[Cardiac involvement in sarcoidosis (author's transl)]

Standard electrocardiogram (ECG), His-bundle electrogram and biphasic thallium myocardial scanning was undertaken in 13 patients with histologically confirmed sarcoidosis (lung stages I--III). Changes in the standard ECG were present in five (sinus bradycardia, A-V nodal and intraventricular conduction disturbances, non-specific S-T--T changes). The His-bundle electrogram was abnormal in four of eleven patients in whom it was recorded (sick-sinus syndrome, supraventricular extrasystoles, damage to A-V node and supraventricular extrasystoles, damage to A-V node and intraventricular conduction disturbances). In seven of twelve patients who had thallium scans there was a definite irreversible defect, questionable abnormality in three others. Seven of ten patients who had all three tests had definite abnormalities in at least one of them. The electrophysiological findings and the abnormal scans point to cardiac involvement in sarcoidosis.

Changes in left ventricular function after intracoronary streptokinase infusion in clinically evolving myocardial infarction

Left ventricular (LV) contrast cineventriculograms were obrained in 174 patients with evolving acute myocardial infarction (AMI) treated by intracoronary streptokinase (SK) infusion. Ejection fraction (EF) increased slightly, from 52% +/- 13% before admission SK intervention to 58% +/- 13% immediately after early recanalization of the completely obstructed coronary vessel (p less than 0.0005, n = 68), while local wall motion usually improved. Immediately improved LV function appears to be the result of early reperfusion and/or decreased LV afterload. In 55 chronic (long-term follow-up) post-AMI (2 to 4 weeks after successful early SK reperfusion) patients, repeat angiography revealed late reocclusion of the infarct vessel in nine patients. Chronic EF was not significantly different from pre-SK intervention EF in these nine patients with late reocclusion, whereas in the remaining 46 patients with persistent patency, EF increased mildly from 52% +/- 13% (before SK intervention) to 56% +/- 16% (in long-term recanalization) (p less than 0.025). Ventricular loading conditions were not different at pre-SK intervention angiography and chronic angiography. EF rose modestly from 51% +/- 14% to 57% +/- 18% in the 23 patients recanalized on follow-up, in whom pre-SK intervention angiography revealed collaterals to the infarcting area (p less than 0.025), whereas there was no EF change in the 23 chronically recanalized patients without pre-SK collaterals. In the eight patients recanalized at late follow-up, who had preadmission chest pain for less than 3 hours and successful SK reperfusion within 4 hours of symptom onset (group A), EF increased significantly from 51% +/- 12% to 65% +/- 6% (p less than 0.025). In the 25 chronically recanalized patients admitted 3 to 6 hours after onset of chest pain, in whom SK reperfusion was successful (group B), EF was unchanged at late study. In the 13 chronically recanalized patients with preadmission chest pain lasting longer than 6 hours, in whom SK reperfusion was successful (group C), EF increased from 52% +/- 13% before SK intervention to 56% +/- 16% at late study (p less than 0.025). Pre-SK intervention angiography revealed collateral vessels to the infarct area in 69% of group C patients but in only 42% of patients in groups A and B. These findings suggest that the critical interval for myocardial salvage, as well as for early and long-term improvement of LV function by SK reperfusion at admission, is 4 hours after onset of chest pain in the majority of AMI patients. This time interval may be longer in patients with well-developed collateral supply to the region of the acute infarct.

Percutaneous transluminal coronary recanalization: procedure, results, and acute complications

Percutaneous transluminal coronary recanalization, a new therapeutic procedure used in acute myocardial infarction, offers significant reduction in mortality, as well as more effective limitation of the zone of infarction than has been possible with other pharmacologic treatment employed in the past. The risk of coronary angiography during acute myocardial infarction was surprisingly low, as was the risk of hemorrhagic complications following the intracoronary administration of relatively low doses of thrombolytic substances such as streptokinase. Mechanical recanalization was possible in about one fifth of patients and successful in approximately half of all such attempts, but complications occurred in a small percentage of attempts at this step. Coronary artery spasm was excluded as a possible cause of occlusion in almost all cases. Selective intracoronary infusion of streptokinase produced the highest degree of myocardial reperfusion, and best results were achieved when therapy was initiated shortly after thrombotic occlusion occurred. Residual stenosis of more than 75% luminal diameter narrowing was present in approximately three fourths of cases after complete thrombolysis, and the majority of patients remained appropriate candidates for coronary bypass surgery or for percutaneous transluminal coronary angioplasty (Grüntzig procedure). Although complete analysis of the efficacy of selective recanalization was difficult because it was not possible to establish a suitable control group for purposes of comparison, the mortality of less than 1% in the present group of 232 patients within the first 6 hours following myocardial reperfusion provides an encouraging result.

[Prazosin long-term treatment in severe chronic cardiac failure (author's transl)]

In addition to digitalis and diuretics, 10 patients with chronic cardiac failure were treated with prazosin (15 mg/d) over a period of 6 months. It was shown that the mean pulmonary artery pressure decreased significantly, on average by 30%, during both rest and exercise. Despite significant decrease of arterio-central venous oxygen difference no improvement of cardiac output was measured after 6 months on prazosin. Cardiac output increased clearly in only 4 patients, particularly during exercise. Heart rate and arterial blood pressure remained statistically unchanged. Eight patients reported subjective improvement of dyspnoea after 6 months. Prazosin plasma levels were between 9.4 and 58.6 ng/ml. Side effects such as orthostatic hypotension, urinary incontinence and disturbances of potency occurred in 4 patients. Antinuclear factors could not be demonstrated after 6 months. These data show that after 6 months of prazosin therapy haemodynamically significant improvement of pulmonary congestion can be demonstrated without concurrent increase of cardiac output. Prazosin is indicated in treatment of chronic cardiac insufficiency with predominant pulmonary congestion an an adjunct to digitalis and diuretic baseline treatment.

[Clinical correlations, lactate extraction, coronary venous bloodflow and Thallium-201 myocardial imaging in patients with isolated left anterior descending muscle bridges: normal variant or obstruction? (author's transl)]

In 848 coronary arteriograms performed in a two-years period 21 patients (2.5%) showed a myocardial bridging of the left anterior descending artery. Resting- and/or stress-ECG were abnormal in half of the patients. Regional lactate-metabolism measured in the great cardiac vein at rest and during maximal atrial pacing was normal (29 +/- 12 resp. 24 +/- 9%). Thermodilution of great cardiac vein bloodflow at rest and during atrial pacing also demonstrated normal values (94 +/- 33 resp. 138 +/- 30 ml/min). Biphasic 201-Thallium myocardial imaging revealed no case of reversible perfusion defect, but surprisingly frequent (5 of 16 patients) clearly irreversible defects limited to the interventricular septum. We conclude that muscle bridges do not cause myocardial ischemia at rest or during exercise.

[Correlation between myocardial Thallium-201 kinetics, myocardial lactate metabolism and coronary angiographic findings in hypertrophic cardiomyopathy (author's transl)]

In 20 patients with idiopathic hypertrophic obstructive and nonobstructive cardiomyopathy (IHSS), biphasic Thallium-201 myocardial scintigraphy was performed. Regional myocardial Thallium-201 kinetics of these patients were analysed by a semiquantitative computerized method and compared with those of 6 normal subjects. In 12 of 18 with IHSS and no coronary artery disease 26 regions of interest with irreversible and 6 regions of interest with reversible Thallium-201 defects could be detected. Most of the Thallium-201 defects were localized in the interventricular septum. The defects were not related to the age of the patients and there was no relationship between the occurrence of reversible Thallium-201 defects and pathological myocardial lactate extraction rate during maximal atrial pacing measured in 14 patients. The percentage (6.8%) of irreversible defect regions in patients with LV outflow obstruction at rest (n = 13) was more than twice higher compared to those (n = 5, 3.2%) without LV outflow obstruction or no provocative pressure gradient, resp. These data suggest that IHSS is often associated with regional ischemic myocardial fibrosis despite normal coronary arteries. Therefore in these patients Thallium scintigraphy cannot be used as a noninvasive screening method to exclude or prove coronary artery disease.

[Non-invasive method for recognition of coronary artery spasm: 201thallium sequential scintigraphy of the myocardium after ergotamine provocation (author's transl)]

For evaluation of coronary artery spasm 201thallium sequential scintigraphy of the myocardium after ergotamine provocation was performed in 10 patients with recurrent angina pectoris at rest and normal exercise ECG. In 9 out of the 10 patients ergotamine administration in the same dosage was repeated during the coronary angiography. A reversible defect in the 201thallium scintigram representative of regional myocardial ischaemia developed in 9 patients after ergotamine. Only in 4 out of the 9 patients angina pectoris and ST elevation were present at the same time. In all cases coronary spasm after ergotamine was demonstrable in the coronary angiogram; in the 4 patients with ergotamine-induced Prinzmetal angina pectoris it consisted of complete vascular occlusion, in the asymptomatic patients of incomplete vascular narrowing of a higher degree. In all cases the spasm could be relieved by ergotamine antidotes within a few minutes.

[Left ventricular hemodynamics at rest and during exercise in patients with idiopathic mitral valve prolapse syndrome (author's transl)]

Idiopathic Mitral Valve Prolapse has been regarded by some authors as a primary cardiomyopathy. To determine, if left ventricular hemodynamics at rest and during exercise are impaired, 20 young symptomatic patients with idiopathic mitral valve prolapse, proven by echo- and phonocardiography, without coronary artery disease or severe mitral regurgitation, underwent supine bicycle exercise stress testing. Pulmonary artery pressure, central venous oxygen saturation and cardiac index as well as heart rate were measured with a Swan-Ganz thermodilution catheter and the results compared with those of 10 voluntary normal subjects. Variance analysis showed no significant differences in global left ventricular hemodynamics between patients with idiopathic mitral valve prolapse and normal subjects at rest as well as during exercise. In addition no significant differences were found between patients with echocardiographical holosystolic or mesosystolic mitral valve prolapse. In patients with idiopathic mitral valve prolapse, global left ventricular hemodynamics are not impaired neither at rest nor during exercise.

[Anti-arrhythmic effect of tocainide (lidocaine congener) on ventricular arrhythmias (author's transl)]

The antiarrhythmic effect of tocainide, an amine analogue of lidocaine, was tested in the course of a double-blind trial on 12 patients with ventricular arrhythmias. Daily dose was 400 or 600 mg every eight hours. In all tested patients the frequency of ventricular extrasystoles, analysed by means of ambulatory 24-hour ECG monitoring, decreased by an average of 70%. In four of nine patients the severity of the ventricular extrasystoles (Lown's classification) was improved by at least one functional class. There was no correlation between the anti-arrhythmic effect and the plasma level of tocainide, which was between 4.1 and 9.7 micrograms/ml. Four patients had side effects in the form of CNS symptoms, but the drug did not have to be discontinued. Tocainide is an orally effective antiarrhythmic drug, an alternative in the treatment of ventricular arrhythmias.

[Left ventricular relaxation and filling abnormalities in patients with HOCM and left ventricular pressure overload (author's transl)]

In order to test the hypothesis that delayed mitral valve opening (MO) with regard to endsystolic dimension (t DS-MO) is specific for hypertrophic obstructive cardiomyopathy (HOCM), LV echograms of patients with different forms of LV hypertrophy due to chronic pressure overload (CPO; aortic stenosis + arterial hypertension, n = 24) and hypertrophic obstructive cardiomyopathy (n = 24) were recorded, digitized and compared with those of normals (N :n = 28(. In patients with HOCM (93 +/- 37 ms; p less than 0.0001) and CPO (66 +/- 31 ms; p less than 0.0001) the time t DS-MO was significantly delayed compared with N (13 +/- 15 MS), due to abnormal relaxation. This prolonged relaxation time resulted in an abnormal diameter increase (delta D) during the isovolumic relaxation phase (HOCM: 4.0 +/- 2.2 MM/CPO: 3.0 +/- 1.8 mm; p less than 0.0001/N:0.6 +/- 0.5 mm) and the rapid filling phase (HOCM 7.6 +/- 2.7 mm; p less than 0.0001/CPO 9.2 +/- 2.9 mm; p less than 0.05 / N: 10.7 +/- 2.2 mm). The echocardiographical signs of an abnormal relaxation are not specific for HOCM, they can be seen in different forms of secondary LV hypertrophy and are accompanied by changes in the diastolic filling pattern.

[Reversible myocardial ischaemia or irreversible myocardial fibrosis? Differentiation by biphasic 201thallium scintigraphy (author's transl)]

The results of biphasic 201thallium (201Tl) scanning were compared with those of coronary arteriography, left ventricular angiogarphy and stress ECG in 56 patients with coronary artery disease and six with no evidence of heart disease. There were 104 201Tl defects, 50 of them reversible. The defects were always located in the area supplied by a critically stenotic coronary artery. Correlation of regional wall motion with 201Tl activity demonstrated that in all forms of abnormal wall motion there was either ischaemia or fibrosis. The resting LV angiogram thus does not make it possible to distinguish between myocardial ischaemia and fibrosis. Taking the LV angiogram as a standard, the rate of false-positive 201Tl scintigrams was 5%, that of false-negative ones 23%. The biphasic 201Tl scintigram was more sensitive than the stress ECG in detecting myocardial ischaemia. It furthermore made it possible to localize the ischaemic (or fibrotic) region within the LV and to estimate its size.

[Short-term localized myocardial ischaemia and its consequences in Prinzmetal angina pectoris (author's transl)]

In a 45-year-old female patient with Prinzmetal angina pectoris coronary angiograms and a 201thallium scintigram were performed during an ergotamine-induced episode of angina. The spontaneous and the ergotamine-induced attacks were characterized by transient ST elevation in the posterior wall ECG leads. The coronary angiogram during the attack showed spasm of the circumflex branch of the left coronary artery. In the 201thallium scintigram a large defect in myocardial thallium uptake was noticed in the posterior wall of the left ventricle. Angina and ECG abnormalities disappeared within 4 minutes. However, the scintigraphic defect disappeared only after 6 hours. The slow recovery of myocardial thallium uptake is thought to represent an alteration of the myocardium after a brief 4 minute interruption of regional coronary arterial blood flow. The diagnostic approach in patients with Prinzmetal angina is discussed.

Left ventricular hemodynamics and function in acute myocardial infarction: studies during the acute phase, convalescence and late recovery

The left ventricular hemodynamics of 70 patients with acute myocardial infarction were determined from measurements of pulmonary arterial end-diastolic pressure, cardiac index, mean arterial pressure and heart rate during the acute phase(first study, 5 hours after admission), 4 to 6 weeks later (second study, during convalescence) and in 35 percent of all subjects 6 to 12 months after the acute infarction (third study). Serial analysis of serum creatine kinase was carried out during the acute phase. The peak CK value normalized for body surface area was used as a rough index of the extent of the acute myocardial necrosis. The condition of all survivors of the acute stage improved. Patients with only slightly reduced left ventricular performance during the acute stage recovered to nearly normal during convalescence. The condition of patients with greatly reduced left ventricular function also improved but remained impaired during convalescence. In all patients the main changes in left ventricular hemodynamics occurred within the first 4 to 6 weeks; there was almost no further alteration during the following 9 months.