Changes in functional health status of older women with heart disease: evaluation of a program based on self-regulation.

OBJECTIVES: This study involving 570 women aged 60 years or older with heart disease, assessed the effects of a disease management program on physical functioning, symptom experience, and psychosocial status. METHODS: Women were randomly assigned to control or program groups. Six to eight women met weekly with a health educator and peer leader over 4 weeks to learn self-regulation skills with physical activity as the focus. Evaluative data were collected through telephone interviews, physical assessments, and medical records at baseline and 4 and 12 months post baseline. RESULTS: At 12 months, compared with controls, program women were less symptomatic (p < .01), scored better on the physical dimension of the Sickness Impact Profile (SIP; p < 0.05), had improved ambulation as measured by the 6-minute walk (p < 0.01), and lost more body weight (p < .001). No differences related to psychosocial factors as measured by the SIP were noted. CONCLUSION: A self-regulation-based program that was provided to older women with heart disease and that focused on physical activity and disease management problems salient to them, improved their physical functioning and symptom experience. Psychosocial benefit was not evident and may be a result of measurement error or due to insufficient program time spent on psychosocial aspects of functioning.

Syncope: diagnosis of cardiac and noncardiac causes.

Syncope is a sudden and temporary loss of consciousness not caused by trauma or seizures. Patients age 65 and older are at elevated risk of syncope-related falls and sudden cardiac death. Cardiovascular causes are generally electrical (ie, arrhythmias) or mechanical (obstruction of central circulation at a cardiac valve or major vascular structure). Noncardiovascular causes include orthostatic hypotension, vasovagal reaction, micturition, carotid sinus hypersensitivity, and neurologic (eg, TIAs). Many causes of syncope can be diagnosed from a thorough history and physical exam. More extensive testing--ECG, Holter monitoring, electrophysiology study--may be indicated for selected patients with unexplained syncope and an unremarkable evaluation.

Efficacy and safety of pravastatin in the long-term treatment of elderly patients with hypercholesterolemia.

PURPOSE: Elevated cholesterol levels are a major risk factor for coronary heart disease, which remains a significant problem in patients beyond age 65 years. Because drug therapy for the control of hypercholesterolemia in elderly patients is frequently considered to be indicated, we investigated the efficacy and safety of pravastatin in the treatment of elderly subjects with primary hypercholesterolemia. PATIENTS AND METHODS: In this 96-week, multicenter, double-blind, placebo-controlled study, 142 subjects (95 women, 47 men) 64 to 90 years of age with elevated cholesterol levels despite dietary intervention were randomized to receive pravastatin 20 mg at bedtime or matching placebo (2:1). Dosage could be doubled after 8 weeks, a bile acid-binding resin could be added after 16 weeks, and nicotinic acid or probucol could be added after 32 weeks, as needed, to adequately lower the low-density lipoprotein cholesterol (LDL-C) levels. RESULTS: Significant reductions in the levels of LDL-C (-30.9%), total cholesterol (Total-C; -21.9%), and triglycerides (TG; -16.7%) and significant increases in the levels of high-density lipoprotein cholesterol (HDL-C; 11.3%) were noted in the group receiving pravastatin treatment at 16 weeks (P < or = 0.001 compared with baseline, P < or = 0.01 compared with placebo). The cholesterol-lowering effects of pravastatin were sustained throughout the 96 weeks of the trial. Pravastatin was well tolerated, with an overall incidence of adverse events nearly identical to that of placebo. CONCLUSIONS: In this study, pravastatin was well tolerated and effective in lowering LDL-C, Total-C, and TG and in raising HDL-C during long-term treatment of elderly patients with primary hypercholesterolemia.

alpha-Interferon treatment for idiopathic hypereosinophilic syndrome.

Idiopathic hypereosinophilic syndrome (HES) is a poorly understood disorder characterized by a markedly elevated peripheral blood eosinophil count in the absence of known associated causes of hypereosinophilia. Idiopathic hypereosinophilic syndrome is associated with eosinophil-induced organ damage, including endomyocardial and pulmonary fibrosis, stroke, and gastrointestinal disease. Treatment of idiopathic HES is centered on the reduction of peripheral circulating eosinophils in an effort to diminish tissue infiltration and destruction. Multiple cytotoxic agents have been tried, with variable results. Prednisone and hydroxyurea have remained the therapies of choice in long term treatment of idiopathic HES. We report here the successful 2 year treatment of aggressive idiopathic HES, refractory to hydroxyurea and prednisone, with alpha-interferon.

Impact of self-management education on the functional health status of older adults with heart disease.

This paper presents findings from the evaluation of a self-management education program based on self-regulation principles. Older men and women (N = 324) were randomly assigned to program and control groups. Outcomes were measured using the Sickness Impact Profile. Twelve months following baseline data collection, psychosocial functioning of program participants was significantly better than that of controls. Different program effects were noted when results were analyzed by participant gender.

Comparison of differences in the hemodynamic response to passive postural stress in healthy subjects greater than 70 years and less than 30 years of age.

To test the hypothesis that age-related increases in arterial pressure alter the cardiovascular response to physiologic stress, 9 healthy elderly volunteers (74 +/- 2 years) and 7 young subjects (27 +/- 3 years) were subjected to a standard 60 degrees upright tilt. Cardiac volumes were measured with patients in the supine position and 5 minutes after they assumed an upright posture using radionuclide ventriculography, while heart rate, blood pressure and forearm cutaneous flow were recorded continuously and simultaneously. Only the expected age-related increase in mean arterial pressure (young subjects, 79 +/- 1 mm Hg; elderly subjects, 99 +/- 3 mm Hg; p less than 0.001) distinguished the 2 groups at baseline. However, during upright tilt, elderly subjects had significant decreases in stroke volume (supine [108 +/- 9 ml] vs upright [78 +/- 9 ml]; p less than 0.01) and cardiac index (supine [3.4 +/- 0.2 liters/min/m2] vs upright [2.8 +/- 0.2 liters/min/m2]; p less than 0.05) because of an inability to reduce end-systolic volume (supine, 44 +/- 6 ml; upright, 51 +/- 7 ml); however, mean arterial pressure was maintained through an increase in peripheral resistance. In contrast, the young relied solely on cardiac adaptations to postural stress by decreasing end-systolic volume (supine, 62 +/- 5 ml; upright, 39 +/- 5 ml; p less than 0.01) and increasing heart rate (57 +/- 2 min-1 to 71 +/- 3 min-1, p less than 0.01), whereby cardiac output and mean arterial pressure were maintained during tilt.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic dissection presenting as spinal cord ischemia with a false-negative aortogram.

This article presents a case of type III aortic dissection presenting as a spinal cord syndrome with a prospectively negative initial aortogram. The patient serendipitously illustrates a multimodality approach to aortic dissection imaging. The advantages and disadvantages of conventional radiography, aortography, computed tomography, echocardiography, and magnetic resonance imaging are discussed.

The influence of physical training on glucose tolerance, insulin sensitivity, and lipid and lipoprotein concentrations in middle-aged hypertriglyceridaemic, carbohydrate intolerant men.

The effects of 9 weeks of moderate intensity exercise training while on a weight-maintaining diet were studied in 19 untrained middle-aged, hypertriglyceridaemic, carbohydrate intolerant men. Initial mean maximum oxygen consumption was low (29.7 +/- 1.0 ml.min-1.kg-1; mean +/- SEM) and improved (34.2 +/- 1.4 ml.min-1.kg-1, p less than 0.01) with exercise training. Fasting glucose, insulin, lipid and lipoprotein concentrations did not change. While the abnormal glucose response to oral glucose did not change with training, insulin concentrations were significantly (p less than 0.05) lower at 90 and 120 min during the final oral glucose tolerance test. Insulin mediated glucose uptake did not change, indicating that the degree of exercise training failed to improve in vivo insulin sensitivity. Significant associations were found between the following parameters measured: fasting concentrations of triglycerides and insulin, very low density lipoprotein-triglycerides and glucose, and measures of in vivo insulin resistance and fasting insulin levels, suggesting that insulin resistance in these glucose intolerant subjects may play a role in their hypertriglyceridaemia. These data indicate that moderate increases in physical training alone are not sufficient to improve the carbohydrate, insulin and lipid metabolism of hypertriglyceridaemic, glucose intolerant men.

Prognostic significance of exercise-induced left ventricular dysfunction in chronic aortic regurgitation.

Twenty-three patients with hemodynamically significant aortic regurgitation (AR) underwent gated equilibrium radionuclide angiography to assess rest and exercise left ventricular ejection fraction (LVEF) before and after aortic valve replacement. Preoperatively, LVEF decreased from 54 +/- 3% at rest to 45 +/- 3% during exercise (p less than 0.001). Two patients died at operation. Postoperatively, after 5.7 +/- 1.6 months, LVEF was 62 +/- 5% at rest and 60 +/- 4% during exercise (difference not significant). Exercise LVEF improved significantly postoperatively (p less than 0.01). The patients were followed for a mean of 30 months (range 1 to 56), after valve replacement and during this period, 13 patients were in functional class I, 5 patients were in class II and 2 patients were in class III. One late death occurred and was unrelated to myocardial failure. Thus, in most patients with AR, exercise LVEF improves after aortic valve replacement. A preoperative decrease in LVEF during exercise in patients with significant AR does not predict a poor postoperative outcome.

Effect of exercise training on glucose tolerance, in vivo insulin sensitivity, lipid and lipoprotein concentrations in middle-aged men with mild hypertriglyceridemia.

The effects of 9 weeks of aerobic exercise training with maintenance of stable body weight upon insulin sensitivity and upon glucose, lipid, and lipoprotein concentrations were studied in 10 middle-aged men with mild hypertriglyceridemia. Following training, mean maximum oxygen consumption improved from 33.5 +/- 1.9 to 39.3 +/- 1.9 mL/kg/min (means +/- SEM), (P less than 0.01). Glucose concentrations, both fasting and during oral glucose tolerance testing, remained stable but both fasting insulin concentrations and insulin responses to oral glucose decreased (P less than 0.1 and less than 0.01, respectively). In vivo insulin sensitivity improved 25 +/- 6.1% (P less than 0.01) following training. Exercise training resulted in decreases in fasting serum triglyceride concentrations from 203 +/- 12.6 to 126 +/- 9.0 mg/dL (P less than 0.01), primarily as a result of the reduction in VLDL-triglycerides (P less than 0.01). The magnitude in percentage decrease of VLDL-triglycerides was found to be significantly correlated (r = 0.71, P less than 0.05) with the magnitude in percent increase in max VO2. Serum cholesterol levels declined from 211 +/- 8.9 to 193 +/- 11.9 mg/dL (P less than 0.01), and the ratio of HDL-cholesterol to total cholesterol was improved. This study demonstrates that exercise training at a level of intensity feasible for many middle-aged men has beneficial effects on several factors that have been associated with an increased risk of cardiovascular disease.

Factors affecting survival in prosthetic valve endocarditis. Review of the effectiveness of prophylaxis.

We review factors affecting survival of 44 episodes of prosthetic valve endocarditis occurring in 39 patients from 1965 to 1982. The mortality was 31.8 percent (14/44), and 21.6 percent (8/37) if the fungal cases are excluded. The development of a new murmur of valvular regurgitation in 18 patients led to valve replacement or death in every patient. Streptococcal endocarditis in 11 patients resulted in no deaths and only two valve replacements; staphylococcal infections had a mortality of 27.1 percent (6/22). Length of medical therapy before valve replacement did not relate to a successful outcome. Eight cases of early staphylococcal endocarditis occurred in which the organism was susceptible to the prophylactic antibiotic therapy. Changes in prophylaxis have led to no cases of early endocarditis over the past three years in 261 valve replacements.

Aortic valve replacement in the elderly.

In order to determine the risk of aortic valve replacement in the elderly, 77 patients over the age of 60 who had undergone this procedure were reviewed. Hypothermic-hyperkalemic cardioplegia was used in all patients. In 55 patients with isolated aortic valve replacement there were three deaths (5.5 per cent). In the entire series of 77 patients there were 13 deaths (13 per cent). In seven patients of an organ other than the heart. In only two patients did the operative death have a myocardial cause. Ninety-two per cent of the patients were in functional class I or II following surgery. Patients should come to surgery before reaching class IV. Aortic valve replacement can be carried out safely in the elderly, and the indications should be the same as for younger patients.

Left ventricular function in patients with ventricular arrhythmias and aortic valve disease.

Forty patients having aortic valve replacement were evaluated preoperatively for ventricular arrhythmia and left ventricular ejection fraction. Arrhythmias were classified as complex or simple using the Lown criteria on the 24-hour ambulatory electrocardiogram; ejection fractions were determined by radionuclide gated blood pool analysis and contrast angiography. The ejection fractions determined by radionuclide angiography were 59.1 +/- 13.1% for 26 patients with simple or no ventricular arrhythmias, and 43.9 +/- 20.3% for 14 patients with complex ventricular arrhythmias (p less than 0.01). Ejection fractions determined by angiography, available for 31 patients, were also lower in patients with complex ventricular arrhythmias (61.1 +/- 16.3% versus 51.4 +/- 13.4%; p less than 0.05). Seven of 9 patients showing conduction abnormalities on the electrocardiogram had complex ventricular arrhythmias. Eight of 20 patients with aortic stenosis had complex ventricular arrhythmias, while 2 of 13 patients with aortic insufficiency had such arrhythmias. It is concluded that decreased left ventricular ejection fraction, intraventricular conduction abnormalities, and aortic stenosis are associated with an increased frequency of complex ventricular arrhythmias in patients with aortic valve disease.

The subcellular particulate NADPH-dependent O2.(-)-generating oxidase from human blood monocytes: comparison to the neutrophil system.

Highly purified preparations of normal human monocytes obtained from peripheral blood were shown to contain a subcellular particulate O2.(-)-generating oxidase system. This O2.(-)-generating activity was present in particulate preparations from monocytes that had been previously stimulated with phorbol myristate acetate but was low or absent in control preparations from unstimulated monocytes or stimulated monocytes from a patient with chronic granulomatous disease. In the stimulated preparations from normal monocytes, O2.(-)-generation was linearly proportional to cell protein concentration, insensitive to inhibition by azide, and dependent on NADPH as substrate. These characteristics are similar to the O2.(-)-generating oxidase system from human neutrophils. A significant difference in the apparent Km for NADPH was shown between preparations from stimulated monocytes and neutrophils (monocyte 83 +/- 16 microM, neutrophil 31 +/- 5 microM, mean +/- SE). Additionally, affinity of the stimulated monocyte particulate preparation for NADH was unmeasurably low.

Functional relationship of the cytochrome b to the superoxide-generating oxidase of human neutrophils.

A subcellular particulate fraction containing the NADPH-dependent O2.--generating oxidase from stimulated human neutrophils was prepared. This fraction was depleted of certain enzyme markers of primary and secondary granules and was devoid of measurable myeloperoxidase, both enzymatically and spectrally. When prepared from neutrophils which had been previously stimulated with phorbal myristate acetate, this fraction contained cyanide-insensitive, pyridine nucleotide-dependent O2.--generating activity with a specific activity of 260 nmol min-1 mg-1. O2.--generating activity is completely ablated by p-chloromercuribenzoate exposure. Preparations from normal unstimulated neutrophils or stimulated neutrophils from a male patient with chronic granulomatous disease had negligible amounts of this O2.--generating enzymatic activity. The dominant chromophore in this preparation was a b-type cytochrome, the spectral and functional characteristics of which are further described herein. Pyridine nucleotide-dependent reduction of the intrinsic cytochrome b closely parallels O2.- generation in this preparation. Specifically, reduction occurs in preparations from phorbal myristate acetate-stimulated neutrophils and is absent in unstimulated or stimulated p-chloromercuribenzoate-inactivated preparations.

The determination of the post-test likelihood for coronary disease using Bayes Theorem.

This report describes a method of using Bayes Theorem for determining the post-test likelihood for coronary disease from the exercise test. The pre-test likelihood is determined from the age, sex, and type of chest pain. Discriminant analysis of the amount of S-T depression, maximum pressure rate product and sex of the patient is then used to determine the sensitivity and specificity of the patient's exercise test for coronary artery disease. The post-test likelihood for coronary artery disease can then be calculated using Bayes Theorem. The discriminant function was estimated from a training set of 174 patients. This was then applied to 113 new patients who had both exercise tests and coronary arteriograms. In this new set, 47 patients had a post-test likelihood of 90% or greater for coronary disease. Only one of these patients had normal coronary arteriograms, a predictive accuracy of 98%. Of the 25 patients with a post-test likelihood of 10% or less for coronary disease, four had multivessel disease and four had single vessel disease. The predictive accuracy for the absence of coronary disease was 68%. The predictive accuracy for the exclusion of multivessel disease was 84%. Eight of 10 patients with left main disease had a post-test likelihood for coronary disease of greater than 90%.

Cardiac arrhythmias during epinephrine-propranolol infusions for measurement of in vivo insulin resistance.

Sixty-eight determination of in vivo insulin resistance were conducted in 35 males (aged 29-63 yr) by measurement of steady-state plasma glucose levels during a combined intravenous infusion of propranolol, epinephrine, glucose, and insulin. Subjects were mildly diabetic and/or hyperlipidemic. All were asymptomatic, denied taking medication, and had no history of cardiac disease. All had normal resting electrocardiograms. During the infusion, mean increases in systolic and diastolic blood pressure were 27 +/- 12.2 (x +/- SD) and 14 +/- 5.7 mm Hg, respectively; mean reduction in heart rate was 19 +/- 6.1 beats/min. Six out of the 35 subjects developed cardiac arrhythmias during the infusion test. Maximal exercise treadmill tests failed to predict all subjects who subsequently developed arrhythmias during the infusion test. These results suggest that this infusion test should be performed under continuous cardiac monitoring and promptly terminated if major arrhythmias develop.

Radionuclide angiography in evaluation of left ventricular function following aortic valve replacement.

Congestive heart failure in patients surviving aortic valve replacement has been associated with a high late mortality. To determine whether myocardial dysfunction in these patients occurred preoperatively, perioperatively, or during the early postoperative period, 19 consecutive patients undergoing aortic valve replacement using cardioplegia and hypothermia were studied by multiple-gated cardiac blood pool imaging. The resting ejection fractions for 8 patients with aortic stenosis did not show significant changes following operation. The 11 patients with aortic insufficiency has resting preoperative values of 58 +/- 15%, which fell to 38 +/- 18% immediately postoperatively (p less than 0.01), with the late values being 51 +/- 16%. Eight of 18 patients (44%) showed deterioration of regional wall motion immediately after operation, which persisted in 3 during the late evaluation. The occurrence of new perioperative regional wall motion abnormalities and persistent perioperative depression in left ventricular function in some patients suggest the need for further improvement in myocardial protection during cardiopulmonary bypass for aortic valve replacement.