Exercise cardiovascular responses to gallopamil in ischemic heart disease.

UNLABELLED: In a single-blind, placebo-controlled, crossover trial versus diltiazem, we evaluated the influence of gallopamil on cardiovascular responses evoked by bicycle exercise. Twelve patients with chronic stable angina were enrolled. After a 5 days placebo run-in period, patients were randomly assigned either to gallopamil (50 mg thrice daily) or diltiazem (60 mg thrice daily) for 10 days. Then, patients were changed to the alternative drug. After placebo, and at the end of each subsequent period, all subjects underwent right heart catheterization by means of a Swan-Ganz thermodilution catheter. Hemodynamics were determined in 3 ways: supine, standing and during a multistage exercise test. RESULTS: anginal attacks were reduced to a similar degree by gallopamil (2.1 +/- 1/week versus 5.8 +/- 2.8/week during placebo, p less than 0.01) and diltiazem (2.0 +/- 0.8/week versus 5.8 +/- 2.8/week during placebo, P less than 0.01). At rest, gallopamil caused a significant decrease in heart rate and a slight fall in systemic vascular resistance. Cardiac index rose during exercise and was higher with respect to placebo at peak exercise (6.7 vs 5.6 l/min/m2, P less than 0.05). As a consequence, stroke volume index and stroke work index both increased at maximum workload (P less than 0.05). Compared to placebo, exercise time was significantly improved by gallopamil (+50%, P less than 0.02) and diltiazem (+38%, P less than 0.05). Likewise, time to onset of ST-segment depression was prolonged by 70% with gallopamil (P less than 0.01) and by 64% with diltiazem (P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Urokinase in the therapy of spontaneous angina]. / L'urochinasi nella terapia dell'angina spontanea.

UNLABELLED: In an open non-comparative clinical study, 19 patients with spontaneous angina pectoris admitted to hospital with attacks lasting greater than 10 minutes, unresponsive to nitrate and/or calcium antagonist treatment, at least 2 ECG readings of raised (greater than or equal to 1.5 mm) or lowered (greater than or equal to 1 mm) ST segment not attributable to earlier AMI in the same area, were treated after the interruption of conventional treatment (mean 47 +/- 34.2 min) with 2 million IU endovenous UK in 15 mins followed by 1 million IU endovenous UK in 60 mins. Sixty minutes after UK administration was terminated, they were given a bolus of 5000 IU calcium heparin, followed by 1000 IU per hour for 2 days. Coronary angiography (Judkins technique) was performed before the start of UK treatment and 15, 30, 45, 60 and 75 minutes into it. RESULTS: Basal coronarography showed only "multiple organic stenosis" in 5 out of the 19 patients, a more complex situation suggestive of thrombi in the coronary arteries in 14. Subsequent angiographies (mean 30 mins later) revealed coronarographic improvement in 11 out of the 19 (58%), or 11 out of 14 (78.5%) if we exclude those with simple stenosis. Angina attacks were significantly lower in the 8 days after UK treatment than in the week before it in terms of number (4 v. 1; p less than 0.01), global severity (7 v. 1.5; p less than 0.01) and global duration (45 v. 4.25 min; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographic correlate of post-reperfusion abnormal Q waves.

To determine whether post-reperfusion acute Q waves are due to irreversible myocardial necrosis, we studied the relationship between abnormal Q waves and left ventricular regional wall motion in 74 patients who had coronary thrombolysis following acute myocardial infarction. In 48 cases, acute pathologic Q waves appeared on the ECG-recordings after coronary reperfusion (group A), whereas in 26 patients the QRS complex had no or only minimal changes (group B). A control group consisted of 27 patients with unsuccessful thrombolysis. Quantitative left ventricular angiography was performed after coronary thrombolysis and repeated before discharge from the hospital. Regional wall motion of the infarcted area was determined by a system of 48 radii traced from the centroid of the end-diastolic and end-systolic silhouettes. Myocardial akinesis was significantly more extensive in group A than in group B (18 +/- 9% vs. 10 +/- 6%, p less than 0.02). Regional wall motion of the infarcted area improved in both groups at predischarge study (mean radial shortening +5 +/- 6% in group A and +4 +/- 7% in group B). Moreover, regional wall motion was significantly better in group A with respect to the control group (angio score of hypo-akinesis 166 +/- 124 vs. 412 +/- 174, p less than 0.01). In conclusion, post-reperfusion abnormal Q waves 1) are associated with more extensive myocardial damage, 2) do not preclude late recovery of ischemic myocardium, and 3) do not necessarily indicate irreversible transmural necrosis.

[The course of residual stenosis after intracoronary thrombolysis]. / Evoluzione della stenosi residua dopo trombolisi intracoronarica.

UNLABELLED: Clinical outcome after coronary thrombolysis are strictly related to the residual stenosis. However, the natural history of this lesion is largely unknown. To assess this topic we evaluated 25 patients who had coronary recanalization by urokinase in acute myocardial infarction. Serial coronary angiograms were taken immediately after fibrinolytic therapy, before hospital discharge and 1 year later. Angiographically detected coronary reocclusion and/or new ischemic events were exclusion criteria. Angiographic analysis was performed at a five-fold magnification. The followings were specifically evaluated: a) vessel contours at the site of the residual stenosis; b) luminal diameter reduction; c) presence of intraluminal filling defects. RESULTS: the vessel narrowing progressively improved from the acute phase (percent of stenosis 92 +/- 7) to the hospital discharge (82 +/- 8%, p less than .01) and to 1 year follow-up (76 +/- 11%, p less than .001 vs hospital discharge). Moreover, the residual stenosis appears to be "complicated" in early period (irregular contours with superimposed thrombus), but become regular and "uncomplicated" at follow-up examination (smooth contours, hourglass configuration, no intraluminal filling defects). IN CONCLUSION: a) the residual coronary stenosis is a dynamic process and may improve at follow-up examination; b) a practical approach to the management of the residual stenosis must take in account the natural history of the lesion to give a correct indication for coronary surgery or PTCA.

[Hemodynamic effects of diltiazem in the subacute stage of myocardial infarct treated by thrombolysis]. / Effetti emodinamici del diltiazem nella fase subacuta dell'infarto miocardico trattato con trombolisi.

Since Ca++-overloading is a major problem after myocardial reperfusion we studied the effects of Diltiazem on the left ventricular diastolic function in the early days following coronary thrombolysis. Twelve patients who had myocardial reperfusion by intracoronary urokinase in acute myocardial infarction were admitted to the study. Previous infarct, cardiogenic shock or late thrombolysis (greater than 4 h from symptoms onset) were exclusion criteria. All subjects were evaluated at control cardiac catheterization 5-8 days after the acute ischemia. Simultaneous left ventricular angiography and high-fidelity pressure recordings by means of a tip-micromanometer and angiographic catheter were performed at rest and after intravenous Diltiazem administration (16 mg over 2' + 0.008 mg/Kg/min). Indexes of myocardial relaxation and early ventricular filling were impaired at rest but improved significantly after Diltiazem (Tab. II). Isovolumic relaxation period fell from 92 +/- 8 msec to 77 +/- 12 msec (p less than .01), T constant of isovolumic pressure decay decreased from 61 +/- 7 msec to 55 +/- 7 msec (p = ns), first-third of filling rate increased from 64 +/- 7% to 79 +/- 6% (p less than .01). On the other hand, indexes of left ventricular compliance were altered after coronary reperfusion (left ventricular end-diastolic compliance 17 +/- 13 mmHg-1. 10(-3), modulus of chamber stiffness .045 +/- .008) but but did not change after calcium-blocker therapy. In conclusion, post-thrombolysis diastolic function is severely impaired at rest, probably because of raised intracellular Ca++ and delayed asynchronous relaxation. Diltiazem improves energy-dependent early diastole, but does not affect ventricular compliance.

[Effects of propafenone on coronary and systemic hemodynamics]. / Effetti del propafenone sulla emodinamica coronarica e sistemica.

This study was undertaken to evaluate the effects of intravenous Propafenone (2 mg/kg over 5') on Left Ventricular (LV) function and coronary blood flow. Twelve patients with coronary artery disease and post-ischemic LV disfunction were examined during routine cardiac catheterization. Serial measurements of central hemodynamics, LV high-fidelity pressure and coronary blood flow were recorded at rest and every 10' after Propafenone administration. Heart rate was unchanged, suggesting that Propafenone did not affect sympathetic tone. Cardiac index slightly decreased (from 3.3 +/- 0.9 L/min/m2 to 3.1 +/- 0.6 L/min/m2 at 10', p = ns), LV end-diastolic pressure rose significantly (from 17.7 +/- 2.1 mmHg to 22.7 +/- 4.2 mmHg at 20', p less than 0.01) and dP/dt max fell from 1897 +/- 291 mmHg/sec to 1577 +/- 312 mmHg/sec (p less than 0.02). Systemic vascular resistances had only minimal changes. Concomitantly, coronary vascular resistances decreased (from 0.77 +/- 0.17 mmHg/ml/min to 0.61 +/- 0.12 mmHg/ml/min, p less than 0.02) and coronary blood flow increased (from 138 +/- 29 ml/min to 172 +/- 21 ml/min, p less than 0.01). No significant difference was noted in myocardial oxygen consumption. No symptoms related to LV failure were observed during the study. In conclusion hemodynamic effects of Propafenone are characterized by moderate LV depression and by coronary artery dilatation, probably due to a calcium blocker-like activity.

[Methods of determination of stroke volume from M-mode echocardiogram of the aortic valve and aortic root. A comparative evaluation]. / Metodi di determinazione della gettata sistolica dall'ecocardiogramma M-mode della valvola aortica e della radice aortica. Una valutazione comparativa applicata.

The purpose of this study is to evaluate four methods of determining left ventricular stroke volume (SV) from aortic valve (AV) and aortic root (AR) M-mode echocardiogram (Table I, formulas 1-4); secondly, to study relations between echocardiographic aortic variables and SV. We studied 20 patients (Pts) in our Coronary Unit, 14 men and 6 women; their ages ranged from 38 to 76 (mean 53.4) years. Seventeen Pts had acute myocardial infarction; two Pts had previous myocardial infarction and heart failure; one Pt had dilated cardiomyopathy and heart failure. Three out of the twenty Pts, had mitral insufficiency (Table II, clinical and hemodynamic data). Patients were studied with high quality M-mode echocardiography. Immediately after the examination repeated measurements of cardiac output by thermodilution technique (TD) were carried out, and values of SV calculated (SV-TD). Twenty-five complete procedures were accomplished. The formulas were applied to every patient's echocardiographic data, and results (SV-ECHO) compared with SV-TD (Table III). Echocardiographic variables, whether single or multiple (terms), were also studied with regard to their relation with SV-TD (Table IV). Mean +/- SD value of SV-TD of the study group was 60.3 +/- 24.7 ml; range 22.7 to 108 ml. Mean +/- SD values of SV-ECHO were as follows: Yeh's formula, based on squared mean AV opening and LVET, 56 +/- 22.6 (ml), r = 0.8278, SEE 12.98; Jacobs' formula, based on aortic box planimetry, 68 +/- 32.5 (ml), r = 0.7129, SEE 23.31.(ABSTRACT TRUNCATED AT 250 WORDS)

[Churg-Strauss syndrome. Apropos of a clinical case]. / Sindrome di Churg-Strauss. A proposito di un caso clinico.

A case of Churg-Strauss allergic vasculitis in a 32-yr-old woman treated with phenylhydantoin for 9 yr for a form of post-traumatic epilepsy is described. The clinical overture consisted of asthmatic bronchitis, followed by the discovery of bronchopneumonic infiltrates and skin and heart lesions. Repeated biopsies revealed evidence of vasculitis involving small-calibre vessels, and extravascular infiltrates composed of eosinophilic granulocytes, lymphocytes and plasma cells, sometimes surrounding necrotic areas. Treatment of this condition is primarily based on cortisone, combined with azathioprine or cyclophosphamide in some cases.