Influence of angiotensin converting enzyme inhibition on exercise performance and clinical symptoms in chronic heart failure: a multicentre, double-blind, placebo-controlled trial.

One hundred and seven patients with chronic heart failure (NYHA class II to IV) stabilized on digitalis and/or diuretics, recruited from 11 centres were randomized into a double-blind, placebo-controlled study to assess the effect of 12 weeks of cilazapril therapy on exercise tolerance and clinical status. Thirty-five patients were randomized to placebo and 72 to cilazapril at a starting dose of 1 mg daily; titration to cilazapril 2.5 mg at week 4 and 5 mg at week 8 (or matching placebo) was carried out in patients who did not improve clinically. Demographic characteristics, including exercise test duration increased from 402 s (+/- 17 SEM) at baseline to 462 s (+/- 19 SEM) at week 12 for the cilazapril group (+15%) and from 405 s (+/- 23 SEM) at baseline to 408 s (+/- 30 SEM) at week 12 in patients on placebo (+1%) (P < 0.001). In the placebo group, patients able to exercise for more than 6 min at baseline showed an increase in exercise duration at week 12 while those able to exercise for up to 6 min at baseline showed a decrease (P = ns). In contrast, cilazapril-treated patients showed an increase in exercise tolerance regardless of baseline exercise test duration; patients with the most impaired exercise tolerance at baseline showed a greater improvement than patients with mildly impaired baseline exercise tolerance (P < 0.05 vs placebo). NYHA class improved by at least one grade in 51% of the cilazapril group vs 32% in the placebo group (P = ns). At the end of the trial, 15% of the patients were non-responders on cilazapril vs 41% on placebo (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of the results of aorto-coronary bypass surgery with the technetium 99m pyrophosphate scintigram (author's transl)]. / Beurteilung der Operationsergebnisse nach aortokoronarem Bypass mittels der Technetium-99m-Pyrophosphat-Myokard-Szintigraphie.

In 40 patients with angiographically-documented coronary artery disease, technetium 99m pyrophosphate (99mTc-PYP) myocardial scintigrams were obtained prior to and four to six weeks after aorto-coronary bypass surgery. In the majority of patients, preoperative and postoperative exercise testing with simultaneous pulmonary artery pressure recordings was performed. In 22 of 30 patients with preoperatively increased 99mTc-PYP myocardial activity, no tracer accumulation could be found postoperatively. In the latter patients, there was also a significant increase in exercise capacity and lessening of ischemic ST-segment depression in the exercise ECG. In the remaining eight patients in whom increased tracer accumulation was found to persist postoperatively, there was no improvement in exercise capacity. In ten patients with no myocardial tracer accumulation preoperatively, unchanged myocardial scintigrams and a significant decrease of the ischemic ST-segment depression in the exercise ECG were seen postoperatively except in one patient with perioperative myocardial infarction. These results were also partially confirmed by repeated coronary angiography and ventriculography. Patent bypass grafts were associated with regional improvement in left ventricular function. The results indicate that postoperative absence of myocardial tracer accumulation appears due to amelioration of preexisting myocardial ischemia at rest. Thus, in the assessment of the results of aorto-coronary bypass surgery, the 99mTc-PYP scintigram offers an important diagnostic potential.

[99mTc-pyrophosphate myocardial scintigraphy in patients with chronic stable angina pectoris (author's transl)]. / Das 99mTc-Pyrophosphat-Myokardszintigramm bei der chronischen Angina pectoris.

In 66 patients suffering on chronic stable angina pectoris myocardial scintigrams with 99mTc-pyrophosphate were evaluated. Patients who had former infarcts or infarct signs in ECG were excluded. 16 normal subjects were used as controls. In all normal subjects and in 35 patients with chronic A.P. a normal myocardial scintigram could be obtained. In the remaining 31 patients a localized myocardial tracer accumulation could be seen. There was a correlation between the tracer accumulation and the limitted left ventricular function. No correlation was found between the severity and the number of involved coronary arteries and a positive scintiphoto. The mechanism of the tracer accumulation is discussed. The results of this investigation show that a positive myocardial scintigram does not prove a myocardial infarction. It is a sign for a insufficiency of the contractility of the left ventricle, probably due to under perfusion.

[Relationship between quinidine plasma level and clinical effect for a new quinidine retard-formulation (author's transl)]. / Beziehung zwischen Chindin-Plasmaspiegel und klinischer Wirkung bei einem neuen Chinidin-Präparat in Retardform.

To convert atrial fibrillation 19 patients (8 male and 11 female) were administered (5-vinyl-2-quinuclidinyl)-(6-methoxy-4-quinolyl)-methanol, a new slow-release quinidine formulation (Chinidinorm), containing 250 mg quinidine bisulphate x 4 H2O per tablet, corresponding to 200 mg quinidine sulphate or 164 mg quinidine base respectively. After careful titration of the effective dosage sinus rhythm could be obtained in 17 patients and auriculo-ventricular rhythm in one patient. The drug failed only in one female patient for the occurrence of diarrhoea. Minimum as well as maximum quinidine levels measured in plasma correlated significantly to the quinidine dosages/kg b.w. administered. Part of the quinidine concentrations measured in plasma was at or under the minimum effective levels, respectively, in literature. According to our results it should therefore be discussed to slightly reduce the lower limit of efficacy for plasma quinidine levels. The new quinidine formulation proved to be effective and poor of side-effects with little variations in effective plasma level. Therefore it is to be considered equivalent to all quinidine retard-formulations on the market at present.

[Serum myoglobin and myocardial infarction (author's transl)]. / Serummyoglobin und Myokardinfarkt.

The serum myoglobin level was determined in 45 healthy persons and 64 patients of whom 43 had a recent proven myocardial infarct. The normal myoglobin value was found to ae 43.7 +/- 16.0 ng/ml. All the patients with myocardial infarct who had been transferred to our Coronary Care Unit showed raised serum myoglobin levels already 4 hours after symptoms commenced, the maximum being reached after 10 hours. 20 hours after myocardial infarction normal values were once again registered. Pathological serum myoglobin levels were also found without infarction after skeletal muscle damage in the course of resuscitation measures, or after operations or in renal failure. The value of the serum myoglobin concentration in the diagnosis of myocardial infarction lies in the early elevation of this parameter, but it is unspecific and the method is relatively laborious.

[Diastolic mitral regurgitation (author's transl)]. / Die diastolische Mitralregurgitation.

An analysis of left ventricular angiograms not seldom revealed a diastolic mitral regurgitation. There was neither a correlation between the diastolic mitral regurgitation and the anatomic situation in the coronary system nor with the left ventricular function. The diastolic regurgitation always occurred in a postextrasystolic pause at the end of the diastole. While the systolic mitral regurgitation produces a jet appearance of contrast material, the diastolic mitral regurgitation is seen as a floating of contrast material into the atrium. The cause of the diastolic mitral regurgitation appears to be an incremented left ventricular filling subsequent to repeated and incoordinately-occurring extrasystoles with diminished systolic ejection which leads to reversal of the pressure gradient between the left atrium and left ventricle and permits regurgitation over the incompletely closed valve.

[Pulmonary artery pressure measurement for assessment of bioavailability of isosorbide dinitrate and pentaerythritol tetranitrate (author's transl)]. / Pulmonalarteriendruckmessung zum Nachweis der Bioverfügbarkeit von Isosorbiddinitrat und Pentaerythroltetranitrat.

In a double-blind cross-over study with 9 patients suffering from ischemic cardiomyopathy with cardiac failure, the effect of 3 different drug preparations on pulmonary artery pressure (PA-pressure) was studied. Iso-Ameritrat is a new drug-combination consisting of a sweet-tasting wrap containing 2.5 mg Isosorbide Dinitrate (ISDN) and of a bitter-tasting core containing 10 mg Pentaerythritol Tetranitrate (PETN) and 200 mg Meprobamate. A statistically significant decrease of PA-pressure values could be observed already 3 minutes after administration of Iso-Ameritrat. Within the next minutes this decrease even augmented and lasted over the whole period of measurement (30 minutes). After administration of the second drug preparation (Ameritrat), containing 10 mg PETN and 200 mg Meprobamate in the core, but not any nitrate in the wrap a slight but also statistically significant decrease of PA-pressure values could be documented. Therefore a sublingual resorption of PETN can be assumed. The precise beginning of the effect of PETN couldn't be assured, but it must be within 5 minutes. A thir preparation, containing only 200 mg Meprobamate in the bitter tasting core caused no significant decrease of PA-pressure values.

[Long-time follow-up scintigraphy with 99m Tc pyrophosphate after myocardial infarction (author's transl)]. / Langfristige szintigraphische Verlaufskontrollen mit 99m-Tc-Pyrophosphat nach akutem Myokardinfarkt.

Follow-up scintigraphies with 99m Tc pyrophosphate 3--4 weeks and 6--12 months after a myocardial infarction revealed the possibility of persisting a myocardial tracer activity in cases in which reinfarction can be excluded. There was a relation between the persistence of the tracer activity and the pressure in the pulmonary artery under stress conditions. The diastolic pulmonary pressure was regular in those patients whose scintiphotos showed no tracer activity in the myocardial area in the follow-up scintigraphy. Patients who showed a persisting tracer activity in the infarcted areal had elevated pressures in the pulmonary artery under stress conditions or even at rest. The elevation of the diastolic pulmonary pressure is a sign of an elevated enddiastolic pressure in the left ventricle caused by a limited left ventricular function. This could be proved by left ventriculography. The results in follow-up scintigraphy 3--4 weeks and 6--12 months after the infarction were quite similar. Therefore we believe that the results of a follow-up scintigraphy 3--4 weeks after an infarction allows to draw prognostic inferences about the further course of the disease.

[Peripheral pulmonary stenosis due to tumour compression (author's transl)]. / Periphere Pulmonalstenosen durch Tumorkompression.

A report is presented of the occurrence of peripheral pulmonary stenosis due to tumour compression in a 12 year-old boy. The tumour was identified as a liposarcoma of the mediastinum, which caused complete occlusion of the left pulmonary artery and stenosis of the right pulmonary artery. This was followed by an extreme increase in prestenotic pressure with right heart failure.

[Diagnostic and prognostic value of scintigraphic methods in cardiology (static methods)]. / Diagnostische und prognostische Bedeutung szintigraphischer Untersuchungsmethoden in der Kardiologie (statische Methoden).

The diagnostic possibilities of myocardial scintigraphy in cardiology are discussed. As an invasive technique the perfusion imaging is described. The valuation of the doubleisotope-scintigraphy for better diagnostic examination during coronary arteriography is accentuated. The 201-Thallium-scintigraphy as a non invasive method is debated. The diagnostic value of the 201-Thallium stress scintigraphy is shown. The similarity of ergometric and pharmacologic provocation with Dipyridamol is represented. In the following the reliability and the specificity of the infarct scintigraphy with 99m-Technetium-pyrophosphate as "hot-spot-technique" is discussed. The follow-up scintigraphy allows to draw prognostic inferences about the further course of a myocardial infarction. The scintigraphic findings were correlated to haemodynamic measurements. Scintigraphic examinations in patients with stable angina pectoris without infarction revealed correlations between the uptake of the tracer in the myocardium and a disturbed left ventricular function. A chronic deficiency in the blood supply of the myocardium is discussed as the cause of the tracer uptake.

[Prognostic significance of follow-up scintigraphy with 99m Tc-pyrophosphate in myocardial infarction (author's transl)]. / Prognostische Bedeutung der Verlaufsszintigraphie mit 99m-Tc-Pyrophosphat beim frischen Myokardinfarkt.

Using 99m Tc-pyrophosphate there is a positive visualization of a transmural myocardial infarction by a localized tracer activity outside of the skeletal system. The uptake of the tracer in the infarcted area is expressed as percentage of the accumulation over the sternum. It reaches a maximum 48-60 hours after infarct onset and then recedes gradually but not strictly linearly. On the occasion of a control scintigraphy 3-4 weeks after the myocardial infarction and after full mobilization 56 per cent of the investigated patients showed a variable decrease of the tracer activity. On 44 per cent the tracer activity in the infarcted area remained unchanged or even increased slightly, though the infarction could be excluded. At the same time performed haemodynamic investigations with measuring the pulmonary artery pressure at rest and under stress conditions showed a good correlation between the persistence of the tracer activity in the infarcted area and the amount of the pulmonary pressure at rest and during stress, manifesting left ventricular function. So the result of a control scintigraphy 3-4 weeks after myocardial infarction allows to draw prognostic inferences about the further course of the disease.

[Pressure curves in the coronary arteries (author's transl)]. / Druckkurvenverhalten im Bereich der Herzkranzgefässe.

During catheterization of the coronary vessels two different pressure curves can be registrated. One curve looks like the aortic pressure while the other is similar the ventricular curve. The diastolic pressure of these curves lies below the aortic diastolic pressure but is higher than the diastolic ventricular pressure. The appearence of the different pressure curves is independent from the morphology of the coronary arteries. The different form of the pressure curves depends on the dynamic of the blood flow in the coronary system which is discussed.

[The accuracy of 201 thalium scintigraphy of the heart under conditions of stress (author's transl)]. / Sensibilität des 201 Thalliumszintigramms des Herzens unter Belastungsbedingungen.

The results of 201 thalliumszintigraphy under stress condition in patients with coronary heart disease with or without myocardial scars have not been uniform. We could show that pathologic stress szintigrams were only found in patients with a singular stenosis in one branch of the left coronary artery. In all those cases who had similar stenosis in both branches of the left coronary artery the stress szintigram appeared to be unchanged or normal. Therefore an unchanged stress szintigram allows no conclusion on the condition of the coronary arteries. A normal stress szintigram can be found as well in patients with normal coronary arteries as in patients with severe coronary heart disease. The examination of 201 thallium szintigrams under stress conditions therefore needs some critical evaluation.

[Ventricular fibrillation under quinidine medication--quinidine syncope (author's transl)]. / Kammerflimmern unter Chinidinmedikation--Chinidinsynkope.

Ventricular fibrillation which may occur unexpected under quinidine medication--called quinidine syncope--is one of the most dangerous complications of quinidine application. These life threatening accidents occur in 0,5-4,4% treated cases. The quinidine syncope occurs mostly at the attempt to eliminate atrial fibrillation or flutter. This dangerous side effect is dose independent. The ECG shows an increased QT duration and large U-waves. It seems to be a reentry-tachycardia caused by unequal recovery times in different parts of the ventricular myocardium.

[Pacemaker failure due to postcardiotomy syndrome--case report]. / Schrittmacherfunktionsstörung durch Postkardiotomiesyndrom--ein Fallbericht.

A failure of the sensing function of a pacemaker with a sutureless myocardial lead caused by postcardiotomy syndrome, is reported. The pacemaker failure appeared on the sixth postoperative day and disappeared after healing of the syndrome. Attention is called to the possibility of a postcardiotomy syndrome causing a pacemaker failure.

[201-Thalium scintigraphy of the myocardium under conditions of rest and exercise (author's transl)]. / Die 201-Thalliumszintigraphie des Myokards unter Ruhe- und Belastungsbedingungen.

The results of 201-Thallium myocardial scintigraphy at rest and after stress conditions in 30 patients are discussed. Among those there were 4 patients without cardiac disease, 7 patients with anterior wall scars after transmural infarction, and 19 patients with coronary heart disease and at least one coronary stenosis greater than 75%. The obtained results were compared to findings in coronary angiography and perfusion scintigraphy. The noninvasive method of 201-Thalliumscintigraphy shows a good correlation to the results of invasive investigations when performed at rest and under stress conditions. It enables greater sensivity and specifity in selection of patients with coronary heart disease compared to stress electrocardiography alone.

[Technetium 99m-diphosphate as an imaging agent in acute myocardial infarction (author's transl)]. / Technetium-99m-Diphosphat in der Diagnostik des frischen Herzinfarktes.

To test the sensitivity and specificity of 99m-Technetium-Diphosphat myocardial scintigraphy in the diagnosis of acute myocardial infarction we examined the scintigrams of 53 patients admitted to our CCU. In all 38 patients with transmural myocardial infarction positive scintigrams with localized uptake of the tracer found. Myocardial imaging was performed 70--90 minutes after the intravenous injection of 15 mCi 99m-Technetium-Diphosphat in anterior and LAO position. The clinical value of the method for proving the presence or absence of a myocardial infarction is demonstrated on infarctions combined with bundle-branch block, pacemaker Ecg and on reinfarction. All normal cases in this group showed no tracer activity outside the bones. In unstable angina pectoris a faint but not localized tracer activity was found.

[Negative and positive imaging of myocardial infarct]. / Negative und positive Darstellung des Myokardinfarktes

In 41 patients myocardial scintigrams were performed using 2 mCi 201T1 and 15 mCi 99mTc-diphosphate. 9 healthy persons showed no myocardial imaging with 99mTc-diphosphate and normal 201T1 scintigrams. Transmural infarctions could be documented by both isotopes, excepted lateral and apical infarctions which could only be shown by means of 99mTc-diphosphate. Non-transmural infarctions could not be identified, myocardial scars however--as was to be expected--showed only activity defects within the 201T1 scintigrams without corresponding images in the 99mTc-diphosphate scans. One patient with severe coronary heart disease showed diffuse diphosphate uptake all over the myocardium with normal 201T1 scintigram. The combined myocardial scintigraphy provides a better diagnosis, enabling an improved localisation of infarction and avoiding misinterpretations.

[Propafenon, a new anti-arrhythmic drug (author's transl)]. / Propafenon--ein neues Antiarrhythmikum

Propafenon, at an initial oral dose of 900 mg, proved an effective anti-arrhythmic drug in 34 patients with frequent ventricular and(or) supraventricular extrasystoles at rest. Long-term ECG monitoring of seven patients revealed that this effect lasted about eight hours. It can be maintained by an oral dose of 300 mg propafenon at eight-hourly intervals, as demonstrated in 21 further patients. Rapid anti-arrhythmic action was achieved in six acute cases with 1.0-1.5 mg propafenon per kg body weight by quick infusion, and lasted for one to one-and-a-half hours. In such cases the drug should, therefore, be given synchronously by the oral route. Side effects related to the gastrointestinal tract, sinus automatism as well as atrio-ventricular and intraventricular conduction, but in no case were very serious.