Dyslipidemia evaluated by brachial artery vasoactivity: a case study of eight patients.

Current National Cholesterol Education Program (NCEP) guidelines consider a desirable low-density lipoprotein cholesterol level to be < 100 mg/dl for an individual with coronary artery disease (CAD). To assess the affect of these cholesterol levels on endothelial cell functioning, flow-mediated brachial artery vasoactivity was measured non-invasively (7.5 MHz ultrasound) before and during Simvastatin (Zocor) therapy. Vasoactivity was expressed as a percent diameter change from baseline to hyperemic conditions and increased from 2.4 +/- 3.0% at baseline to 13.1 +/- 3.4% (p < .05) and 15.1 +/- 2.7% (p < .01) as cholesterol decreased from 243 +/- 24.7 to 221 +/- 27.3 and 213 +/- 22 mg/dl after three and six months, respectively, during therapy. LDL cholesterol subsequently decreased from 155 +/- 22.1 at baseline to 143 +/- 20.2 and 130 +/- 10.6 after three and six months of treatment, respectively. In conclusion, vasoactivity was found to correlate inversely with cholesterol levels (r = 0.44). This suggests that vasoactivity responds to changes in cholesterol levels and that endothelial function improves by lowering cholesterol levels.

Aortic atherosclerosis and stroke.

METHODS: Studies using transesophageal echocardiography (TEE) suggest aortic atherosclerosis may be a risk factor for stroke, particularly stroke of undetermined mechanism, but controls in prior studies were not balanced for vascular risk factors. We used TEE to evaluate aortic atherosclerosis in 60 patients with stroke compared with a high-risk control population of 46 subjects. We also examined the possible association of plasma viscosity and fibrinogen levels to aortic atherosclerosis. RESULTS: The mean maximal plaque thickness (MMPT) was similar for the control (2.8 +/- 3.6 mm) and the stroke group (3.3 +/- 3.5 mm), but varied with stroke mechanism. The MMPT was similar in stroke of undetermined and atherosclerotic mechanism [3.5 +/- 4 mm (n = 25) and 4.2 +/- 4.3 mm (n = 16), respectively], significantly greater than in stroke of other mechanisms (1.7 +/- 1.2 mm, P < .05, n = 19). Patients with stroke of undetermined mechanism were four times more likely (95% confidence interval [CI] 1.2-12) to have plaques >/=5 mm compared with controls. Ulcerated plaque was associated with plaque thickness (P < .001) and plasma viscosity (P < .001). CONCLUSIONS: Aortic atherosclerosis is associated with stroke of undetermined cause suggesting atherosclerosis is a cause of stroke of undetermined etiology. Plaque ulceration was associated with the thickness of aortic plaque and plasma viscosity.

Coronary venous retroperfusion of arterial blood for the treatment of acute myocardial ischemia.

Synchronized coronary venous retroperfusion of autologous arterial blood was offered to patients referred for medically refractory unstable angina or evolving myocardial infarction with contraindications to thrombolytic therapy. Primary endpoints of angina, ST segment deviation, and two-dimensional echocardiographic systolic wall motion were followed to determine the efficacy of retroperfusion in patients prior to and then during angioplasty, surgical intervention, or pharmacological management, as the clinical picture warranted. Over a 12 month period, 21 patients were referred and 15 received retroperfusion. All experienced full relief of angina (p = 0.008). ST segment deviations and systolic wall motion of ischemic zones were observed to improve (p = 0.06 ST changes; p = 0.0001 wall motion changes) with synchronized retrograde perfusion. During attempts to remove patients from retroperfusion, statistically significant (p < 0.01) reproducible changes in these same endpoints were documented. Retroperfusion appears to improve acute myocardial ischemia. This technique functions well in the intensive care unit environment with only fluoroscopy as technical imaging support.

Late potentials in mitral valve prolapse.

To determine the incidence and significance of late potentials in patients with mitral valve prolapse, we performed surface signal-averaged electrocardiography and 24-hour ambulatory electrocardiographic (ECG) monitoring in 41 patients with moderate to severe mitral valve prolapse on two-dimensional echocardiograms. Late potentials were defined as the presence of either a root mean square voltage of the last 40 msec of the QRS (RMS-40) of less than 20 mu v or a low-amplitude signal duration (LAS-40) of greater than 39 msec. Despite the absence of clinically significant ventricular tachycardia by history and on ambulatory ECG monitoring, 12 patients had late potentials on their signal-averaged electrocardiograms. Clinical characteristics could not differentiate patients with from patients without late potentials, and all patients were doing well at a mean follow-up of 34 months except for one noncardiac death. We conclude that late potentials on the surface signal-averaged electrocardiogram are a common and benign finding in patients with mitral valve prolapse and their clinical significance should be determined only in the presence of other findings.

The role of two-dimensional echocardiology in the diagnosis of infective endocarditis [corrected].

Two-dimensional echocardiography has had a significant impact on and is considered the technique of choice for the diagnosis and management of infective endocarditis. Over a thirty-six month period, 106 patients were evaluated by echocardiography for the possibility of endocarditis. The diagnosis of endocarditis was determined by strict clinical and laboratory criteria. All clinical histories, blood cultures, echocardiograms, and autopsy results were reviewed. Five echocardiograms were technically inadequate, resulting in a study population of 101 patients. The age of the patients ranged from forty-five days to eighty-eight years (mean fifty-seven years). The clinical manifestations of endocarditis included fever (83%), chills (60%), congestive heart failure (25%), and splenomegaly (18%). Twelve patients had preexisting valvular or congenital heart disease. Gram-positive cocci were the most common microorganisms. Complications included mitral regurgitation, subarachnoid hemorrhage, renal infarction, stroke, and a pulmonary embolus. The patients were divided into two groups: Group I consisted of 36 patients with definite vegetations by echocardiography, and Group II had 65 patients with no vegetations. In Group I, acute infective endocarditis was present in 35 patients, whereas only 4 patients had endocarditis in Group II. The sensitivity of two-dimensional echocardiography for detecting endocarditis was 90%. The specificity was 98%. The predictive accuracy for a positive test was 97%, and the predictive accuracy for a negative test was 94%. Thus, two-dimensional echocardiography appears to have a high sensitivity, specificity, and predictive value in the evaluation of patients with suspected endocarditis.

Late variation in ventricular function after myocardial infarction.

To assess the possible role of variables not related to early infarct artery reperfusion in predicting late changes in ventricular function after infarction, paired early (mean 6.6 +/- 3.5 days after admission) and late (12.7 +/- 7.0 months later) cross-sectional echocardiograms from 54 infarction survivors were retrospectively reviewed. Ejection fraction was calculated from digitized biapical echocardiographic views on a graphics tablet. Changes of 0.10 or more in LVEF were correlated with 23 clinical variables. By stepwise regression analysis, Q-wave infarction and low early LVEF independently predicted late improvement in function. Early high LVEF and interval infarction were the only independent predictors of late declines in function. Overall, when patients were indexed by early left ventricular systolic function, a pronounced late "regression to the mean" was noted with initially high values tending to fall and low values to rise (r = -0.44, p less than 0.001). This effect must be accounted for in any acute intervention trial in myocardial infarction. The occurrence of Q-wave infarction does not exclude late improvement in ventricular function.

Therapy of ischemic cardiomyopathy with pentoxifylline.

Abnormal blood rheology is a known characteristics of coronary artery disease. The authors evaluated the effects of pentoxifylline on the exercise capacity ejection fraction and symptoms of 9 patients with ischemic cardiomyopathy. All patients had signs and symptoms of left ventricular dysfunction. All had at least two major vessels obstructed as determined by coronary angiography. Pentoxifylline 400 mg three times daily was administered for twelve weeks. Seven of 9 patients responded with increases in ejection fraction and exercise tolerance. Exercise tolerance correlated with improvement or lack of improvement in ejection fraction. For all patients at twelve weeks post-therapy mean ejection fraction increased 9.8% over baseline (p = .07), total treadmill time increased 15% (p = .27), and mean double product increased 13% (p = .03). Anginal symptoms were significantly improved over baseline at twelve weeks of therapy (p greater than .001), as well as dyspnea on exertion (p = .03). Pentoxifylline was well tolerated. Pentoxifylline may benefit ischemic cardiomyopathy by improving coronary perfusion owing to favorable alterations in hemorheologic properties.

Short-term control of supraventricular tachycardia with verapamil infusion and calcium pretreatment.

Nineteen consecutive patients with atrial fibrillation/flutter or other types of supraventricular tachycardia were given intravenous (IV) calcium salts (1 g) followed by verapamil infusion at a rate of 1 mg/min. Successful treatment was defined as control of ventricular response to less than or equal to 100 beats per minute (bpm) or conversion to sinus mechanism in patients with atrial arrhythmias: 11 patients had atrial fibrillation; three had atrial flutter; four had reentrant supraventricular tachycardias (SVT); and one had paroxysmal SVT. Therapy was successful in all patients. The mean dose of verapamil required to achieve desired outcome was 20 mg. Heart rate showed no significant change as a result of calcium pretreatment (160 bpm v 151 bpm). However, heart rate was significantly decreased, to 95 bpm, after treatment with verapamil. Blood pressure showed no change from baseline with either calcium or verapamil therapy. Verapamil infusion following IV calcium successfully treats atrial fibrillation/flutter or SVTs without depressing systemic blood pressure.

Lipid screening in a rural West Virginia clinic.

West Virginia leads the nation in mortality from coronary heart disease among both men and women aged 35 to 74. Although there has been some research with respect to behavioral risk factors, little is known about the prevalence of high serum cholesterol among West Virginia residents. The present paper begins this examination by reporting the results of a medical chart audit conducted recently in a rural medicine clinic in Matewan, West Virginia. Results revealed that only 17 per cent of the 501 charts reviewed reported serum cholesterol. Significant differences were noted between the local sample and a national comparison for two groups. The implications of these findings are discussed.

Left ventricular pseudoaneurysm after myocardial infarction.

As is evident from our case and others, post-myocardial infarction pericarditis with the formation of pericardial adhesions creates a suitable milieu for left ventricular pseudoaneurysm. Although the conditions for pseudoaneurysm formation are rarely met, the clinician should be aware of this diagnosis, even long after myocardial infarction, because of its associated mortality and also because it is surgically curable.