Praecordial tracings of myocardial aneurysms

Slow filling period/rapid filling period ratio in the apexcardiogram: relation to the diagnosis of coronary artery disease

Apexcardiograms were performed in 68 consecutive patients who had either normal findings or coronary artery disease on cardiac catheterization. The height of the a wave in relation to the total apexcardiographic deflection (a/H) and the duration of both the rapid (RFW) and the slow (SFW) filling periods were determined in each case. The patients were classified into three gorups: I, no evidence of heart disease on catheterization; II, significant coronary artery disease with elevated left ventricular end-diastolic pressure; and III, coronary artery disease with normal filling pressure. There was a significant difference (P less than 0.001) between the SFW/RFW values (mean +/- 1 standard deviation) in control subject (group I, 2.3 +/- 0.5) and in subjects with coronary artery disease (group II, 4.7 +/- 1.6 and group III, 4 +/- 1.7). Setting the upper limit of normal for SFW/RFW at 2.8 (mean + 1 standard deviation) identified 94 percent of patients, in group II, 71 percent of patients in group III and 86 percent of all patients with coronary disease (group II plus group III). This sensitivity appeared greater than that of the a/H ratio. Only 2 of 17 patients (12 percent) without coronary atherosclerosis had an SFW/RFW ratio greater than 2.8. It is concluded that (1) the slow/rapid filling period ratio is a useful noninvasive measurement for identifying subjects with ischemic heart disease; (2) the increased values for slow/rapid filling period ratio associated with obstructive coronary lesions may be caused by impairment of early left ventricular distensibility; and (3) this ratio should be determined in patients with other forms of heart disease to determine its specificity.

Effects of nitroglycerine ointment on the apexcardiogram and systolic time intervals

Ten patients with angina pectoris and a previous myocardial infarction were administered nitroglycerine (NTG) ointment, sublingual NTG, and a placebo ointment in a double-blind study. Left ventricular function was monitored noninvasively over 3 hours. Two patients showed no response to any of the NTG preparations and were excluded from the results. Left ventricular function improved in all remaining patients after both the sublingual NTG and the NTG ointment, but not the placebo ointment. This improvement was evidenced by a redution in a wave amplitude and duration of the apexcardiogram (ACG). At the same time the isovolumic relaxation time increased significantly and indicated a reduction in left atrial pressure. Also, a simultaneous improvement in the slope of the systolic wave indicated improved wall motion. The ΔLVET decreased, presumably because of a decrease in venous return due to peripheral pooling. None of these parameters changed significantly during the con trol period or after application of the placebo ointment.

The onset of the effect after sublingual NTG was 3-5 minutes with a duration of 15-30 minutes. The NTG ointment had its onset of action at 20-30 minutes, a peak effect at 90 minutes, and a still significant effect at 3 hours. These findings clearly demonstrate the improvement in left ven tricular function that occurs in patients with ischemic heart disease in the absence of chest pain, and suggests that continual usage would be benefi cial even in patients with infrequent angina.

Value of serial apexcardiograms during and after myocardial infarction

Apexcardiograms were systematically recorded serially in 40 patients after acute myocardial infarction, in an additional 21 patients with proven aneurysms, and in 18 patients with good ventricular performance following myocardial infarction. Abnormalities of the "A" wave and systolic waves of the apexcardiogram correlated well with akinesia or dyskinesia proven by cinefluoroscopic and cineangiographic studies. Third and fourth heart sounds and apical systolic murmurs also correlated well with evidence of ventricular dysfunction. This study indicates that the apexcardiogram is a good qualitative tool for serially assessing patients following acute myocardial infarction and that the results on invasive study may be predicted in most patients.

The value of left parasternal impulse recordings in the assessment of mitral regurgitation

Left parasternal cardiograms were recorded at the fifth intercostal space in 30 patients with mitral regurgitation. Early systolic outward movements (E), late systolic outward movements (LOM), and the ratio of the LOM area to the total area occupied by the left parasternal cardiogram (LPC area) were examined. Thirteen patients had pure mitral regurgitation due to ruptured chordae tendineae (ten patients) or "floppy mitral valve" (three patients). In these patients LOM/E correlated significantly with the regurgitation volume determined by the difference between angiographic and Fick stroke volumes, ( r = 0.93, P < 0.01), and with the height of the "v" wave in the pulmonary artery wedge pressure tracings ( r = 0.79; P < 0.01). Simultaneous recordings of left parasternal movements and pulmonary wedge pressures in eight patients in this group showed a close relationship between LOM and "v" waves.

Fourteen patients had rheumatic heart disease and mitral regurgitation associated with mitral stenosis of varying degrees of severity. In this group there was no significant correlation between LOM/E or LOM area/LPC area and the regurgitation volume or the height of the "v" wave. Of three patients who had congenital atrial septal defect in addition to mitral regurgitation, none had prominent LOM in the left parasternal cardiogram.

This study suggests that if mitral stenosis and atrial septal defect can be excluded on clinical evidence, the left parasternal cardiogram may be used to obtain a noninvasive assessment of the severity of mitral regurgitation, particularly in patients with recent onset of the disease.

Serial observations on left ventricular dysfunction in acute myocardial infarction. II. Systolic time intervals in power failure

Systolic time intervals corrected for heart rate were studied serially in 50 patients with acute myocardial infarction (AMI) 1, 5, and 20 days after the onset of symptoms from simultaneously recorded kineto-, phono-, and electrocardiograms and carotid artery pulse tracings. Left ventricular ejection time (LVET), electromechanical systole (QA 2 ), and mechanical systole (M 1 A 2 ) decreased from the first to the fifth day ( P < 0.001) and increased again toward normal by the twentieth day. There was a clear correlation with the clinically assessed severity of AMI; the high prevalence of abnormal values indicated a frequent and early impairment of left ventricular performance. In severe power failure, deterioration was indicated by progressive shortening of the systolic time intervals, as contrasted to gradual improvement noted in uncomplicated infarctions. Similarly, LVET, QA 2 , and M 1 A 2 displayed a significant correlation with the grade of radiologically assessed pulmonary vascular congestion on the first day. A relationship between LVET, QA 2 , and isovolumic contraction time (ICT)/LVET and the degree of paradoxical cardiac pulsation became apparent on the fifth day. LVET, M 1 A 2 , ICT/LVET, and preejection period (PEP)/LVET were more abnormal in the nine patients who died than in the 41 survivors ( P < 0.05). PEP and ICT showed no correlation with clinically or radiologically assessed severity or prognosis of infarction, in contrast to findings in chronic heart failure. Decrease of contractility in AMI appears not to be directly reflected in preejection intervals. These findings indicate the value of externally measured left ventricular systolic time intervals, especially LVET, in assessment of the severity and prognosis of AMI.

Jugular, hepatic, and praecordial pulsations in constrictive pericarditis

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