Use of aminocaproic acid (ACA) in extra-amniotic MTP in patients on anti-coagulant therapy

A case of rheumatic heart disease (RHD) with prosthetic mitral valve endocarditis receiving anticoagulation with heparin, underwent medical termination of pregnancy in a second trimester. The following report entails the use of aminocaproic acid (ACA) in preventing excessive bleeding during and after the procedure, while the patient continued to receive anticoagulant therapy.

Short-term vasodilator effect of captopril in patients with severe mitral regurgitation is parasympathetically mediated

BACKGROUND

Few data exist regarding the effects of angiotensin converting enzyme inhibitors in patients with regurgitant valvular lesions. We postulated an immediate improvement in cardiac performance with captopril in mitral regurgitation, which, in a hemodynamically compensated group of patients, might be mediated through parasympathetic vasodilation rather than through blockade of angiotension converting enzyme.

METHODS AND RESULTS

Hemodynamics were examined before and 90 minutes after oral captopril (25-50 mg) in 18 patients (mean age, 31 years) with chronic, severe mitral regurgitation in New York Heart Association functional class II and III. One group of patients was given captopril alone (group 1, n = 9) and a second group was given captopril plus atropine 0.04 mg/kg i.v. (group 2, n = 9). Captopril alone (group 1) produced decreases in heart rate (90-81 beats/min, p less than 0.001), mean arterial pressure (90-73 mm Hg, p less than 0.001), systemic resistance (28-23 Wood units, p = 0.068), and pulmonary wedge pressure (19-14 mm Hg, p less than 0.001). There was no improvement in either arteriovenous oxygen difference or thermodilution cardiac output; in fact, the latter slightly declined (3.45-3.35 l/min, p = 0.002). Pretreatment with atropine (group 2) diminished the effects of captopril on heart rate (107-103 beats/min, p = 0.065 for atropine effect by two-way ANOVA), mean arterial pressure (88-82 mm Hg, p = 0.01 for atropine effect), and systemic resistance (26-27 Wood units, p = 0.04 for atropine effect).

CONCLUSIONS

In patients with chronic, severe mitral regurgitation, captopril reduced systemic arterial and left ventricular filling pressures but did not immediately augment cardiac output as expected. Furthermore, the modest systemic vasodilator effect of captopril was parasympathetically mediated.

[The follow-up in adulthood of subjects with progressive rheumatic disease in childhood. Considerations of secondary prevention]

We reviewed 57 patients who had previously suffered from rheumatic fever (RF) after an average period of 7.2 (+/- 2.8) years without penicillin prophylaxis. In 24 cases (42%) RF began with carditis and in 9 patients valvular damage remained after hospital discharge. Prophylaxis with retard penicillin every four week was carried out for 5.5 +/- 1.8 years. At present the patients are all asymptomatic. There was in 7 cases mild valvular damage without clinical and instrumental involvement. There was not recurrency after the end of prophylaxis, except for a doubtful case, analysed in the Discussion. Although our cases are not numerous, we believe that a regular prophylactic treatment over 5 or 6 years is sufficient to avoid any recurrency in patients with previous RF. After this period of treatment, only subjects with valvular damage should have further extensive treatment until their 20th year and always for a period not shorter than ten years.

Isolated rheumatic carditis, a disease in search of diagnostic criteria

We report a case of acute dilated cardiomyopathy with histologic proof of inflammatory myocarditis. Although immunosuppressive therapy seemed to induce the resolution of the inflammatory infiltrate, it had no effect on the clinical course. The diagnosis of isolated rheumatic carditis was considered because of the finding of a very high antistreptolysin O titre and lack of evidence for either viral disease, infection with group C and G streptococci or other causes of spuriously high titres of anti-streptolysin O. In view of our conclusion longterm chemoprophylaxis was instituted.

A double-blind placebo-controlled trial of prednisone in active rheumatic carditis

In view of the controversy surrounding the use of corticosteroids in the management of active rheumatic carditis, a prospective double-blind controlled clinical trial comparing prednisone (2 mg/kg/24 h in three divided doses) versus placebo was carried out in 35 children with this disease, using strict clinical criteria to define carditis and excluding cases where the diagnosis was doubtful. The duration of the study, which included long-term follow-up, was 7 years. The results failed to show that prednisone at this dosage and frequency was of any benefit either in the short-term clinical response or in the long-term follow-up with regard to later requirement of valvular surgery (using the 5% level of significance). Other findings were that one-third of cases improved with time, irrespective of treatment, most of them having mild to moderate carditis initially.

Captopril treatment in rheumatic heart disease with congestive heart failure. A preliminary report

A small scale controlled trial of captopril (ACE inhibitor) was conducted in 8 children with congestive heart failure due to rheumatic mitral regurgitation with or without mild mitral stenosis. The age of the patient ranged from 5.5 to 13 years (mean 9.3 years). Four children, served as control group, received digitalis and diuretics as standard treatment; while the other 4 children also received 2 x 12.5 mg of captopril in addition to standard treatment. The effect of both regimens were measured by using changes of left ventricular function as seen on the echocardiogram performed before treatment, and then 3, 7 and 14 days thereafter. Definite conclusion cannot be made because of the small number of patients; but it is apparent that some improvements of left ventricular functions in the captopril group were more evident when compared with that of the control group of standard treatment. Side effects of captopril were not found.

Renal papillary necrosis in a child with rheumatic carditis treated with aspirin

A child with rheumatic carditis developed acute renal failure due to renal papillary necrosis while receiving a short course of aspirin treatment. It is suggested that in this child the aspirin therapy predisposed the renal medulla to hypoxic damage induced by the carditis and congestive heart failure. It is therefore recommended that children receiving aspirin or other nonsteroidal anti-inflammatory drugs, even for a short time, be closely observed and the drug discontinued of hypoxia is evident. Moreover, during illnesses tending to cause hypoxia such as carditis, aspirin or other nonsteroidal anti-inflammatory drugs are best avoided since they are additional risk factors for renal damage.

[Combined immunocorrection--a prospective method for treating secondary immunodeficiency]

Clinico-immunological examination of 180 patients with chronic bronchitis and 207 patients with rheumatic heart disease revealed high therapeutic efficacy of combined use of such immunomodulators as levamisole, hemodes, sodium nucleinate. Combined treatment removes immunity defects and normalizes clinical symptoms.

Recurrence of rheumatic fever after valve replacement

While recurrence of rheumatic fever is common, recurrence after valve replacement has not been reported. A 15-year-old Ethiopian boy returned from America after mitral valve replacement in May 1986. He did not take antibiotic prophylaxis and, in February 1987, had recurrent rheumatic fever. The literature on recurrence of rheumatic fever and prophylaxis is reviewed. Monthly injections of benzathine penicillin have been shown to be the most effective drug to prevent rheumatic fever recurrences. It is recommended that patients with rheumatic heart disease in the developing world should take prophylaxis for life.

Factors affecting the clinical response to treatment with digoxin and two calcium antagonists in patients with atrial fibrillation

It has been suggested that patients in whom atrial fibrillation (AF) is associated with poor exercise tolerance respond better to treatment with xamoterol plus digoxin than to digoxin alone; this may be attributable to better control of exercise induced tachycardia. We have examined data obtained during studies comparing digoxin and two calcium antagonists in the treatment of AF to see whether subgroups of patients with particularly poor exercise tolerance, rheumatic heart disease or rapid post-exercise heart rates might derive particular benefit from one modality of treatment as opposed to another. The results do not indicate that calcium antagonists improve exercise tolerance compared with digoxin in any of these subgroups despite achieving consistently better control of exercise induced tachycardia.

Penicillin and the marked decrease in morbidity and mortality from rheumatic fever in the United States

There has been a marked decline in mortality due to rheumatic fever in the United States. We present evidence for the important role of penicillin in changing the severity of rheumatic carditis, beginning about 1946. Since that year, mortality due to rheumatic carditis has rapidly decreased to zero at the hospital we studied (House of the Good Samaritan, Boston), the rate of loss of all murmurs in patients at the study hospital accelerated simultaneously and exceeded 40 percent by 1970, and the rates of decline in national mortality due to rheumatic carditis accelerated fourfold with the advent of antibiotics. These data, together with reports of recent outbreaks of rheumatic fever, emphasize the importance of continued efforts to diagnose and treat Group A streptococcal pharyngitis.