Nicardipine for stable angina pectoris

Nicardipine, 30 and 40 mg thrice daily, was administered to 66 patients with stable angina pectoris in a multicentre, randomised, double-blind, cross-over trial. With nicardipine therapy, duration of exercise and cumulative oxygen consumption increased, while times to onset of angina and 1 mm ST segment depression were prolonged. Anginal frequency and nitroglycerin consumption declined with use of nicardipine, but this did not reach statistical significance. Resting heart rate increased slightly and resting blood pressure decreased. Two patients on nicardipine and one on placebo sustained acute infarction. Otherwise, side effects were generally mild and transient.

Long-term effectiveness of verapamil in stable and unstable angina pectoris. One-year follow-up of patients treated in placebo-controlled double-blind randomized clinical trials

The clinical responses to 12 months' treatment with verapamil were evaluated in 63 patients with stable and unstable angina pectoris in whom the effectiveness of verapamil had been established in short-term double-blind placebo-controlled randomized clinical trials. In 41 patients with effort-related angina, long-term responses were sustained for periods exceeding 1 year. Twenty patients were evaluated by clinical history and showed a sustained reduction in frequency of anginal attacks and consumption of nitroglycerin with verapamil compared with the initial placebo control periods; the magnitude of this benefit was similar to that observed during double-blind treatment with the drug. Twenty-one patients were evaluated by serial treadmill exercise testing and showed a sustained improvement in exercise duration after 4, 8, 16, 24, and 52 weeks of verapamil treatment; withdrawal of the drug resulted in a deterioration of exercise performance to levels similar to those seen before initiation of therapy. In 22 patients with unstable angina at rest, verapamil produced an amelioration of anginal symptoms that was sustained in most patients for longer than 1 year. However, these patients continued to have a high incidence of death and myocardial infarction in a frequency similar to that previously reported in large clinical studies using either combinations of verapamil and nitrates, nifedipine and propranolol, or propranolol and nitrates. Calcium-channel antagonists may decrease the number of patients requiring coronary artery bypass surgery for relief of refractory angina, but they do not appear to alter the natural history of the disease.

Continuing medical education in New York County: physician attitudes and practices

New York County physicians were surveyed by questionnaire concerning their attitudes and practices regarding continuing medical education (CME). There were 1,558 responders, and they included those practicing in shared health facilities (SHF) and random samples of academicians on the faculties of the four medical schools and of the entire physician population of Manhattan. Reading professional books and journals was regarded as by far the most important CME activity by all three groups of physicians, and this activity consumed about four hours per week. All physicians spent several days and often as much as two weeks per year attending professional meetings and formal postgraduate courses. The former were rated as not very useful and the latter as quite useful for CME. Major impediments to CME participation for all groups were time away from home and practice, expense, loss of income, and scheduling problems. Relevance, quality, and organization of CME courses were not major impediments. SHF physicians differed little from other physicians in their attitudes, perceptions, and practices concerning CME.

Improved criteria for admission to cardiac care units

Patients requiring specialized cardiac care unit interventions (CCUIs) were identified from 414 consecutive admissions with known or suspected myocardial infarction (Ml). Cardiac care unit interventions included administration of lidocaine hydrochloride, atropine sulfate, sodium nitroprusside, or vasopressors; Swan-Ganz or arterial catheterization; insertion of temporary pacemaker; and electroshock. Almost all interventions occurred in a high-risk group that had one or more of three findings: (1) ongoing chest pain, (2) pulmonary rales, or (3) one or more ventricular premature contractions (VPCs) on 12-lead ECG. Of 306 high-risk patients, 41% received at least one CCUI, and 4% died in the CCU. In contrast, of the 108 low-risk patients with none of the three criteria, only 6% received any CCUI, and none died in the CCU. This study suggests that patients who do not have ongoing pain, congestive heart failure, of VPCs when first evaluated have a very low risk of early complications and may not require intensive care.

Coexisting hypertrophic heart disease and mitral valve prolapse. A continuum of hereditary cardiac disease?

The finding at autopsy of typical pathologic features of hypertrophic heart disease (idiopathic hypertrophic subaortic stenosis, IHSS) and mitral valve prolapse (MVP) in a single patient prompted study of a number of close relatives of this patient. Several additional cases of IHSS or MVP were found. The HLA typing of this kindred revealed that four out of seven members tested had the Bw 35 antigen. Although the association might be due to chance, this kindred, together with prior reports of similar bizarre myocardial cellular disarray in HISS and MVP, suggest the hypothesis that in some instances, IHSS and MVP may represent a continuum of hereditary cardiac disorders.

Effect of additional valve lesions on left ventricular ejection time in aortic stenosis

Rate-corrected left ventricular ejection time was measured from the aortic pressure tracings of 171 catheterised patients with aortic valve area less than or equal to 1.2 cm2. In 50 patients with pure aortic stenosis, left ventricular ejection time in increased with decreasing valve area and was significantly higher (468 +/- 5 ms, mean +/- SEM) than in 13 normal subjects (435 +/- 5 ms). Additional aortic regurgitation in 72 patients further increased the left ventricular ejection time to 484 +/- 4 ms. Significant mitral stenosis (mitral valve are less than or equal to 1.2 cm2) in 6 patients with aortic stenosis and 33 patients with aortic stenosis and regurgitation reduced the left ventricular ejection time to normal. Similarly, severe mitral regurgitation in 3 patients with aortic stenosis and regurgitation reduced left ventricular ejection time to normal, though slight or moderate mitral regurgitation in 4 of these patients did not. These data show that the prolonged left ventricular ejection time in aortic valve disease may be restored to normal in the presence of coexisting significant mitral disease.

Serum myoglobin in myocardial infarction: the "staccato phenomenon." Is acute myocardial infarction in man an intermittent event?

When serum was sampled frequently and soon after acute myocardial infarction, myoglobinemia was extremely common, occurring in 12 of 13 selected patients. Myoglobin first appeared in the serum within a few hours after infarction, but not consistently earlier than creatine phosphokinase. The peak level of serum myoglobin was reached appreciably earlier than the peak values of serum creatine phosphokinase activity. Time of earliest myoglobin appearance in the serum, peak level of myoglobin measured, and duration of detectable myoglobin release all correlated poorly with clinical and biochemical estimates of severity of myocardial infarction. There was no correlation between myoglobin levels and infarct size as estimated from creatine phosphokinase kinetics. Myoglobin appeared in the serum in multiple short "staccato" bursts, or episodes, often lasting only one to two hours. The hypothesis is suggested that the pattern of myoglobin appearance is a reflection of the episodic nature of acute myocardial infarction. Although isolated myoglobin determination may not be useful at present, for quantification of total myocardial damage, its pattern of release may be a sensitive marker for studying the time course of infarction, and may be useful to evaluate therapeutic interventions designed to interrupt an ongoing syndrome of myocardial necrosis.

Aspirin therapy in angina pectoris: effects on platelet aggregation, exercise tolerance, and electrocardiographic manifestations of ischemia

If altered platelet function contributes to poorly perfused zones of myocardium in patients with angina pectoris, then specific antiplatelet therapy might improve cardiovascular function and exercise performance. Exercise tolerance on a bicycle ergometer, heart rate-blood pressure product, and ischemic ECG changes at exercise end-point were compared before and during oral aspirin therapy (2.4 Gm. per day for 2 weeks) in 11 normal subjecs and in 11 patients with stable angina pectoris. Platelet aggregation threshold in response to ADP and epinephrine was measured. Untreated patients had increased platelet aggregability when compared to normal subjects...

Myoglobinemia following acute myocardial infarction

Myoglobin was identified in the serum of 11 of 21 patients after myocardial infarction by a sensitive specific complement fixation technic. This method allowed detection of as little as 0.03 mug of myoglobin. The assay tended to underestimate small concentrations of myoglobin due to serum interference. Myoglobinuria occurred with myoglobinemia but did not reflect the level of myoglobinemia or the duration of elevated serum levels. Larger amounts of myoglobin, 0.4 mug/ml or greater, were found in patients with severe infarctions, three of four of whom died as a result of this illness.

Pathophysiology of cardiogenic shock. Quantification of myocardial necrosis, clinical, pathologic and electrocardiographic correlations

Clinical and pathologic data were correlated in 22 patients with cardiogenic shock and 10 "control" patients who died suddenly after infarction without shock. A pathologic technique of ventricular mapping allowed quantification of recent as well as old infarction. Total left ventricular (LV) damage averaged 51% (range 35-68%) in the shock patients and 23% (range 14-31%) in the control group. Shock was associated with recent infarction (all 22 patients), old infarction (21 patients) and extension of infarction (18 patients). Extension, often in a subepicardial manner, averaged 6% of LV mass (range 3-10%) in 18 patients with shock; it preceded shock in four, coincided with the onset of shock in six, and followed shock in seven patients with shock. In contrast, small extensions averaging 2% of LV mass were found in three, and multiple recent infarctions in two control patients. Although progressive myocardial damage was a common pathologic finding, it was infrequently recognized clinically. The electrocardiogram reflected evidence of recent infarction in 56%, old infarction in 31%, and extension in only 30% of patients. These data suggest that appropriate early therapeutic intervention might limit myocardial damage by preventing extension or reinfarction. Since shock was best correlated with total LV damage, such limitation of infarction might reduce the incidence and mortality of cardiogenic shock.

Objective haemodynamic assessment after acute myocardial infarction

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Lactate metabolism after aorto-coronary artery vein bypass grafts

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