Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.

OBJECTIVES: The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. BACKGROUND: The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. METHODS: The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. RESULTS: Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). CONCLUSIONS: Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

[Epidural spinal cord stimulation in therapy-resistant angina pectoris]. / Epidurale Rückenmarkstimulation bei therapieresistenter Angina pectoris.

Spinal cord stimulation (SCS) has routinely been used since the beginning of the 1970s. The initial indications for stimulation were the so-called deafferentation or neurogenic pain. Further work has confirmed that neurostimulation is useful in severe peripheral vascular disease in relieving pain and increasing capillary blood flow and oxygen tension. The effects are similar to those of sympathectomy. In 1964 Apthorp et al. discovered that sympathectomy relieved angina in about 75% of patients. The use of SCS to treat angina follows logically from its use in peripheral vascular disease. METHODS. The pain-relieving effect of SCS was investigated in two patients, 54 and 69 years old, who were hospitalised for 8 and 28 days. Both patients had severe angina pectoris (duration 2 and 15 years, New York Heart Association class III and II), related to three-vessel disease, and one of them had previously undergone his third bypass operation. The other patient was not considered suitable for surgery. The antianginal treatment (long-acting nitrates, beta-blockers, calcium antagonists) was regarded as optimal and was not changed during the observation period (Table 1). SURGICAL TECHNIQUE AND STIMULATION EQUIPMENT. We used the commercially available Medtronic SCS system. The operation was performed under local anaesthesia to allow the patient to answer questions during the intraoperative stimulation. The epidural space was punctured at the level of T7-T8 in one case and T11-T12 in the other. The electrode tip was positioned in the midline or a few millimetres to the left at the T1-T2 level (Figs. 1, 2), so that the patient felt a prickling sensation in the precordial area and into the arms. The distal end of the electrode was sutured to the fascia and connected via a tunnelled extension lead to the external pulse generator. The pulse width was 200 microseconds, frequency 80 Hz. An appropriate amplitude (usually 8-10 V) was used for comfortable paraesthesia. The study consisted of two parts: a run-in period (1 week) to standardise the stimulation when mobilisation was performed. A treatment period (18 months) to determine the patient's working capacity after continuous stimulation (Table 2). After a successful run-in period a Medtronic receiver was implanted, connected to the electrode and stimulated by external pulse generator. Different variables were used to assess the effect: pulse rate, blood pressure, the product of pulse rate and systolic blood pressure, estimated anginal pain, and ST changes in the electrocardiogram (ECG) before, during and after mobilisation. RESULTS. The stimulation was carried out for 30 min 10-12 times a day during the run-in period and five to six times a day during the treatment period. Altogether there was slight lowering of heart rate and systolic blood pressure. Consequently the product of heart rate and systolic blood pressure was diminished. In one case (NYHA II) the distinct disorder of repolarisation reverted to the normal condition as shown on ECG. In the other case (NYHA III) the ECG remained unchanged because of a severe aneurysm of the cardiac wall. Both patients experienced nearly complete pain relief after a few days for 6 and 12 months respectively. However, an increasing effort tolerance could be demonstrated in both patients by reducing the extent of the heart failure (NYHA II/III to NYHA I/II) (Table 2). DISCUSSION. Our two hospitalised patients had clinically intractable angina pectoris and severe manifestations of heart disease corresponding to at least NYHA functional class II-III. Both were unsuitable for operation and showed no improvement on individually titrated maximal oral antianginal drug treatment. During SCS treatment significant improvement was obvious: chest pain, ST-segment depression, and the extent of heart failure could be reduced. Both patients reached a better NYHA functional class, exhibited increased working capacity and reported reductions in anginal attacks and pain. Th

Intravenous recombinant tissue plasminogen activator (rt-PA) and urokinase in acute myocardial infarction: results of the German Activator Urokinase Study (GAUS).

The effects of recombinant tissue plasminogen activator (rt-PA) and urokinase on patency and early reocclusion of infarct-related coronary arteries were investigated in a single blind, randomized multicenter trial in 246 patients with acute myocardial infarction of less than 6 h duration. Both 70 mg of single chain rt-PA with an initial bolus of 10 mg and 3 million units of urokinase with an initial bolus of 1.5 million units were given intravenously over 90 min. The first angiographic study at the end of the infusion revealed a patent infarct-related artery (Thrombolysis in Myocardial Infarction trial [TIMI] grade 2 or 3) in 69.4% of 121 patients given rt-PA versus 65.8% of 117 patients given urokinase (p = NS). Among patients treated within 3 h from symptom onset a patent infarct-related artery was found in 63.9% of 72 patients given rt-PA versus 70% of 70 patients given urokinase (p = NS). There were five cardiac deaths in each group and one fatal intracranial hemorrhage in the rt-PA group. The in-hospital reinfarction rate was 8.9% versus 13.2% for patients treated with rt-PA and urokinase, respectively. There was no difference in left ventricular function at baseline and follow-up catheterization studies. Both drugs were well tolerated and there was no significant difference in cardiovascular or bleeding complications between the two groups. It is concluded that rt-PA and urokinase in the dosages used provide similar efficacy and safety in the treatment of acute myocardial infarction. Reocclusion during the first 24 h may be less frequent after urokinase treatment.

Treatment of hypertensive urgencies and emergencies with nitrendipine, nifedipine, and clonidine: effect on blood pressure and heart rate.

Nitrendipine is a new calcium antagonist of the 1,4-dihydropyridine group with strong vasodilating properties. In a randomized trial involving 45 patients, whose mean blood pressure was 236 +/- 24/129 +/- 21 mm Hg, 5 mg nitrendipine (given sublingually via a phiole) was compared with 20 mg nifedipine (given sublingually via two pierced 10-mg capsules) and 0.15 mg clonidine (given intravenously). Blood pressure and heart rate were assessed for 8 h after intake of the antihypertensive agents. Within 60 min, nitrendipine reduced blood pressure by an average of 78 +/- 17 mm Hg for the systolic and 42 +/- 12 mm Hg for the diastolic. Heart rate fell significantly from 106 +/- 17 to 87 +/- 11 beats/min. Nifedipine produced equivalent falls in systolic (-72 +/- 15 mm Hg) and diastolic (-41 +/- 11 mm Hg) blood pressure, but increased heart rate from 89 +/- 13 to 103 +/- 14 beats/min within 1 h. Intravenous administration of clonidine lowers systolic (-84 +/- 13 mm Hg) and diastolic (-35 +/- 10 mm Hg) blood pressure within 60 min. Heart rate decreased from 96 +/- 15 to 84 +/- 9 beats/min. The antihypertensive effect of each drug was maintained until 8 h after medication. Main side effects were observed in the nifedipine group (flush and reflex tachycardia) and in the clonidine group (dry mouth and drowsiness). In conclusion, nitrendipine, nifedipine, and clonidine show similar efficacy in the treatment of hypertensive urgencies and emergencies. However, sublingual application of the calcium antagonists is simple and safe; moreover, nitrendipine is better tolerated than nifedipine and clonidine.

[Intravenous infusion of recombinant tissue-type plasminogen activator (rt-PA) and urokinase in acute myocardial infarct: intermediate results of the G.A.U.S. study (German Activator Urokinase Study)]. / Intravenöse Infusion von recombinant tissue plasminogen activator (rt-PA) und Urokinase beim akuten Myokardinfarkt: Zwischenergebnisse der G.A.U.S.-Studie (German Activator Urokinase Study).

The effects of recombinant tissue plasminogen activator (rt-PA) and urokinase on patency and early reocclusion of infarct-related coronary arteries were investigated in a single blind, randomised multicenter trial in up to now 125 patients with acute myocardial infarction of less than six hours duration. Both, 70 mg of single-chain rt-PA with an initial bolus of 10 mg, and 3 million U of urokinase with an initial bolus of 1,5 million U were given intravenously over 90 minutes. The first angiogram at the end of the infusion revealed a patent infarct-related artery (TIMI grade 2 or 3) in 68% of 62 patients with rt-PA vs. 63% of 63 patients with urokinase (n.s.). Twenty-four hours later patent infarct-related arteries occurred in the same frequency in the rt-PA group and in the urokinase group (71.5% vs. 74.6%, n.s.), although additional recanalisation procedures in sequence with the first angiography were performed more frequent in the rt-PA group. There were two cardiac deaths in either group. In-hospital reinfarction rate was 9.7% vs. 17.5% for patients treated with rt-PA and urokinase, respectively. Both drugs were well tolerated, no significant difference of cardiovascular or bleeding complications could be observed between the two groups. It is concluded that rt-PA and urokinase in the dosages used provide similar efficiency and safety in the treatment of acute myocardial infarction.

Oral ISDN for the treatment of patients with acute myocardial infarction.

In a controlled randomized trial the effect of treatment with 60 mg orally administered ISDN in patients with acute myocardial infarction was studied. Besides the usual clinical investigations, hemodynamics were checked; pulmonary artery pressure and cardiac output during the first 4 days were measured. 509 patients were included in the trial. Based on other researchers' considerations about limitation of infarct size we formed a subgroup of 132 patients to be treated within 8 h after onset of symptoms. The mortality for the entire ISDN-group was not influenced compared with that for the control group. If treatment with ISDN was started within the first 8 h after onset of symptoms of acute myocardial infarction, mortality in this group was significantly lower than that in the control group. In the group of patients receiving treatment within the first 8 h we found positive effects: a fall of pulmonary artery pressure with consecutive rise of cardiac output, mainly in patients showing high left ventricular end-diastolic filling pressures. In the treated group we found a significant decrease in arrhythmias and angina pectoris. When left ventricular hemodynamics were tested before discharge from the hospital patients treated with ISDN during the first 8 h again showed favorable results. We conclude that treatment with ISDN in the early phase of acute myocardial infarction is beneficial particularly for patients with high left ventricular filling pressures.

[Treatment of cardiogenic shock after acute myocardial infarction with intra-aortic balloon counterpulsation (author's transl)]. / Die Behandlung des kardiogenen Schocks bei akutem Herzinfarkt mit der intraaortalen Ballon pulsation

Intra-aortic balloon counterpulsation (IABP) was used in 20 patients with acute myocardial infarction and cardiogenic shock, after four hours of drug treatment. In all instances the abnormal haemodynamic state had been demonstrated. Four patients were successfully treated and finally discharged home. In two with post-infarction ventricular septal defect and cardiogenic shock, IABP also successfully reversed the shock state, while in seven the shock state was reversed but they died 2-8 days after IABP had been stopped. IABP failed in seven patients who died during its application. In those in whom IABP failed there had been no significant fall in pulmonary-artery pressure and no significant increase in stroke volume. The post-mortem examinations demonstrated that cardiogenic shock was irreversible where more than 50% of the left ventricular myocardium had been infarcted.

[Lymphangiosis carcinomatosa of the lung and cardiopulmonary shock as initial findings in gastric cancer (author's transl)]. / Lymphangiosis carcinomatosa mit kardiopulmonalem Schock als Leitbefund beim Magenkarzinom

A case is reported of a 34 year old woman, who was hospitalized because of cardiopulmonary shock of sudden unsuspected onset. X-ray examination revealed diffuse interstitial pulmonary infiltration. Intra-aortal counter-pulsation did improve the condition only for short time. On autopsy an adenocarcinoma of the stomach was found, as well as diffuse carcinomatous infiltration of pulmonary lymph and arterial vessels. Thus lymphangiosis carcinomatosa has to be taken into consideration in discussing the differential diagnosis of diffuse interstitial pulmonary infiltration in young patients. The presence of microangiopathic hemolytic anemia may help to establish the diagnosis.