Heart transplantation as a treatment option for end-stage heart disease in patients older than 65 years of age

Because of the critical donor organ shortage for heart transplantation, selection of recipients should be based on the potential for maximum benefit. To evaluate the effects of advancing age on outcome after heart transplantation, we compared the clinical variables of 12 recipients aged 65 years or older (66.1 +/- 0.9 years [x +/- standard deviation]; range, 65 to 67 years) with those of 57 patients aged 55 to 64 years (59.3 +/- 2.7 years) at the time of the procedure. The two study groups were similar in sex, race, pretransplantation heart disease, immunocompatibility, maintenance immunosuppression, and length of first hospitalization at the time of the procedure. Groups were also similar regarding the incidence of malignancies, fractures, diabetes, neurologic complications, and renal dysfunction occurring over the follow-up period. Patients 65 years of age or older had a significantly higher number of hospital days (36 +/- 29 versus 15 +/- 18 days; p < 0.02) and increased frequency of infections/month (0.7 +/- 0.3 versus 0.3 +/- 0.4 infections/month; p < 0.03) during the first postoperative year. Older patients had a higher incidence of cytomegalovirus infections (50% versus 19%; p < 0.06), lower rates of rejection at 1 and 6 months after operation (p < 0.03), and more severe functional limitation (p < 0.002) than patients aged 55 to 64 years. One-year actuarial survival was not significantly different in the two groups. The results of our study suggest that, because of lower rejection and higher infection rates, heart transplantation recipients older than 65 years of age should receive less intense immunosuppression.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex differences in the impact of coexistent diabetes on survival in patients with coronary heart disease

OBJECTIVE

To evaluate the sex difference in the impact of diabetes on survival in patients with coronary heart disease.

RESEARCH DESIGN AND METHODS

Cohort study based on a sample from a hospital registry in Chicago, IL. A total of 974 consecutive patients (585 men and 389 women) with angiographically confirmed coronary artery disease were followed for 4.6 yr.

RESULTS

At baseline, 160 men and 155 women had diabetes. The age-adjusted relative risk of death from all causes for patients with diabetes versus patients without diabetes was 0.93 (95% confidence interval 0.65-1.34) in men and 1.99 (95% CI 1.30-3.05) in women. For cardiac death, the corresponding relative risk was 1.00 (95% CI 0.64-1.56) and 1.96 (95% CI 1.19-3.24) in men and women, respectively. Baseline differences in age, hypertension, body mass index, number of diseased vessels, and ejection fraction did not fully explain the excess mortality risk in diabetic women. Excess risk was apparent in both cardiac and noncardiovascular categories. Among nondiabetic patients, the risk of death was significantly lower in women compared with men (multivariate-adjusted relative risk = 0.61, 95% CI 0.41-0.89). However, the mortality risk of diabetic women became similar to men as a whole (relative risk = 1.13, 95% CI 0.80-1.60).

CONCLUSIONS

Diabetes confers a substantially higher risk of mortality in women than in men when it occurs in the presence of coronary heart disease.

Delay between onset of chest pain and arrival to the coronary care unit among minority and disadvantaged patients

Prehospital delay is an important cause of out-of-hospital coronary mortality. To determine the effects of decision time delay in a patient population comprised mainly of blacks and the underprivileged, 74 consecutive patients with acute chest pain necessitating admission to the coronary care unit in a large urban hospital were studied. Delay time from onset of chest pain to the decision to seek medical care was markedly prolonged in patients with myocardial infarction (n = 24; mean time: 11.3 +/- 18 hours) as well as in patients with chest pain who did not develop myocardial infarction (n = 50; mean time: 20.5 +/- 26 hours). In addition, transfer time from the emergency room to the coronary care unit was likewise unduly long (mean time: 4 +/- 3.8 and 4.1 +/- 6 hours for patients with and without myocardial infarction, respectively). This study documents a significant delay in the decision time among patients with low socioeconomic status, mostly inner-city blacks, and in the transfer time from emergency room to the critical care unit in a large public hospital. These findings must be taken into consideration when planning strategies to improve the health-care delivery system to blacks and the underprivileged and further lend support to the practice of initiating thrombolytic therapy in the emergency room.

Risk/benefit ratio of perioperative OKT3 in cardiac transplantation

This study shows that perioperative OKT3 provides no benefit in terms of the time of onset or frequency of rejection or patient survival. However, it does result in an increased incidence of infection, particularly CMV infection. Thus, the risk/benefit ratio of perioperative OKT3 does not appear favorable. However, a multicenter, randomized trial including a larger number of patients and longer patient follow-up will be required to definitively answer the question.

The prognostic role of left ventricular hypertrophy in patients with or without coronary artery disease

OBJECTIVE

To examine the association between echocardiographically determined left ventricular hypertrophy and mortality in patients with and without coronary artery disease.

DESIGN

Cohort study with a mean follow-up period of 4 years.

SETTING

An inner-city public hospital in Chicago.

PATIENTS

A cohort of 785 patients, most of whom were black and had hypertension.

INTERVENTIONS

Coronary arteriography for presumed coronary artery disease and echocardiography.

MAIN OUTCOME MEASURE

All-cause and cardiac mortality.

RESULTS

Left ventricular hypertrophy, based on left ventricular mass corrected for body surface area, was present in 194 of 381 patients (51%) with coronary artery disease and in 162 of 404 patients (40%) without coronary artery disease. Patients with left ventricular hypertrophy had worse survival than those without hypertrophy in both the group with coronary artery disease and the group without coronary artery disease. After adjustment was made for age at baseline, sex, and hypertension, the relative risk for death from any cause in patients with hypertrophy compared with patients without hypertrophy was 2.14 (95% CI, 1.24 to 3.68) among those with coronary artery disease and 4.14 (CI, 1.77 to 9.71) among those without coronary artery disease.

CONCLUSIONS

Echocardiographically determined left ventricular hypertrophy is an important prognostic marker in patients with or without coronary artery disease. The effect of reversing ventricular hypertrophy in patients with and without coronary disease deserves further study.

Survival rates with coronary artery disease for black women compared with black men

OBJECTIVE

To evaluate the influence of gender on the prognosis of coronary heart disease among black patients.

DESIGN

Cohort study based on a consecutive sample from a hospital registry, with a mean follow-up of 4 years.

SETTING

An inner-city public hospital in Chicago, Ill.

PATIENTS

The study included 1719 consecutive black patients (780 men and 939 women) who had any one of the following events: cardiac catheterization for presumed coronary heart disease, hospitalization for acute myocardial infarction, or coronary artery bypass grafting.

RESULTS

Hospital and operative mortality rates following acute myocardial infarction and coronary artery bypass grafting were similar between the two sexes. The relative risks for cardiac death in women vs men were 0.88 (95% confidence interval [CI], 0.60 to 1.28), 0.79 (95% CI, 0.53 to 1.17), and 0.79 (95% CI, 0.34 to 1.85) for coronary artery disease, acute myocardial infarction, and coronary artery bypass grafting, respectively, after adjusting for age, history of diabetes, hypertension, angina pectoris and myocardial infarction, number of diseased vessels, and ejection fraction. Compared with patients of the same sex with normal angiograms, relative risk estimates were 5.0, 10.1, and 6.3 for women and were 1.8, 4.0, and 2.0 for men in the same three groups of patients, respectively.

CONCLUSIONS

Survival with coronary artery disease in black women is similar to that observed in black men, but relative to members of the same sex without the disease, the prognosis for women is considerably worse than for men.

Serum lipids and their correlates in Chinese urban and rural populations of Beijing and Guangzhou. PRC-USA Cardiovascular and Cardiopulmonary Epidemiology Research Group

In 1983 and 1984, surveys were conducted in four Chinese population samples, urban and rural for both Beijing and Guangzhou, as part of PRC-USA collaborative research in cardiovascular and cardiopulmonary epidemiology. Serum total cholesterol (TC), HDL-cholesterol (HDL-C), and triglycerides (TG) were measured in 4280 men and 4695 women aged 35-54 years, in laboratories standardized by the US Centers for Disease Control. Age-adjusted mean serum TC was higher in urban than rural samples and generally higher in Beijing than Guangzhou, ranging from 155 mg/dL for Guangzhou rural women to 187 mg/dl for Guangzhou urban women. Group mean values of HDL-C varied from 48 to 59 mg/dl, higher in Beijing than Guangzhou, and higher in women than men. TC/HDL-C ratio ranged from 3.05 to 3.82. Serum TG values were higher for Beijing than Guangzhou; the lowest group mean values of 78 mg/dl and 75 mg/dl were in rural Guangzhou men and women. Mean body mass index (BMI) was uniformly low, ranging from 20 kg/m2 for rural Guangzhou to 24 kg/m2 for urban Beijing. Multiple regression analyses showed that BMI was positively and independently related to serum TC, LDL-C, TG, and TC/HDL-C, and inversely related to HDL-C. Smoking was positively related in both sexes to TG and TC/HDL-C, and inversely related to HDL-C. Smoking was also positively related to TC and LDL-C in men. In men, alcohol was positively related to TC and HDL-C, and was inversely related to TG and TC/HDL-C. Heavy manual work was inversely related to TC, LDL-C, and TC/HDL-C in men, but not related to lipids in women. Thus, for these Chinese population samples, despite their lower serum TC and BMI, the correlates of serum lipids are similar to those in western populations. These variables accounted for only part of the observed urban-rural and north-south differences in serum lipids among these Chinese population samples. The significance of the relatively low serum TC and TG and high HDL-C in relation to low cardiovascular disease in Chinese populations is the object of further investigation in follow-up studies.

Structure of a tricyclic subunit of manzamine A

(4a alpha,7a beta,10a beta)-2-Benzyl-1,2,3,4,4a,7,7a,8,9,10-decahydro-8,8- dimethylpyrrolo[2,3-i]isoquinolinium iodide, C20H29N2+.I-, M(r) = 424.37, monoclinic, P2(1)/n, a = 9.441 (4), b = 10.378 (4), c = 20.023 (9) A, beta = 91.56 (3) degrees, V = 1961 (1) A3, Z = 4, Dx = 1.44 g cm-3 (188 K), lambda(Mo K alpha) = 0.7107 A, mu = 16.16 cm-1, F(000) = 864, T = 188 K, R = 0.0288 for 3070 reflections [Fo greater than or equal to 4 sigma(Fo)]. The crystal structure determination was undertaken in order to establish the configuration around C10a. The rings of the isoquinoline group are trans, with the pyrrole moiety cis fused. The A ring is in the chair conformation, while the cyclohexene ring, B, is in the boat conformation owing to the cis fusion of the five-membered pyrrole ring. The pyrrole ring, C, assumes the half-chair conformation. The C-N bonds of the quaternary N atom, N8, are longer than those of the tertiary N atom, N2 [1.517 (2) for N8 and 1.463 (2) A for N2].

[Study on casting precision of plat castable ceramic crowns]

The plat castable ceramic crown was made with investment material prepared in our college with our own casting technique by a Chinese-made casting machine. The accuracy and fitness of the crown were studied and appraised. Results show that the margin of fitness is 46 microns and that the cement film thickness of the dies in the spacer material group is 65.13 microns. Hence the results are satisfactory. The Plat castable ceramic crown might be used in clinical dentistry.

Changes in pulmonary hemodynamics with aging in a predominantly hypertensive population

The impact of aging on pulmonary hemodynamics was investigated in 322 patients who underwent right- and left-sided cardiac catheterization and echocardiographic examination, and were free of coronary disease, impaired left ventricular systolic function and left ventricular dilatation. Most of the patients were black (83%) and hypertensive (78%). Mean pulmonary artery pressures increased progressively with age: 16.7 +/- 4.6, 17.9 +/- 6.4 and 20.6 +/- 8.0 mm Hg for those aged less than 45 (n = 50), 45 to 64 (n = 238) and greater than or equal to 65 years (n = 34), respectively (p = 0.020). Pulmonary vascular resistance was 99 +/- 42, 116 +/- 62 and 160 +/- 68 dynes s cm-5, and the ratio of pulmonary to systemic vascular resistance was 78, 80 and 105%, respectively, for the 3 age groups (p less than 0.001). Along with these changes, a decrease in cardiac output and an increase in systolic blood pressure and systemic vascular resistance with age were noted. The effect of age on mean pulmonary artery pressure and pulmonary vascular resistance was statistically significant after adjustment for gender, smoking status, body weight, left ventricular hypertrophy, systolic blood pressure and systemic vascular resistance. Consideration should be given to age-related changes in the pulmonary circulation when defining physiologically normal values.

Atrial natriuretic factor and renin synthesized in cultured aortic smooth muscle cells of rats

This study was designed to determine whether or not atrial natriuretic factor (ANF) is present in the vascular walls and to observe the differences in ANF between control (WKY) and stroke-prone spontaneously hypertensive rats (SHRsp). It was found that ANF is indeed present in the vascular wall of the distal aorta. HPLC analysis of the extracts from cultured aortic smooth muscle cells (ASMC) and medium revealed that intracellular ANF was mainly in the form of ANF(1-126), at levels of 0.82 +/- 0.03 (SHRsp) and 1.04 +/- 0.10 ng/10(6) cells (WKY), while the major form in the medium was ANF(99-126), at levels of 0.40 +/- 0.06 and 0.60 +/- 0.06 ng/10(6) cells, respectively. Both forms were present in smaller amounts in SHRsp than in WKY rats. On the contrary, both renin activity and angiotensin I concentrations in SHRsp cells were significantly higher than those in the WKY controls. In addition, immunocytochemistry showed positive ANF staining in cultured ASMC of both strains. The results suggest that ANF can be synthesized and secreted by cultured ASMC from rats.

Survival of heart failure patients with preserved versus impaired systolic function: the prognostic implication of blood pressure

The impact of impaired versus preserved systolic function on survival of patients with heart failure was investigated in 78 patients with decompensated heart failure. Patients were classified on the basis of their left ventricular systolic performance, as defined by fractional shortening (FS); group I (n = 56) had impaired systolic function (FS less than 24%) and group II (n = 22) had preserved systolic function (FS greater than or equal to 24%). Mean ejection fraction was 15 +/- 5% and 40 +/- 13% for these groups, respectively. By the end of 48 months, 36 patients in group I had died compared with only 22 patients in group II (p less than 0.05). Both systolic and diastolic blood pressure were significantly lower in the deceased patients compared with the survivors in group I (p less than 0.05). There was a trend for an opposite direction in the relationship of blood pressure to mortality in group II. We conclude that the prognosis of patients with heart failure and preserved systolic function is more favorable than that of those with impaired function, and that blood pressure may have a differential prognostic meaning in the two groups.

[An observation of the anticancer activity of mitoxantrone hydrochloride injection]

Experimental results of anticancer activity of DHAQ.HCl are reported in this paper. It was discovered that DHAQ.HCl, mitoxantrone hydrochloride, had an obvious anticancer effect on the experimental tumor strains:Ehrlich ascites cancer, Sarcoma-180, Leukemia P388, etc., and that it was more effective to Leukemia P388 than to other strains. The anticancer activity of DHAQ.HCl was better than DHAQ (P less than 0.05). No side effect was observed on the local sites (s.c.) of tumor planted or drug injected. And also a good anticancer effect was observed on the sites of tumor planted by local injection. It is suggested that this observation can provide some information on the choice of routes of administration of this drug clinically.

Reoperation in the treatment of recurrent intracranial malignant gliomas

Fifty-five consecutive patients with recurrent intracranial malignant gliomas were reoperated at Memorial Sloan-Kettering Cancer Center from 1972 to 1983. The patients were 10 to 70 years old (median, 48 years). Thirty-five patients (64%) had glioblastoma multiforme, and 20 (36%) had anaplastic astrocytoma. The median interval between the first operation and reoperation was 43 weeks. The Karnofsky rating before reoperation ranged from 40 to 90 (median, 70). Eleven patients (20%) had more than one reoperation. The mortality rate was 1.4% per procedure, and the morbidity rate was 16% per procedure. After reoperation, 41 patients (75%) had chemotherapy and/or radiation therapy. The median survival for all patients was 92 weeks. The median survival after reoperation was 36 weeks. Patients with Karnofsky ratings of greater than or equal to 70, with anaplastic astrocytomas, or in whom gross total removal of the tumor was undertaken lived longer than their respective counterparts (P less than 0.05). Prereoperation Karnofsky rating and extent of surgical resection were the most important independent factors related to survival after reoperation according to multivariate analysis (P less than 0.01 and P less than 0.05, respectively). Twenty-five patients (45%) had improved Karnofsky ratings after reoperation, and the 32 patients (58%) who were independent after reoperation were able to stay so for more than 6 months of their survival time (median value). Reoperation is feasible and can be accomplished with acceptable mortality and morbidity. When intracranial malignant gliomas recur, the combined use of reoperation and adjuvant therapy prolongs good quality life.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular responses to exercise of participants in a trial on the primary prevention of hypertension

The Chicago study on the Primary Prevention of Hypertension (PPH) is a long-term, randomized controlled trial to test the ability of nutritional-hygienic non-pharmacological methods to prevent high blood pressure in hypertension-prone persons aged 30-44 years at entry. In order to assess the effects of this programme on cardiovascular responses to exercise, graded submaximal treadmill exercise tests were done serially at baseline and during the trial. Eighty-five participants (48 intervention, 37 control) successfully finished baseline and 2- or 3-year follow-up tests. The exercise maximal double product (DP) [systolic blood pressure (SBP) X heart rate/100] was significantly lower for both groups at 2-3 years compared with baseline, and this reduction was greater for the intervention than for the control group (-27.1 versus -15.5; P = 0.055). Similarly, improvement in maximal increase in DP (maximal DP minus standing DP) was greater for the intervention than the control group (-22.1 versus -9.9, respectively; P = 0.068). The lowest DP during the 6-min recovery period and the debt DP (lowest recovery DP minus standing DP) fell significantly at 2-3 years compared with baseline in the intervention but not in the control group (-12.7 versus -4.8; P = 0.017 for the first index, and -7.7 versus +0.9; P = 0.029 for the second). These interim data from this trial indicate that its intervention procedures favourably influenced cardiovascular responses to graded submaximal exercise.

Sex differential in the relationship of electrocardiographic ST-T abnormalities to risk of coronary death: 11.5 year follow-up findings of the Chicago Heart Association Detection Project in Industry

The independent contributions of ST segment depression and/or T wave abnormality (ST-T abnormalities) on the baseline resting electrocardiogram to risk of 11.5 year coronary heart disease (CHD) mortality were explored among 9203 white men and 7818 white women who were 40 to 64 years old and without definite CHD at entry in the Chicago Heart Association Detection Project in Industry. At baseline, prevalence rates of ST-T abnormalities were age related for both sexes, and at every age the rate was higher in women than men (age-adjusted prevalence rates 12.3% and 8.1%, respectively). Univariate analysis showed that ST-T abnormalities were associated with significantly increased risk of death from CHD for both men and women. However, men with ST-T abnormalities had much greater age-adjusted and multiple risk factor-adjusted absolute excess risk and relative risk than women with such electrocardiographic abnormalities. When baseline age, diastolic pressure, serum cholesterol, cigarettes/day, history of diabetes, and baseline use of antihypertensive medication were included in the multivariate analysis, ST-T abnormalities remained significantly related to death from CHD in men but not women. The interaction term between sex and ST-T abnormalities was at a borderline level of statistical significance by Cox regression analysis. In conclusion, ST-T abnormalities indicate an increased risk of subsequent death from CHD independent of major coronary risk factors for middle-aged U.S. men, but this is not clearly so for women.