Real-World Efficacy of Azelaic Acid 15% Gel for the Reduction of Inflammatory Lesions of Rosacea

Approximately 16 million Americans have rosacea, an inflammatory cutaneous disorder with central facial erythema, papules, pustules, telangiectasia, flushing, and swelling being among the more commonly recognized features. Overexpression of cathelicidin peptide LL-37 has been implicated in the pathophysiology of rosacea. Azelaic acid has been found to inhibit the pathologic expression of cathelicidin, as well as the hyperactive protease activity that cleaves cathelicidin into LL-37. Given these findings, a small prospective, open-label, interventional trial was undertaken to assess the effects of azelaic acid 15% gel on inflammatory lesions of papulopustular rosacea in a real-world setting. Use of azelaic acid was associated with a significant reduction in inflammatory lesions, which persisted beyond the active treatment phase. Overall, azelaic acid 15% gel is an appropriate initial topical therapy for the treatment of moderate facial rosacea.

Optimisation of coronary angiography exposures requires a multifactorial approach and careful procedural definition

OBJECTIVE

This study investigates the factors associated with higher doses for both single-plane and biplane procedures and establishes centre-specific 75th percentile levels.

METHODS

602 patients undergoing coronary angiography in a large hospital at Sydney were recruited to the study, and causal agents for high radiation doses were investigated: gender, procedural complexity, severity of coronary artery disease, presence of coronary bypass grafts, entry approach (radial or femoral), level of operator experience; and a single-plane or a biplane imaging system was employed.

RESULTS

The 75th percentile levels were calculated. The results demonstrated that, for both systems, higher exposures were associated with patients who were male (p<0.001), had coronary vessel disease (p<0.001) and had a history of coronary bypass grafts (p<0.001). In addition, for biplane systems, procedural complexity (p<0.001), types of entry approach (p<0.001) and levels of operator experience (p<0.001) significantly impacted upon the dose. Biplane examinations recorded higher doses than single-plane procedures (p<0.001) and the inclusion of left-sided ventriculography contributed to the overall dose by up to 10%.

CONCLUSION

The 75th percentile levels in this study represent the tentative reference levels and are 48.9, 44.2 and 56 Gy cm(2) for all exposures, single-plane- and biplane-specific exposures, respectively, and compare favourably with the diagnostic reference level values established elsewhere internationally, with only the UK and Irish data being lower.

ADVANCES IN KNOWLEDGE

Specific agents have been identified for dose-reducing strategies and the importance of operator training is highlighted. The assumption that biplane procedures may reduce the patient dose should be treated with caution.

Effects of intravenous verapamil on the haemodynamic response to exercise in patients with angina pectoris

The effects of intravenous Verapamil (V) on exercise haemodynamics and ventricular function were compared in 13 patients with stable effort angina. Intravascular pressures, thermodilution cardiac output and radionuclide ejection fraction were measured simultaneously at rest and during exercise. At rest Verapamil produced systemic vasodilation. During exercise at identical workloads compared to control, Verapamil increased cardiac index (CI) and decreased AVO2 difference. Pulmonary artery wedge pressure was lower. Ejection fraction was higher (control-55 +/- 11% vs V-64 +/- 11%) as the disproportionate increase in end systolic volume relative to the end diastolic volume was prevented. Verapamil is effective in exercise induced angina and alters haemodynamics primarily through its vasodilating properties associated with an increased CI.

Randomized double-blind trial of sotalol versus lignocaine in out-of-hospital refractory cardiac arrest due to ventricular tachyarrhythmia

AIM

We aimed to compare the efficacy of sotalol versus lignocaine for the treatment of patients with out-of-hospital ventricular fibrillation refractory to > or = 4 defibrillatory shocks.

BACKGROUND

The outcome of patients in ventricular fibrillation refractory to > or = 4 defibrillatory shocks is poor. In a previous randomized trial, sotalol was superior to lignocaine for acute termination of ventricular tachycardia not causing loss of consciousness.

METHODS

Patients of the Ambulance Service of New South Wales treated by paramedics with continued ventricular fibrillation despite standard resuscitation and > or = 4 defibrillatory monophasic shocks were eligible. Drug doses were sotalol 100 mg or lignocaine 100 mg, given as i.v. boluses. A further 2 min of cardiopulmonary resuscitation was given and then defibrillation was repeated twice. If this failed, half the initial dose of the trial drug was repeated and a further > or = 2 shocks were given.

RESULTS

Sixty patients were randomized to sotalol and 69 randomized to lignocaine. There was no significant difference between the two groups in the clinical characteristics of the patients or in the number of shocks received. Outcomes in the sotalol and lignocaine groups were survival to hospital admission in 7 (12%) and 16 (23%), respectively (P = 0.09), and survival to hospital discharge in 2 (3%) and 5 (7%), respectively (P = 0.33).

CONCLUSIONS

Sotalol is not superior to lignocaine for treatment of ventricular fibrillation refractory to multiple shocks. The overall outcome of this group of patients is poor regardless of the pharmacological intervention (lignocaine or sotalol).

Prognostic implication of ST-segment resolution following primary percutaneous transluminal coronary angioplasty for ST-elevation acute myocardial infarction

BACKGROUND

ST-segment changes have been shown to correlate with myocardial tissue perfusion. Complete ST-segment resolution after thrombolysis in acute myocardial infarction is associated with lower mortality and better left ventricular function. Primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction restores better epicardial coronary flow to the infarct-related artery than thrombolysis. However, ST changes may persist and flow can remain poor despite a patent vessel.

AIM

To examine the prognostic implication of ST-segment resolution immediately following primary and rescue PTCA for ST-elevation acute myocardial infarction (STEMI).

METHODS

Records of 201 consecutive primary and rescue PTCA performed at Westmead Hospital for STEMI from January 2000 to December 2001 were reviewed. ST-segment elevation (taken 20 ms after the end of the QRS complex) was measured immediately before and after the procedure. ST-segment resolution of greater than 70% after the procedure was considered as -'complete' ST-segment resolution, whereas ST-segment resolution of less than 70% was considered as 'incomplete' ST-segment resolution.

RESULTS

Of the 201 patients, 117 (58%) had complete ST-elevation resolution and 84 (42%) did not. There was a significant difference in survival free of major adverse cardiovascular events; 60% of those with complete ST-segment resolution were event-free at 2 years compared with 35% of those patients without complete ST-segment resolution.

CONCLUSION

ST-segment resolution after primary and rescue PTCA for STEMI is associated with significantly higher event-free survival. The goal of primary angio-plasty should be the restoration of normal epicardial flow with normalization of ST-segments.

Elliptografting: the right fit

BACKGROUND

A number of new recipient grafting techniques have evolved employing micrografting, minigrafting, and follicular unit technologies as larger hair transplantation sessions incorporating smaller grafts have evolved.

OBJECTIVE

To introduce a new recipient graft device-the elliptograft-and compare it to standard circular minigrafts and laser-generated slot grafts.

METHODS

A blinded study was performed of 30 patients (mean age 44 years) with grades II-V male pattern Norwood or medium Ludwig female pattern androgenetic alopecia. Ten patients were transplanted with the second-generation elliptograft punch, 10 were treated with 2 mm circular minigrafts, and 10 were transplanted with the recipient sites created by the hybrid Er:YAG/CO2 laser in a slot configuration. The front three rows in each patient were transplanted utilizing No-Kor needle-generated micrografts in all three patient study subgroups.

RESULTS

Comparable hair growth density was achieved utilizing conventional circular minigraft, freehand laser slit, and elliptograft technologies. Healing time was slightly prolonged in the laser transplant subgroup; however, the time for initial hair growth was comparable in all three patient populations. Aesthetic improvement was judged superior in the elliptograft population by blinded physician observers, which correlated with good patient satisfaction.

CONCLUSION

Combined micro-mini elliptografting utilizing the newly described elliptograft punch produces excellent hair density correlated with high patient satisfaction.

Small-vessel sclerotherapy

Small vessel telangiectasias are commonly seen in clinical dermatology. This article focuses on the evaluation of these patients and treatment. The types of sclerosing agents and the techniques of sclerotherapy are discussed in detail.

Interaction between transient metabolically mediated dilatation and pressure induced constriction in the canine coronary artery

This study explored the interaction between metabolically mediated vasodilatation (ventricular extra-activation) and pressure induced vasoconstriction (transient augmentation of aortic diastolic pressure). Eight dogs having formalin-induced heart block were chronically instrumented with aortic and left ventricular catheters and an electromagnetic flow probe on the left circumflex coronary artery. At a heart rate of 60 beats/min a single ventricular extra-activation introduced at 200 ms after the normal paced beat resulted in a 13 +/- 1% decrease in diastolic coronary vascular resistance index (DCVRI) in the first response beat (D1) and a persistent vasodilatation lasting for five beats (D1-D5). An increase in aortic diastolic pressure (32 +/- 3% for 520 +/- 15 ms) resulted in 13 +/- 2% increase in DCVRI in the D1 which was not evident in subsequent beats. Following a combined intervention, DCVRI in D1 was not significantly different from control but DCVRI did decrease to a greater degree in the subsequent response beats (D2-D7). These data indicate that the responses of two opposing vasoactive stimuli, i.e., pressure induced vasoconstriction and metabolic vasodilatation, were negated in the first response beat. The metabolically mediated vasodilatation was unaltered in the subsequent response beats.

The development of a Marjolin's cancer in a human immunodeficiency virus-positive hemophilic man and review of the literature

BACKGROUND

The malignant potential of chronic ulcers and scars secondary to a variety of injuries is well characterized in the medical literature. Furthermore, it has been reported that human immunodeficiency virus (HIV)-positive patients have a higher incidence of basal cell carcinoma (BCC) than the general population.

OBJECTIVE

To describe a case of an unusually aggressive morpheaform BCC that developed in a 28-year-old HIV-positive patient. The tumor developed in a scar 25 years after the initial trauma (Marjolin's ulcer).

METHODS

Description of a case and review of the literature of Marjolins ulcer.

RESULTS

The tumor was removed in a seven-stage, 21-section, micrographically controlled excision. Intraoperatively, perineural invasion of the infraorbital nerve was observed. The postoperative defect was repaired using a full-thickness skin graft.

CONCLUSION

Although most malignancies arising within chronic scars are SCCs, BCCs and a number of other tumors have been described. Mohs micrographic surgery was effective in treating this aggressive morpheaform BCC. A high degree of suspicion in any changing healed scar is recommended.

Can the electrophysiologic study predict treatment outcome in patients with sustained ventricular tachyarrhythmias unrelated to coronary artery disease?

Sustained ventricular tachyarrhythmias unrelated to coronary artery disease are uncommon. Currently there are no clear guidelines to aid selection of the most appropriate treatment strategy. Therefore, factors potentially predictive of arrhythmia recurrence and death and the ability of the electrophysiologic study to predict treatment outcome in patients with spontaneous sustained ventricular tachyarrhythmias unrelated to coronary artery disease were examined in 41 medically treated patients followed for a median of 25 (range 1-76) months. Examined factors were: syncope associated with the spontaneous arrhythmia, the morphology and cycle length of the presenting arrhythmia, underlying ventricular function, cardiac pathology, and the results of drug assessment at electrophysiologic study. Random variability in the ease of arrhythmia induction at electrophysiologic study was measured for the group as a whole and was allowed for in prediction of an effective drug response. The 95% confidence intervals for variability in the ease of repeat arrhythmia induction at the same study were < or = 1 extrastimulus and for variability in the ease of repeat arrhythmia inductions at different studies were < or = 2 extrastimuli. Poisson regression models were used for data analysis. Arrhythmia recurrence was most likely in: (1) patients on treatment not predicted to be anti-arrhythmic at electrophysiologic study; (2) patients whose treatment was not assessable at electrophysiologic study because the arrhythmia was not reliably inducible; (3) patients with impaired ventricular function; and (4) re-entered patients whose arrhythmia had recurred on previously allocated therapy. The risk of arrhythmia recurrence decreased with time from hospital assessment. All five deaths occurred in patients with impaired ventricular function.

CONCLUSIONS

drug efficacy should be tested at electrophysiologic study in patients with reproducibly inducible clinical arrhythmias. Treatment not proven to be anti-arrhythmic at electrophysiologic study is usually ineffective. Patients with ventricular dysfunction are at highest risk of death from arrhythmia recurrence and should be considered for an implantable defibrillator, arrhythmia surgery, or heart transplantation if drug treatment is not predicted to be effective or is not assessable at electrophysiologic study.

Clinical response of alopecia, trichorrhexis nodosa, and dry, scaly skin to zinc supplementation

Two unrelated patients had dry brittle hair, alopecia, trichorrhexis nodosa, dry scaly skin, pigment dyschromia, short stature, and neurosecretory growth hormone deficiency. By means of the zinc tolerance test, patient 1 was shown to have zinc deficiency, whereas no clear zinc deficiency could be demonstrated in patient 2. In both patients, hair and the skin abnormalities responded to oral zinc therapy.

Skin diseases in children with HIV infection and their association with degree of immunosuppression

Since the recognition of the acquired immunodeficiency syndrome (AIDS) in 1981, several dermatologic manifestations have been associated with the syndrome, including candidiasis, dermatophyte infection, molluscum contagiosum, herpes simplex and zoster, bacterial infection, and malignancy. Skin diseases have been observed in both the adult and the pediatric human immunodeficiency virus (HIV) infection in an academic hospital setting in relationship to the current CDC classification of pediatric HIV infection. The severity of dermatologic manifestations is correlated with the immune status of the patients. The latter was determined by T4 helper cell numbers and lymphoproliferative responses to mitogens and recall antigens. More severe T helper cell depletion was associated with a wider spectrum and increased severity of dermatologic manifestations.

Hyperemic response to coronary occlusion during a single diastole in conscious dog

This study determined whether the reactive hyperemic response to a 400-ms diastolic coronary occlusion is dependent on ventricular systole. Studies were obtained on 11 conscious dogs with complete heart block paced at 60 beats/min. A pressure catheter was chronically implanted in the aorta. An electromagnetic flow probe and pneumatic occluder were implanted on the circumflex coronary artery. Three interventions were employed: 1) interruption of pacing for a single beat generating a long diastolic period of 2,000 ms in duration (LDC); 2) introduction of a 400-ms diastolic coronary occlusion early in a long diastole (LD4); and 3) a 400-ms diastolic occlusion during uninterrupted pacing (400R). The rise in diastolic coronary vascular resistance index noted during LDC was inhibited significantly in the last 600 ms of diastole during LD4. Thus an intervening systole is not required for a reactive hyperemic response to a diastolic coronary occlusion. During 400R, the resistance index was lower than that found during LD4. The reactive hyperemic response may be caused by either a myogenic or metabolic mechanism or by both. The greater vasodilatation observed after the postocclusion systole in 400R probably reflects metabolic influences.

Continuous varicella-zoster infection associated with acyclovir resistance in a child with AIDS

Acyclovir has become the treatment of choice for varicella-zoster virus (VZV) infections in immunocompromised individuals. This article describes a 4-year-old girl congenitally infected with human immunodeficiency virus who developed a continuous cutaneous infection with VZV that persisted over a 14-month period until her death. Initial episodes of varicella and zoster were responsive to acyclovir treatment; however, subsequent recurrences necessitated administration of multiple courses of acyclovir. Lesions became markedly hyperkeratotic, slow healing, and persistent despite acyclovir therapy. Numerous attempts to isolate virus from the lesions yielded only one isolate late in the course of therapy. This virus clearly demonstrated acyclovir resistance in vitro. Bizarre manifestations of VZV infection could present both diagnostic and therapeutic dilemmas. Prolonged acyclovir treatment of highly immunocompromised patients with acquired immunodeficiency syndrome and severe VZV may lead to the appearance of resistant virus.

Demonstration of coronary artery myogenic vasoconstriction in the awake dog

The aim of this study was to determine whether or not coronary vasoconstriction occurs in response to a transient increase in coronary perfusion pressure. Eleven awake dogs with formalin-induced heart block, chronically instrumented with aortic and left ventricular catheters and left circumflex coronary and aortic electromagnetic flowprobes, were studied at a paced heart rate of 60 beats/min. A transient increase in aortic diastolic pressure of 17.3 +/- 1.5% for 330 +/- 20 ms and of 33.6 +/- 2.2% for 520 +/- 20 ms, via the inflation of an intra-aortic balloon, resulted in an increase in diastolic coronary vascular resistance index in the first response beat of 6 +/- 1% and 11 +/- 1%, respectively. An identical increase in diastolic coronary flow produced by the omission of a single paced beat resulted in no significant change in diastolic coronary vascular resistance index in the first response beat. Thus, the increase in diastolic coronary vascular resistance index following diastolic pressure augmentation is related to the increase in aortic diastolic pressure and not to the increase in diastolic coronary flow. These data are consistent with that of a brief myogenic response.

Usefulness of ejection fraction response to exercise one month after acute myocardial infarction in predicting coronary anatomy and prognosis

The prognostic value of left ventricular (LV) ejection fraction (EF) measured during maximal exercise testing early after acute myocardial infarction (AMI) was assessed in 75 patients, aged 65 years or younger, a mean of 36 days after AMI. At follow-up for a mean 12 months (range 6 to 26), medical complications developed in 15 patients: cardiac death in 5, ventricular fibrillation in 1, reinfarction in 2, unstable angina in 5, and severe cardiac failure in 2. Seven other patients underwent coronary artery bypass grafting for severe angina. When LVEF less than 50% at rest was compared with LVEF of 50% or more, the 2-year life-table survival free of complications was 54 +/- 21% compared with 84 +/- 19% (p less than 0.05). When exercise LVEF less than 50% was compared with LVEF of 50% or more, the 2-year survival rate free of medical complication was 42 +/- 32% compared with 83 +/- 20% (p less than 0.05). LVEF change from rest to exercise was not related to prognosis. Patients with combined medical and surgical events tended to have lower rest and exercise LVEFs, but changes in LVEF during exercise were again unrelated to prognosis. Sixty-five patients underwent coronary arteriography. After inferior AMI the mean LVEF was lower in those with multivessel than in those with 1-vessel coronary artery disease at rest (47 +/- 13% vs 59 +/- 7%, p less than 0.005) and during exercise (47 +/- 13% vs 59 +/- 9%, p less than 0.005); however, the change in LVEF during exercise was not related to coronary anatomy anatomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic mediation of single brief diastolic occlusion reactive hyperemic responses

We tested the hypothesis that coronary reactive hyperemia following a single brief diastolic occlusion and subsequent systole is coupled to myocardial metabolic activity and myocardial O2 consumption (MVO2). Sixteen conscious dogs with Formalin-induced heart block were studied. A 400-ms diastolic occlusion was introduced during normal ventricular pacing, resulting in a reactive hyperemic repayment of 216 +/- 22%. A 400-ms diastolic occlusion was also introduced during a higher level of myocardial metabolic activity induced by ventricular paired pacing. MVO2 and mean coronary blood flow were significantly increased relative to these parameters during normal pacing, but reactive hyperemic repayment (189 +/- 18%) was not significantly changed. A third set of conditions was designed to measure the response to a 400-ms occlusion during normal pacing while eliminating the difference in magnitudes of myogenic influences that may exist between paired pacing and normal pacing. Adenosine and phenylephrine were infused intravenously during normal pacing to maintain mean aortic pressure and mean coronary flow at paired pacing levels. MVO2 was similar to O2 consumption during normal pacing in the absence of drug infusion, but the reactive hyperemic repayment was significantly reduced (94 +/- 22%) relative to paired pacing. Thus the magnitude of reactive hyperemic response after a brief diastolic occlusion is related primarily to myocardial metabolic activity.

Dermatologic findings and manifestations of acquired immunodeficiency syndrome (AIDS)

We present a review of the spectrum of human T-lymphotropic virus type III (HTLV-III) infection with particular emphasis on cutaneous manifestations in 217 patients. Correlations are made with immunodeficiency as measured by absolute T-helper cell number. A classification is presented of these dermatologic findings.

Unusual features of scabies complicating human T-lymphotropic virus type III infection

Four cases of "exaggerated scabies" are described in patients who were immunodeficient secondary to human T-lymphotropic virus type III (HTLV-III) infection. As in classical scabies, these patients had a pruritic dermatitis but lacked the usual distribution of the eruption. The rash was initially misdiagnosed in all four patients. Scabies should be considered in pruritic dermatitis in patients at risk for HTLV-III infection.

Vacuolar myelinopathy of the brain and lamellar ichthyosis

A 13-month-old child with lamellar ichthyosis and numerous cutaneous and systemic infections died following an abrupt episode of severe hypotension. Postmortem examination revealed white matter vacuolation in the brain stem tegmentum and cerebellar hemispheres similar to that seen in toxicity from hexachlorophene, to which our patient was not exposed. The patient had been treated with many commonly used medications, including 13-cis-retinoic acid, a relatively new drug with apparent therapeutic benefit in hyperkeratotic dermatoses. This had been given systemically during the patient's last week of life. Possible relationships between the white matter lesions and extrinsic toxic agents are discussed.

Functional and reactive hyperemia are unaltered by homocysteine in conscious dogs

The purpose of this study was to test the hypothesis that L-homocysteine thiolactone (L-HCTL), through its reaction with adenosine to form S-adenosylhomocysteine, may modulate myocardial functional and reactive hyperemic responses. Reactive hyperemic responses to 10-sec occlusions or 400-msec diastolic occlusions of the circumflex coronary artery and functional hyperemic responses to ventricular extra-activations were studied in a chronic heart-blocked dog preparation during a control period and following L-HCTL (40 mg/kg). In two additional dogs multiple venous blood samples and left ventricular myocardial biopsies were obtained following L-HCTL to measure changes in plasma homocysteine and tissue S-adenosylhomocysteine. Despite a 75-fold increase in peak plasma homocysteine and a 26-fold increase in tissue S-adenosylhomocysteine, L-HCTL did not alter myocardial functional and reactive hyperemic responses. The rapid increase in myocardial S-adenosylhomocysteine confirmed cellular entry of homocysteine and its reaction with endogenous adenosine. The failure of L-HCTL to alter functional and reactive hyperemic responses suggests that either such treatment does not affect myocardial release of adenosine or that adenosine is not an important regulator of coronary flow.

Granulocytic sarcoma. A new finding in the setting of preleukemia

Preleukemia is a well-defined syndrome of hematopoietic dysfunction that may antedate the development of acute myelogenous leukemia. Granulocytic sarcoma refers to neoplastic infiltration in the skin, composed of immature cells of the granulocyte series. We report two cases of granulocytic sarcoma in the setting of preleukemia. The clinical importance of these cases, as well as the cutaneous manifestations of leukemia and the clinical spectrum of granulocytic sarcoma, are presented.

Effect of aminophylline on coronary reactive and functional hyperaemic response in conscious dogs

This study was undertaken to determine whether adenosine release from myocardial cells plays a role in coronary reactive and functional vasomotion. Reactive hyperaemic blood flow responses to 10 s complete occlusions and 400 ms diastolic occlusions of the left circumflex coronary artery and to the vasomotor responses to the increased cardiac demand following ventricular extra-activation were examined in a chronic, heart-blocked dog preparation during a control period and following intravenous bolus administration of aminophylline (5 mg X kg-1). Aminophylline administration resulted in a 19% decrease in the blood flow debt repayment ratio of 10 s reactive hyperaemic responses compared with the control period. However, administration of aminophylline had no effect on the coronary vascular response to 400 ms diastolic occlusions or to ventricular extra-activations. These observations indicate that adenosine may play a role in the coronary vascular response to prolonged interventions but that other factors, as yet unidentified, may be implicated in the beat-to-beat regulation of coronary vascular resistance.

Comparison of thallium-201 scanning in idiopathic dilated cardiomyopathy and severe coronary artery disease

To determine whether cardiomyopathy could be distinguished from coronary artery disease, we used thallium scanning to study 25 patients with severe left ventricular dysfunction and chronic heart failure. Ten patients had normal coronary arteries and idiopathic cardiomyopathy (ejection fraction 20 +/- 5%), and 15 patients had multivessel coronary disease and left ventricular dysfunction (ejection fraction 25 +/- 6%). The exercise time and maximal heart rate were similar in the two groups. Two patients with cardiomyopathy and 11 with coronary artery disease had a positive exercise ECG (p less than 0.05). Thallium scans showed perfusion defects in all 25 patients. The perfusion defects were complete in nine coronary artery disease patients (60%) and in one patient (10%) with cardiomyopathy (p less than 0.05). Extensive defects involving more than 40% of the left ventricular circumference, the number of segments involved, redistribution on the 4-hour scan, lung uptake and ventricular size were similar in the two groups. Perfusion defects on thallium scanning can occur in patients with idiopathic dilated cardiomyopathy and chronic heart failure. Thallium scanning cannot be reliably used in patients with chronic heart failure to distinguish coronary artery disease from cardiomyopathy unless complete defects are present.

Verapamil in stable effort angina: effects on left ventricular function evaluated with exercise radionuclide ventriculography

A double blind placebo-controlled study was performed in 12 patients with stable angina pectoris to evaluate the effects of oral verapamil (320 mg/day) on left ventricular function, as measured at rest and during exercise with gated equilibrium radionuclide ventriculography. On verapamil, patients had a lower heart rate-blood pressure product at each work load than with placebo. Anginal threshold increased by 28 +/- 19 watts (p less than 0.005), and maximal exercise capacity increased by 20 +/- 14 watts (p less than 0.001) with verapamil, but the rate-pressure product at the onset of angina and at maximal exercise was unchanged. Left ventricular ejection fraction at rest during verapamil therapy was the same as with placebo therapy. On exercise during placebo therapy, the ejection fraction decreased from 40 +/- 9 to 35 +/- 11 percent (p less than 0.025) because end-systolic volume increased disproportionately compared with end-diastolic volume. On exercise during verapamil therapy, the ejection fraction did not decrease (44 +/- 8 versus 45 +/- 12 percent) and was significantly higher at identical work loads than on placebo because of a smaller increase in end-systolic volume. Oral verapamil is effective treatment for effort angina and may prevent the decrease in left ventricular ejection fraction due to exercise-induced ischemia.

Multivessel coronary artery spasm

A 60-year-old patient with variant angina was shown to have myocardial ischemia in two different regions supplied by separate major coronary arteries. Neither artery had significant coronary atherosclerotic obstruction. Ventricular fibrillation was noted during ST-segment elevation in anteroseptal leads. The attacks of pain and arrhythmias disappeared during nifedipine therapy.

Surgical division of an accessory atrioventricular connection in the posterior septal region following ventricular fibrillation in the Wolff-Parkinson-White syndrome

A young man presented with atrial fibrillation and a rapid ventricular response which degenerated into ventricular fibrillation. Electrophysiological study demonstrated an accessory atrioventricular connection in the posterior septal region. This was sectioned to prevent recurrence of his arrhythmia. Post-operative electrophysiological study demonstrated that the surgical section was successful.