Relevance of anaesthesia for dofetilide-induced torsades de pointes in alpha1-adrenoceptor-stimulated rabbits

BACKGROUND AND PURPOSE

No information is available concerning the effects of anaesthetics in the most frequently used in vivo pro-arrhythmia model. Accordingly, in this study we examined the effect of pentobarbital, propofol or alpha-chloralose anaesthesia on the pro-arrhythmic activity of the class III anti-arrhythmic dofetilide in alpha(1)-adrenoceptor-stimulated rabbits.

EXPERIMENTAL APPROACH

Rabbits anaesthetized intravenously with pentobarbital, propofol or alpha-chloralose were infused simultaneously with the alpha(1)-adrenoceptor agonist phenylephrine (15 microg kg(-1) min(-1), i.v.) and dofetilide (0.04 mg kg(-1) min(-1), i.v.). The electrocardiographic QT interval, the T (peak)-T (end) interval and certain QT variability parameters were measured. The heart rate variability and the baroreflex sensitivity were utilized to assess the vagal nerve activity. The spectral power of the systolic arterial pressure was calculated in the frequency range 0.15-0.5 Hz to assess the sympathetic activity.

KEY RESULTS

Pentobarbital considerably reduced, whereas propofol did not significantly affect the incidence of dofetilide-induced torsades de pointes (TdP) as compared with the results with alpha-chloralose (40% (P=0.011) and 70% (P=0.211) vs 100%, respectively). In additional experiments, neither doubling of the rate of the dofetilide infusion nor tripling of the rate of phenylephrine infusion elevated the incidence of TdP to the level seen with alpha-chloralose. None of the repolarization-related parameters predicted TdP. The indices of the parasympathetic and sympathetic activity were significantly depressed in the alpha-chloralose and propofol anaesthesia groups.

CONCLUSIONS AND IMPLICATIONS

In rabbits, anaesthetics may affect drug-induced TdP genesis differently, which must be considered when results of different studies are compared.

Coronary flow reserve, insulin resistance and blood pressure response to standing in patients with normoglycaemia: is there a relationship?

AIMS

To establish the relationships between coronary flow reserve, cardiovascular autonomic function, and insulin resistance characterized by the homeostasis model assessment insulin resistance score in patients with normal carbohydrate metabolism according to the World Health Organization (WHO) and American Diabetes Association (ADA) criteria, and with morphologically normal epicardial coronary arteries.

METHODS

Twenty-five patients [12 women and 13 men, mean (sd) age: 53 +/- 11 years] with normal coronary angiography were enrolled into the study. Coronary flow reserve was measured during stress transoesophageal echocardiography. Autonomic dysfunction was assessed by means of five standard cardiovascular reflex tests. The fasting serum glucose and insulin levels were determined and the homeostasis assessment model insulin resistance score was calculated.

RESULTS

In patients with normal carbohydrate metabolism, negative correlations were observed between the coronary flow reserve and both the serum insulin level (r = -0.445, P = 0.026) and the homeostasis assessment model insulin resistance score (r = -0.449, P = 0.024). The systolic blood pressure response to standing also correlated with the coronary flow reserve (r = -0.519, P = 0.011). The heart rate response to deep breathing, the Valsalva ratio, the 30/15 ratio and the sustained handgrip test results were not correlated with the coronary flow reserve.

CONCLUSIONS

Our data suggest the possible role of insulin resistance and early sympathetic nerve dysfunction in the development of decreased coronary flow reserve in patients without diabetes mellitus or impaired glucose tolerance.

Helicobacter pylori-induced immunological responses in patients with duodenal ulcer and in patients with cardiomyopathies

The interaction between the bacteria and the host is a key factor determining the clinical consequences of H. pylori infection. The immune system plays an important role in either promoting or preventing the disease. The mucosal production of TNF-alpha, IL-6, IL-8 and IL-10 and the CagA status were investigated in H. pylori-positive patients with duodenal ulcer (DU). The concentrations of these cytokines in gastric antral mucosal specimens from patients infected with H. pylori (n = 40) were determined by ELISA and compared with data on mucosal specimens from H. pylori-negative patients (n = 12). The local TNF-alpha, IL-6 and IL-8 concentrations in the antral biopsy samples were significantly higher (p < 0.001) in the patients infected with H. pylori than in the samples from the H. pylori-negative subjects. CagA positivity was demonstrated in 39 (97.5%) of the 40 patients with DU, and in 41 (70.7%) of H. pylori-positive (58 of 100) healthy blood donors. In complementary studies focusing on extragastric disease, it was found that 57% of patients with ischaemic heart disease were seropositive as concerns H. pylori, and 91% of them had antibodies against human heat shock protein 60, too. This study suggests that, besides the bacterial virulence factor, the host response of an increased mucosal production of inflammatory cytokines can be relevant to the gastric pathophysiology in H. pylori-induced DU. At the same time, in ischaemic heart diseases the role of autoimmune processes induced by H. pylori cannot be excluded.

Clinical value of left atrial appendage flow velocity for predicting of cardioversion success in patients with non-valvular atrial fibrillation

BACKGROUND

Echocardiographic parameters for predicting cardioversion outcome in patients with non-valvular atrial fibrillation are not accurately defined.

OBJECTIVE

To evaluate the role of left atrial appendage flow velocity detected by transoesophageal echocardiography for prediction of cardioversion outcome in patients with non-valvular atrial fibrillation enrolled in a prospective. multicentre, international study.

METHODS

Four hundred and eight patients (257 males, mean age: 66 +/- 10 years) with non-valvular atrial fibrillation lasting more than 48 h but less than 1 year underwent transthoracic echocardiography and transoesophageal echocardiography before either electrical (n=324) or pharmacological (n=84) cardioversion.

RESULTS

Cardioversion was successful in restoring sinus rhythm in 328 (80%) and unsuccessful in 80 patients (20%). Mean left atrial appendage peak emptying flow velocity was significantly higher in patients with successful than in those with unsuccessful cardioversion (32.4 +/- 17.7 vs 23.5 +/- 13.6 cm x s(-1); P<0.0001). At multivariate logistic regression analysis, three parameters proved to be independent predictors of cardioversion success: the atrial fibrillation duration <2 weeks (P=0.011, OR=4.9, CI 95%=1.9-12.7), the mean left atrial appendage flow velocity >31 cm x s(-1) (P=0.0013, OR=2.8, CI 95%=1.5-5.4) and the left atrial diameter <47 mm (P=0.093, OR=2.0, CI 95%=1.2-3.4). These independent predictors of cardioversion success outperformed other univariate predictors such as left ventricular end-diastolic diameter <58 mm, ejection fraction >56% and the absence of left atrial spontaneous echo contrast.

CONCLUSION

In patients with non-valvular atrial fibrillation, measurement of the left atrial appendage flow velocity profile by transoesophageal echocardiography before cardioversion provides valuable information for prediction of cardioversion outcome.

Determinants of spontaneous baroreflex sensitivity in a healthy working population

Baroreflex sensitivity (BRS) by the spontaneous sequence technique has been widely used as a cardiac autonomic index for a variety of pathological conditions. However, little information is available on determinants of the variability of spontaneous BRS and on age-related reference values of this measurement in a healthy population. We evaluated BRS as the slope of spontaneous changes in systolic blood pressure (BP) and pulse interval from 10 minutes BP (Finapres) and ECG recordings in 1134 healthy volunteers 18 to 60 years of age. Measurement of BRS could be obtained in 90% of subjects. Those with unmeasurable spontaneous BRS had a slightly lower heart rate but were otherwise not different from the rest of the population. BRS was inversely related to age (lnBRS, 3.24-0.03xage; r(2)=0.23; P:<0.0001) in both genders. In addition, univariate analysis revealed a significant inverse correlation between BRS and heart rate, body mass index, and BP. Sedentary lifestyle and regular alcohol consumption were also associated with lower BRS. However, only age, heart rate, systolic and diastolic BP, body mass index, smoking, and gender were independent predictors of BRS in a multivariate model, accounting for 47% of the variance of BRS. The present study provides reference values for spontaneous BRS in a healthy white population. Only approximately half of the variability of BRS could be explained by anthropometric variables and common risk factors, which suggests that a significant proportion of interindividual differences may reflect genetic heterogeneity.

[The clinical value of coronary flow reserve in ischemic heart disease as measured by dipyridamole stress transesophageal echocardiography]

The relationship between coronary flow reserve and the result of coronarography was examined. 152 patients were investigated by stress transoesophageal echocardiography and coronary angiography. The value of coronary flow reserve was significantly lower in cases of significant coronary stenosis than in those patients who had a normal coronarography (in patients with left anterior descending coronary artery stenosis: 1.77 +/- 0.47 vs in cases with normal coronary angiogram: 3.19 +/- 1.15). There was no difference in the value of CFR in those cases where not only LAD stenosis but CX or RC stenosis was also found. The value of coronary flow reserve was significantly higher in RC or CX patients than that of LAD patients. In patients with positive stress and negative coronarography (X syndrome) the coronary flow reserve was 1.23 +/- 0.2, which value was significantly lower as compared to patients with significant coronary stenosis.

[Impending paradoxical embolism]

The case history of a 49-year-old female patient is reported, who was operated on because of varicose vein in the left lower extremity. A few days after the operation serious signs of cerebrovascular insult appeared. The clinical picture and the result of an urgent transoesophageal echocardiography are described; a serpentine thrombus was found to be trapped in the patent foramen ovale. During continuous intravenous heparin treatment, the patient gradually recovered, but a residual neurological deficit could be detected on discharge from the hospital. Six days after the admission, repeated transoesophageal echocardiographic examination showed no signs of intracardiac thrombus. The clinical feature of the illness, the predisposing factors, the diagnostic and therapeutic possibilities are discussed.

Cytokine production and antibodies against heat shock protein 60 in cardiomyopathies of different origins

OBJECTIVE

There is growing evidence that proinflammatory cytokines play an important role in a variety of cardiac pathophysiological conditions. The purpose of this study was to determine the circulating tumour necrosis factor (TNF) and interleukin-6 (IL-6) levels in patients with dilated cardiomyopathy (DCM) (n = 40) or ischaemic heart disease (IHD) (n = 38) in comparison with the corresponding data from patients with hypertrophic cardiomyopathy (HCM) (n = 10) or valvular aorta stenosis (AS) (n = 10) and from healthy blood donors (n = 20).

METHODS

To investigate the possible sources of cytokines, the in vitro cytokine-inducing capacity of the patients' peripheral blood leucocytes was also measured. The TNF and IL-6 expression levels in the myocardium were investigated from biopsy specimens. The study of the immunological background of the cardiomyopathies was supplemented with screening of anti-heat shock protein 60 (Hsp60) antibodies in the sera of the patients.

RESULTS

Elevated levels of circulating TNF (25-150 U/ml) and IL-6 (50-500 pg/ml) were found in 85% of the patients in the DCM and IHD groups, whereas only the IL-6 level was elevated (125-500 pg/ml) in the HCM patients. The in vitro TNF-alpha production was higher than in the normal controls only in the DCM group. The ventricular tissue of the DCM patients expressed TNF-alpha and IL-6. In vitro experiments were performed to examine the production of TNF and IL-6 by cultured rat cardiac myocytes (H9C2) under hypoxic conditions. Even a short hypoxic treatment resulted in cytokine production between 4 and 72 h following reoxygenization. Considerable amounts of anti-Hsp60 antibodies were found in 80% of the IHD patients and in 65% of the DCM patients. The in vitro cytokine production of leucocytes and the frequency of anti-Hsp60 positivity in patients with HCM or AS was not significantly different from those in the normal blood donors.

CONCLUSIONS

These results demonstrate that TNF-alpha and IL-6 are of pathophysiological importance in some but not all types of cardiomyopathies, and the sources of cytokine production may differ. The mechanism of the development of primary DCM is still unknown; the high in vitro production of proinflammatory cytokines in the leucocytes of patients with DCM, the presence of TNF and IL-6 in their cardiac tissue and the high prevalence of anti-Hsp60 antibodies in their sera suggest a strong immunological background in the pathophysiology of the disease.

[Molecular genetics of the long QT syndrome: clinical aspects]

The long QT syndrome (LQTS) is a heart disorder which is characterised by the prolongation of the QT interval of the surface electrocardiogram and is associated with malignant arrhythmias, syncopal episodes, torsade de pointes form ventricular tachycardias and an increased risk of sudden cardiac death. There are two familial forms of LQTS, the autosomal dominant Romano-Ward syndrome and the autosomal recessive Jervell-Lange-Nielsen syndrome which is associated with congenital senzorineural deaf-mutism. Recent advances in molecular genetics have allowed to identify mutations in four genes, KvLQT1 (11p15.5), HERG (7q35), SCN5A (3p21) and minK (21q22), which cause LQTS. There is a fifth genetic locus known on chromosome 4 (4q25-27), where the disease causing gene has not been identified yet. As LQTS genes code proteins which form sodium and potassium channels of the heart, LQTS can be regarded as the disease of cardiac ion channels. The KvLQT1 and minK genes code the slowly activating, delayed rectifier (Iks) potassium channel, the HERG gene code the rapidly activating, delayed rectifier (Ikr) potassium channel of the heart, while the SCN5A gene codes a cardiac sodium channel. Mutations in KvLQT1, minK and HERG genes affects repolarising, rectifier potassium currents, while SCN5A mutations cause delayed inactivation and reopening of the cardiac sodium channel, which initiates the depolarisation of cardiac cells. Both alterations result in a prolongation of cardiac repolarisation which is represented in the elongation of the QT interval. Elucidation of the genetic base of the disease provided new tools in the clinical management of LQTS. It has been shown that changes in the repolarisation parameters on the ECG may be predictive for the causative gene and different LQTS genes are associated with different clinical picture. More importantly, it is possible to use "gene-specific" therapy in LQTS which specifically targets ion channels affected by given gene mutations.

Endoscopic CO(2) laser therapy of selected cases of supraglottic marginal tumors

Endoscopic CO(2) laser intervention can be used as conservation surgery for supraglottic laryngeal carcinomas in carefully selected patients. We analyzed retrospectively our experience in managing patients with early supraglottic carcinomas operated on at the Clinic of Otorhinolaryngology, Szeged, Hungary, during the 10-year period between 1987 and 1997. Conservation surgery was the treatment of choice in 187 patients, but only 23 (12%) were selected for endoscopic CO(2) laser surgery. Laser surgery was indicated predominantly for T1 cancer of the epiglottis (n = 15), but was also performed for T2 cancers (n = 8). Of the 23 supraglottic tumors treated, 16 had no signs of recurrence to date (1.5 to 9 years after surgery) a local control rate of 70%. Six patients with recurrences underwent salvage therapies that included repeated laser excisions (n = 3), radiotherapy (to 60 Gy), horizontal supraglottic laryngectomy and total laryngectomy. One patient was not resectable because of multiple metastases. Our experience with endolaryngeal CO(2) laser excision indicates that it is a reasonable method in selected cases of supraglottic tumors, but one-third of the patients required salvage treatment.

Coronary vasospasm as a source of false positive results during dobutamine echocardiography

BACKGROUND

Several studies have demonstrated a consistently high sensitivity of dobutamine echocardiography whereas test specificity in these series has been variable. The aim of this study was to evaluate whether coronary vasospasm--elicited by alpha1 adrenoreceptor stimulation--may be a significant source of false positive responses during dobutamine stress.

METHODS

From the data bank of four institutions we selected 113 patients (75 males, 38 females, mean age 55 +/- 12 years) with dobutamine echocardiography performed (up to 40 micrograms/kg/min and atropine 1 mg if needed) before a coronary angiography showing normal or near normal (visually assessed stenosis severity < 50%) coronary arteries. The following variables--which were previously reported influencing dobutamine echo specificity--entered the multivariate statistical analysis: age, sex, heart rate at baseline and at peak stress, baseline echo, hypertension, site of asynergy, and spasm at coronary angiography.

RESULTS

Twenty-five patients had a positive dobutamine test. The positivity occurred in the left coronary territory in 15 and in the right coronary territory in 10 cases. All the 6 patients with spontaneous spasm during angiography had a false positive stress test result. By multivariate analysis only coronary artery spasm during angiography (p = 0.0015) and history of hypertension (p = 0.0031) were significant predictors of false positive results of dobutamine stress echocardiography.

CONCLUSIONS

Coronary artery spasm may be an important source of false positive results during dobutamine stress echocardiography.

[Clinical and molecular genetics of hypertrophic cardiomyopathy]

Recent developments in molecular genetics have allowed to identify mutations in seven genes coding the beta myosin heavy chain, troponin T, alpha tropomyosin, myosin binding protein C, essential and regulatory myosin light chains and troponin I causing hypertrophic cardiomyopathy. These mutations affect critical, evolutionary conserved nucleotides of these genes and influence vital functions of the encoded proteins. As all seven genes encodes sarcomeric proteins in the heart muscle, hypertrophic cardiomyopathy is regarded these days as a disease of the sarcomer. Recent data indicate that some mutations are associated with "malignant" clinical picture, with rapidly developing, severe symptoms of the disease and increased risk of sudden cardiac death while other mutations bear a more favourable prognosis. Apart of the disease causing mutation other factors, including disease modifier genes, are likely to make an impact on the clinical appearance of hypertrophic cardiomyopathy. The knowledge provided by molecular genetics influences the clinical management of the disease even today and based on the investigation of mutation carrying patients new diagnostic criteria was proposed for hypertrophic cardiomyopathy. The challenge for the future is the establishment of routine genetic diagnostics and the development of possible gene therapy.

Coronary artery-descending aorta fistula as an unusual collateral in a patient with postductal coarctation

We report on the case of a 45-year-old man with recurrent syncope and angina with shortness of breath on exertion. Invasive and noninvasive diagnostic methods revealed severely stenosed bicuspid aortic valve, postductal coarctation of the aorta, and a coronary artery-descending aorta fistula. After surgical correction of the coarctation, ligation of the fistula, and aortic valve replacement, the patient's symptoms resolved.

[Cardiovascular complications of pancreatis diseases]

Under physiological conditions, the pancreas scarcely influences the function of the cardiovascular system, although the hormones produced in the healthy pancreas (insulin, glucagon and somatostatin) affect the myocardial contractility in pharmacological doses. Among the diseases of the pancreas, the pancreatic tumours (insulinoma, glucagonoma and vipoma), furthermore the acute and chronic pancreatitis involve cardiovascular complications, which influence the outcome of the disease. Although the clinical picture is dominated by the metabolic changes of the excessively produced hormones in pancreatic tumours, the cardiac and vascular effects of the hormones may be considerable. In acute necrotizing pancreatitis, enzymes released from the pancreas and inflammatory mediators transform acute necrotizing pancreatitis into "multiple organ disease"; one of the important forms of this disease is the cardiovascular shock syndrome. One of the best-known complications of chronic pancreatitis is the pancreoprive diabetes mellitus, and beside that other, nonspecific cardiac alterations (e.g. ECG-changes) may occur.

Effect of postural changes on arterial baroreflex sensitivity assessed by the spontaneous sequence method and Valsalva manoeuvre in healthy subjects

The objective of this study was to compare the baroreflex sensitivity (BRS) assessed by the new, non-invasive, spontaneous sequence method (BRS-sequence) with the Valsalva manoeuvrebased BRS. Fourteen healthy volunteers were studied in the supine position, during 60 degrees head-up tilt (HUT) and during -30 degrees head-down tilt (HDT). Blood pressure and R-R intervals were continuously and non-invasively recorded using a Finapres device. The BRS-sequence was assessed by analysing the slopes of spontaneously occurring sequences of three or more consecutive beats in which systolic blood pressure and R-R interval of the following beat increased or decreased in the same direction in a linear fashion; it was compared with data obtained during the Valsalva manoeuvre in each position. The time and frequency domain indices of R-R interval variability were also evaluated. The mean difference of BRS between the two non-invasive methods was 3.86 ms/mmHg with a standard deviation of 9.14 ms/mmHg. BRS was decreased during HUT and increased during HDT as assessed by both techniques. The changes in BRS were associated with vagal withdrawal and sympathetic activation during HUT and enhancement in the cardiac vagal tone and reduction in the sympathetic activity during HDT. We conclude that the BRS-sequence technique provides a reliable method to study the neural control of the circulation, although the body position in consecutive measurements needs to be standardized.

Noninvasive monitoring of hemodynamic changes in acute pancreatitis in rabbits

Hemodynamic parameters of experimental acute necrotizing pancreatitis (AP) were monitored by means of echocardiography in rabbits. Left ventricular (LV) systolic and diastolic parameters were determined before and 1, 3, 6, 12, 18, and 24 hr after injection of taurocholic acid in the pancreatic duct in AP animals. Temporary LV dilatation was observed 6 hr after the AP induction [LV end-diastolic (ED) diameter from 1.16 +/- 0.04 to 1.22 +/- 0.04 cm, P < 0.05, ED volume from 2.98 +/- 0.34 to 3.57 +/- 0.75 ml, P < 0.05] without decrease in systolic function. Cardiac output (CO) and stroke volume (StV) was increased in both groups 3 hr after the operation (from 0.53 +/- 0.15 to 0.71 +/- 0.06 L/min, P < 0.05 in AP), but in the AP animals it remained high. However, 24 hr after AP induction, both the CO and the StV were decreased significantly. The LV diastolic function was impaired 1 hr after AP induction, but had recovered after 12 hr. In conclusion, an early diastolic impairment followed by LV enlargement could be noninvasively observed in experimental AP in rabbits.

Changes in left ventricular mass during treatment with minoxidil and cilazapril in hypertensive patients with left ventricular hypertrophy

Attainment of the regression of hypertension-associated left ventricular hypertrophy (LVH) seems to be a desirable goal of blood pressure (BP)-reducing therapy. Since antihypertensive drugs of differing types may exhibit markedly different abilities to modulate LVH, we examined the effects of the angiotensin-converting enzyme inhibitor cilazapril, and the potassium channel activator minoxidil, alone or in combination with each other, on the left ventricular mass (LVM) in patients with severe essential hypertension who had LVH detected by echocardiography. All patients received the same base therapy of bopindolol and guanfacine. After a run-in period, they were treated with: (1) cilazapril (n = 10); (2) minoxidil, combined with a diuretic (n = 10); or (3) both cilazapril and monoxidil (n = 6) for 12 months. The LVM index (LVMI; LVM per body surface area) was estimated every 3 months by means of echocardiography. Each kind of therapy decreased the arterial pressures to a similar degree. The 1-year treatment with the cilazapril-based regimen resulted in a significantly diminished LVMI (from a mean +/- s.d. of 173 +/- 38 to 152 +/- 22 g/m2; P < 0.05). On the other hand, the minoxidil-based therapy led to a significant increase in LVMI (from 148 +/- 19 to 170 +/- 35 g/m2; P < 0.05). There were no significant LVMI changes in patients receiving the combined, cilazapril + minoxidil-based treatment (172 +/- 34 vs the pretreatment 183 +/- 54 g/m2). The results confirm that long-term treatment with cilazapril is effective both in reducing BP and in reducing LVM. In spite of yielding a satisfactory reduction of BP, minoxidil therapy, even in combination with a diuretic and a beta-blocker, may lead to an aggravation of pre-existing LVH; this effect of minoxidil could be prevented by the simultaneous administration of cilazapril.

Changes in blood pressure and heart period variability in patients with recent acute myocardial infarction

1. A decreased heart period variability and baroreflex sensitivity in patients with acute myocardial infarction have already been documented. Since one of the major determinants of heart period variability is blood pressure variability, it would be important to know the characteristics of blood pressure regulation in this setting. The changes in blood pressure variability during the acute phase of myocardial infarction have not yet been studied. 2. We investigated the blood pressure variability and the heart period variability in 11 patients with acute myocardial infarction 3 to 5 days after their admission. Thirteen age matched patients with no evidence signs of ischaemic heart disease or previous myocardial infarction served as controls. We used the frequency domain indexes of short term measurements of finger blood pressure variability and heart period variability. The spectral powers for both heart period variability and blood pressure variability were divided into three major components: total frequency (0.01-0.4 Hz), low frequency (0.04-0.15 Hz) and high frequency (0.15-0.4 Hz). 3. All of the frequency-domain components of the heart period variability were significantly decreased in patients with recent acute myocardial infarction compared to the controls: Ln(total power): 5.68 +/- 0.24 vs. 7.21 +/- 0.29, Ln(low-frequency power): 4.31 +/- 0.28 vs. 7.05 +/- 0.53, Ln(high-frequency power): 3.50 +/- 0.33 vs. 5.48 +/- 0.32. Acute myocardial infarction patients showed a significantly reduced blood pressure variability in all frequency components compared to the controls: Ln(total power): 4.21 +/- 0.18 vs. 6.79 +/- 0.48, Ln(low-frequency power): 2.40 +/- 0.24 vs. 4.36 +/- 0.21, Ln(high-frequency power): 3.31 +/- 0.25 vs. 5.66 +/- 0.38. 4. We hypothesize that the reduced blood pressure variability in the acute phase of myocardial infarction could be related to a relative invariance of stroke volume. The underlying mechanism is the reduced left ventricular compliance.

[Effect of cilazapril in patients with essential hypertension: effect on cardiac hypertrophy]

Numerous antihypertensive drugs exist with different modes of action, which have a really effective impact on hypertension. The life expectancy of hypertensive patients is known to depend on the degree of damage caused to their target organs by the hypertension itself. Cardiovascular hypertrophy and its complications are considered to be among the major elements of this process. This work evaluates the effectiveness of the long-term treatment of essential hypertensive subjects (n = 10) with a long-acting ACE-inhibitor, cilazapril, as concerns their blood pressure and cardiac hypertrophy. Cilazapril given orally in a daily dose of 2.5 mg effectively lowered both the systolic (delta 30 mm Hg) and the diastolic (delta 19 mm Hg) blood pressure. No changes were found in body weight or heart rate, and only one side-effects (skin rash) was reported. Cilazapril considerably decreased the left ventricular mass and hence the hypertrophic index of hypertensive patients with cardiac hypertrophy, suggesting that ACE inhibitors are effective not only in lowering blood pressure and decreasing hypertrophy, but also in lowering the cardiac morbidity and mortality.

Cardiac manifestations in primary Sjögren's syndrome

OBJECTIVE

To determine cardiac manifestations in primary Sjögren's syndrome (SS).

METHODS

Echocardiographic examination was undertaken in 64 patients (62 women, two men) with primary SS (54 definite (DSS) and 10 probable (PSS)) who had systemic symptoms. Twenty one healthy women volunteers of similar age acted as controls.

RESULTS

Acute exudative pericarditis occurred in only one patient. An echogenic pericardium was demonstrated in 21 patients (19 DSS, two PSS) (33%) who had a previous symptom free pericarditis, but in none of the controls. Pulmonary pressure was significantly greater in the patients than in the controls (31 (SD 8) mm Hg compared with 24 (7) mm Hg), but there was no significant difference between the DSS and PSS groups. Left ventricular (LV) systolic function was similar in patients and controls. Twenty two patients (20 DSS, two PSS) and one control subject were excluded from LV diastolic function evaluation because of conditions likely to influence the parameters. Of the remaining 42 patients with SS (34 DSS, eight PSS), 21 (17 DSS, four PSS) had impaired diastolic function, confirmed by several diastolic parameters. LV diastolic dysfunction and echogenic pericardium occurred independently of each other, and there was no correlation between the occurrence of these silent cardiac abnormalities and the clinical and laboratory findings.

CONCLUSIONS

Obvious cardiac involvement is rare in primary SS, but clinically silent manifestations (symptom free pericarditis and LV diastolic dysfunction) are common. The clinical and prognostic significance of these changes cannot yet be defined.

Familial dilated cardiomyopathy: a worse prognosis compared with sporadic forms

OBJECTIVE

To establish the time of onset of dilated cardiomyopathy (DCM) by review of annual chest x rays, which are obligatory in Hungary.

DESIGN

A retrospective survey of chest x rays of a cohort of confirmed cases of DCM, to assess time of onset of cardiomegaly. Clinical course was compared by follow up over a mean of six years from the time of diagnosis.

SUBJECTS

240 patients with DCM (31 familial, 209 non-familial). Diagnosis was made by echocardiography in all cases and confirmed by coronary angiography and heart biopsy in some cases.

MAIN RESULTS

At diagnosis, the mean age of the patients was 31.8 years in the familial group and 39.6 years in the non-familial group (P < 0.05). The time between the onset of cardiomegaly (cardiothoracic ratio > 0.45) and clinical diagnosis was 8.0 and 10.1 years respectively (P < 0.05). The six year survival was 6% in the familial group and 23% in the non-familial group (P < 0.05).

CONCLUSIONS

The familial form of DCM is the more malignant form: it occurs at an earlier age and progresses more rapidly than non-familial DCM.

[15-year echocardiographic follow-up of acromegalic patients]

An echocardiographic follow-up of 25 patients (pts) was performed, after the first examinations in 1978-1979. 15 pts have died in the last 15 years (Group 1), while 10 still living (Group 2). In Group 1 either the impaired global left ventricular at the time of the first echocardiography predicted a high mortality i.e. there were only two pts with normal echocardiographic findings. The other 6 acromegalic pts with a "normal heart" have survived. The left ventricular hypertrophy of pts in Group 2 was observed to increase during the 15-year follow-up, because of the development of systemic hypertension. In conclusion, the echocardiographic findings are of a good predictive value in estimations of the survival rate in acromegalic pts.

[Effect of lovastatin on serum lipids and lipoproteins. Hungarian multicenter, open-label study]

The authors studied the effects of lovastatin on the parameters of serum and lipoprotein lipids in an open multicenter trial. 160 patients with hypercholesterolemia participated in the study, 151 of whom completed the trial. After a 4 week period of dietary measures, the patients were treated with lovastatin for 12 weeks while combining standard lipid lowering diet. The initial dose of the drug was 20 mg, this was increased until serum cholesterol level decreased under 5.2 mmol/l, or to a maximal daily dose of 80 mg. By the end of the 12th week, serum cholesterol level was reduced by an average of 33% (p < 0.001), LDL-cholesterol by an average of 45% (p < 0.001), serum triglyceride concentration by an average of 22% (p < 0.001) and HDL-cholesterol increased by an average of 13% (p < 0.001). Lovastatin showed a very good safety profile, therapy had to be cancelled due to the occurrence of adverse events only in 4 cases.

[Comparative evaluation of dipyridamole and dobutamine 2-dimensional echocardiography in ischemic heart disease]

Dipyridamole and dobutamine stress were performed in the same 41 angiographically controlled patients. Both tests were followed by 2 dimensional-echocardiography. The dose of dipyridamole was 0.56 mg/kg/4 min. or 0.84 mg/kg over 10 min., while the dose of dobutamine was 10-20-30-40 and 40 micrograms/kg/min. over 3 min. each step. In addition, to reach the submaximal heart rate 0.25 mg/min Atropine was also injected for 4 minutes in 13 cases. One vessel disease was found in 15 cases, and 2 vessel disease was in 2 cases. The number of coronarography negative cases was 24. The sensitivity, specificity, positive and negative predictive values for both tests were 70%, 91%, 85% and 81%, respectively. False positive results were observed in 2 cases and false negative ones were found in 5 cases, mainly at left anterior descendent stenosis. There was a good agreement between the wall motion abnormality and the anatomic localization of stenoses. Both non-invasive tests are suitable for the diagnosis of ischaemic heart disease.

[Familial dilated cardiomyopathy]

The author surveys the literature and gives a state of art of familial dilatative cardiomyopathy including his own experience. In the past two decades, III familial dilatative cardiomyopathy cases have been encountered in 30 families in their own material, which means a 21.5 percent incidence rate as concerns the total number of dilatative cardiomyopathy patients. The inheritance pattern was autosomal dominant in the majority of the cases. Both cardiomegaly (20 vs 29.6 ys) and the complaints (29.9 vs 37.6 ys) displayed an earlier onset in familial dilatative cardiomyopathy than in the nonfamilial form. The characters of the signs and symptoms did not differ otherwise between the two groups. Significant differences were observed between the two groups in the progression of the disease: the five-year survival rate after the onset of the symptoms was 23.1 percent in the familial cases and 52.1 percent in the non-familial form (p = 0.026).

An unusual Doppler-echocardiographic finding in case of a Björk-Shiley mitral prosthetic valve thrombosis

We report a patient in whom the commonly accepted Doppler echocardiographic findings failed to suggest prosthetic valve dysfunction. This was diagnosed by M-mode technique. We therefore feel that M-mode echocardiography still has its place in the complete evaluation of patients with suspected prosthetic valve dysfunction.

[Diagnosis of femoral pseudoaneurysm and factors contributing to its incidence after heart catheterization]

Two-hundred patients who underwent heart catheterization between 30 November 1989 and 30 September 1990, were followed up to establish the frequency of the vascular complications (mainly femoral pseudoaneurysm) of the procedure. Factors were evaluated which may promote the occurrence of femoral pseudoaneurysms. This complication was diagnosed in 6 cases. Two-dimensional and Doppler echocardiography (conventional and colour-coded) played an important role in the diagnosis. Systemic hypertension, anticoagulant therapy, obesity and technical difficulties (multiple punctures and catheter guidance problems) proved to be factors promoting femoral pseudoaneurysms. Serial echocardiograms revealed a tendency to spontaneous healing even in cases of relatively large pseudoaneurysms.

[The significance of the dipyramidole echocardiography test in ischemic heart disease]

The diagnostic value of the dipyridamole echocardiography test was investigated in 46 patients who underwent coronary angiography due to suspected ischaemic heart disease. Twenty-two of 46 patients were found to have a narrowing of at least 70% one vessel. Twenty-four hour ECG monitoring was also performed on 19 patients on the day of the dipyridamole test. The sensitivity and specificity of the two-dimensional echocardiography test (new wall motion abnormality) were 72.7% and 62.5%. The ECG (V2-5-9) had a low sensitivity during the test (43.8%). Good agreement was found between the localization of the wall motion abnormalities and the site of anatomic narrowing in the ischaemic group. No significant ventricular arrhythmias were detected, and the sensitivity and specificity of ST-T changes were found to be 62.5% and 54.6% by means of Holter monitoring. The dipyridamole echocardiography test proved to be a suitable noninvasive method for the diagnosis of ischaemic heart disease and for the selection of patients for coronary angiography.

[Doppler echocardiography in the examination of normally functioning artificial mitral and aortic valves]

Patients with prosthetic valves were investigated by Doppler echocardiography in 902 cases between November 1987 and February 1990. The parameters of 209 of 344 mitral and 258 of 299 aortic prosthetic valves were evaluated. No significant correlation was found between the type of aortic or mitral prosthetic valves and the measured gradient. As concerns the size of the valve and the measured gradient, a close correlation for aortic valve replacement was detected. For a normally functioning mitral prosthetic valve, a maximum early diastolic velocity of less than 2 m/s (16 mm Hg gradient) and a pressure half-time of less than 130 ms (mitral valve area 1.8 cm2) were characteristic. In cases of aortic valve replacements, the maximum velocity was less than 3 m/s (36 mm Hg gradient), except for the small-diameter valves. More than 95% of the cases met these criteria. (Even if small-diameter valves were included, a maximum velocity of more than 3 m/s occurred only in 8.9%.) Doppler echocardiography is a suitable tool for detecting normal prosthetic valve function, while colour Doppler allows the optimal alignment of jet direction and Doppler beam.

Effects of chronic alcohol ingestion on myocardial lipid and fatty acid composition in adult turkeys

STUDY OBJECTIVE

The aim was determine whether alcohol induced left ventricular dilatation and myocardial lesions in turkeys are associated with changes in the phospholipid and fatty acid compositions of the cardiac tissue.

DESIGN

Triglyceride, phospholipid, and cholesterol concentrations and the fatty acid compositions of phospholipids and triglycerides were measured in the myocardium of control and alcohol fed turkeys. Tissue samples were taken from the anteroapical wall of the left ventricle.

SUBJECTS

Seven week old domestic Nicholas turkeys were used (10 controls and 10 ethanol fed); the alcohol, comprising more than 20% of the dietary energy, was given in the drinking water for 16 weeks.

MEASUREMENTS AND MAIN RESULTS

Left ventricular function was assessed by echocardiography at the end of the treatment. Different phospholipid fractions were isolated by two dimensional thin layer chromatography, and individual fatty acids were identified by gas chromatography. Non-invasive evaluation of the cardiac function revealed a dilatation of the left ventricle and an impaired contractile function in the alcoholic birds. Increased amounts of triglyceride, phosphatidylinositol, sphingomyelin, lysophosphatidylcholine, and lysophosphatidylethanolamine were found in the left ventricle of the alcoholic turkeys. Examination of the fatty acid compositions of different phospholipids and the triglyceride fraction revealed an increase in the saturated/unsaturated ratio following ethanol treatment. In the phospholipid fractions of the alcoholic birds the arachidonic acid (20:4n-6) content was significantly decreased as were the linolic (18:1) and linoleic (18:2n-6) acid contents in the triglycerides.

CONCLUSIONS

These alterations in the myocardial phospholipid and fatty acid compositions may contribute to the electrophysiological and functional derangements of the left ventricle in alcoholic cardiomyopathy.

[Systemic thrombolysis in acute obstruction of an artificial valve]

Prosthetic valve thrombosis is a characteristic, but fortunately not frequent complication of surgical valve replacement. Its occurrence may lead to haemodynamic catastrophe. Three cases involving prosthetic valve thrombosis are presented. Two patients suffered from thrombosis after tricuspid valve replacement (St. Jude Medical), while the third occurred after mitral valve replacement (Sorin). In the acute phase, systemic thrombolysis was initiated (2 MU Streptokinase during 22-28 hours). The obstruction of one of the tricuspid valves and the mitral valve was eliminated. Lysis of the other tricuspid valve was not complete, but it helped the patient to survive the acute phase until reoperation. Embolization occurred in the inferior extremity after thrombolysis of the mitral prosthetic valve, but it was cured. Two-dimensional and Doppler echocardiography (conventional and colour-coded) played an important role in the diagnosis of the obstruction and in the follow-up of the effectivity of thrombolysis. Systemic thrombolysis may be a lifesaving procedure in acute prosthetic valve thrombosis. In spite of the potentially dangerous complications, it has to be attempted.

[Judging the severity of regurgitation in acquired heart defects using color-coded Doppler echocardiography]

In the study, 139 valvular regurgitations of 120 patients (55 mitral and 84 aortic regurgitations) were investigated and compared by means of colour flow mapping and heart catheterization. During the echocardiographic examination, the length and width of the regurgitant jets were measured and the jet area was planimetered besides the subjective grades. The above parameters were correlated with the angiographic grades. Good agreement was found between the results of the two methods. As concerns the different parameters of the regurgitant jets in mitral regurgitation, the most severe (grade IV) category was easily distinguished from the others, while in aortic regurgitation all four categories were differentiated by colour flow mapping. These measurements indicated that colour-coded Doppler echocardiography is a suitable tool for detection of the severity of valvular regurgitations in a noninvasive way.

[Cardiolite (99m-Tc-isonitrile) SPECT studies in patients prior to coronary bypass surgery]

The authors studied with 99m-Tc Cardiolite (methoxy-isobutyl-isonitrile) SPECT examination the effect of coronary bypass operation on the myocardial perfusion. One week before and 3 weeks after the operation examinations were performed first with dipyridamol loading and 24 hours later in rest. The regional perfusion of the myocardium was studied on the basis of transversal section-pictures of corrected axis position. In the examinations preceding the operation the global sensitivity of the method was found to be 100%. In the demonstration of the structures of the ramus descendens 95%, of the ramus circumflexus and of the right coronary artery 100% sensitivity was reached. In postoperative examinations following the bridging of the ramus descendens anterior the improvement of the perfusion of the corresponding ventricular segment was found in 15/20 during the loading and in 7/8 cases following the bridging of the ramus circumflexus and right coronary artery. Improving perfusion was demonstrated in 17/20 and in 6/8 cases in rest. On the basis of the results the authors consider their method suitable for the study of the regional blood perfusion and for the examination of the changes taking place upon coronary bypass operations.

Reversible impairment of myocardial function in hypoparathyroidism causing hypocalcaemia

A 25 year old woman presented with severe myocardial dysfunction. Laboratory tests showed hypocalcaemia caused by hypoparathyroidism. After the restoration of normal concentrations of serum total and free ionic calcium indices of left ventricular function returned to normal and her symptoms disappeared.

[Morphologic studies of emdomyocardial biopsy specimens]

Authors have studied 153 heart biopsies of 120 patients and results of 133 endomyocardial biopsies studied by light and electron microscopy are described. In addition to typical morphological picture of myocarditis, in majority of cases non-specific changes appearing also in idiopathic cardiomyopathy were observed and their ultrastructure is fully stated. Results are compared to relevant data of literature. Indications, informative value, practical and scientific research significance of myocardial biopsies are briefly overviewed.

[Direct and indirect immunofluorescence studies in congestive myocardial diseases]

Immunfluorescence examinations were made on 118 patients with congestive cardiomyopathy. Standard techniques of direct immunfluorescence (DIF) were employed on myocardial biopsy material in 61 cases, and of indirect immunfluorescence (IIF) on the serum in 89 cases. On the basis of the assumed aetiologies, the patients were classified into 6 groups: definitely alcoholic, presumably alcoholic, familial, peripartum, chronic myocarditic and idiopathic; studies were then made of the frequencies of pathological immunological processes in the individual groups. The highest incidences of DIF-positive cases were observed in the familial, peripartum, chronic myocarditic and idiopathic groups (67-87%). In the presumably alcoholic group the corresponding incidence was 37%, and in the definitely alcoholic group it was 25%, in contrast with expectations. Interestingly, very strong IIF-positive reactions too were observed in these alcoholic groups. It is possible that, besides the effect of alcohol, the fact that the immune background becomes pathological is also a significant factor in the emergence of the congestive cardiomyopathy in the alcoholic groups.