The physical examination in acute cardiac ischemic syndromes.

The physical examination in acute cardiac ischemia remains a valuable tool when done with skill. Ischemia without infarction alters cardiac function, and the physical examination yields findings that reflect these changes. Ischemia with infarction alters structure and function, resulting in physical findings that are usually more dramatic and of longer duration, sometimes permanent. Carefully done, the physical examination provides information that helps in management of the immediate course, predicts prognosis, and allows for better interpretation of cardiovascular tests, both invasive and noninvasive.

Hypothesis: warfarin administered simultaneously with heparin infusion will prevent heparin-discontinuance associated coronary thrombosis.

Recent studies have evidenced an association between the time of heparin discontinuance and coronary artery reocclusion. Some investigators have concluded that inadequate heparinization was responsible, and further heparin infusion or an increase in dose would have been indicated. However, several investigators (Rao: Thrombosis Research 24:181-186, 1981; Marciniak and Gockerman: Lancet September 17:581-584, 1977; Fisken et al.: Lancet December 10: 1231, 1977; Conard et al.: Thrombosis Research 22:507-511, 1981; Kakkar et al.: Lancet January 12:103-104; Green: Lancet February 16:374, 375; Harborne and Nicolaides: Thrombosis Research 43:657-662, 1986; Bonen et al.: Thrombosis Research 27:123-124, 1982; Blomback et al.: Acta Physiologica Scandinavica 58:306-318, 1963; Holm et al.: Scandinavian Journal of Haematology 35:564-569, 1985; Andersson et al.: Thrombosis Research 34:333-340, 1984) have demonstrated that antithrombin III levels are reduced in patients on intravenous heparin. Both reduced antithrombin III levels and reduced rate of antithrombin inhibition of thrombin at the time of heparin discontinuance may increase the risk of coronary rethrombosis. If this theory is correct, increasing heparin infusion may exacerbate this risk. We propose an investigation that will provide evidence for or against the decreased antithrombin III theory, and in doing so, test an experimental therapy designed to prevent coronary reocclusion upon heparin discontinuance. In a randomized, placebo-controlled double-blinded study, we will determine whether simultaneous administration of warfarin with heparin initiation provides more time to increase antithrombin III levels and prevent coronary reocclusion upon heparin discontinuance, compared to heparin without warfarin therapy.

Spontaneous rupture of a coronary artery with false aneurysm formation. Successful surgical repair.

A patient with diffuse atherosclerotic coronary arterial disease was demonstrated to have a spontaneous rupture of the proximal right coronary artery, with formation of a false aneurysm. This was recognized at angiographic study, and the patient subsequently underwent a revascularization operation with suture ligation of the aneurysm.

Systemic embolization of the disk occluder of the Wada-Cutter prosthetic valve. A late complication.

The results in 22 patients in the Denver area with Wada-Cutter prostheses were reviewed. There were 14 late deaths, with an average follow-up of six years. Four cases of valve malfunction not related to thrombosis were documented. There were three cases of embolization of the occluder. A survivor is reported. Clinical evaluation of the group suggested new mitral regurgitation to be a sensitive indicator of impending embolization of the occluder. Documentation of valve malfunction warrants valvular replacement.