Effects of pregnancy and chronic exercise on maternal cardiac structure and function.

This study examined the interactive effects of pregnancy and aerobic conditioning on maternal cardiac structure and function. Effects of closely monitored cycle ergometer conditioning were studied during the second (TM2) and third trimesters (TM3) in 22 previously sedentary pregnant women (exercised group, EG) and a nonexercising pregnant control group with similar characteristics (CG, n = 19). Subjects were studied in the resting state by two-dimensional echocardiography and during cycle ergometer exercise at three steady-state power outputs at the start of TM2 (ENTRY), at the end of TM2 and TM3 (postconditioning), and 3-4 months postpartum (NPR, nonpregnant reference, CG only). Aerobic conditioning did not increase left ventricular dimensions beyond those attributable to pregnancy itself. In addition, in contrast with previous studies of nonpregnant women, physical conditioning during pregnancy did not reduce heart rate (HR) in the resting state. During exercise, the slope of the HR versus oxygen uptake (VO2) regression decreased significantly between preconditioning and the end of TM3 in the EG, suggesting that training-induced reductions in HR become more evident with increasing exercise intensity. Also, significant reductions in oxygen pulse (VO2/HR) were observed at all three work rates in the CG, but not in the EG. These findings support the hypothesis that the cardiovascular effects of aerobic conditioning are obscured by more powerful effects of pregnancy in the resting state but become "unmasked" during strenuous exercise.

Are psychotropic drugs at therapeutic levels a concern for cardiologists?

OBJECTIVE: To review the cardiovascular effects of psychotropic drugs when used in therapeutic doses and to assess their clinical relevance for cardiologists. Information on newer psychopharmacological agents is also presented. DATA SOURCES: MEDLINE was used to search the relevant English language medical literature over the past five years. Standard texts and selected earlier references were also used. Input was obtained from local experts. DATA SYNTHESIS: Many antipsychotics and antidepressants have the potential for causing malignant ventricular arrhythmias and cardiac conduction disturbances. Postural hypotension is also a common side effect with important associated morbidity. The effects of psychotropic drugs on myocardial contractile properties are not significant at therapeutic dose levels. Older agents, such as phenothiazines, tricyclic antidepressants and monoamine oxidase inhibitors, are responsible for most of the reported adverse cardiovascular effects of psychotropic drugs. Selective serotonin reuptake inhibitors are a newer class of antidepressants that are free from significant direct cardiovascular adverse effects; however, if combined with other agents such as the monoamine oxidase inhibitors, they can cause cardiovascular collapse as part of a potentially fatal 'serotonin syndrome'. These newer agents can also exaggerate the actions of certain cardiac drugs through effects on their metabolism by inhibition of cytochrome P450 isoenzymes. CONCLUSION: The adverse cardiovascular effects of psychotropic medications in therapeutic doses are a valid concern for cardiologists. Familiarity with these drugs and their interactions is essential to avoid important undesired reactions with potential fatal consequences.

Reversible cardiogenic shock in an angry woman--case report and review of the literature.

A previously healthy woman presented with ischemic cardiac pain and ST elevation suggestive of acute myocardial infarction following a 45 min argument. Despite receiving tissue plasminogen activator, she developed cardiogenic shock and objective evidence of recurrent ischemia, with only a small creatine kinase rise. Angiography revealed the unexpected findings of normal coronary anatomy and akinesis of the distal two-thirds of the left ventricle. Apart from an iliac vein thrombosis, the remainder of her course was characterized by dramatic recovery of cardiac function. The differential diagnosis of myocardial infarction with angiographically normal coronary arteries is discussed, with emphasis on aspects relevant to this case. The presence of high titre anticentromere antibodies, anticardiolipin antibodies, protein S deficiency and supportive physical findings, suggested the diagnosis of concurrent antiphospholipid antibody syndrome (with secondary acquired protein S deficiency) and CREST syndrome. The pathogenesis likely involved an interaction between stress, vasospasm, and thrombosis.

Electrocardiographic and echocardiographic characteristics of female athletes.

This study examined electrocardiographic and echocardiographic characteristics of endurance- and resistance-trained female athletes. The subjects were 10 varsity caliber endurance-trained athletes, 10 resistance-trained athletes, and 10 nonathletes. Data collection included anthropometric measurements, VO2max, standard 12-lead ECGs and left ventricular dimensions measured by M-mode and two-dimensional echocardiography. For endurance-trained athletes, absolute left ventricular end-diastolic volume and values normalized for lean body mass were significantly greater than in nonathletes. An interstudy comparison of female vs male endurance-trained athletes from the same population also revealed significantly lower values for M-mode left ventricular mass expressed per kilogram of lean body mass in the former. Absolute and normalized wall thicknesses were not significantly greater in resistance-trained athletes compared to the other two groups. Wall thickness indexed for lean body mass was similar for the three groups. Sinus bradycardia was observed in all endurance athletes and in four resistance-trained athletes. ECG criteria were unreliable for the prediction of left ventricular enlargement. It appears that both female resistance- and endurance-trained athletes exhibit a lesser degree of enlargement of left ventricular wall thickness and mass than male athletes. A close relationship between skeletal and cardiac muscularity in resistance-trained athletes of both genders also was supported.

Change in atrial volume following restoration of sinus rhythm in patients with atrial fibrillation: a prospective echocardiographic study.

OBJECTIVES: To determine if restoration of sinus rhythm in patients with atrial fibrillation decreases atrial size, 16 patients undergoing elective cardioversion were prospectively studied. The frequent coexistence of atrial fibrillation and atrial dilation is well recognized. Recent data have demonstrated that atrial enlargement may be the result, rather than the cause, of atrial fibrillation. DESIGN: Echocardiographic examinations were performed before cardioversion, and at 24 h, three and six months of follow-up. Atrial dimensions were assessed in multiple orthogonal imaging planes and atrial volume was calculated using an ellipsoid formula. SETTING: A tertiary care university teaching hospital. PATIENTS: All patients admitted to hospital between June 1989 and June 1990 for elective cardioversion were considered for enrollment. Informed consent was obtained in all cases. Patients were excluded if echocardiographic images were technically inadequate or reversion to normal sinus rhythm was not achieved. Twenty-five patients were considered for inclusion. The final study population consisted of 16 patients. Complete follow-up data were obtained in 10 cases. MAIN RESULTS: Conversion to sinus rhythm resulted in a decrease in mean left atrial volume from 38.5 cm3 to 34.2 cm3 (P < 0.01) at 24 h, 21.7 cm3 (P < 0.02) at three months and 19.6 cm3 (P < 0.02) at six months. Mean right atrial volume decreased from 33.4 cm3 to 29.4 cm3 (P < 0.01) at 24 h, 19.1 cm3 (P < 0.02) at three months and 16.3 cm3 (P < 0.02) at six months of follow-up. CONCLUSIONS: Conversion from atrial fibrillation to sinus rhythm results in a significant decrease in both left and right atrial volumes.

Anterior wall myocardial infarction in a 15-year-old diabetic female associated with spontaneously resolving coronary thrombosis.

Myocardial infarction is an uncommon event in childhood and adolescence, and only rarely is found to be due to atherosclerotic disease. This report describes a 15-year-old diabetic female with an acute anterior wall myocardial infarction in whom initial coronary angiography showed a thrombus of the proximal anterior descending coronary artery which had resolved spontaneously by the time a follow-up study was carried out six weeks later. None of the usual precipitating causes of myocardial infarction in childhood were found, and repeat angiography did not demonstrate any fixed coronary artery disease. The relevant literature is reviewed and it is speculated that endothelial dysfunction, coronary spasm and altered coagulability may have contributed to the formation of intraluminal thrombus and subsequent infarction in this patient.

Cardiac responses of young women to conditioning for a 10 kilometer race.

Seven previously sedentary women (mean age, 19 yrs) participated in an 11-week running program (4-5 sessions/week) in preparation for a 10 km race. Training intensity was 80-85% of maximum heart rate reserve. Exercise duration began at 20 minutes/session and was lengthened 5 minutes/session every 2 weeks. A control group consisting of 4 women was also evaluated. Maximal oxygen uptake (VO2max, ml/kg/min) increased 11% in the trained group and decreased 6% in the control group during the study (p less than 0.05). Oxygen uptake, cardiac output (Q), and stroke volume (SV) increased significantly (p less than 0.05) in the trained group during each of 3 levels of steady state cycle ergometer exercise (heart rate targets: 115, 135 and 155 beats/min, respectively). Arteriovenous oxygen difference (a-V02 diff) was not increased significantly after training. Resting left ventricular dimensions and performance evaluated by echocardiography also did not change significantly after training. It was concluded that short-term conditioning in this population results in an increased exercise Q without concomitant increases in left ventricular dimensions or arteriovenous oxygen difference.

Relationships between cardiac dimensions, anthropometric characteristics and maximal aerobic power (VO2max) in young men.

Echocardiographic dimensions, anthropometric data and maximal oxygen uptake (VO2max) were studied in 26 healthy sedentary male controls (mean age, 22.0 yrs) and 15 male endurance athletes (mean age, 20.3 yrs). Athletes displayed significantly greater mean values for left ventricular internal dimension at end-diastole (LVIDd), end-diastolic volume (LVEDV) and left ventricular mass (LVM). Statistically significant positive correlations were observed within the sedentary control group between left ventricular end-diastolic dimensions (LVIDd, mm and/or LVEDV, cm3) and body height (cm), body weight (kg), chest circumference (cm) and body surface area (m2). Left ventricular mass (LVM, g) correlated significantly with lean body mass (kg). Ectomorphic somatotype rating (Ecto) correlated negatively with LVEDV and LVM. Finally, VO2max (l/min) correlated significantly with LVIDd, LVEDV and LVM. Multiple linear regression analysis indicated that the degree of endomorphy (Endo), LVIDd (mm/m2) and chest circumference accounted for 89% of the variance in VO2max (ml/kg/min) within the athlete group. Endo, Ecto and LVIDd (mm/m2) accounted for 86% of the variance in VO2max (ml/kg/min) in the control group. This study supports the hypothesis that maximal aerobic power can be predicted from cardiac and anthropometric measurements.

Cardiac tamponade secondary to haemophilus pericarditis: a case report.

Pyogenic pericarditis is encountered uncommonly in clinical practice. The majority of cases of clinically apparent pericarditis are viral in origin. When bacterial infection of the pericardial space does occur the causative organism is usually Staphylococcus or Streptococcus species. Isolation of an haemophilus organism from the pericardial space in this condition is distinctly unusual. There are only 10 previously reported cases in the literature of pericarditis secondary to Haemophilus influenzae. This report describes the case of a 36-year-old woman who presented with haemophilus empyema and purulent pericarditis progressing to cardiac tamponade. There are isolated reports of successful treatment of pyogenic pericarditis with closed drainage and antibiotics. In the absence of clear evidence demonstrating the efficacy of this approach the authors favour open exploration of the pericardial space.

The 'athletic heart syndrome'. A critical review.

Cardiological findings in athletes are often similar to those observed in clinical cases. Electrocardiographic and cardiac imaging abnormalities as well as physical findings may be the same in both of these groups. Bradycardia and rhythm disturbances are the most common abnormalities in athletes. Most athletes with abnormal electrocardiograms are asymptomatic and numerous investigators have failed to detect heart disease in association with such electrocardiograms. In contrast to cardiac dysfunction observed in clinical cases, enhanced or normal ventricular systolic and diastolic function have been reported in athletes. In endurance athletes, this is associated with very high values for maximal aerobic power (VO2max). Absolute and body size-normalised cardiac dimensions in most athletes do not approach values from chronic disease states, and may not exceed echocardiographic normal limits. In addition, pathological and physiological enlargement appear to be biochemically and functionally different. Myosin ATPase enzyme expression and calcium metabolism are different in rats with pathologically or physiologically induced enlargement. The reported biochemical differences underlie systolic and diastolic dysfunction in pathological enlargement. Conversely, trained rodents and humans have demonstrated enhanced systolic and diastolic function. It is important to note that cardiac enlargement observed in athletes is the result of normal adaptation to physical conditioning and/or hereditary influences. Conversely, pathological changes result from disease processes which can lead in turn to reduced function, morbidity and mortality. Since the mid 1970s echocardiography has been used to compare cardiac dimensions in male endurance- and resistance-trained athletes. A sport-specific profile of eccentric and concentric enlargement has been documented in endurance and resistance athletes, respectively. Subsequent studies of athletes have examined factors such as age, sex and degree of competitive success to determine their contribution to these sport-specific cardiac profiles. Unique athletic subgroups have also been analysed and have included ballet dancers, rowers, basketball players and triathletes. However, there is a paucity of data on cardiac dimensions in female athletes. Finally, physical conditioning studies have also examined echocardiographic dimensions before and after endurance and resistance training. Significant enlargement of internal dimensions, wall thickness or left ventricular mass have been reported but such increases are relatively small and by no means universal. Several conflicting explanations for enlarged cardiac dimensions appear in the literature. Chronic volume and pressure haemodynamic overloading during physical conditioning has been proposed to explain eccentric and concentric cardiac enlargement in endurance- and resistance-trained athletes respectively. However, twin studies suggest that hereditary factors may be important determinants of cardiac dimensions and/or the degree of cardiac adaptability to physical conditioning.(ABSTRACT TRUNCATED AT 400 WORDS)

Prediction of left ventricular mass from the electrocardiogram.

Multiple stepwise regression methods were used to derive electrocardiographic (ECG) models for prediction of the echocardiographic left ventricular (LV) mass index from standard 12-lead ECG measurements using data files of 203 men and 252 women. The correlation between echocardiographic and ECG estimates of LV mass index was R2 = 0.58 for men and R2 = 0.42 for women. A separate logistic regression model was derived for classification of LV hypertrophy as a dichotomized dependent variable. This classifier chose R (aVL), T (V6), and S (V1) for men and R (aVL), T (V6), and S (I) for women and produced a moderate sensitivity (53.7% for men and 63.4% for women) and specificity (94.9% for men and 92.9% for women). We conclude that the initial performance of these and other recently developed multivariate estimators of LV mass and LV hypertrophy classifiers is promising enough to subject them to further studies to evaluate their utility as risk predictors.

Quantitation and significance of systolic mitral leaflet displacement in mitral valve prolapse.

Superior systolic displacement of the mitral leaflets is the echocardiographic finding generally used to diagnose mitral valve prolapse, but its clinical significance is not clearly established. This study was designed to determine if the presence of leaflet thickening, displacement in the multiple imaging planes or the quantitative degree of displacement could be used to identify clinically important valvular abnormality. To this end, these findings were prospectively assessed and correlated with the presence of mitral regurgitation and ventricular arrhythmia in 49 patients with displacement and in 49 age-matched control subjects with no identifiable displacement. Both ventricular arrhythmia and mitral regurgitation were found to occur with significantly greater frequency in patients with leaflet displacement than in control subjects. However, among the patients with leaflet displacement, both these complications occurred with greater frequency in subgroups characterized by the presence of leaflet thickening, quantitatively greater displacement and displacement evident in 2 orthogonal imaging planes. Logistic regression analysis demonstrated that the best echocardiographic predictor of either ventricular arrhythmia or mitral regurgitation was the quantitative degree of leaflet displacement. These results indicate that most patients with echocardiographic evidence of leaflet displacement had very low incidences of ventricular arrhythmia and mitral regurgitation. Subgroups, however, could be identified echocardiographically in which both complications occurred with significantly greater frequency.

Constrictive pericarditis and anemia post myocardial infarction.

A 67-year-old male presented with acute inferolateral myocardial infarction complicated by transient acute post infarction pericarditis. Six weeks later, he developed Dressler's syndrome associated with moderately severe anemia of chronic disease. Both of these resolved over the next few weeks, however, shortly thereafter, right sided congestive heart failure occurred. This progressed despite medical therapy and the diagnosis of constrictive pericarditis was made 10 months post infarction. Total pericardectomy was done one year after the onset of acute myocardial infarction with complete resolution of signs and symptoms.

Reversible obstructive hypertrophic cardiomyopathy in the Beckwith-Wiedemann syndrome.

Patients with the Beckwith-Wiedemann (B-W) syndrome have been reported to have an increased risk of congenital heart disease and of idiopathic cardiomegaly on chest x-ray. In the infant described here, reversible obstructive hypertrophic cardiomyopathy was documented and its relationship to the metabolic features of the B-W syndrome is discussed.

A new surgical technique to correct double chambered right ventricle associated with anomalous left anterior descending coronary artery.

A 42 year old woman with symptomatic double chambered right ventricle had the additional features of an anomalous left anterior descending coronary artery and attachment of the tricuspid valve to the area of subinfundibular stenosis which precluded conventional repair. A non-valved Dacron conduit was used to bypass the obstruction. The patient is asymptomatic two years later.

Electrocardiographic diagnosis of left ventricular hypertrophy in the presence of left bundle branch block: an echocardiographic study.

This study tests the electrocardiographic diagnosis of left ventricular (LV) hypertrophy in the presence of left bundle branch block (BBB). The LV mass of 125 patients with left BBB was estimated by echocardiography. M-mode echocardiography was technically adequate in 80% of patients. LV mass was calculated using previously validated M-mode formulas and then indexed to body surface area. The known shifts in the QRS voltage and axis with the onset of left BBB led to the selection of 4 electrocardiographic parameters for the diagnosis of LV hypertrophy: R in aVL 11 or more; QRS axis -40 degrees or less (or SII greater than RII); SV1 + RV5 to RV6 40 or more; SV2 30 or more and SV3 25 or more; these parameters were used in cumulative fashion. This cumulative approach was superior to using single conventional criterion such as the SV1 + RV5 or RV6. When LV hypertrophy was defined as an M-mode index of at least 115 g/m2, the sensitivity was 75% and specificity 90%. Using an M-mode mass of at least 215 g as the standard, the sensitivity was 73% and the specificity 66%. LV hypertrophy can be diagnosed by electrocardiographic criteria in the presence of left BBB at least as reliably as in normal conduction.

Mitral regurgitation due to lupus endocarditis treated with valve replacement.

A murmur of mitral regurgitation developed in a 20-year-old woman with a 2-year history of systemic lupus erythematosus. Echocardiography revealed thickening of both valve leaflets and abnormal diastolic motion of the posterior one, confirming the diagnosis of mitral endocarditis. The mitral regurgitation progressed to cause congestive heart failure, which was refractory to drug therapy but was effectively treated with mitral valve replacement.

The impact of an ECG computer analysis program on the cardiologist's interpretation. A cooperative study.

Nine experienced electrocardiographers and the ECG computer program developed in the Veterans Administration (AVA 4.0) were evaluated against ECG-independent evidence of 180 patients' true diagnoses. A cross section of cardiac abnormalities was included. Each reader was given the 12-lead and orthogonal 3-lead ECG. The impact of ECG computer reports on the interpretations by the nine readers was evaluated by comparing their interpretations before and after the addition of a computer report. Using only high probability statements, the average accuracy of ECG diagnosis by the nine readers was 54%. It increased to 62% when the computer report was added. Computer interpretation was correct in 76%. It was shown that the Bayesian classification method together with multivariate analysis, used in the VA program, are mainly responsible for the improvement in diagnostic accuracy.