaneurysms, and therefore the term abscess should not be used in these cases. Although further studies are needed, our findings suggest that PCs more likely occur by infectious tissue weakening and subsequent dissection rather than as a result of primary abscess formation with secondary rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intracoronary ultrasonography--a supplement to coronary arteriography]

Intracoronary ultrasound is a new technique, by means of which it is possible for the first time to visualise coronary artery wall structures in vivo. Compared to conventional coronary angiography the advances of this new modality appear to be: 1) Improved diagnosis of minimal and non-obstructive atherosclerosis; 2) Characterisation of plaque morphology, thereby being an aid in decision on interventional procedures (PTCA, atherectomy, stent placement); 3) Better delineation of coronary artery lumen area, which improves the accuracy of stenosis graduation both before and after interventional procedures. The examination can be performed in up to 95% of cases. The procedure appears to be safe with a reported complication rate of myocardial infarction and bypass surgery of 0.16% in 1837 cases; transient coronary artery spasms occurred in about 3%. Complications are predominantly associated with interventional procedures. Although intracoronary ultrasound has mainly been used for research purposes, results of ongoing trials assessing its clinical utility, as well as technological improvement providing more consistent image quality, suggest that the procedure will evolve into an important adjunct to coronary angiography.

Left ventricular opacification after intravenous injection of Albunex. The effect of different administration procedures

A clinical study has been performed to investigate the influence of different administration procedures on the degree of contrast enhancement of the left ventricle. The administration variables assessed included Albunex injection rate, arm position, flushing rate and flushing fluid. Twenty-four healthy male volunteers were included. Compared to an injection rate of 1 ml/sec an injection rate of Albunex of 2 ml/sec caused an earlier appearance of contrast in the right ventricle (1 heart beat), whereas transpulmonary passage was not influenced. Horizontal arm position caused a delay in time to peak intensity of 2 to 3 heart beats in both systole and diastole as compared to elevated arm position. Injection rate of 1 ml/sec compared to 2 ml/sec caused a higher peak intensity and mean area under the curve and a longer mean time to peak intensity and transit time. Differences varied from 6 to 230 grey level units out of mean values of 2500. All the observed differences were small and thus probably of no clinical importance. The present study indicates that improvements in the pressure stability characteristics of the albumin microspheres in Albunex have been achieved. This implies that a simple administration procedure can be used. It is recommended that the contrast agent, after resuspension, is injected through a three-way stop cock cannula, followed by 10 ml of saline for flushing. The cannulas or syringes used should be no smaller than 20 G. The injection rate should be 1-2 ml/sec, depending on the diameter of the cannula. By using this procedure, a reliable transpulmonary passage and left ventricular opacification may be obtained.

Prevalence of cardiovascular malformations and association with karyotypes in Turner's syndrome

The aim of the study was to establish the prevalence of cardiovascular malformations in females with Turner's syndrome and analyse possible associations with the various karyotypes. One hundred and seventy nine of 393 females who had Turner's syndrome diagnosed in Denmark were examined. Complete chromosome analysis was available in all cases. Clinical examination, electrocardiography, and echocardiography including Doppler were performed. The distribution of the various karyotypes was 45,X, 58%; mosaic monosomy X, 35%; and structural abnormalities of the X chromosome, 7%. In 46 (26%) of the females a total of 69 cardiovascular malformations were found; aortic valve abnormality (18%) and aortic coarctation (10%) being the most common. There was a significant difference in the prevalence of cardiovascular malformations between 45,X and mosaic monosomy X (38% v 11%), primarily due to a significant difference in the prevalence of aortic valve abnormalities and aortic coarctation. Pulmonary valve abnormalities were seen only in females with mosaic monosomy X but the prevalence was low (3%). No patient with structural abnormalities of the X chromosome had cardiovascular malformations.

Short and long-term cardiovascular effects of growth hormone therapy in growth hormone deficient adults

OBJECTIVE

Since GH substitution therapy is now available for adult GH deficient patients, information on the cardiovascular effects of GH substitution has assumed major clinical interest. We have therefore assessed cardiovascular effects of short and long-term growth hormone substitution therapy in these patients.

PATIENTS AND MEASUREMENTS

Doppler echocardiography was performed in 21 GH deficient patients after 4 months placebo and 4 months GH therapy, in a double blind cross-over study. In an open design study, 13 patients were reinvestigated following 16 months and 9 patients following 38 months of GH therapy. Twenty-one age and sex-matched normal control subjects were also investigated.

RESULTS

Heart rate was increased in placebo treated patients as compared to controls. After 4 months of GH treatment, heart rate showed a further increase (10%, P < 0.01) and seemed to remain elevated after 16 months of GH therapy. Systolic and diastolic blood pressures were significantly lower in placebo treated patients than in controls, and did not change significantly after GH treatment. The left ventricular diastolic diameter was reduced in patients as compared to controls, but increased after 4 months GH therapy (P > 0.05) and seemed to increase further during prolonged GH treatment. Cardiac index was at the same level in controls and in placebo-treated patients, but increased by 20% following GH therapy and remained elevated after 16 and 38 months (P < 0.05) of GH substitution.

CONCLUSION

Following GH substitution in GH deficient adult patients, left ventricular diastolic dimensions increased and seemed to normalize, while heart rate and cardiac output were found to be increased to supranormal levels.

[Left ventricular hypertrophy in patients with aortic stenosis. A comparison between electrocardiography and echocardiography]

Using echocardiography (ECHO) as the reference method, the aim of this study was to determine the sensitivity, specificity, and predictive value of the electrocardiogram (ECG) in detection of left ventricular hypertrophy (LVH) in patients with aortic stenosis. Forty-one patients, 18 men and 23 women aged 25-80 years (mean 49 years) with uncomplicated aortic stenosis were studied. ECG-LVH was estimated by standard fixed voltage criteria. ECHO-LVH was defined according to left ventricular mass (LV mass) calculated by the Penn method. In the total material, the correlation between ECG-LVH and ECHO-mass was poor (r = 0.56, p < 0.05). The sensitivity and specificity of the ECG was respectively 50% and 100%. The positive predictive value of the ECG in detection of LVH was high (100%). We conclude that the sensitivity of the ECG in detection of LV hypertrophy is unsatisfactorily low. Accordingly, it is recommended that echocardiography be performed in all patients suspected of aortic stenosis.

Sudden death caused by thrombosed coronary artery aneurysm. Two unusual cases of Kawasaki disease

Kawasaki disease primarily affects children below 5 years of age, and fatal coronary complications usually occur within 6-12 months following the acute illness. We report 2 unusual fatal cases of thrombosed coronary artery aneurysms. The first case was an 11-year-old boy, who died suddenly 2 months after the acute illness. He had a classical clinical picture, but was misdiagnosed. The second case was a 29-year-old man without history of recent febrile episodes or cardiac symptoms. Both subjects fulfilled the stage 4 criteria of Kawasaki disease (healing stage) with extensive old myocardial damage. The cases illustrate the great variation in the clinical picture of Kawasaki disease. Teenagers can also be affected, and extensive myocardial damage may be asymptomatic for many years.

Cardiac function in patients with human immunodeficiency virus infection and with no other active infections

OBJECTIVE

to investigate cardiac function and prognostic significance of echocardiographic findings in patients with uncomplicated human immunodeficiency virus (HIV)-infection.

PATIENTS AND METHODS

Doppler echocardiography was performed in 60 male patients with HIV-infection and no signs of other active infections, and in 36 age and sex matched normal control subjects. The survival time of the patients was assessed 36 months after the echocardiographic examination.

RESULTS

None of the patients had significant pericardial effusions, intracardiac tumors, signs of valvular endocarditis or dilated cardiomyopathy. In none of the patients were the fractional shortening or the early and atrial mitral flow ration (E/A ratio) below the 95% confidence limit of the control group. The E/A ratio was slightly, but significantly, decreased in AIDS patients both as compared to asymptomatic HIV-infected patients and as compared to normal control subjects because of increased heart rated in the AIDS patients. Within the three-year observation period, 28 of the patients died from HIV-related disease. In the group of deceased patients, there was no significant correlation between blood pressure, heart rate, left ventricular diameters, fractional shortening, E/A ratio and the survival time.

CONCLUSION

In a population of HIV-infected patients with no other active infections, cardiac abnormalities seen to be uncommon, and the echocardiographic fractional shortening and E/A ratio were not related to the survival time of such patients. Thus, our data does not evidence that HIV is a direct cardiac pathogen.

[Transesophageal echocardiography for registration of hemodynamics. A new tool in anesthesiology]

During the last ten years, transesophageal echocardiography has become an important tool for cardiac monitoring. In other countries it is widely applied, especially in cardiac surgery, but the areas of application are still expanding. Transesophageal echocardiography is a non-invasive technique in contrast to most other methods available for monitoring central haemodynamics. The complication frequency is extremely low. However, correct therapeutic decisions depend on profound experience with the equipment and image interpretation. The scope of transoesophageal echocardiography as a new tool in haemodynamic monitoring is described in this paper together with preliminary results.

Lethal myocardial infarction subsequent to compression of the left anterior descending coronary artery induced by traumatic hematoma

Post-traumatic myocardial infarction is a well-known although rare complication of blunt chest traumas. In cases of proximally located damage to the coronary arteries, modern vascular surgery such as bypass operations may be lifesaving. In this paper we describe a case, where a healthy 35-year-old man developed a lethal myocardial infarction 8 days after a chest trauma caused by a moped. The ECG obtained 4 h after the accident showed extensive transmural ischemia of the anterior wall. At autopsy a hematoma originating from a side branch was found to compress the left anterior descending coronary artery immediately distal to its origin from the main stem. This finding suggests that bypass surgery could have saved the life of this young man. Patients with evidence of myocardial ischemia following chest traumas should be transferred to a cardiac center as early as possible.

Importance of abstention from alcohol in alcoholic heart disease

A case of alcohol-associated heart disease, presenting with congestive heart failure, was followed for 36 months. After abstinence from alcohol, fractional shortening rose from 13 to 60%. After 1 1/2 years of abstinence and normal physical capacity, the alcoholic abuse was resumed. Eleven months later, the patient was again in overt heart failure. Withdrawal of alcohol was again associated with significant clinical improvement, but despite being in functional NYHA class I, fractional shortening only increased from 14 to 29%. Endomyocardial morphology was unrelated to the severity of the disease. Alcoholic heart disease is partially reversible, but total abstinence is necessary to preserve cardiac function.

[Percutaneous pulmonary balloon valvuloplasty in Denmark]

Percutaneous balloon valvuloplasty of valvular pulmonary stenosis (PPB) was carried out for the first time in 1982 and is now regarded as the primary method of treatment of this condition. The results of the first PPB treatments in Denmark are presented here. PPB was planned in 28 patients and was carried out in 25 (22 children and 3 adults). PPB was carried out on two occasions in one patient. Twenty-three patients had isolated valvular pulmonary stenosis and two patients had Fallot's anomaly. No complications of significance occurred after the treatments. The average gradient for all dilatations was 77 +/- 24 mm Hg prior to and 36 +/- 23 (p less than 0.0001) immediately after PPB. The gradient was reduced by more than 50% in 68% of the patients. In 14 patients, the gradients over the pulmonary valve was measured by Doppler technique or by cardiac catheterization greater than 6 months after PPB. In these patients, the average gradient was 69 +/- 21 mm Hg prior to PPB, 29 +/- 12 mm Hg (p less than 0.0001) immediately after PPB and 27 +/- 9 mm Hg (p less than 0.0001) at the most recent control examination, on an average 12 months (range 6-24 months) after PPB. In the same patient group, significant reduction of the electrocardiographic right-sided hypertrophy was found at the most recent control examination. It is concluded that PPB is an effective and safe treatment of valvular pulmonary stenosis.

Immune complexes and complement activation following rupture of intracranial saccular aneurysms

Circulating immune complexes (CIC) and complement activation (plasma C3d levels) were monitored during a 2-week period in patients with ruptured cerebral aneurysms and also in patients with cerebral hematoma unrelated to saccular aneurysms. Thirteen of 18 aneurysm patients were found to have CIC on admission as compared to three of 21 healthy blood donors (p less than 0.001). The presence of CIC in aneurysm patients was associated with a poor prognosis. Eight of nine patients who developed angiographic vasospasm had CIC on admission compared with one of four without vasospasm. Patients with vasospasm showed a twofold increase in plasma C3d levels at the time when the spasm occurred, whereas no significant changes in the C3d concentration could be demonstrated in aneurysm patients without spasm or in patients with hematoma unrelated to aneurysm rupture. These findings suggest that immunological processes involving complement-activating immune complexes are involved in the pathogenesis of cerebral vasospasm following rupture of saccular aneurysms.

Clinical improvement and long-term survival after surgical treatment of postinfarction left ventricular aneurysm

Left ventricular aneurysmectomy was performed on 45 men and 12 women (mean age 57 years) during a 12-year period. The hospital mortality was 14% and the cumulative 5-year survival 57% +/- 9 (SE). Of 35 survivors, 33 underwent a follow-up study (mean 28 months post-operatively). The mean cardiothoracic index fell from 0.58 +/- 0.08 (SD) to 0.51 +/- 0.04 and the mean left ventricular ejection fraction (EF) improved from 0.30 +/- 0.08 to 0.38 +/- 0.01 (both changes significant). Echocardiographic parameters showed no significant improvement in left ventricular function. The NYHA classification was I or II in 85% of the patients at follow-up, but in only 23% preoperatively. Preoperative EF greater than or equal to 0.30 was associated with 76% +/- 16 (SE) cumulative 5-year survival as compared with 31% +/- 12 when EF had been less than 0.30. In view of these results, left ventricular aneurysmectomy should be recommended for all symptomatic patients.

The C3-F gene in patients with intracranial saccular aneurysms

The C3-F gene has previously been found associated with atherosclerotic vascular diseases. The occurrence of the C3-F gene was therefore investigated in a group of 110 hospitalized patients with intracranial saccular aneurysms. The C3-F gene occurred equally often in patients and controls. In patients with a ruptured aneurysm, however, the C3-F gene frequency was significantly increased in subjects aged 40-49 years followed by a marked and statistically significant decline with increasing age. The findings suggest that the C3-F gene may be a risk factor for early aneurysm rupture.

Autoantibodies and vascular events in essential hypertension: a five-year longitudinal study

The relationship between serum autoantibodies and vascular events was investigated in 140 patients with essential hypertension during a five-year period. The influence of time upon incidence of autoantibodies was assessed in 55 normotensive controls of roughly the same distribution of age and sex. Thirty-four patients experienced a vascular event, which was fatal in 10 cases (7.1%). Eight of these 10 patients had autoantibodies in serum before the events, and the presence of autoantibodies at entry to the study tripled the five-year relative risk for vascular events. Antinuclear antibodies (ANA) and smooth muscle antibodies (SMA) especially contributed to this increased risk. The vascular events were followed by a significantly increased occurrence of ANA. In the control subjects no events occurred and no significant increases in the presence of autoantibodies were found during the five years. ANA and SMA positive sera showed no significant complement fixing properties, and the autoantibodies studied seemed to be secondary to tissue damage. Despite this, they seemed to reflect an ongoing injury of the vascular bed.

Immunogenetic markers in essential hypertension

In a series of 148 patients with essential hypertension, the presence of the atherosclerotic C3-F gene and HLA-antigen frequences were investigated, and the results were compared with those in 62 age and sex matched normotensive controls. The frequency of C3-F was significantly higher in patients (p less than 0.03), as was HLA-B15 in patients with a positive family history of hypertension (p less than 0.05). The presence of the C3-F gene was associated with an increased risk (= 10.2) for coronary heart disease, and B15 was associated with an increased risk (= 6.0) for cerebral events in both familial and non familial cases of hypertension. It is suggested that determination of the C3-F gene and HLA-antigens might be a tool in the identification of hypertensive patients at particular high risk for vascular events, irrespective of BP levels. The study support the suggestions that some genetic factors may act via immunological pathways.

Autoantibodies in untreated and treated essential hypertension: relationship to histocompatability leucocyte antigen-B15 and vascular complications

1. The presence of autoantibodies and the histocompatibility leucocyte antigen (HLA) antigen B15 was studied in relation to vascular complications (WHO III) in 148 patients with essential hypertension. 2. Nine of 36 patients with WHO stage III hypertension had autoantibodies, compared with seven out of 78 normotensive controls. 3. The frequency of B15 was 36.1% in hypertensive patients with stage III hypertension and 14.8% in controls. Nine of 18 patients with cerebral complications had B15 and four out of 18 with cardiac complications had B15. 4. The relative risk of vascular complications was 3.4 times higher in B15-positive patients with essential hypertension compared with B15-negative patients. 5. This study suggests that B15-positive patients with essential hypertension represent a subgroup with a higher risk of vascular complications. Long-term studies are needed to determine whether B15 might serve as predictor for vascular complications. 6. The study adds further support to suggestions of a genetic and possibly HLA-linked connection between essential hypertension, diabetes and autoimmunity.

The pathogenesis of propranolol-withdrawal syndrome in essential hypertension

1. In hypertension, the beta-adrenoreceptor-blocker-withdrawal syndrome comprises tachycardia, sweating, tremor and general malaise, symptoms resembling thyrotoxicosis. 2. The effect of abrupt cessation of propranolol on serum concentrations of thyroxine (T4) and triiodothyronine (T3) was therefore investigated in five patients with uncomplicated essential hypertension, treated with propranolol in doses from 160 to 480 mg/day. 3. Four of the five patients developed one or more of the above-mentioned symptoms within 2-6 days after withdrawal of propranolol. 4. A mean relative increase in serum free T3 of 51% (range 22-74%) was found in these four patients on the day of onset of symptoms. 5. The increase in free T3 in the five patients correlated positively with total serum propranolol on the last day the drug was given (r = 0.91, 2P = 0.03). 6. As an increase in T3 was found only in patients suffering the withdrawal syndrome, and was maximal the day the symptoms appeared, despite a variation in time of onset from 2 to 6 days, it is suggested that the beta-adrenoreceptor-blocker-withdrawal syndrome, at least partially, is caused by rebound increased production of T3, induced by the well-known inhibition of the monodeiodination of T4 to T3 during beta-adrenoreceptor blockade. 7. This assumption may explain the clinical symptoms and the reported transient increased beta-adrenoreceptor sensitivity with unchanged serum concentrations of catecholamines.