The perils of pharmacological treatment for obesity: a case of sibutramine-associated cardiomyopathy and malignant arrhythmias.

A 58-year-old woman presented with severe left ventricular dysfunction and malignant arrhythmias after taking combination drug treatment for weight loss. The combination treatment included sibutramine, liothyronine, hydrochlorothiazide diuretic, metformin and fucus. The effect of these drugs individually and in combination is discussed, with particular reference to it being a malignant combination. The patient showed reversability of the left ventricular dysfunction and negative ventricular stimulation studies after cessation of the drug concoction.

Aortocoronary saphenous vein bypass aneurysm--an unusual presentation.

Aneurysms of aortocoronary saphenous bypass grafts are an unusual and rare complication of coronary artery bypass surgery. Approximately 30 such cases have been reported in the literature. Atheromatous aneurysms usually appear late (more than 10 years after grafting). They are usually asymptomatic, but may manifest for investigation as a lesion altering the mediastinal contour. We report a further case of an atherosclerotic aortocoronary saphenous vein graft aneurysm in which the patient presented with angina due to aneurysmal compression of the host vessel.

Pulmonary arterial thrombosis in secundum atrial septal defect.

Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.

Torsade de pointes due to coxsackie B3 myocarditis.

Viral myocarditis may present with a variety of electrocardiologic aberrations. Torsade de pointes, a potentially malignant ventricular arrhythmia associated with prolongation of the QT interval has not been described in patients with acute viral myocarditis. This report details this finding in a patient with coxsackie B3 myocarditis in whom symptomatic torsade de pointes was documented.

Combined unilateral pulmonary artery agenesis and contralateral peripheral pulmonary artery stenosis.

Unilateral absence of a pulmonary artery is a rare congenital malformation. This report details the finding in two cases of this anomaly associated with peripheral stenosis of the contralateral pulmonary artery.

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis.

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.

Electrocardiographic differentiation of the causes of left ventricular diastolic overload.

Left ventricular hypertrophy due to diastolic overload is characterized by the following in lead V6: (a) tall R wave; (b) prominent initial Q wave; (c) minimally elevated concave-upward ST segment; and (d) relatively tall symmetrical T wave. Reciprocal deep S waves are seen in lead V1. This study reflects a further evaluation of these parameters in the four main causes of left ventricular diastolic overload: mitral incompetence, aortic incompetence, patent ductus arteriosus, and ventricular septal defect. An S wave in lead V1 which is equal to or greater than the R wave in lead V6 excludes the diagnosis of mitral incompetence.

Effects of atenolol on exercise capacity in patients with mitral stenosis with sinus rhythm.

Exercise capacity is frequently impaired in patients with mitral stenosis (MS) and sinus rhythm (SR). The resulting increased heart rate, which shortens the diastolic filling period, and the increased cardiac output lead to further elevations of left atrial pressure and subsequent pulmonary congestion. The effect of the beta-receptor blocking agent atenolol, 100 mg/day, was assessed in 13 patients with MS and SR. Exercise performance was assessed using a modified multistage Bruce protocol after 2 weeks of placebo and after 2 weeks therapy with atenolol in a single-blind, crossover, placebo-controlled, randomized study. Atenolol resulted in significant decreases in mean heart rates at rest and during exercise (p = 0.0015) and a significant increase in total exercise time (p = 0.0015). Maximal exercise capacity was also significantly improved (p = 0.0015). All patients were both objectively and subjectively improved by atenolol. Thus, beta-blockade with atenolol improves exercise capacity in patients with MS and SR and may be of benefit to most such patients. The improved effort tolerance is attributed to reduction of the exercise-associated sinus tachycardia by beta-blockade, allowing a longer diastolic filling period and better left atrial decompression.

Transudative ascites with a high protein content. Case reports.

The case reports of 2 patients with constrictive pericarditis and 1 patient with the Budd-Chiari syndrome are used to show that high-protein ascites may occur in the absence of disease of the peritoneum. Protein content should not be the only factor assessed in differentiating between transudative and exudative ascites.

Sarcoid dactylitis in black South African patients.

Six black South Africans with sarcoid dactylitis are described. By the term sarcoid dactylitis we mean sarcoid involvement of the bone and soft tissue of the fingers. Three of the six patients developed dactylitis during the course of chronic sarcoid. These patients had multisystem disease. In all three patients dactylitis developed after the diagnosis of sarcoid was established. However, in the other three patients dactylitis was the presenting feature of sarcoidosis, and none of these patients had evidence of chronic fibrotic sarcoid elsewhere. This finding is at variance with the observation that bony sarcoid is always a feature of chronic, poor prognosis, fibrotic sarcoid of all organ systems; these patients may form a sub-group with bony involvement and good prognosis. The significance, however, of this latter localized presentation of sarcoid is that clinically and histologically it is easily confused with tuberculoid leprosy and has been misdiagnosed.

Oral propafenone in the suppression of chronic stable ventricular arrhythmias.

The efficacy of propafenone hydrochloride, a new antiarrhythmic agent, was evaluated in the treatment of chronic stable ventricular arrhythmias. Twenty-five patients who had suffered a myocardial infarction three months or longer before the trial were studied. All exhibited a minimum mean frequency of 30 ventricular ectopic beats per hour over at least two 24-hour Holter monitoring periods with the last recorded tape serving as a control. The mean decrease in ventricular ectopic activity with propafenone was 65.62 percent (p = less than 0.001). Side effects were infrequent, minimal, and of no clinical consequence. Oral propafenone was found to be an effective drug for reducing the level of chronic ventricular ectopy, as reflected by a short-term trial.

The early signs of right bundle branch block.

Complete right bundle branch block manifests with a rSR' configuration in right orientated leads and a duration of 0.12 sec or longer. Incomplete right bundle branch block is perceived as this classic rSr' configuration and a duration of less than 0.12 sec. This presentation reflects the early development of right bundle branch block which first manifests with a hitherto undescribed sign, namely: a diminution of the S wave amplitude in lead V2. Further progression of the right bundle branch block leads to slurring or notching of the upstroke of the S wave in lead V2 followed by the development of a r' deflection. With further progression, the r' deflection becomes increasingly taller until the advent of complete right bundle branch block which is characterized by a widening of a very tall R' deflection with an apical notch or plateau.

Postexercise blood pressure as a predictor of hypertension.

A study on 721 healthy male aircrew assessed whether the blood pressure response to exercise could be used to predict the development of hypertension. A positive blood pressure response to exercise, recorded 30 s after the completion of exercise, was defined as a systolic blood pressure of 200 torr or more (systolic test) or a raised diastolic blood pressure (diastolic test). While 236 (32.7%) became hypertensive with a blood pressure greater than 149/90 torr, 17% of these had shown a positive systolic response and 17% a positive diastolic response. The other 485 individuals (67.3%) remained normotensive throughout the mean follow-up period of 68 months (range 12-170 months). Of this group, 88% never manifested a positive systolic or diastolic response to exercise. Although 5% of the normotensive subjects manifested a positive systolic response to exercise, and 12% manifested a positive diastolic response to exercise, a longer period of follow-up may reduce this figure. It is concluded that exercise related blood pressure is a useful test in predicting the development of essential hypertension.