Primary Myocardial Disease

Quantifying the contribution of alcohol to cardiomyopathy: A systematic review

Alcohol has a direct toxic impact on the heart, and while there is an ICD code for alcoholic cardiomyopathy, the burden of alcohol-attributable cardiomyopathy is not clear. For the usual estimation of this burden via population-attributable fractions, one would need to determine the risk relationships, i.e., average risk associated with different dimensions of alcohol exposure. The most important among these risk relationships is the dose-response relationship with different levels of average alcohol consumption. To establish risk relationships, we systematically searched for all studies on dose-response relationships, directly and indirectly, via reviews. The results did not permit computation of pooled estimates through meta-analyses. There were clear indications that heavy drinking (≥80 g per day) over several years was linked to high risk of cardiomyopathy, with greater lifetime exposure of alcohol linked to higher risks. Some studies indicated potential effects of patterns of drinking as well. As such, the global quantification of alcohol-attributable cardiomyopathy will have to rely on other methods than those used conventionally.

Quantifying the global contribution of alcohol consumption to cardiomyopathy

Background

The global impact of alcohol consumption on deaths due to cardiomyopathy (CM) has not been quantified to date, even though CM contains a subcategory for alcoholic CM with an effect of heavy drinking over time as the postulated underlying causal mechanism. In this feasibility study, a model to estimate the alcohol-attributable fraction (AAF) of CM deaths based on alcohol exposure measures is proposed.

Methods

A two-step model was developed based on aggregate-level data from 95 countries, including the most populous (data from 2013 or last available year). First, the crude mortality rate of alcoholic CM per 1,000,000 adults was predicted using a negative binomial regression based on prevalence of alcohol use disorders (AUD) and adult alcohol per capita consumption (APC) (n = 52 countries). Second, the proportion of alcoholic CM among all CM deaths (i.e., AAF) was predicted using a fractional response probit regression with alcoholic CM crude mortality rate (from Step 1), AUD prevalence, APC per drinker, and Global Burden of Disease region as predictions. Additional models repeated these steps by sex and for the wider Global Burden of Disease study definition of CM.

Results

There were strong correlations (>0.9) between the crude mortality rate of alcoholic CM and the AAFs, supporting the modeling strategy. In the first step, the population-weighted mean crude mortality rate was estimated at 8.4 alcoholic CM deaths per 1,000,000 (95% CI: 7.4–9.3). In the second step, the global AAFs were estimated at 6.9% (95% CI: 5.4–8.4%). Sex-specific figures suggested a lower AAF among females (2.9%, 95% CI: 2.3–3.4%) as compared to males (8.9%, 95% CI: 7.0–10.7%). Larger deviations between observed and predicted AAFs were found in Eastern Europe and Central Asia.

Conclusions

The model proposed promises to fill the gap to include AAFs for CM into comparative risk assessments in the future. These predictions likely will be underestimates because of the stigma involved in all fully alcohol-attributable conditions and subsequent problems in coding of alcoholic CM deaths.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-017-0137-1) contains supplementary material, which is available to authorized users.

Left atrial abnormality by electrocardiogram predicts left ventricular hypertrophy by echocardiography in the presence of right bundle-branch block

BACKGROUND

Left ventricular hypertrophy (LVH) on the electrocardiogram (ECG) may be masked in the presence of complete right bundle-branch block (RBBB). Left bundle-branch block on the ECG is associated with LVH at autopsy in 93% of hearts studied. However, RBBB does not predict LVH and the usual ECG criteria applied for LVH may not be reliable in the presence of RBBB.

HYPOTHESIS

The study was undertaken to evaluate left atrial (LA) abnormality as a criterion for the diagnosis of LVH in the presence of RBBB.

METHODS

Left atrial abnormality in the ECG was assessed by two independent observers as a criterion of LVH in the presence of RBBB in 100 patients, and data were compared with those of 50 patients without LA abnormality.

RESULTS

Left ventricular hypertrophy was confirmed by echocardiographic determination of left ventricular (LV) mass in both groups. Observers reliably differentiated between hypertrophied and normal-sized LV in the presence of RBBB by using LA abnormality as an ECG criterion when correlated with LV mass determined by echocardiography. Observer 1 correctly detected LVH in 88% and Observer 2 in 82% of patients. False positive diagnosis was made in 12 and 18% of patients by Observers 1 and 2, respectively. Observers' performance of recognition of LA abnormality in the present study was 94%. Results showed sensitivity of 76 and 70% and specificity of 84 and 92% for Observers 1 and 2, respectively. Left ventricular mass increased significantly and was diagnostic of LVH in 92% of patients with LA abnormality. Left ventricular mass was high in 84% of patients when corrected by body surface area. LVH in the presence of RBBB by the ECG was found in only seven patients (5%) when six commonly used conventional criteria of diagnosis of LVH by ECG were employed. Regression analysis found LA abnormality to be a strong independent predictor of increased LV mass. Multiple regression analysis revealed that age, body mass index, body surface area, and frontal axis are also significant predictors of LV mass.

CONCLUSION

The results obtained by the correlation of LA abnormality by ECG and LVH by echocardiography conclude that LA abnormality by ECG was significantly diagnostic of LV hypertrophy in the presence of RBBB.

Activation of coagulation system in dilated cardiomyopathy: comparison of patients with and without left ventricular thrombus

OBJECTIVES

We aimed to investigate plasma levels of molecular markers for platelet activity, thrombin activation and fibrinolytic status in patients with dilated cardiomyopathy (DCM) with and without left ventricular (LV) thrombus and to compare these markers between patients with DCM and control participants.

MATERIALS AND METHODS

The study population comprised 60 patients with DCM who met the inclusion criteria. Patients were divided into two groups: 22 patients with LV thrombus and 38 patients without LV thrombus. The age-matched control group consisted of 23 healthy participants (18 men and five women with a mean age of 49). Patients with DCM and healthy participants were compared with respect to platelet activity, thrombin activation and fibrinolytic status. These comparisons were also performed in patients with DCM with and without LV thrombus.

RESULTS

Platelet factor 4 (28.2+/-4.4 ng/ml compared with 20+/-3.1 ng/ml, P<0.01) and beta-thromboglobulin (40+/-2 ng/ml compared with 17+/-3 ng/ml) levels, reflecting platelet activity, were significantly higher in patients with DCM than in control participants. Fibrinopeptide A (6.94+/-0.69 ng/ml compared with 1.96+/-0.1 ng/ml, P<0.001) and thrombin-antithrombin III complex (5.26+/-2.60 ng/ml compared with 3.17+/-1.23 ng/ml, P<0.001) levels, as markers of fibrin generation, were also higher in patients with DCM than in normal participants. Plasma levels of D-dimer (118+/-16 ng/ml compared with 85+/-3 ng/ml, P<0.001) and plasmin-alpha2-plasmin inhibitor complex (0.8+/-1.1 microg/ml compared with 0.6+/-1.7 microg/ml, P<0.001) in patients with DCM significantly exceeded those in the normal participants. There were no statistically significant differences between patients with and without LV thrombus in DCM with respect to platelet activity, thrombin activation and fibrinolytic status.

CONCLUSION

We have shown that platelet activation, thrombin activation and fibrinolytic activity are increased in patients with DCM compared to control participants. However, these markers reflecting coagulation activation in patients with LV thrombus are comparable to those in patients without LV thrombus.

Antithrombotic therapy in heart failure: a randomized comparison of warfarin vs. aspirin (HELAS)

It is uncertain whether anti-thrombotic treatment reduces the incidence of thrombo-embolism in patients with heart failure, so there is a need for a large scale controlled study to assess the effects of anti-thrombotic therapy in this setting. We report the design of a randomized controlled multicenter double blind trial examining the effects of aspirin, warfarin and placebo in patients with heart failure on the risk of thrombo-embolism. We planned to recruit 6000 patients with heart failure without contraindications to anticoagulants or antiplatelet agents and to follow them for a mean time of 2 years following randomization. The study was planned to determine the rate of thrombo-embolic and haemorrhagic events and death among patients randomized to aspirin, warfarin and placebo, stratified according to the presence or absence of underlying coronary disease. Ancillary studies parallel to the main study will attempt to identify clinical and echocardiographic risk factors for thrombo-embolism and will also examine whether hemostatic or neurohormonal mechanisms contribute to an increase in the risk of thrombo-embolism in patients with heart failure. We hoped that the results of the study would improve the clinical management and cost-effectiveness of treatment for patients with heart failure. However, the recruitment of patients proved more difficult than expected and a number of centers decided not to participate. To avoid a great delay it was decided by the principal investigators and submitted to the executive committee to terminate enrolment in this study when 300 patients had been enrolled, and accept that this is a pilot study.

Frequency of echocardiographic improvement in left ventricular cavity size and contractility in idiopathic-dilated cardiomyopathy

In this study, we used 2-dimensional echocardiography to serially evaluate 32 patients with recent onset dilated cardiomyopathy. We found that in 12 patients (37%) there was resolution of left ventricular dilation as well as concomitant normalization of left ventricular contractility.

Antiplatelet and anticoagulant therapy in the prevention of thromboemboli in chronic heart failure

Thromboembolism is an important complication in patients with heart failure. Several recent clinical trials have established the efficacy of anticoagulant therapy in patients with heart failure and atrial fibrillation. There is renewed interest in examining the role of antiplatelet and anticoagulation therapy in patients with heart failure in sinus rhythm. There is a need to identify patients at risk for thromboembolism in heart failure. However, there are data to suggest that occult thromboembolic events may contribute to disease progression, ischemic events, and sudden cardiac death. This review summarizes the incidence, potential mechanism, and therapeutic approaches for management of thromboembolism in heart failure.

Safety of dobutamine stress echocardiography in patients with left ventricular apical thrombus

We demonstrate that patients with left ventricular mural apical thrombi can safely undergo dobutamine stress echocardiography. These patients also have more severe wall motion abnormalities at rest compared with a group of patients with left ventricular dysfunction without evidence of apical thrombus.

Ejection fraction and risk of thromboembolic events in patients with systolic dysfunction and sinus rhythm: evidence for gender differences in the studies of left ventricular dysfunction trials

OBJECTIVES

The aims of this study were to describe the incidence and spectrum of thromboembolic events experienced by patients with moderate to severe left ventricular systolic dysfunction in normal sinus rhythm and to study the association between ejection fraction and thromboembolic risk.

BACKGROUND

The annual incidence of thromboembolic events in patients with heart failure is estimated to range from 0.9% to 5.5%. Previous studies demonstrating a relation between worsening left ventricular systolic function and thromboembolic risk are difficult to interpret because of the prevalence of atrial fibrillation, an independent risk factor for thromboembolism, in the patients with a lower ejection fraction.

METHODS

This is a retrospective analysis of the Studies of Left Ventricular Dysfunction prevention and treatment trials data base. Patients with atrial fibrillation were excluded, resulting in 6,378 participants in sinus rhythm at the time of randomization. Thromboembolic events include strokes, pulmonary emboli and peripheral emboli. Separate analyses were conducted in each gender because there was evidence of a significant interaction between ejection fraction and gender on the risk of thromboembolic events (p = 0.04).

RESULTS

The overall annual incidence of thromboembolic events was 2.4% in women and 1.8% in men. On univariate analysis, a decline in ejection fraction was [corrected] associated with thromboembolic risk in women (relative risk [RR] per 10% decrease in ejection fraction 1.58, 95% confidence interval [CI] 1.10 to 2.26, p = 0.01), but not in men. On multivariate analysis, a decline in ejection fraction remained independently associated with thromboembolic risk in women (RR per 10% decrease 1.53, 95% CI 1.06 to 2.20, p = 0.02), but no relation was demonstrated in men.

CONCLUSIONS

In patients with left ventricular systolic dysfunction and sinus rhythm, the annual incidence of thromboembolic events is low. Ejection fraction appears to be independently associated with thromboembolic risk in women, but not in men.

Experimental idiopathic dilated cardiomyopathy under low-calcium condition

Administration of long-term, low-dose Na2EDTA leads to moderate or severe thinning of the right ventricular wall with or without rupture. These morphological manifestations are known to be site-dependent on the constriction of pulmonary arteries (Yamaguchi et al. 1993a). They sometimes ensue from aneurysmal dilatation and/or plexiform-like-lesion in a pulmonary artery (Yamaguchi et al. 1993b). The present contribution reports that experimental animals who survived for a longer period, maximum for 6 months, showed dilatation of the left ventricle with a mode-rately thin ventricular wall as well as right ventricular changes, which are similar to the morphological manifestations in idiopathic dilated cardiomyopathy.

Pulmonary vasculature in idiopathic dilated cardiomyopathy: a morphometric study

The pulmonary vascular alterations of seven patients with idiopathic dilated cardiomyopathy (IDC) were morphometrically examined, and the relation between the vascular alterations and morphological status of the hearts was studied. Most patients with IDC showed not only fibrous thickening of small pulmonary veins but also intimal circumferential fibrosis and medial hypertrophy of small pulmonary muscular arteries to various degrees. The histological features of the pulmonary vessels were compatible with hypertensive vascular changes observed in patients with mitral stenosis. There was a significant correlation between medial hypertrophy of the pulmonary muscular arteries and right ventricular hypertrophy. The pulmonary vascular changes in IDC were always associated with left atrioventricular dilatation, but were only found in patients with prominent hypertrophy of the left ventricles. Medial hypertrophy of the pulmonary muscular arteries was related more to left ventricular hypertrophy than to left ventricular dilatation. These findings suggest that the pulmonary vascular changes in IDC are caused by venous pulmonary hypertension, which may be developed at the late stage when left ventricular hypertrophy predominates.

Prediction of outcome in late-stage cardiomyopathy

One hundred thirty-three patients with dilated heart failure, 80 with coronary artery disease, and 53 with idiopathic dilated cardiomyopathy were followed for a mean of 29 months. Patients with ischemic heart disease had a worse prognosis than those classified as having idiopathic cardiomyopathy. Features from history, physical examination, and diagnostic tests done when patients were referred to our clinic were checked for univariate association with survival and were used in Cox model survival analysis to define risk groups. Neither the overall group nor either subgroup showed a relationship between ejection fraction and survival. The best variables for predicting long-term mortality included underlying coronary artery disease, basal systolic blood pressure of less than 120 mm Hg, presence of congestion on chest radiogram, and age over 64. Other variables did not improve risk prediction in the overall group. Among patients with ischemic heart disease, blood pressure, congestion, maximal heart rate on treadmill test, and the presence of left bundle branch block on the initial electrocardiogram all contributed. Only systolic blood pressure and the symptom score were related to survival in idiopathic cardiomyopathy.

Influence of enoximone and UDCG-115 on coronary hemodynamics in idiopathic dilated cardiomyopathy

Coronary hemodynamics were studied in 24 patients with idiopathic dilated cardiomyopathy and in 17 patients without any significant heart disease under resting conditions using the argon method. Neither myocardial blood flow normalized for 100 g muscle tissue nor myocardial oxygen consumption per minute (MVO2) or oxygen supply-demand ratio were different between these 2 groups of patients. When enoximone (1 to 2 mg/kg body weight) was given intravenously in patients with idiopathic dilated cardiomyopathy, myocardial oxygen consumption decreased by only 8% (difference not significant), whereas a significant (p less than 0.05) 26% decrease of myocardial oxygen consumption was observed after UDCG-115 (1.25 mg/hour intravenously). However, with both substances the oxygen supply-demand ratio significantly increased from 1.46 +/- 0.10 to 1.57 +/- 0.20 (p less than 0.025; enoximone) and from 1.40 +/- 0.08 to 1.56 +/- 0.19 (p less than 0.05; UDCG-115), respectively. It is concluded from these data that (1) resting coronary hemodynamics related to a unit of myocardium are not different between normal and idiopathic dilated cardiomyopathy, and (2) phosphodiesterase inhibitors exert beneficial effects on coronary hemodynamics by improving the oxygen supply-demand ratio.

Idiopathic dilated cardiomyopathy: analysis of 152 necropsy patients

Certain clinical and cardiac necropsy findings are described in 152 patients aged 16 to 78 years (mean 45) with idiopathic dilated cardiomyopathy: 109 (72%) were men and 43 (28%) were women. Compared with the women, the men had a significantly (p less than 0.05) shorter mean duration of chronic congestive heart failure (CHF) (43 vs 69 months), a higher percentage of habitual alcoholism (40 vs 24%) and a higher mean heart weight (632 vs 551 g). The male to female ratio among the 58 known alcoholics was 7.3:1 and among the 70 known nonalcoholics, 1.5:1 (p less than 0.05). The mean duration of clinical evidence of CHF was similar among the known alcoholics and the known non-alcoholics (each 50 months). Of the 152 patients, 148 (97%) had clinical evidence of chronic CHF; in 114 patients it was the initial manifestation of idiopathic dilated cardiomyopathy, and in most it became intractable and caused death. The interval from onset of chronic CHF to death (known in 120 patients) ranged from 1 to 264 months (mean 54). Comparison of the 27 patients surviving greater than 72 months after onset of chronic CHF to the 64 patients surviving less than or equal to 36 months disclosed a significantly higher frequency in the longer survival group of older patients, of women, of habitual alcoholics, of patients with chest pain syndromes, diabetes mellitus, pulmonary emboli, of patients treated with warfarin and of patients with larger hearts at necropsy. Each of the 4 patients without chronic CHF died suddenly and sudden death was the initial manifestation of idiopathic dilated cardiomyopathy in them. An additional 33 patients also died suddenly, but each of them previously had had chronic CHF. Of the 79 patients (of the 131 for whom information was available) with either pulmonary or systemic emboli or both, 67 (85%) had either right- or left-sided thrombi or mural endocardial plaques or both, whereas of the 52 patients without emboli, 36 (69%) had intracardiac thrombi or plaques (p less than (0.05). Electrocardiograms in the last 6 months of life in 101 patients disclosed atrial fibrillation in 25; complete left (41 patients) or right (6 patients) bundle branch block or indeterminate intraventricular conduction delay (4 patients) in 51 patients; QRS voltage indicative of ventricular hypertrophy in 44 patients (left ventricular in 39 patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Dynamic limitation of coronary vasodilator reserve in patients with dilated cardiomyopathy and chest pain

Twenty-six patients with dilated cardiomyopathy and angiographically normal coronary arteries, 12 of whom gave a history of anginal chest pain, underwent noninvasive and invasive hemodynamic study. During treadmill exercise testing, patients with a history of angina demonstrated worse effort tolerance (7.4 +/- 4.9 versus 13.6 +/- 5.1 minutes, p less than 0.005) and a lower end-exercise systolic blood pressure-heart rate product (17.9 +/- 3.4 versus 23.6 +/- 4.9 mm Hg.beats/min x 10(3), p less than 0.005) compared with patients without a history of angina. During rapid atrial pacing after ergonovine, 0.15 mg intravenously, 11 of the 12 patients with a history of angina experienced their typical chest pain, in contrast to only 1 of 12 patients without a history of angina. The angina group, compared with the nonangina group, had significantly lower great cardiac vein flow (118 +/- 24 versus 160 +/- 43 ml/min, p less than 0.01), and higher coronary resistance (0.87 +/- 0.21 versus 0.66 +/- 0.25 mm Hg.min/ml, p less than 0.05), significant widening of the arterial--great cardiac vein oxygen difference and a significant fall in cardiac index during pacing. Further, ergonovine resulted in higher coronary resistance during pacing in the angina group compared with pacing alone (+0.16 +/- 0.16 mm Hg min/ml, p less than 0.01), in the absence of significant reduction in epicardial coronary artery luminal diameter. After dipyridamole, 0.5 to 0.75 mg/kg intravenously, to 21 patients, the 7 patients with a history of angina had significantly lower flow (149 +/- 37 versus 218 +/- 73 ml/min, p less than 0.05) and higher coronary resistance (0.59 +/- 0.09 versus 0.43 +/- 0.17 mm Hg.min/ml, p less than 0.05) than did the nonangina group. It is concluded that patients with dilated cardiomyopathy and chest pain unrelated to epicardial coronary artery disease exhibit impaired vasodilator responses to both metabolic and pharmacologic stimuli, and an increased sensitivity to the vasoconstrictor effects of ergonovine. Whether these findings are of etiologic or long-term prognostic significance is unknown.

Dilated cardiomyopathy and myocarditis: natural history, etiology, clinical manifestations, and management

This monograph begins and ends with a statement of uncertainty regarding many aspects of dilated cardiomyopathy. Natural history studies identify patients with widely differing outcomes. A host of prognostic factors have emerged, yet it would appear that the major determinants of survival are as yet unrecognized. The diagnosis remains primarily one of exclusion, and management is largely nonspecific and supportive. The frequency of sudden cardiac death is well documented, but the ability to accurately identify patients at risk and the efficacy of antiarrhythmic therapy is unestablished. The emerging success of cardiac transplantation is a source of encouragement. The causes of dilated cardiomyopathy remain a source of intense investigation. Accumulating evidence (much of it circumstantial) does, however, implicate a viral etiology and perhaps altered function of the immunoregulatory system. However, the disparity between the severity of functional disturbance with the relative lack of histologic markers of cellular necrosis implies a disturbance at a cellular level. The etiology or etiologies remain elusive. Future investigation directed at fundamental aspects of cardiac cellular biology may provide the answers.

Mitral valve prolapse

Mitral valve prolapse is a common mitral valve disorder manifested clinically as a midsystolic click and/or a late systolic murmur (the click-murmur syndrome) and pathologically as billowing or prolapsing mitral leaflets (the floppy valve syndrome). Not only is it one of the two most common congenital heart diseases and the most common valve disorder diagnosed in the United States, but it is also prevalent throughout the world. Mitral valve prolapse may be associated with a variety of other conditions or diseases. Diagnosis of mitral valve prolapse should be made on clinical grounds and, if necessary, supported by echocardiography. The majority of patients with mitral valve prolapse suffer no serious sequelae. However, major complications such as disabling angina-like chest pains, progressive mitral regurgitation, infective endocarditis, thromboembolism, serious arrhythmias, and sudden death may occur. Unless these serious complications occur, most of the patients with mitral valve prolapse need no treatment other than reassurance, including those with atypical chest pain or palpitation unconfirmed by objective data. Therapy with a beta-blocker for disabling chest pain and/or arrhythmias and antiplatelet therapy for cerebral embolic events may be indicated. In occasional patients with significant mitral regurgitation surgery may be necessary.

Relation between alcohol intake, myocardial enzyme activity, and myocardial function in dilated cardiomyopathy. Evidence for the concept of alcohol induced heart muscle disease

Detailed drinking histories were taken in 38 patients in whom dilated cardiomyopathy was diagnosed by cardiac catheterisation and left ventricular biopsy. On the basis of the drinking history twenty patients were classified as being in an abstinent or light drinking group and eighteen patients as being in a heavy drinking group (daily alcohol intake in excess of 80 g or cumulative lifetime intake exceeding 250 kg). Activities of myocardial creatine kinase, lactate dehydrogenase, alpha hydroxybutyric dehydrogenase, malic dehydrogenase, and aspartate amino-transferase were all higher in the heavy drinkers and myocardial enzyme activity correlated with cumulative lifetime alcohol intake, maximum daily intake, and recent daily intake. Activities of creatine kinase, alpha hydroxybutyric dehydrogenase, and malic dehydrogenase correlated with ejection fraction, irrespective of the alcohol intake of the patient. These findings were not altered by exclusion of patients with hypertension. The results indicate that among patients with dilated cardiomyopathy there is a group characterised by a high alcohol intake and raised myocardial tissue enzymes which supports the concept of alcoholic heart muscle disease as a distinct entity.

The value of echocardiographic regional wall motion abnormalities in detecting coronary artery disease in patients with or without a dilated left ventricle

To evaluate the usefulness of echocardiographic regional wall motion abnormalities (RWMA) in detecting coronary artery disease (CAD) in patients with left ventricular (LV) dysfunction and a normal-sized or dilated left ventricle, 103 patients were studied by two-dimensional echocardiography (2DE) and cardiac catheterization. In 60 patients (group I) who had LV dysfunction and a dilated left ventricle by echo (patients with dilated cardiomyopathy), RWMA were detected in 44 patients and 38 (86%) of them had significant CAD, usually two- or three-vessel obstruction; of the 16 patients with dilated cardiomyopathy (DCM) and diffuse LV hypokinesis, eight (50%) had evidence of CAD. Thus the presence of RWMA by 2DE had an 83% sensitivity, a 57% specificity, and a 77% predictive accuracy in detecting CAD in patients with DCM and thus in distinguishing ischemic from idiopathic DCM. In 43 patients with LV dysfunction but normal LV size (group II), the sensitivity, specificity, and predictive accuracy of RWMA in detecting significant CAD was 95%, 100%, and 95%, respectively. We conclude that the detection of RWMA by 2DE is highly suggestive of significant CAD in patients with LV dysfunction and normal-sized or dilated left ventricle; the finding, however, of diffuse LV hypokinesis does not exclude CAD in these patients, especially when the left ventricle is dilated.

Sensitivity of electrocardiographic criteria for left ventricular hypertrophy according to type of cardiac disease

The sensitivity of 30 electrocardiographic criteria for left ventricular (LV) hypertrophy, isolated or combined, was examined to determine the relation to the underlying disease. Patients with coronary artery disease (CAD), systemic hypertension, valvular heart disease and cardiomyopathy were evaluated. A cardiac partition technique was used to define ventricular hypertrophy. Single electrocardiographic criteria often showed high sensitivity for 1 disease state, but not for others. Precordial voltage criteria were most sensitive for those with hypertensive and valvular disease. A QRS axis of more than -30 degrees occurred most often in patients with CAD. Both left atrial abnormality and abnormal T-wave inversion of more than 1 mm in V6 occurred with a high sensitivity in general; however, T-wave inversion of more than 1 mm in V6 had a low sensitivity in cardiomyopathy. Methods using combinations of various electrocardiographic criteria improved sensitivity. Using these methods, sensitivity of the electrocardiogram for LV hypertrophy was excellent for patients with systemic hypertension and valvular heart disease and acceptable by usual standards for patients with CAD and cardiomyopathy. Because the use of a single criterion is often ineffective, methods using multiple electrocardiographic criteria to detect LV hypertrophy are recommended when the patients under study have diverse cardiac diseases.

Beneficial effects of nifedipine on rest and exercise myocardial energetics in patients with congestive heart failure

Rest and exercise systemic hemodynamic parameters, coronary blood flow, and myocardial energetics were assessed before and 15 min after the sublingual administration of 20 mg of nifedipine in 10 patients with idiopathic congestive cardiomyopathy. When compared with control, nifedipine increased rest and exercise cardiac index by 37% and 28%, respectively (p less than .001). Peripheral vasodilation was demonstrated with a drop in systemic arterial pressure, exercise pulmonary capillary wedge pressure, and systemic vascular resistance (p less than .05). The calcium-channel blocker did not alter myocardial oxygen consumption; however, coronary blood flow increased by 32% at rest (p less than .01) while coronary vascular resistance diminished both at rest and after exercise compared with control (p less than .05). Nifedipine elicited a decrease in the rest and exercise aortocoronary sinus oxygen difference while the coronary sinus oxygen saturation increased (p less than .01). In this group of patients with idiopathic congestive cardiomyopathy, nifedipine enhanced myocardial performance while increasing coronary blood flow and favorably altering the myocardial oxygen supply-demand balance.

Cardiovascular effects of alcohol with particular reference to the heart

Alcohol has acute and chronic cardiovascular effects. Acutely, alcohol depresses cardiac function and alters regional blood flow. Even when withdrawn from alcohol for several days, alcoholics may still manifest evidence of left ventricular dysfunction. In some alcoholics a severe muscle disorder may ensue with the clinical features of a dilated cardiomyopathy. The concomitant presence of a thiamine deficiency or cirrhosis may produce hemodynamic changes that can obscure the clinical features of alcohol-induced heart muscle disease. Alcoholics may also develop acute myocardial infarction with patent coronary arteries; some may have cardiac arrhythmias even without other evidence of heart disease. Although epidemiological studies suggest that moderate users of alcohol have fewer coronary events than teetotalers, such studies also demonstrate a relation between alcohol abuse and hypertension and an increased occurrence of coronary disease. Thus, the injurious cardiovascular effects of alcohol must be considered when establishing recommendations for its use.

The cardiomyopathies: a review of terminology, pathology and pathogenesis

A classification of the cardiomyopathies based on functional and morphological features is outlined, a detailed account of the pathology of each type is presented and possible pathogenetic mechanisms are reviewed. Myocarditis and its relationship to cardiomyopathy is considered and the main morphological and aetiological factors are presented.

Alcohol and the heart

Acute alcohol ingestion can lead to alterations of either mechanical function or electrophysiologic properties of the heart, whereas chronic consumption can lead to progressive cardiac dysfunction and congestive cardiomyopathy. On the other hand, alcohol appears to have a protective effect for coronary artery disease when consumed in low amounts, although prophylactic use of alcohol is not recommended.

Left atrial abnormality as an electrocardiographic criterion for the diagnosis of left ventricular hypertrophy in the presence of right bundle branch block

Left atrial (LA) abnormality determined from precordial lead V1 was assessed by 2 observers as a criterion of left ventricular (LV) hypertrophy in the presence of right bundle branch block (BBB) in 23 patients. The presence of LV hypertrophy was confirmed from a postmortem cardiac partition technique and defined at 2 levels of confidence: probable and definite hypertrophy. Observers reliably differentiated between the hypertrophied and normal-sized ventricle in the presence of right BBB by using LA abnormality as an electrocardiographic criterion. When defined as definite hypertrophy, observer 1 correctly identified LV hypertrophy in 78% of the cases and observer 2 in 67% of the cases. False-positive results were present in 21% of cases by observer 1 and 14% by observer 2. Comparable results were achieved when a definition of probable hypertrophy was used. Observer performance of recognition of LA abnormality in this study was satisfactory with 91% agreement between observers. Our results are comparable and in some instances superior to conventional criteria commonly recommended to diagnose LV hypertrophy on the electrocardiogram without right BBB.

Regression of myocardial cellular hypertrophy with vasodilator therapy in chronic congestive heart failure associated with idiopathic dilated cardiomyopathy

Forty-nine patients with idiopathic dilated cardiomyopathy (IDC) were evaluated to determine the hemodynamic and morphologic effects of vasodilator therapy. Hydralazine (225 mg/day, H), isosorbide dinitrate (160 mg/day, I), and combination H + I therapy were compared with placebo (P) at baseline and after 3 months of continuous therapy. Thirty-three randomly assigned patients completed the study. Hemodynamic parameters included the echocardiographic percent change of left ventricular diameter (% delta D), the systolic time intervals ratio of preejection period to left ventricular ejection time (PEP/LVET), the pulmonary capillary wedge pressure, mean pulmonary artery pressure, cardiac index, systemic vascular resistance, and pulmonary vascular resistance. An endomyocardial biopsy was performed at baseline and after 3 months; the myocardial cell diameter of 50 cells per biopsy was measured. During the 3-month study 5 patients died; there was not a significant difference among the groups in the number of deaths. The % delta D and PEP/LVET did not change in the P or I groups but did improve significantly from baseline in the H and H + I groups. The pulmonary capillary wedge and mean pulmonary artery pressures and the pulmonary vascular resistance did not change in the P or H groups but did decrease significantly in the I and H + I groups. The P and I groups did not have improvement in systemic vascular resistance or cardiac index, whereas the H group had a decrease in systemic vascular resistance and an increase in cardiac index from 2.5 +/- 0.4 to 3.1 +/- 0.4 liters/min/m2 (p less than 0.05). The H + I group also had a decrease in systemic vascular resistance; the cardiac index increased from 2.3 +/- 0.4 to 3.1 +/- 0.4 liters/min/m2 (p less than 0.01). Myocardial cell diameter did not change in the P or I group. Cell diameter of the H group decreased from 25.4 +/- 3.1 microns at baseline to 23.1 +/- 3.8 microns (p less than 0.05) after 3 months of continuous therapy. The H + I group decreased its cell diameter from 23.9 +/- 3.7 to 22.2 +/- 2.2 microns (p less than 0.05). Compared with P and H, patients treated with I alone or H + I had a significant reduction of preload. In contrast to P and I, H alone and H + I elicited improvement in parameters of inotropy and afterload, and this improvement was accompanied by a reduction in cell diameter. Chronic therapy of heart failure with H and H + I effects a persistent augmentation of cardiac function and improvement of myocardial cellular morphology.

Significance of ventricular tachycardia in idiopathic dilated cardiomyopathy: observations in 35 patients

To evaluate the significance of ventricular tachycardia (VT) in idiopathic dilated cardiomyopathy (IDC), 35 consecutive patients seen between 1976 and 1980 were studied. The criteria for diagnosis of IDC were based on clinical, laboratory, and cardiac catheterization findings. All patients had right and left heart catheterization, left ventriculography, and coronary cineangiography. Long-term ambulatory electrocardiograms (Holter) were obtained in all patients at the time of diagnosis. There were 24 male and 11 female patients aged 22 to 72 years (mean +/- standard deviation [SD]51 +/- 12). Frequent ventricular premature beats (VPB) (30/h) were observed in 29 patients (83%): complex VPB (Lown grades 3, 4, and 5) in 93% and simple VPB in 7%. Twenty-one patients (60%) had nonsustained VT consisting of 3 to 46 beats (8 +/- 5) with rates from 75 to 210/min. No difference between patients with and those without VT was observed in regard to the presenting symptoms, functional classification, electrocardiographic findings, heart size on chest X-ray, and the hemodynamic measurements including cardiac index, left ventricular end-diastolic pressure, and ejection fraction. Patients with VT were older (p less than 0.05). Follow-up observation from 4 to 74 months (34 +/- 17) showed that 2 patients died suddenly (1 with and 1 without previous VT), a third patient died from intractable congestive heart failure, and the fourth from sepsis. It is concluded that (1) the incidence of ventricular arrhythmias in IDC is high, (2) VT is frequent and tends to occur in the nonsustained form, and (3) there is no correlation between VT and the clinical and hemodynamic findings. VT does not appear to predict prognosis during a relatively short follow-up period in patients with IDC.

Pathophysiology of chest pain in patients with cardiomyopathies and normal coronary arteries

To clarify the pathogenesis of chest pain in patients with cardiomyopathies, we compared coronary blood flow and other indicators of ischemia at rest and during pacing-induced tachycardia in nine patients with cardiomyopathy (four hypertrophic and five congestive) and in five control subjects. Coronary blood flow was reduced at rest and during pacing in cardiomyopathy patients compared with controls. In patients with hypertrophic cardiomyopathy, pacing induced chest pain in all, increased ST-segment depression in three patients and increased coronary venous lactate concentration. With pacing, two of five patients with congestive cardiomyopathy had chest discomfort and three had increased ST-segment depression, but coronary venous lactate concentration did not change significantly. In both groups of cardiomyopathies, the ratio of the systolic and diastolic pressure-time indexes tended to decrease more than in controls during pacing. Thus, myocardial perfusion is decreased in patients with cardiomyopathy, both at rest and during pacing. The changes detected during pacing point to subendocardial ischemia as the likely mechanism for angina in hypertrophic and possibly also in congestive cardiomyopathy.

Comparative study of the echocardiographic findings in hypertensive and nonhypertensive cardiomyopathy

Thirty adult male patients with advanced myocardial disease were evaluated by echocardiography. Fourteen were hypertensive; 16 were normotensive. In the former group, 7 subjects had hypertension alone; 7 had combined hypertension and alcoholism or ischemia. The latter group included 4 patients with ischemia, 6 patients with alcoholism, and 6 with idiopathic cardiomyopathy. Nine of the 14 hypertensives and 3 of 6 subjects with ischemic disease had diabetes. Compared to the normotensives, the hypertensive subjects had greater posterior wall thickness (10.4 ± 1.3 mm versus 8.3 ±1.1 mm) (p < 0.001), a larger left ventricular mass (expressed as cross-sectional area) (26.8 ± 6.6 cm2 versus 19.6 ± 3.3 cm 2) (p < 0.001) and a larger aortic root dimension (34.9 ± 2.8 mm versus 30.3 ± 5.5 mm) (p < 0.01). Aortic root size was >32 mm in 12 of 16 hypertensive and in only 3 of 16 without hypertension.

Reduction in the percentage of systolic thickening of the septum was more pronounced than that of the posterior wall in all types of cardiomyopathy (1.30 ± 4.0% versus 24.6 ± 16.0%, respectively) (p < 0.001) and excursion of interventricular septum and posterior wall was uniformly depressed. Ischemic heart disease could therefore not be differentiated from other forms of cardiomyopathy by analysis of segmental function.

When cardiomyopathy was associated with mitral insufficiency, the posterior aortic root motion was greater (6.6 ± 1.7 mm) than in its absence (3.4 ± 1.0 mm) (p < 0.001), and the septal excursion was more pronounced with mitral incompetence. Additional echocardiographic features of cardiomyopathy included the uniform presence of multiple systolic echoes and "hammock" appearance of the mitral valve and AC notching of the tricuspid valve.

We conclude that hypertensive cardiomyopathy can be distinguished from nonhypertensive types of advanced heart disease but that ischemic, alcoholic, and idiopathic cardiomyopathies cannot be differentiated by echocardiography.

Prevalence of clinically occult cardiomyopathy in chronic alcoholism

The mean absolute heart weight and mean heart weight to body weight ratio of a group of 43 alcoholics, screened from 1,970 consecutive autopsy reports at the Detroit General Hospital by selecting alcoholics with only ethyl alcohol abuse as an etiology of heart disease, are compared to those of a group of similarity selected age-matched nonalcoholic controls. None of the alcoholics was clinically suspected of having had cardiomyopathy. The statistically significant increased mean absolute heart weight and heart weight to body weight ratio of the alcoholic group reflected the presence of subclinical alcoholic cardiomyopathy. In addition, several of the patients in the alcoholic group displayed gross and microscopic cardiac pathologic changes consistent with alcoholic cardiomyopathy occurring in the absence of cardiomegaly.

The natural history of idiopathic dilated cardiomyopathy

Between 1960 and 1973, a total of 104 patients at the Mayo Clinic had a diagnosis of idiopathic dilated cardiomyopathy on the basis of clinical and angiographic criteria; these patients were followed up for 6 to 20 years. Twenty-one percent of the patients had a history of excessive consumption of alcohol, 20 percent had had a severe influenza-like syndrome within 60 days before the appearance of cardiac manifestations and 8 percent had had rheumatic fever without involvement of cardiac valves several years before; thus, possible etiologic risk factors of infectious-immunologic type may be important. Eighty patients (77 percent) had an accelerated course to death, with two thirds of the deaths occurring within the first 2 years. Twenty-four patients (23 percent) survived, and 18 of them had clinical improvement and a normal or reduced heart size. Univariate analysis at the time of diagnosis revealed three factors that were highly predictive (p less than 0.01) of the clinical course: age, cardiothoracic ratio on chest roentgenography and cardiac index. Systemic emboli occurred in 18 percent of the patients who did not receive anticoagulant therapy and in none of those who did; thus, anticoagulant agents should probably be prescribed unless their use is contraindicated.

The small coronary arteries in alcoholic cardiomyopathy

The small coronary arteries of two patients with alcoholic cardiomyopathy were studied by means of fine particle barium injection and soft x-ray technic. The spatial architecture of these small arteries which penetrated into the depth of the right and left ventricular myocardium were normal. Their lumina were somewhat dilated and their luminal surfaces were smooth. The "tree circulatory units" were described from this study and were found to be normal. The left ventricular myocardium was richly supplied with small arteries, whereas the myocardium of the right ventricle was not so richly supplied. The myocardium of the papillary muscles and the trabeculae carneae of the left ventricle also had a good supply of small arteries, as did the remote endocardial myocardial appendages. Numerous fine hair-like arteries extended to the epicardial myocardium of the right ventricle to form a brush-like appearance.

Electrocardiographic changes in cardiomyopathic Syrian hamsters (strain BIO 8262)

Under ether anesthesia electrocardiograms were derived from Syrian hamsters (strain BIO 8262) suffering from cardiomyopathy and muscular dystrophy. In addition, ventricular weights and body weight were determined. Young hamsters -- not yet showing morphological signs of the cardiomyopathy with the exception of possible left ventricular hypertrophy -- demonstrated only a longer ventricular activation time than normal hamsters. With the onset of cardiac necrotization left axis deviation in frontal plane projection and right bundle branch blocks are developing in the cardiomyopathic hamsters followed by first degree atrioventricular conduction defects. During the late stage of the cardiomyopathy left bundle branch blocks are additionally arising, while left ventricular hypertrophy is disappearing. Since no overt heart failure is occurring in this strain of cardiomyopathic hamsters, gradual development of high degree conduction defects is assumed to terminate their lives. The electrocardiographic pattern of the hamster cardiomyopathy fits partly into that of human primary as well as secondary cardiomyopathy. Nevertheless, it seems to form an entity of its own, as arrhythmias, higher degree atrioventricular conduction disturbances, typical signs of ventricular or septal hypertrophy, abnormal P and Q waves, ST segment and T wave changes are lacking.

Cardiomegaly of unknown origin among Nigerian adults: role of hypertension in its aetiology

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Electrocardiographic abnormalities in alcoholic cardiomyopathy. A study of 65 patients

Electrocardiograms of 65 patients with alcoholic cardiomyopathy seen over a five-year period were reviewed. ST segment and T wave abnormalities, left ventricular hypertrophy, biatrial enlargement, left atrial enlargement, premature ventricular contractions, prolonged PR interval, and left anterior hemiblock are the most frequently encountered abnormalities. A combination of left ventricular hypertrophy and biatrial enlargement with or without left anterior hemiblock is most specific, Atrial flutter or fibrillation, pathologic Q waves, and bifascicular block are not uncommon findings, while isolated right atrial or right ventricular abnormalities, and isolated posterior hemiblock or right bundle branch block are rare. Electrocardiographic changes are in general similar to those seen in any diffuse cardiomyopathy and reflect biventricular involvement.