[Cardiovascular instability in schizophrenic patients may be caused by alpha 1-blocking activity of major tranquilizer--measurement by isometric handgrip test].

In order to prove the hypothesis that cardiovascular instability of schizophrenic patients is caused by alpha 1-blocking effect of major tranquilizer, we measured the blood pressure (BP), the heart rate (HR), and serum epinephrine and norepinephrine levels before and after isometric handgrip (IHG) test in schizophrenic patients and normal adults (control). The results were as follow: (1) In schizophrenic patients systolic BP rose significantly less than in controls after IHG test. (2) HR in patient group was constantly higher than in control group. (3) Though HR after IGH test decreased in normal group, there was no significant difference in HR before and after IHG test in patient group. (4) In patient group, norepinephrine level was higher than in control group before IHG test but it did not increase after IHG test, while it did increase in normal group. It is concluded that alpha 1-receptors are selectively blocked and the reactivity to norepinephrine is reduced in schizophrenic patients who has been taking a major tranquilizer. This results in the impairment of the ability to control immediately BP corresponding to postural change and to exercise, which probably causes instability in circulatory state in schizophrenic patients under general anesthesia.

[A 62-year-old survivor with Ebstein's anomaly without right ventricular failure].

A 62-year-old woman was admitted our hospital because of concussion of the brain. The level of consciousness improved within several days. Cardiac examination was performed because the patient had experienced feelings of fainting since one year previously, and heart murmur also was heard. The electrocardiogram showed WPW configuration. At the same time that she complained of feelings of fainting, the electrocardiogram showed supraventricular tachycardia. The echocardiogram showed displacement of the septal tricuspid leaflet and mild tricuspid valve, regurgitation. Cardiac catheterization was performed and, using the intracardiac electrocardiogram, we confirmed atrialized right ventricle. We diagnosed this patient as having Ebstein's anomaly with WPW syndrome. The clinical manifestations of this anomaly are quite variable, depending upon the spectrum of pathology and the presence of associated malformations. It is well documented that a considerable proportion of these patients are able to survive into adult life. However, the patient who survives into the sixth decade without a sign of heart failure is extremely rare. We speculate that this patient had not developed right ventricular failure until her 60's because she had a milder form of Ebstein's anomaly and did not have any other congenital heart disease.

Kawasaki disease complicated by acute myocardial infarction due to thrombotic occlusion of coronary aneurysms 19 years after onset.

A 25-year-old man with a history of Kawasaki disease from the age of 7 had acute inferior myocardial infarction. Emergency right coronary arteriogram showed successive coronary aneurysms at the proximal to middle portion of the right coronary artery, and total occlusion at the proximal segment. Intracoronary thrombolysis was performed and the right coronary artery was recanalized. On left coronary arteriography, coronary aneurysms and mild localized stenoses at the inlet and outlet of the aneurysms were found. It was suggested that the myocardial infarction was caused by thrombotic occlusion of coronary aneurysms complicated with Kawasaki disease.

[Myocardial perfusion and left ventricular function during exercise evaluated by 201Tl myocardial scintigraphy and 99mTc radionuclide ventriculography in patients treated with PTCA].

To evaluate the effects of percutaneous transluminal coronary angioplasty (PTCA), we investigated myocardial ischemia and left ventricular function during exercise before and after successful PTCA in 30 patients. We used extent and severity scores of 201thallium (201Tl) exercise myocardial scintigraphy to assess myocardial ischemia and determined global and regional left ventricular ejection fraction (EF and REF) of 99mTc-RBC exercise radionuclide ventriculography to assess left ventricular function. The extent and severity scores of stress images were significantly less after PTCA than before PTCA. The scores of the redistribution images were unchanged before and after PTCA. Global EF during exercise was significantly higher after PTCA than before PTCA. There was no difference in resting global EF between before and after PTCA. Myocardial ischemia induced by exercise was semi-quantitatively analyzed as transient perfusion defect with severity score. Severity score was significantly less after PTCA than before PTCA. delta EF, which was obtained by subtraction of resting global EF from exercise one, was significantly higher after PTCA than before PTCA. However, the degree of improvement in myocardial ischemia and left ventricular function varied from patient to patient. In 17 patients with one-vessel left anterior descending artery disease, delta REF, which was determined by subtracting resting regional EF from exercise one, was significantly higher in septal and apical segments after PTCA than before PTCA. Myocardial ischemia and left ventricular function under exercise were alleviated by PTCA. However, the degree of improvement varied from patient to patient and it might have been affected by various factors including coronary dissection, edema, thrombus, restenosis, spasm, side branch stenosis or occlusion, distal thrombus, and myocardial hibernation.

A case of clinically diagnosed pure septal infarction.

Interventricular septal involvement in myocardial infarction is usually associated with infarction of the left ventricular anterior free wall, as the obstruction is at the major portion of the left anterior descending coronary artery. Acute myocardial infarction with obstruction only of the first septal branch is rare. We describe here a case of pure septal infarction. The case was diagnosed by emergency coronary arteriogram (CAG). Although the patient had a large first septal branch, his global left ventricular function was preserved. Abnormal findings were localized in only septal region as determined by left ventriculography (LVG), two-dimensional echocardiography (2DE), and 99mtechnetium pyrophosphate (99m Tc-PYP) and 201thallium (201Tl) myocardial scintigraphy.

Comparative effects of calcium-channel blockers and beta-adrenergic blocker on early diastolic time intervals and A-wave ratio in patients with hypertrophic cardiomyopathy.

To compare the effects of calcium-channel blockers with those of beta-adrenergic blockers in patients with hypertrophic cardiomyopathy (HCM), diastolic time intervals (IIA-O time, from the second heart sound to the O point of apexcardiogram, IIA-MVO time, from IIA to the mitral valve opening, and MVO-O time, from the MVO to the O point of apexcardiogram), and A-wave ratio measured from apexcardiogram were evaluated before and after more than three months of treatment. In both groups, heart rate significantly decreased after treatment. The IIA-MVO time was not affected by either drug. The IIA-O and the MVO-O times were significantly shortened by calcium-channel blockers (from 234.6 +/- 77.4 ms to 204.6 +/- 39.2 ms; p less than 0.01, and from 133.1 +/- 66.4 ms to 100.3 +/- 34.0 ms; p less than 0.01, respectively). However, they were not affected by beta-adrenergic blocker. A-wave ratio significantly decreased after calcium-channel blockers (from 18.0 +/- 9.8% to 13.7 +/- 7.3%; p less than 0.01) and beta-adrenergic blocker (from 21.7 +/- 12.6% to 17.2 +/- 8.0%; p less than 0.01). From these observations, it is suggested tht calcium-channel blockers improved the early diastolic filling rate, whereas beta-adrenergic blocker did not affect it. It is concluded that the effects of calcium-channel blockers and beta-adrengergic blocker on early diastolic time intervals were different in patients with HCM.

Quantitative analysis of acute myocardial infarction using single photon emission computed tomography using technetium-99m pyrophosphate.

The usefulness of single photon emission computed tomography (SPECT) using technetium-99m pyrophosphate (99mTc-PPi) was evaluated in 15 patients with acute myocardial infarction. SPECT was performed with a rotating gamma camera after conventional planar images were made. Infarct size was measured from transaxial images of myocardial pyrophosphate uptakes. In each slice, the boundary was defined by subtracting 70 percent of the maximal counts and the number of voxels automatically counted. This subtraction rate was determined by phantom study and by comparing SPECT using 99mTc-PPi with thallium-201-gated myocardial scintigraphy (201Tl gated SPECT). The planar images showed diffuse uptakes in two of the 15 patients, and in these cases it was difficult to detect the infarct site. In contrast, SPECT images clearly imaged the infarct site consistent with the electrocardiographic findings, and they were definitely separated from the uptakes in the bones in all cases. Infarct size, ranging from 3.4 ml to 78.3 ml, correlated well with cumulative creatine kinase release (r = 0.84, p less than 0.01, y = 772x + 13900). Correlation of infarct size with peak serum creatine kinase level was also significant (r = 0.66, p less than 0.01, y = 10.6x + 693). In conclusion, SPECT with 99mTc-PPi is a useful means of investigating the spatial distribution of pyrophosphate uptake and of evaluating the size of myocardial infarction.

Adverse effects of atrial fibrillation and syncope induced by calcium-channel blockers in hypertrophic cardiomyopathy.

Calcium-channel blockers are useful for the treatment of hypertrophic cardiomyopathy (HCM), but, their adverse effects, especially, those of diltiazem, have not been of much concern. Forty patients with HCM were treated with calcium-channel blockers such as nifedipine, diltiazem, and verapamil. Atrial fibrillation was induced by diltiazem in two patients and verapamil induced syncope in one patient. The clinical and hemodynamic characteristics of the patients were as follows. All of them had the obstructive type of HCM (HOCM). One of them had a high pressure gradient of the left ventricular outflow tract and the others had earlier onset. In these patients, the left atrial overload seemed to be severe. The vasodilating action of calcium-channel blockers decreases the systemic pressure and in turn, may increase the pressure gradient and the left ventricular end-diastolic pressure. The elevated left ventricular end-diastolic pressure causes the left atrial overload which could be at risk of atrial fibrillation in patients with HCM. Therefore, calcium-channel blockers should be used carefully in peculiar cases of HOCM.