[Silent myocardial ischemia]

Silent myocardial ischemia seems a relatively frequent manifestation of coronary insufficiency. The practice of more and more sophisticated tests to detect myocardial ischemia shows that it is a relatively frequent pathological occurrence. It occurs in patients with an abnormality or a transient or constant failure of the alarm system, represented by pain during the ischemia. It is an heterogenous picture which may take the appearance of a completely silent ischemia (the metabolic, hemodynamic and electrical consequences of ischemia being the only symptoms of coronary insufficiency, demonstrated by the presence of severe, angiographic or anatomical, stenoses); of a silent transient ischemia (with alternance of symptomatic and silent episodes or with silent episodes after myocardial infarction); of myocardial necroses without pain or ischemic myocardiopathies. It is the consequences of either an ischemia which is too moderate to reach the pain threshold, or a severe ischemia in patients presenting alterations of the transmission system and of the perception of pain. It has metabolic, hemodynamic and anatomical consequences which may lead to necrosis or degeneration and fibrosis of the myocardium. The prognosis of a painless disease is difficult to make but it does not seem to be as poor as the one of the usual forms of ischemic cardiopathies. Medical treatment is mandatory, and surveillance of its efficacy must be systematic using the techniques of detection of the ischemia.

[Coronary revascularization at the acute phase of myocardial infarction. Short and median-term survival of 359 patients. Multicenter study]

Three hundred and fifty nine consecutive patients from 4 different French centres who underwent attempted early coronary revascularisation during the acute phase of myocardial infarction by intracoronary thrombolysis (309 cases) intravenous thrombolysis (26 cases) and transluminal angioplasty (24 cases) were reviewed to evaluate the short and medium term results of these non-surgical techniques. Three groups of patients were identified from the results of initial and secondary coronary angiography: 1) deaths during the procedure (1.9%), 2) successes, with immediate and stable revascularisation (65%), 3) failures, also including initial successes with secondary reocclusion (33.1%). The global mortality at one month was 10.9%. This was significantly lower after revascularisation (p less than 0.001): 4.7% in patients with successful procedures and 17.6% in the others. The one year survival rate was also significantly higher in patients successful revascularisation (93 +/- 4% vs 75 +/- 8%, p less than 0.001). There were more recurrent infarctions and residual angina in patients with successful early coronary revascularisation: 7.7% and 12% respectively vs 4.2% and 8.4% respectively in the other patient group. In the successful group, 200 patients (86%) had one or more stenoses greater than 70% narrowing after coronary revascularisation. The recurrent infarction rate in the 94 patients treated medically was 9% and 17% had residual angina compared to 6% and 10% respectively in the 106 patients referred for coronary bypass surgery or undergoing complementary angioplasty. Three conclusions may be drawn from this non-randomised study of coronary revascularisation during the acute phase of myocardial infarction: attempts at coronary revascularisation do not aggravate the immediate prognosis of myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of cardiac failure with enalapril]

The fall in cardiac output observed in cardiac failure induces stimulation of the renin-angiotensin-aldosterone system. This results in strong constriction of the arterioles which in turn increases the fall in cardiac output and aggravates myocardial alteration. Angiotensin-converting enzyme inhibitors therefore act on a major physiological mechanism of cardiac failure. In this double-blind study 36 cardiac failure patients treated with digitalis derivatives and diuretics were divided into two groups: one group received enalapril in addition to the other drugs, the other group received a placebo. The functional symptoms, exercise tests, left ventricular function and haemodynamic values were improved in two-thirds of the patients treated with enalapril, whereas no improvement was observed in those who received the placebo. Enalapril maleate was given by injection to 10 patients with acute left ventricular failure following myocardial infarction; a useful fall in pulmonary capillary pressure and systemic arterial resistance occurred within one hour. Enalapril represents an effective physiopathological treatment of severe cardiac failure.

[Anti-arrhythmia and electrophysiological effects of encainide in supraventricular tachycardias]

In order to assess the electrophysiologic effects and anti-arrhythmia effects of encainide after acute IV injection and chronic oral therapy, a group of 10 patients (mean age 54) with recurrent supraventricular tachycardia was studied. Seven patients had more than 2 attacks per month, and supraventricular tachycardia (SVT) resulted in severe symptoms in the three remaining SVT was due to AV nodal re-entry in 6 patients and to concealed accessory pathway in 4. After a control study, SVT was initiated, and encainide (0.75 mg/kg) was infused intravenously in attempt to stop the tachycardia. A second study was achieved. After 4 days of oral therapy (25 or 50 mg T.I.D.) a third study was performed, including SVT initiation attempts. Encainide depressed conduction in all cardiac tissues, and this effect was more evident after oral administration. Antegrade I:I conduction cycle length increased of 13.9% (p less than 0.05), and the same parameter in retrograde conduction increased of 30.03% (p less than 0.05). IV injection interrupted 2 of 10 SVT only. However, after 30 minutes, 5 re-initiated SVT were nonsustained, and mean cycle length increased from 326 +/- 21 to 397 +/- 51 (p less than 0.01). After oral therapy, SVT was initiated in 4 of 10 patients, nonsustained in 3. During long term follow-up (one year or more), no severe adverse effect has been reported. Three patients are still experiencing short events of well-tolerated SVT. Hence, moderate or low doses or oral encainide may safely control recurrent supraventricular tachycardia.

[Oral propafenone in resistant auricular arrhythmia]

Paroxysmal episodes of atrial frequently cause severe functional disturbance because of their recurrent nature. Propafenone (Rythmol) is a very active anti-arrhythmic at the ventricular level which acts by decreasing the rate of atrio-ventricular and intra-ventricular conduction and by prolonging the refractory period of the right atrium and the accessory pathways. The authors conducted an open study of this drug in 20 cases with resistant, recurrent atrial fibrillation. All of the patients were known to have recurrent episodes of atrial fibrillation which could not be prevented by a variety of antiarrhythmic agents. They performed a clinical, electrocardiological and laboratory evaluation of these patients. Holter monitor recordings were performed prior to entry into the study, during the first week of treatment, between the 4th day and the 8th day, on the 20th day, at the 2nd month and between the 3rd and 6th months. Propafenone was prescribed at a dose of 900 mg per day and the initial dose was reduced to 600 mg after the 3rd month of treatment. Five patients can be classified as therapeutic failures, as the arrhythmia recurred. These patients presented a "vagal" atrial fibrillation preceded by an episode of bradycardia. 15 patients can be considered to have obtained a successful result, as no recurrences were detected during the 6 month observation period. The electrical and laboratory tolerance was satisfactory. The most frequent side effects were minor transient gastrointestinal disturbances.

[Coronary angioplasty immediately after intracoronary thrombolysis during the acute phase of myocardial infarction]

Since the introduction of intracoronary thrombolysis in the acute phase of myocardial infarction, all workers have observed a high incidence of coronary reocclusion (about 20%) essentially in the first hours and days after coronary recanalisation (CR). This had led to some groups carrying out transluminal coronary angioplasty (TCA) at the same time as CR by thrombolysis in situ to treat significant residual postthrombolysis stenosis. This french multicentre study carried out in 5 centres concerned 9 men (average age: 46.1 years) with 5 anterior infarcts (total thrombosis of the LAD artery) and 4 inferior infarcts (total thrombosis of the right coronary artery-RCA). Intracoronary trinitrate was ineffective in relieving the occlusion in all cases. In 5 cases, the thrombolytic protocol was streptokinase (SK) 3 000 u/min for 60 minutes; in the other 4 cases, the plasminogen-urokinase (Pg-UK) protocol was used. Thrombolysis was successful in all 9 cases. The results of TCA performed at the same time were also good (8/9 successes; 4 LAD and 4 RCA) without any complications during the procedure. There was only one immediate post-TCA reocclusion on a LAD artery. In all cases the initial ECG appearances of infarction remained, CR only appearing to prevent extension of the necrosis. The successful results of CR + TCA were maintained in 6 out of 7 patients reinvestigated 2 days to 6 months (average 6 months) after the initial procedure: the only case of reocclusion occurred after 48 hours on a RCA. The overall procedure never exceeded 2 hours.

[So-called rudimentary or nontransmural myocardial infarction. Coronary lesions, course and prognosis]

Eighty patients admitted to hospital between 1975 and 1980 for "non-transmural" myocardial infarction (72 men, 8 women, mean age 56 +/- 9 years) were studied. The diagnosis was based on a severe attack of pain of over 30 minutes duration, increased serum cardiac enzyme levels (CKMB greater than 24 U; SGOT greater than 60 U), pyrexia and signs of inflammation. The patients were divided into two groups according to their ECG changes: Group A: "rudimentary" infarction with prolonged T wave inversion from V1 to V5, narrow transient Q waves and reduction of R wave amplitude in the corresponding leads; Group B: persistant prolonged, intercritical ST depression greater than 2.5 mm (subendocardial infarct). All patients underwent selective coronary angiography and left ventriculography in the RAO projection within 15 days of admission. The angiographic data (coronary score, ejection fraction, alinetic perimeter) were compared to those of 2 randomly chosen control groups: Group C: 30 inferior wall infarcts with coronary angiography and regularly followed-up; Group D: 30 transmural anterior infarcts with coronary angiography, regularly followed-up. Four factors were analysed during follow-up: the incidence of death after discharge from hospital, transmural infarction, unstable angina and cardiac failure. All patients were treated medically (nitrate derivatives, betablockers, calcium antagonists). Sixteen patients in Group A (p less than 0,025) were operated and excluded from the prognostic study. The angiographic data showed a high incidence of isolated, severe LAD disease in Group A (59.2% of cases) and that multivessel disease was commoner in Group B (78.4%). A collateral circulation revascularising the LAD was observed in 42% of patients in Group A. (ABSTRACT TRUNCATED AT 250 WORDS)

[Value of provocation tests in the evaluation of the treatment of ventricular tachycardias with amiodarone]

The role of provocation tests for the assessment of amiodarone therapy in patients with ventricular tachycardia remains a subject of controversy: recent studies seem to show that the ability to initiate VT in patients on amiodarone is compatible with a good long-term result. Eighteen patients, 16 male and 2 female, average age 56 years, were treated with amiodarone (600 mg/day in 15 cases, and 400 mg/day in 3 cases) and submitted to provocative tests before and after treatment. The mean follow-up period was 14 +/- 4 months. In Group I (5 patients), VT could not be initiated after treatment and there were no relapses of the arrhythmia. In Group II (6 patients), non-sustained VT could be initiated and only one relapse was observed after a close reduction from 600 to 400 mg/day; Group III comprised 5 patients with spontaneous recurrences. An identical VT could be initiated during electrophysiological investigation which served as a basis for selection of an effective antiarrhythmic association. Two patients could not be studied after drug impregnation (1 sudden death, 1 exacerbation of VT). The results of this study show that provocative pacing can be useful in evaluating the efficacy of amiodarone, as in Groups I and II (61% of patients) a favourable prognosis could be predicted in 91% of cases. In cases of therapeutic failure with spontaneous recurrences of VT, the same provocation tests enabled a more effective drug combination to be selected.

[Evaluation of ventricular tachycardia by endocavitary stimulation. Apropos of 46 cases]

Thirty six patients (21 coronary artery disease, 8 cardiomyopathy, 3 mitral valve prolapse and 4 apparently normal) underwent endocavitary stimulation studies. The protocol consisted in delivering one or two right ventricular extrastimuli and twice the diastolic threshold either during spontaneous rhythm (S2 and S2-S3) or a paced ventricular rhythm (S1-S2 and S1-S2-S3). In 9 patients overdrive ventricular pacing at 150-200 bpm was required. Thirteen of the 15 documented sustained ventricular tachycardias could be induced by electrical stimulation (87%). In addition, 9 sustained ventricular tachycardias were induced in patients in whom the symptomatology corresponded to poorly tolerated tachycardia but in whom the documented arrhythmia was non-sustained ventricular tachycardia (4 cases), frequent ventricular extrasystoles with doublets (2 cases) or rare, isolated ventricular extrasystoles (3 cases). The method was less sensitive in non-sustained ventricular tachycardia in which the arrhythmia was induced in 10 of the 17 cases (59%). An antiarrhythmic drug was selected on the basis of these studies in 28 patients, 21 of whom had sustained ventricular tachycardia. There were 6 therapeutic failures with a follow-up of 6 to 24 months, three of which were observed in patients with coronary artery disease and a precarious haemodynamic state. This subgroup is not suitable for this type of evaluation. After reviewing other published series the authors emphasise the value of these investigations in chronic sustained ventricular tachycardia, in ventricular tachycardia with cardiovascular collapse and in the assessment of syncope of unknown origin. However, the systematic investigation of repetitive ventricular responses after ventricular stimulation in patients at high risk of sudden death remains controversial.

[Electrophysiological effects of encainide in man]

Encainide is an antiarrhythmic agent under evaluation; it is effective in ventricular and supraventricular arrhythmias. Its electrophysiological effects seem to differ according to the route of administration, oral or intravenous, probably because of the effects of active metabolites. Two electrophysiological studies were carried out in 20 patients, under basal conditions, and after 4 to 10 days oral administration at doses ranging from 75 to 300 mg/day. Encainide depressed intra-atrial conduction (prolongation of the P-A interval from 29,7 +/- 2,2 to 36 +/- 4,5 ms, p less than 0,01), slowed conduction in the atrioventricular mode (prolongation of the A-H interval from 74 +/- 14 to 98 +/- 15 ms, p less than 0,01) and the His-Purkinje system (lengthening of H-V from 50 +/- 3 to 70 +/- 6,2 ms, p less than 0,001). The sinus node function was depressed with lengthening of the corrected sinus node recovery time (297 +/- 64 to 387 +/- 71 ms, p less than 0,01) and of the sinoatrial conduction time (173 +/- 25 to 219 +/- 43, p less than 0,01). The atrial and ventricular refractory periods were significantly longer (245 +/- 16 ms to 273 +/- 10 ms, p less than 0,001, and 237 +/- 12 to 266 +/- 19 ms, p less than 0,01, respectively). This new antiarrhythmic agent therefore seems to act at all levels which suggests that it may have wide ranging antiarrhythmic effects.

[Oral and injectable amrinone in cardiac insufficiency]

The authors report the results of a study of amrinone which was prescribed orally and by injection. 12 patients with stage III congestive heart failure were treated with oral amrinone. Prior to inclusion in the trial, all of the patients underwent a complete clinical, radiological and laboratory examination. They were examined by ergometric haemodynamic tests with measurement of the cardiac output and by echocardiography. After discharge from hospital, the patients were reviewed clinically every week and cyclo-ergometric and echocardiographic examinations were performed at 4, 8 and 12 weeks. At the end of the study, a further haemodynamic survey was performed in 8 patients. Two patients left the trial because of thrombocytopenia which appeared between the 10th and 25th day of treatment and 2 others left the trial (1 death, 1 treatment failure). In the 8 patients who completed the trial, the authors found: a functional improvement (improvement by one NYHA class within 3 months), a mean gain of 40 Watts at the last stress test, an 11% improvement in the ejection fraction and in the rate of circumferential shortening, a decrease in the filling pressure (16 mm Hg) and an improvement in the cardiac index (mean of 700 ml). A haemodynamic study was conducted in 4 patients who received amrinone by injection (1 mg/kg by slow intravenous injection, followed by an infusion of 10 ng/kg/min). The authors observed a mean drop in left ventricular end-diastolic pressure of 9 mm Hg an increase in the cardiac index of 1.02 l/min/m2, without any significant variation in the mean blood pressure or the heart rate.

[Threatened extension of myocardial infarction in situ and coronary spasm]

The authors report a case of threatened spread occurring 4 days after posterior-inferior myocardial infarction and involving the same territory. The spontaneous occurrence during coronary angiography of an occlusive spasm of the right coronary artery with recurrence of angina and ST elevation in the area of initial necrosis suggests that this mechanism might be the contributory factor to the threat of in situ spread. Thus intermittent coronary occlusion from repeated spasm can bring about incomplete necrosis of the area of dependent myocardium and by extension threaten the viability of groups of still healthy cells. A syndrome of this kind initially requires coronary-dilating medical treatment, with nitrate derivatives and calcium inhibitors and then early coronary angiography with the use of pharmacodynamic tests to assess the suitability of surgery.

[Effect of captopril in left ventricular failure during the acute stage of myocardial infarction]

The oral inhibitor of the converting enzyme of angiotensin has previously been used successfully in the treatment of chronic cardiac failure. Its action as an arterial and venous vasodilator and in significantly reducing the heart rate which we have previously reported, led us to assess its effects in left ventricular failure during acute myocardial infarction. The effects of captopril were compared with those of isosorbide dinitrate in 10 patients with left ventricular failure during acute myocardial infarction. An arterial and venous vasodilatation was obtained with both drugs. Captopril induced a greater fall in left ventricular filling pressures and significantly reduced the heart rate, leading to a slight increase in left ventricular systolic work index. Pulmonary arterial resistances decreased more significantly with captopril whilst systemic arterial resistances fell equally. The left ventricular function curve was shifted to the left by both captopril and isosorbide dinitrate, but only captopril induced an upward shift and only captopril caused very significant reductions in the rate-pressure product. The plasma renin activity of these patients was high but the correlation with the vasodilator effect was poor. There was little change in medium-term survival (50% mortality). These results indicate that captopril may be a valuable drug in the treatment of left ventricular failure in acute myocardial infarction. However, its oral presentation makes it difficult to determine the optimal dose.

[Myocardial infarction before the age of 35. Clinical and coronarographic aspects]

Myocardial infarction under the age of 35 is no longer a rarity. A series of 22 patients exhibited all the usual epidemiological, clinical and angiographic features of the disease: risk factors, predominantly excessive smoking associated with dyslipoproteinaemia in 50% of the cases; onset during exercise in one quarter of the cases, more frequently than in elderly people; and absence of significant lesions at angiography in one third of the cases. Angiography of the coronary arteries, performed in the early stages of infarction in 5 patients, demonstrated the presence of several factors in the pathogenesis of arterial occlusion in young people, i.e. thrombosis in almost every case, arterial spasm in 10% of the patients and atheromatous plaques with little or no stenosis in one half.

[Side effects induced by captopril. Comparison of a series of hypertensive patients with renal failure and a series with cardiac failure]

The first oral converting enzyme inhibitor, Captopril, has been used to treat hypertension and cardiac failure since 1978. Based on this two year experience, we studied the side-effects of this drug in 64 patients, a privileged series as it included 32 hypertensive patients with chronic renal failure and 32 patients with cardiac failure and normal renal function. After 16 months of treatment, we observed 19 p. 100 of skin complaints, 17 p. 100 disturbance of taste, 6 p. 100 oral problems, and one case of orthostatic hypotension. From the biological point of view: 20 p. 100 eosinophilia, 10 p. 100 hyperkalemia, 5 p. 100 antinuclear antibodies, 2 p. 100 renal failure, and one case of agranulocytosis. The group with renal failure had many more side effects due to a relative dosage (corrected for weight and renal function) which was three times as great. It would therefore appear to be essential to adapt the dosage in each individual case, a task which we have attempted using a formula which considerably reduced the incidence of side effects in our series: (formula; see text)

[Are calcium inhibitors useful in the treatment of effort angina pectoris]

Effort angina is the result of acute myocardial ischemia on exercise due to an imbalance between myocardial oxygen demand and supply. During exercise, ischemia is provoked by an increase in myocardial oxygen needs (tachycardia, increased blood pressure, etc.) which cannot be met by increased coronary blood flow. The commonest cause of insufficient flow is coronary atherosclerosis. Coronary spasm does, however, play a role, whether it occurs during exercise on normal or atheromatous coronary vessels. Classical anti-anginal therapy is directed towards a reduction in the intense adrenergic activity associated with exercise, and to the limitation of myocardial oxygen consumption. Calcium inhibitors which cause peripheral vasodilation, decrease ventricular wall tension and coronary resistance, are usually reserved for unstable or resistant angina. We studied 10 patients with stable effort angina for over 2 years with significant (greater than 70 per cent) atheromatous lesions on coronary angiography unsuitable for surgical treatment. The patients underwent a randomised double blind trial to compare the effects of propranolol, diltiazem and placebo. Exercise ECG was performed after a treatment period of one week, 3 hours after drug administration. The results showed a significant improvement of work capacity with propranolol and diltiazem as compared to placebo. Propranolol (160 mg/day) was more effective than diltiazem (180 mg/day) in 6 patients. In 4 cases, the improvement with diltiazem and propranolol was the same. The association of the two drugs in one open study in 5 patients was even more effective in 3 patients. The small number of patients studied makes it impossible to draw any firm conclusions. Although calcium inhibitors are the treatment of choice in coronary spasm and betablockers in effort angina, diltiazem exerts an anti-anginal effect by reduction of myocardial oxygen consumption without depression of myocardial contractility, as other workers have shown.

[Isosorbide dinitrate in the treatment of threatening myocardial infarction (author's transl)]

Thirty patients with threatening myocardial infarction were treated with intravenous isosorbide trinitrate. Eight patients had increasingly severe angina, 6 had de novo crescendo angina, 3 had Prinzmetal angina and 13 had signs of impending extension of a previous infarct. In all cases the anginal attacks occurred spontaneously. The drug was administered in association with a beta-blocker or a calcium antagonist. The initial dosage was 33 mcg/min and dosage adjustments ranged from 16 to 130 mcg/min. the main duration of treatment was 3.6 days. Pain was controlled in all patients. Anginal attacks ceased completely and permanently in 24, but the remaining 6 became isosorbide dinitrate-dependent and could only be weaned by aortocoronary bypass. The effects on the drug on heart rate and blood pressure remained moderate and never interfered with dosage adjustments. Coronary artery angiography was performed without any trouble in 25 patients, 21 of whom underwent myocardial revascularization by venous grafts.

[Ventricular extrasystoles in the convalescence phase of myocardial infarction. Relation to angiographic data]

A series of 80 patients hospitalised for recent myocardial infarction underwent: --three continuous ambulatory 24 hour recordings (Holter method) on the 15th, 22nd days, and 6 months after infarction; --selective coronary angiography with left ventriculography, with a study of left ventricular performance and analysis of segmental contractility (Leighton's method). Five patients died over a mean follow-up period of 16 months. At the third week when physical activities were reintroduced 72,3 p. 100 of patients had frequent ventricular extrasystoles (Lown's Class II) or repeated ventricular extrasystoles (Classes III, IV, V). Holter monitoring gave reproducible results with a tendency to aggravation between the Ist and the 6th month (repetitive ventricular activity increasing from 35 to 45 p. 100). 55 p. 100 of posterior infarcts had few extrasystoles whilst 47 p. 100 of anterior infarcts had severe arrhythmias (Classes III, IV and V). There was a significant correlation between the presence of multivessel disease and severe ventricular extrasystoles 60 p. 100 of patients with multiple vessel lesions had repetitive ventricular activity (p less than 0,02). Positive correlations were established between: severe ventricular arrhythmias and a reduction in ventricular ejection fraction (p less than 0,01), dyskinesia in the infarcted zone (p less than 0,01) and reduction in wall motion of the non infarcted zones. The presence of incomplete occlusion of early revascularisation by collateral circulation in the infarcted zone seemed to favour severe ventricular arrhythmias. Five patients died (arrhythmias or cardiac failure): the association of severe hypokinesia and reduced left ventricular performance with repetitive ventricular activity was demonstrated. It is concluded from the correlations obtained between ventriculography and continuous electrocardiographic monitoring that repetitive ventricular activity is associated with severe reduction in left ventricular performance. The immediate gravity and poor prognosis of the ventricular arrhythmias are the result of the extent of the myocardial damage.

[Cutaneous cholesterol in the young and aged coronary patient]

Serum cholesterol (ch), its lipoprotein fractions and triglycerides were measured in three populations of proven coronary patients (less than 50 years, n = 56; between 50 and 65 years, n = 56; greater than 65 years, n = 23); the risk factor total ch/HDL ch was calculated. The level of skin cholesterol was also estimated by skin biopsy in each patient and compared to that of three control populations of the same age. The results indicated that 1) there was no significant difference in skin cholesterol of patients with myocardial infarction whatever their age, 2) there was a significant difference (p less than 0,001) with control subjects of the same age except in the over 65 population, 3) the total cholesterol was normal in all three groups, 4) the HDL cholesterol of coronary patients over 50 year old was normal and slightly reduced in younger coronary patients, 5) the ratio total ch/HDL ch was increased in coronary patients under 50, but normal after this age, 6) the triglyceride level was higher in the young coronary patients than in those over 50 years old. Four conclusions are drawn: 1) the total Ch/HDL ch ratio is a good indicator of coronary risk in patients under 50 years old but shows less sensitive variations than the level of skin cholesterol, 2) the ch/HDL ch in coronary patients between 50 and 65 years old is normal; the only laboratory finding which correlates with the coronary event is skin cholesterol; after 65 years of age the skin cholesterol stabilises to the same levels as found in control subjects; 3) from the outset, at whatever age infarction occurs, skin cholesterol is increased (about 0,45 mumol/100 ngr of fresh skin), whilst the risk factor is higher in the younger population; 4) skin cholesterol shows less variation in the three coronary groups than the other blood parameters measured. It would therefore appear to be a very discriminating index of coronary atherosclerosis.

Beneficial effects of captopril in left ventricular failure in patients with myocardial infarction

1 Ten patients with acute myocardial infarction and left ventricular failure were studied. Acute myocardial infarction was anterolateral in eight patients, posterolateral in one, and anteroseptal in one. Three patients were grade II, 4 grade III, and 3 grade IV of Killip's classification. None presented with arterial hypertension but mean values of plasma renin activity and serum aldosterone were 20.7 ng/ml/h and 13.5 ng/100 ml. Haemodynamic measurements were performed by using a flow-directed catheter. Cardiac output was determined in triplicate by thermo-dilution (Edwards computer). Classic haemodynamic measurements included: heart rate, cardiac index, stroke volume index, stroke work index, blood pressure, right atrial pressure, pulmonary vascular resistance, systemic vascular resistance, and pulmonary diastolic blood pressure. Curves of ventricular function correlating stroke work index and pulmonary diastolic blood pressure were constructed. Haemodynamic changes after drug therapy were tested for significance using the paired t test. All patients received heparin, oxygen, and an intravenous infusion of isosorbide dinitrate.

2 Haemodynamic measurements were repeated at 30 min intervals and after isosorbide infusion until values returned to normal. The infusion was then discontinued and pressures returned to control values. At this time, oral captopril was administered, the first dose being 12.5 mg. Subsequent doses of 12.5 mg up to 50 mg were given if systolic blood pressure remained above 100 mm Hg and pulmonary diastolic pressure greater than 18 mm Hg. When the most effective oral dose was determined it was administered at six hourly intervals. This therapy resulted in an improvement of functional class, with a reduction in Killip's grade from class III to 1.7 (mean value). Heart rate, mean atrial pressure, and pulmonary diastolic pressure decreased by 10%, 32% and 41%. Cardiac index increased from 2.4 ± 0.8 l/min/m2 to 2.8 (p < 0.02) and stroke volume index increased by 37.2%. Pulmonary vascular resistance decreased by 22.14% (p < 0.001) and the product of heart rate × blood pressure decreased by 33.6% (p < 0.001).

3 Haemodynamic effects of oral captopril treatment were beneficial in left ventricular failure and acute myocardial infarction without immediate side effects. In acute left ventricular failure the renin angiotensin system was appreciably stimulated. All ten patients who were treated for a mean of 6.5 days showed a significant subjective, clinical, and haemodynamic improvement. After discharge from the coronary care unit anterolateral infarctions produced by ventricular fibrillation resulted in four deaths.

4 These data suggest that captopril may be an effective therapy in acute myocardial infarction with left ventricular failure and that it is more effective than other vasodilators. Nevertheless, more patients need to be studied for a longer period before definite conclusions can be drawn.