Ventricular tachycardia during exercise treated by verapamil

The case history of two patients with symptomatic ventricular tachycardia is described. The first patient with systolic narrowing of a segment of the left anterior descending artery did not show any improvement on class I and III antiarrhythmic drugs. Oral verapamil suppressed the arrhythmia which showed some features of triggered activity. Cessation of the drug resulted in symptomatic recurrence. The second patient presented with a sustained ventricular tachycardia showing the morphology of right bundle branch block and left axis deviation. During electrophysiologic study the tachycardia was not inducible after oral verapamil. No definite conclusion on the mechanism of the arrhythmia could be drawn, nor on the mechanism of the antiarrhythmic action of verapamil in the first patient. Appropriate techniques to prove the efficacy of verapamil are needed in patients when it is given for chronic treatment of ventricular tachycardia.

Pulse wave velocity recordings in a family with ecchymotic Ehlers-Danlos syndrome

Pulse Wave Velocity (P.W.V.) is recorded pneumatically in 27 members of a large family with ecchymotic Ehlers-Danlos syndrome, and compared to registrations in 216 normal subjects. Five relatives, ranging from 3 to 50 years of age, are found to have lowered P.W.V., indicating an increased distensibility of the arterial wall. This might be due to a collagen type III deficiency.

Influence of hypotensive drug treatment in elderly hypertensives: study terminating events in the trial of the European Working Party on High Blood Pressure in the Elderly

The European Working Party on High Blood Pressure in the Elderly (EWPHE) trial was a double-blind randomized placebo-controlled trial of antihypertensive treatment in patients over the age of 60 years. Entry criteria included both a sitting diastolic blood pressure on placebo treatment in the range 90-119 mmHg and a systolic blood pressure in the range of 160-239 mmHg. The patients (n = 840) were randomized either to active treatment (hydrochlorothiazide + triamterene) or matching placebo. If the blood pressure remained elevated, methyldopa was added to the active regimen and matching placebo in the placebo group. An overall intention-to-treat analysis, combining the double-blind part of the trial and all subsequent follow-up, revealed a non-significant change in total mortality rate (-9%, P = 0.41) but a significant reduction of cardiovascular mortality rate (-27%, P = 0.037). The latter was due to a reduction of cardiac mortality (-38%, P = 0.036) and to a non-significant decrease of cerebrovascular mortality (-32%, P = 0.16). In the double-blind part of the trial, total mortality rate was not significantly reduced (-26%, P = 0.077). Cardiovascular mortality was reduced in the actively treated group (-38%, P = 0.023), due to a reduction of cardiac deaths (-47%, P = 0.048) and to a non-significant decrease of cerebrovascular mortality (-43%, P = 0.15). Deaths from myocardial infarction were reduced (-60%, P = 0.043). Study-terminating morbid cardiovascular events were significantly reduced by active treatment (-60%, P = 0.0064). In the patients randomized to active treatment there were 14 fewer cardiovascular deaths per 1000 patient-years during the double-blind part of the trial. Version 3.

Post-cardiac injury syndrome and an increased humoral immune response against the major contractile proteins (actin and myosin)

To better understand the pathogenesis of the post-cardiac injury syndrome (PCIS) 2 models of cardiac injury were studied. One hundred twenty-nine patients who underwent cardiac surgery and 80 patients with acute myocardial infarction (AMI) were prospectively followed and the levels of anti-heart antibodies (AHA), anti-actin antibodies (AAA) and anti-myosin antibodies (AMA) were determined. In the surgical group, PCIS developed in 27 patients (21%) and incomplete PCIS in 36 (28%). In the AMI group, PCIS did not develop in any patient, but incomplete PCIS developed in 11 patients (14%) (p less than 0.001). The surgical group showed a significantly higher humoral immune response than the AMI group when analyzed for AHA and anti-contractile protein antibodies. After cardiac surgery, AHA developed in 59 patients (46%), AAA developed in 33 (26%) and AMA developed in 49 (38%); in the AMI group, significant levels of AHA, AAA and AMA developed in 16 (20%), 7 (9%) and 13 patients (16%), respectively. These studies show a significant correlation between the PCIS clinical classification and auto-antibodies raised against heart contractile proteins.

Association between post-pericardiotomy syndrome and coronary occlusion after aortic valve replacement

Fever, leucocytosis, and pericardial and pleural effusions developed after the first postoperative week in a 56 year old man who had undergone aortic valve replacement. Four months later, coronary angiography showed bilateral proximal stenosis of the coronary arteries. In this patient post-pericardiotomy syndrome and subsequent coronary artery stenosis were thought to be associated and an immunological mechanism was suspected.

Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial

A double-blind randomised placebo-controlled trial of antihypertensive treatment was conducted in patients over the age of 60. Entry criteria included both a sitting diastolic blood pressure on placebo treatment in the range 90-119 mm Hg and a systolic pressure in the range 160-239 mm Hg. 840 patients were randomised either to active treatment (hydrochlorothiazide + triamterene) or to matching placebo. If the blood pressure remained raised, methyldopa was added to the active regimen and matching placebo in the placebo group. An overall intention-to-treat analysis, combining the double-blind part of the trial and all subsequent follow-up, revealed a non-significant change in total mortality rate (-9%, p = 0.41) but a significant reduction in cardiovascular mortality rate (-27%, p = 0.037). The latter was due to a reduction in cardiac mortality (-38%, p = 0.036) and a non-significant decrease in cerebrovascular mortality (-32%, p = 0.16). In the double-blind part of the trial, total mortality rate was not significantly reduced (-26%, p = 0.077). Cardiovascular mortality was reduced in the actively treated group (-38%, p = 0.023), owing to a reduction in cardiac deaths (-47%, p = 0.048) and a non-significant decrease in cerebrovascular mortality (-43%, p = 0.15). Deaths from myocardial infarction were reduced (-60%, p = 0.043). Study-terminating morbid cardiovascular events were significantly reduced by active treatment (-60%, p = 0.0064). Non-terminating cerebrovascular events were reduced (-52%, p = 0.026), but the non-terminating cardiac events were not (+3%, p = 0.98). In the patients randomised to active treatment there were 29 fewer cardiovascular events and 14 fewer cardiovascular deaths per 1000 patient years during the double-blind part of the trial.

Detection of anti-contractile antibodies after cardiac surgery using ELISA assay

Sera from 196 patients were collected before and after cardiac surgery to measure antibodies against heart tissue and against actin and myosin. In the post-operative period antibodies were found in 87 patients (44%) producing a cross-striated fluorescence pattern in heart tissue. Antibodies against the major contractile proteins were found in 91 patients (46%), anti-actin antibodies in 49 patients (25%) and anti-myosin antibodies in 65 patients (33%). We found a significant correlation (P less than 0.0001) between the antibodies producing a cross-striated fluorescence pattern and antibodies recognizing contractile proteins. These results suggest that contractile proteins evoke an immune response after cardiac surgery and that this response may compromise cardiac function.

Single ventricle in pregnancy: case report and review of the literature

A pregnancy complicated by cyanotic heart disease due to single ventricle was recently managed at the authors's institution. Review of the literature showed only five previous case reports. The management of this uncommon disorder is presented along with a review of the literature. The presence of pulmonary hypertension appears to be a major determinant in assessing maternal risk.

Association of anti-heart antibodies and circulating immune complexes in the post-pericardiotomy syndrome

The post-pericardiotomy syndrome (PPS) is a common complication of cardiac surgery. In order to better understand the pathogenesis of this complication we undertook a prospective, triple blind study of consecutive long term survivors of cardiac surgery. We followed 82 patients and determined anti-heart antibodies (AHA), circulating immune complexes (CIC) and anti-viral antibodies (AVA) on sera pre-operatively and serially post-operatively. According to the clinical features of pericarditis, fever and leucocytosis, patients were divided into three groups: (1) complete PPS with all three symptoms, (2) incomplete PPS with two symptoms and (3) no PPS with one or no symptoms. Clinical PPS was found in 16 patients (19.6%). All of these patients had positive AHA, 12 patients (75%) had increased CIC and five patients (31%) had a four-fold or greater rise in titre to viruses studied. Twenty-four patients (29.2%) had an incomplete PPS. It was accompanied by positive AHA in 17 patients (70.8%), increased CIC in 14 patients (58.3%) and a four-fold rise or greater in virus titre in seven patients (29.2%). No PPS was found in forty-two patients (51.2%). It was accompanied by positive AHA in eight patients (19%), increased CIC in 10 patients (24%) and a four-fold or greater rise in virus titre in 12 patients (28.6%). There was a good correlation between the presence of PPS, AHA, CIC and the type of operation. Heart valve replacement surgery was more frequently complicated by PPS. Development of post-operative AHA and increased CIC were also more frequently found. We found a good correlation between PPS, positive AHA and increased CIC. No correlation was found between PPS and virus serology.

The progress of patients in the European Working Party on Hypertension in the Elderly trial

792 hypertensive patients above the age of 60 have entered the double-blind multicentre trial of the European Working Party on High blood pressure in the Elderly (EWPHE). Half were treated with hydrochlorothiazide and triamterene and half were given placebo and a second capsule was given and if necessary up to 2 g of methyldopa/day. The measurements in a sample of 157 patients suggested 80-86% compliance rate. A significant blood pressure difference of 25/10 mm Hg was obtained between the groups and maintained during five years of follow-up. The increase in serum creatinine found in the actively treated group was related to the decrease in sitting systolic blood pressure. Changes in serum uric acid correlated with changes in serum creatinine both in the placebo and in the actively treated group. Fasting blood glucose changed significantly in the active treatment group. The balance between this decreased risk on the basis of the blood pressure reduction and the increase produced by the rise in blood glucose and the other treatment effects remains to be determined. The trial continues and more patients are being admitted.

Antihypertensive therapy in patients above age 60 with systolic hypertension. A progress report of the European Working Party on High Blood Pressure in the Elderly (EWPHE)

1. Although systolic blood pressure elevation is responsible for increased incidence of cardiovascular accidents in old people, the preventive benefit of lowering systolic hypertension in elderly has not been confirmed. 2. A double blind study comparing the effects of a placebo and of an active regimen (hydrochlorothiazide-triamterene with or without methyldopa) in people over 60 years with isolated systolic hypertension has been undertaken by the European Working Party on High blood pressure in the Elderly (EWPHE). 3. The actively treated group shows a lowered sitting blood pressure (-15/6 mm Hg), a mild increase of serum creatine, serum uric acid and blood glucose and a mild decrease of serum potassium after two years of treatment when compared to the spontaneous changes observed in the placebo treated group. 4. The study is continuing to evaluate if the blood pressure reduction prevents or reduces the incidence of cardiovascular accidents, although some biochemical changes were provoked by the treatment.

Comparison of abdominal circumference measurements by real-time and B-scan techniques

In an effort to evaluate the efficacy of measuring abdominal circumference with real-time ultrasound, 53 patients were scanned with both contact scanning and linear array real time. Image measurements were made blindly from both types of equipment. Abdominal circumference measurements with real time compared favorably with those obtained from contact images (r = +0.984).

Near haploid cell line in lymphoid blast crisis of Ph1-positive chronic myeloid leukemia

This report describes a case of lymphoid blast crisis of a chronic myelocytic leukemia with the occurrence of a double chromosomal population carrying a Philadelphia chromosome. Fifty-five % of the cells have 28 chromosomes, and 36% show the exact duplicate of the near haploid chromosome complement. The similarities between this near haploid cell line and those previously reported, as well as the presence of such clones in acute lymphoblastic leukemia, are discussed. In the leukemic lymphoblasts, the association of the Philadelphia chromosomes with a near haploid karyotype described so far in acute lymphoblastic leukemia provides further support for the concept of a pluripotent Philadelphia chromosome-positive stem cell common to both lymphoid and myeloid lines.

Antihypertensive therapy in patients above age 60 years (Fourth Interim report of the European Working Party on High Blood pressure in Elderly: EWPHE)

1. A total of 450 hypertensive patients above the age of 60 years have entered the double-blind multicentre trial of the European Working Party on High blood pressure in Elderly (EWPHE). After stratification and randomization half were treated with one capsule daily containing 25 mg of hydrochlorothiazide and 50 mg of triamterene and half were given placebo. In those receiving active treatment, if blood pressure control was not adequate they were given a second capsule and if necessary up to 2 g of methyldopa/day.

2. No significant differences between the groups were present before randomization. A significant blood pressure difference of 25/10 mmHg was obtained between the groups and maintained during 4 years of follow-up. No major disturbances in serum potassium or serum sodium were noted with the present drug combination.

3. During the initial phase an increase in serum creatinine and serum uric acid was noted in the actively treated group, which was maintained during the later years. This increase in serum creatinine in the actively treated group was related (P = 0·003 and r = −0·247) to the decrease in sitting systolic blood pressure. Changes in serum uric acid were (r = 0·3 and P = 0·003) correlated with the changes in serum creatinine both in the placebo and in the actively treated group, but independent of the change in creatinine; the serum uric acid was on average 1 mg higher in the actively treated than in the placebo group.

4. Fasting blood glucose did not change significantly in the placebo-treated group but in the active treatment group the rise was statistically significant.

5. A favourable influence on prognosis by active treatment can be expected on the basis of the blood pressure reduction and in the absence of major electrolytes disturbances. However, the balance between this decreased risk and the increased risk produced by the rise in blood glucose and the other treatment effects remains to be determined. Therefore the trial continues and more patients are being admitted.

Antihypertensive therapy in elderly patients. Pilot trial of the European Working Party on High Blood Pressure in the Elderly

A study protocol for a double-blind randomised control trial of hypotensive treatment in elderly hypertensive patients has been tested in a number of pilot centres throughout Europe. It was shown that this study is possible from the logistic point of view. In these elderly patients, hydrochlorothiazide + triamterene treatment with or without methyldopa, maintained a significant hypotensive effect in the absence of major electrolyte disturbances. The initiation of hypotensive therapy did not provoke an excess of cardiovascular complications. The influence of hypotensive therapy on the general well-being and on the morbidity and the mortality of elderly patients with high blood pressure, is thereby being assessed. The study will continue for 5 years and other centres are invited to join.

Left ventricular systolic time intervals during acute myocardial infarction

Left ventricular systolic time intervals (LVSTI) were measured several times daily during 10 days in 47 patients with acute myocardial infarction without major complications. Left ventricular ejection time (LVET) and the interval between the beginning of depolarization and the aortic component of the second heart sound (Q-A2) decreased progressively during the first 72 hr. Shortening of Q--A2 and LVET was most marked in patients with heart failure and persisted till the end of the observation period. Q-upstroke (Q-U) prolonged progressively during the first 3 days, mainly in patients with heart failure. After 10 days, Q-U tended to return to normal except in decompensated patients. Definite diurnal variation in LVSTI were observed; LVET and Q--A2 were longest in the morning hours. Multiple regression analysis of LVSTI with a series of clinical variables revealed that R-R interval, age, sex, digitalis administration, day after infarction, hour of the day, peak of SGOT, and survival are significantly and independently correlated with the changes in LVSTI.

Influence of clonidine (Catapressan-ST155) on the muscle blood flow in the legs of hypertensive patients (Antagonism of tolazoline)

Using the Xenon133 local clearance technique, the influence of clonidine on the blood flow in the tibial anterior muscle of hypertensive patients was studied. Within 10 min after a single, slow intravenous injection of 0.15 mg clonidine, the mean blood pressure and the resting muscle blood flow decreased significantly, while the calculated resistance in this vascular bed tended to increase. During chronic oral administration of varying doses of clonidine, no significant changes were found in the muscle blood flow and vascular resistance at rest; however, determined after maximal ischemic exercise, the muscle blood flow was significantly decreased and the vascular resistance increased. Twenty mg tolazoline, injected intravenously in patients under chronic clonidine treatment, increase pulse rate and blood pressure but further decrease the resting muscle blood flow in the first 15 minutes after the injection.