Eight-year mortality in the Emory Angioplasty versus Surgery Trial (EAST)

OBJECTIVES: To evaluate the long-term outcome of patients randomized to coronary bypass surgery or coronary angioplasty. BACKGROUND: The Emory Angioplasty versus Surgery Trial (EAST) is a single center randomized comparison of a strategy of initial coronary angioplasty (n = 198) or coronary bypass surgery (n = 194) for patients with multivessel coronary artery disease. The primary end point (death, myocardial infarction or a large ischemic defect at 3 years) was not different, and repeat revascularization was significantly greater in the angioplasty group. Subsequently, the National Heart, Lung and Blood Institute supported a five-year extension of the trial. METHODS: After the three year anniversary visit, annual questionnaires, telephone contact and examination of medical records were accomplished until death or the eight year anniversary in 100% of the patients surviving at 3 years. RESULTS: Survival at 8 years is 79.3% in the angioplasty group and 82.7% in the surgical group (p = 0.40). Patients with proximal left anterior descending stenosis and those with diabetes tended to have better late survival with surgical intervention although not reaching statistical significance. After the first 3 years, repeat interventions remained relatively equal for both treatment groups. CONCLUSIONS: Long-term survival is not significantly different between angioplasty and surgery, and late (three to eight year) revascularization procedures were infrequent. Patients without treated diabetes had similar survival in both groups.

Angioplasty or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators.

The Emory Angioplasty versus Surgery Trial (EAST) showed that multivessel patients eligible for both percutaneous transluminal coronary angioplasty (PTCA) and coronary bypass surgery (CABG) had equivalent 3-year outcomes regarding survival, myocardial infarction, and major myocardial ischemia. Patients eligible for the trial who were not randomized because of physician or patient refusal were followed in a registry. This study compares the outcomes of the randomized and registry patients. Of the 842 eligible patients, 450 did not enter the trial. Their baseline features closely resembled those of the randomized patients and follow up was performed using the same methods. In the registry there was a bias toward selecting CABG in patients with 3-vessel disease (84%) and PTCA in patients with 2-vessel disease (54%). Three-year survival for the registry patients was 96.4%, which was better than the randomized patients, 93.4% (p = 0.044). Angina relief in the registry was equal for CABG and PTCA patients and was better for the PTCA registry (12.4%) than PTCA randomized patients (19.6%) (p = 0.079). Thus, the registry confirms that EAST is representative of all eligible patients and does not represent a low-risk subgroup. Since baseline differences were small, improved survival in the registry may be due to treatment selection. Physician judgment, even in patients judged appropriate for clinical trials, remains a potentially important predictor of outcomes.

Emory Angioplasty Versus Surgery Trial (EAST): design, recruitment, and baseline description of patients.

In patients with multivessel coronary artery disease who require revascularization there is uncertainty as to the selection of the appropriate patients for percutaneous transluminal coronary angioplasty (PTCA) as opposed to coronary artery bypass grafting (CABG). To define the relative roles of PTCA and CABG for multivessel disease, 392 patients were randomly assigned to revascularization by PTCA or CABG and followed for 3 years. This is a single-center randomized study in which individual group assignment was known but grouped data remained blinded until a full 3 years of follow-up was complete on all patients. The patients were randomized in 4 strata: (1) 2-vessel disease with 1 lesion per vessel; (2) 2-vessel disease with multiple lesions in at least 1 vessel; (3) 3-vessel disease with 1 lesion per vessel; and (4) 3-vessel disease with multiple lesions in at least 1 vessel. All data were collected on study-specific forms and sent to an independent biostatistical coordinating center for entry into a computerized database. All data will be analyzed by intention-to-treat. The primary endpoint of the trial is the composite of death of any cause, Q-wave myocardial infarction within 3 years, or a large reversible thallium defect at 3 years. Multiple secondary endpoints will include each of the components of the primary endpoint, the need for additional procedures, angiographic status at 1 and 3 years measured by an independent quantitative coronary arteriography laboratory, and measures of quality of life. A total of 5,118 patients were screened, of whom 3,371 were excluded for angiographic reasons, 191 because the angioplasty operators or surgeons believed that the patients were anatomically unsuitable, and 714 for clinical exclusions, leaving 842 eligible patients, of whom 392 were randomized. Of these, 40% had triple-vessel disease and 60% had double-vessel disease. There was no baseline difference between the 2 treatment arms for any clinical or major angiographic variable. This randomized trial will permit an in-depth comparison of coronary angioplasty and coronary surgery in comparable patients suitable for either procedure. Clinical, angiographic, and quality-of-life comparisons will be made and should be helpful in medical decision making between the 2 procedures.

A randomized trial comparing coronary angioplasty with coronary bypass surgery. Emory Angioplasty versus Surgery Trial (EAST)

BACKGROUND: The clinical benefit of percutaneous transluminal coronary angioplasty (PTCA) as compared with coronary-artery bypass grafting (CABG) for patients with multivessel coronary artery disease has not been established. To determine the outcomes of these treatments in patients referred for the first time for coronary revascularization, we conducted a three-year prospective, randomized trial comparing the two procedures. METHODS: Revascularization was performed by accepted methods. Follow-up clinical information was collected every six months, and coronary arteriography and thallium stress scanning were performed at one and three years. The primary end point was a composite of death, Q-wave myocardial infarction, and a large ischemic defect identified on thallium scanning at three years. Secondary end points included clinical and angiographic status and the need for additional revascularization procedures. Data were analyzed according to the intention-to-treat principle. RESULTS: Of the 5118 patients screened for the trial, 842 (16.5 percent) were eligible for enrollment, and 392 (7.7 percent) agreed to participate. A total of 194 patients were randomly assigned to the CABG group, and 198 to the PTCA group. The primary end point occurred in 27.3 percent of the CABG group and 28.8 percent of the PTCA group (P = 0.81). Death occurred in 6.2 percent of the CABG group and 7.1 percent of the PTCA group (P = 0.73 by log-rank test). At three years, the proportions of patients in the CABG group who required repeated bypass surgery (1 percent) or angioplasty (13 percent) were significantly lower than the proportions in the PTCA group (22 and 41 percent, respectively; P < 0.001). Angiographic studies at three years showed a greater degree of revascularization in the CABG group. Angina was more frequent in the PTCA group (20 percent) than in the CABG group (12 percent). CONCLUSIONS: We found that CABG and PTCA did not differ significantly with respect to the occurrence of the composite primary end point. Consequently, the selection of one procedure over the other should be guided by patients' preferences regarding the quality of life and the possible need for subsequent procedures.

Clinical and angiographic outcomes after coronary artery stenting for acute or threatened closure after percutaneous transluminal coronary angioplasty. Initial results with a balloon-expandable, stainless steel design.

BACKGROUND: Acute occlusion after balloon coronary angioplasty is associated with an increased risk of angina, emergency coronary artery bypass grafting (CABG), myocardial infarction (MI), and death. Stents offer a way of restoring patency and avoiding these complications. METHODS AND RESULTS: One hundred sixteen patients underwent attempted stent placement for imminent or total acute closure after PTCA. In 103 patients (110 stents, 105 procedures) the stent was successfully deployed (89%). Angiographic success (final diameter stenosis of < 50%) was achieved in 94 placements (85%). Seventy-one phase 2 procedures (CABG optional, n = 96; phase 1, CABG required, n = 9) were angiographically successful without complications of death, Q-wave myocardial infarction, or CABG (clinical success 74%). Stent placement was associated with resolution of ST-segment deviation and angina in 84% of patients. Five deaths and 5 Q-wave MIs occurred during hospitalization. Two deaths were related to pulmonary insufficiency from chronic lung disease and one patient died after rescue stent placement for left main coronary artery occlusion during routine angiography. Another patient died after CABG was followed by right ventricular MI. The last death occurred in an elderly patient who suffered a stroke while on intravenous heparin. During hospitalization nine patients developed reocclusion after stent placement (8.6% of procedures) and six had repeat PTCA. CABG was performed after 29 stent procedures (28%). The first nine patients underwent CABG as a mandate of the phase 1 protocol. In addition, nine patients had CABG after stenting with a good angiographic result but with a large amount of myocardium at risk. Clinical follow-up was obtained in all patients at a median of 14 months (range, 2 to 43). There were three late deaths (3%), two Q-wave myocardial infarctions (2%), 16 repeat PTCAs (16%), and 15 CABG procedures (15%). Angiographic restenosis (percent diameter > or = 50%) using caliper measurements was found in 30 of 57 patients (53%) at a median of 4 months (93% of patients eligible). A total of 41 procedures were successful and unaccompanied by death, emergency or elective coronary artery bypass grafting, or angiographic restenosis in follow-up. Restenosis and/or clinical events (death, MI, CABG, repeat PTCA) were associated with non-Q MI, hypertension, diabetes, left circumflex coronary artery stenting, saphenous vein graft stenting, smaller caliber artery stenting, higher balloon to artery ratios, and shorter inflation times. CONCLUSIONS: Coronary artery stenting for acute closure after PTCA relieves myocardial ischemia and provides an alternate means of treatment. This series includes early learning curve experience; 70% (67 of 96) of patients were spared emergency coronary artery bypass graft surgery when this adverse outcome occurred. Certain clinical and angiographic subsets are at increased risk for restenosis and future cardiac events.

Angiographic predictors of a rise in serum creatine kinase (distal embolization) after balloon angioplasty of saphenous vein coronary artery bypass grafts.

Distal coronary embolization is thought to be increased in the balloon angioplasty of coronary by-pass vein grafts. One hundred fifty-five procedures of balloon angioplasty involving single vein graft dilatation were successfully performed. Distal coronary embolization was defined as an elevation of creatine phosphokinase greater than twice the preangioplasty value and positive MB fraction. Twenty procedures were found to have embolism by this definition. Forty preangioplasty angiograms were randomly selected from the remaining procedures and analyzed as a control group. Eight angiographic features were evaluated as possible risk factors for distal coronary embolization, i.e., diffusely diseased vein graft, presence of thrombus, ulcerated lesion surface, marked eccentricity, large plaque volume, lesion angulation, abrupt proximal face and ectasia. A diffusely diseased vein graft (p = 0.002), presence of thrombus (p = 0.006), irregular or ulcerated lesion surface (p = 0.007), large plaque volume (p = 0.02) and marked eccentricity (p = 0.03) were found to be important predictors by univariate analysis. A diffusely diseased vein graft and a large plaque volume were found to be important independent predictors by multivariate analysis. The presence of thrombus and an irregular or ulcerated lesion surface frequently coexist with a diffusely diseased vein graft. It is concluded that a diffusely diseased vein graft and a large plaque volume are important independent predictors of distal embolization, and thrombus and an ulcerated lesion surface are also important.

Recent changes in the management and outcome of acute closure after percutaneous transluminal coronary angioplasty.

The major cause of morbidity and mortality associated with percutaneous transluminal coronary angioplasty (PTCA) is acute closure. This study compared the clinical outcome of 2 groups of patients who experienced acute closure during PTCA. One group was treated during a period when intracoronary stents, laser balloons and perfusion balloons were available for treatment of acute closure (group II). These results were compared with the clinical outcome a group of similar patients who were treated for acute closure during a period that immediately preceded the availability of these devices (group I). One hundred sixty-six patients had acute closure in group I, whereas 156 patients experienced acute closure in group II. Baseline clinical characteristics were similar for both groups. There was no difference in ejection fraction, number of vessels diseased, degree of stenosis or number of vessels attempted between the 2 groups. Patients in group II had more balloon inflations and longer balloon inflation times when compared with patients in group I. Of the 156 patients in group II, 47% were treated with either an intracoronary stent, laser balloon or perfusion balloon. Group II patients had fewer Q-wave myocardial infarctions (9.1 vs 20.3%, p = 0.005). In addition, peak creatine phosphokinase levels (826 +/- 1,515 vs 517 +/- 1,050, p < 0.01) and mean residual stenosis (40.7 +/- 33.2 vs 58.0 +/- 34.4%, p < 0.0001) were also lower in group II patients. There was also less coronary artery bypass grafting during the same admission (38.6 vs 29.5%, p = 0.02) in group II patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of serum lipoprotein (a) as a predictor of restenosis after percutaneous transluminal coronary angioplasty.

Serum lipoprotein (a) (Lp[a]) has been associated with coronary artery atherosclerosis. Its association with restenosis after percutaneous transluminal coronary angioplasty (PTCA) has not been previously studied. Serum levels of Lp(a), in addition to other lipoproteins, and their components using standard assays, were determined in subjects undergoing cardiac catheterization within 10 months after PTCA. Clinical (e.g., sex, diabetes, angina class) and angiographic (e.g., PTCA percent diameter reduction) factors were not different between the group without (diameter reduction less than 50%; group A) and the group with (diameter reduction greater than or equal to 50%; Group B) restenosis. Total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, apolipoprotein A-I, apolipoprotein B and Lp(a) were compared. Univariate predictors of restenosis were serum triglycerides (2.50 +/- 1.07 mmol/liter for group A vs 1.72 +/- 0.79 +/- mmol/litre for group B, p = 0.008), and Lp(a) (median: 7.0 mg/dl [range 0 to 44] for group A vs 19 mg/dl [range 1 to 120] for group B; p = 0.006). Stepwise logistic regression revealed the only significant independent predictor of restenosis to be serum Lp(a) (p = 0.018). Each quintile of Lp(a) was associated with a progressively higher risk of restenosis, with the highest quintile (40 to 120 mg/dl) having an odds ratio of 11 (95% confidence interval 9 to 13) compared with the lowest quintile (0 to 3.9 mg/dl) (p = 0.033). A serum Lp(a) of greater than 19 mg/dl was associated with an odds ratio of 5.9 (95% confidence interval 4.6 to 7.2) (restenosis rates of 58% in the group with 0 to 19 mg/dl and 89% in the group with 19 to 120 mg/dl; p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Vitamin E supplementation, plasma lipids and incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA).

To test whether alpha-tocopherol prevents restenosis following percutaneous transluminal coronary angioplasty (PTCA), we enrolled patients in a double-blind, placebo-controlled trial. Patients were randomized after successful PTCA to receive vitamin E in the form of dl-alpha-tocopherol, 1200 IU/day, orally vs an inactive placebo for 4 months. Patients' blood was analyzed at baseline and at 4 months post-PTCA for differences in plasma lipids, lipoproteins, apolipoproteins, alpha-tocopherol, retinol, beta-carotene and lipoperoxide concentrations. One hundred patients completed the protocol. No significant difference was found in any parameter except alpha-tocopherol level between the vitamin E group and the placebo group, verifying compliance. Follow-up cardiac catheterization was obtained in 83% of the patients receiving placebo and in 86% of the patients receiving dl-alpha-tocopherol. Including thallium and exercise stress testing, objective information was obtained for practically all the patients receiving dl-alpha-tocopherol or placebo. Restenosis was defined as the presence of a lesion with greater than or equal to 50% stenosis in a previously dilated artery segment and results were analyzed with respect to pre- and post-PTCA artery diameter, vessel diameter at follow-up, and restenosis rate. Patients receiving dl-alpha-tocopherol had a 35.5% restenosis angiographically documented vs 47.5% restenosis in patients receiving the placebo. The overall incidence of restenosis defined by an abnormal angiogram or thallium test or exercise stress test was 34.6% in patients receiving dl-alpha-tocopherol and 50% in patients receiving the placebo. This difference (p = 0.06) did not reach significance because of an inadequate sample size.

Percutaneous transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical follow-up.

BACKGROUND: Angioplasty of chronically totally occluded vessels has been associated with a success rate well below and restenosis rate well above that for angioplasty of stenosed segments. However, long-term clinical outcome after successful revascularization of a chronically totally occluded vessel has not been reported in detail. METHODS AND RESULTS: Accordingly, data for 480 patients undergoing angioplasty for chronic total occlusion at Emory University Hospital, Atlanta, Ga., from 1980 to 1988 were analyzed for predictors of in-hospital procedural and clinical (procedural success and absence of in-hospital complications) success, restenosis, and 4-year clinical follow-up. The study population was grouped by procedural and clinical success and failure. The groups were then compared for outcome, both in hospital and long term. The initial clinical success rate was 66% (317 of 480 patients). Independent correlates of failure were the number of vessels diseased (p less than 0.001), vessel location of the lesion (p = 0.016), and absence of any distal antegrade filling (p = 0.002). Follow-up data revealed 98% cardiac survival and 96% overall survival at 4 years for the group as a whole. Freedom from myocardial infarction or cardiac death was significantly greater in patients with clinical success (93%) than with clinical failure (89%, p = 0.0044). In the successful group, 87% were free from coronary surgery after 4 years compared with 64% in the failure group (p less than 0.0001). Two thirds of the patients were free of angina at last follow-up. The presence of angina at follow-up was the same for patients successfully treated and for those with failed angioplasty, which may be related to the frequent use of coronary surgery in the failure group. CONCLUSIONS: In well-selected cases, the success rate for angioplasty of chronic total occlusion is acceptable. Furthermore, long-term clinical benefit is suggested by the high freedom from coronary surgery, myocardial infarction, and death in the patients who underwent successful revascularization.

Effects of nonionic versus ionic contrast media on complications of percutaneous transluminal coronary angioplasty.

To evaluate the effect of contrast agents on percutaneous transluminal coronary angioplasty (PTCA) complications, 913 patients undergoing 1,058 separate PTCA procedures were prospectively randomized to receive either nonionic iopamidol (Isovue-370) [n = 507 PTCA procedures] or ionic contrast media, meglumine sodium diatrizoate (Renografin-76) [n = 551 PTCA procedures]. Angioplasty operators, technicians, nurses and patients were blinded to the agent used. All patients were pretreated with 0.6 mg of atropine sulfate intravenously before any contrast injections. Hypotension (mean arterial pressure less than 65 mm Hg associated with contrast injections) occurred during 8.5% of PTCA procedures in which the patients were receiving iopamidol and during 9.5% of the procedures in which the patients were given diatrizoate (difference not significant). Bradycardia (heart rate of less than 40 beats/min associated with contrast injections) developed during 5.7% of procedures when patients were given iopamidol and during 5.1% of procedures when patients were given diatrizoate (difference not significant). The need for additional atropine or temporary pacing during the procedure was similar for patients given iopamidol and diatrizoate. The overall incidence of ventricular tachycardia or fibrillation, or both, during the procedure occurred less frequently when iopamidol was used compared with diatrizoate (1 vs 2.5%, p = 0.045). These serious ventricular arrhythmias were attributable to contrast injections in 0.6% of the PTCA procedures when iopamidol was given and in 2.0% of the cases in which diatrizoate was the contrast agent (p = 0.09). Only 1 patient had an allergic reaction to the contrast agent, and this was in a patient who received iopamidol.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracoronary stenting during percutaneous transluminal coronary angioplasty.

A flexible, balloon-mounted, coil stent was developed to address the problems of acute closure and long-term restenosis, which currently limit the safety and efficacy of percutaneous transluminal coronary angioplasty. The device is made of 0.006-in. stainless steel suture material and is mounted on balloons, 2.5-4.5 mm in diameter, for use in the coronary circulation. Results of studies in canine coronary arteries have demonstrated long-term patency and stability, and studies in the atherosclerotic arteries of rabbits have suggested late results with stenting that might be superior to those obtained with balloon angioplasty alone. Initial clinical studies have focused on the use of the device as a "bridge" to surgery if closure occurs. The stent appears to have been successful in this application. A phase 2 study is now examining the stent as definitive therapy for acute closure in certain anatomic subsets of patients. Information on long-term patency is pending. If this is favorable, the device will be studied to see if it reduces the incidence of restenosis in the subset of patients in whom balloon dilatation alone fails to produce an optimal hemodynamic result.

Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty.

It is unknown whether the addition of dipyridamole to aspirin as pretreatment for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) decreases acute complications. In this study 232 patients were prospectively randomized to receive either aspirin 325 mg orally 3 times daily (group 1, n = 115) or aspirin 325 mg orally 3 times daily plus dipyridamole 75 mg orally 3 times daily (group 2, n = 117) before elective PTCA. All clinical, angiographic and PTCA-related variables were similar between groups. Angiographic success rate was 93% in both groups. Clinical success was achieved in 107 patients (92%) in group 1 and in 101 patients (88%) in group 2 (difference not significant). Q-wave myocardial infarction occurred in 2 patients (1.7%) in group 1 and 5 patients (4.3%) in group 2 (difference not significant). Emergency coronary artery bypass grafting was required in 3 patients (2.6%) in group 1 and 7 patients (6.1%) in group 2 (difference not significant). There was 1 in-hospital death (in group 2). In this study, the addition of dipyridamole to aspirin as pretreatment of patients undergoing PTCA did not significantly reduce acute complications compared to aspirin alone.

Intravascular stents.

Restenosis and/or acute closure continue to affect at least one third of all patients undergoing coronary angioplasty; pharmacologic and mechanical methods are therefore being developed to prevent this. The current information on intravascular stents is reviewed and the potential for this device to impact on acute closure and restenosis discussed.

Tear or dissection after coronary angioplasty. Morphologic correlates of an ischemic complication.

Intimal tear or dissection is an important descriptor of ischemic complications after coronary angioplasty, but only the minority of patients will develop an acute ischemic event. To identify additional factors that may predict the development of an ischemic event when arterial disruption occurs during otherwise uncomplicated angioplasty, the records of 1,346 patients prospectively identified as having tear or dissection without immediate vessel closure were examined. Ischemic complications, defined as ischemic chest pain, myocardial infarction, the need for coronary bypass surgery, or death, occurred in 120 patients (9%). Significant multivariate correlates of an ischemic complication were the presence of unstable angina or a totally occluded vessel before angioplasty and diameter stenosis of greater than 30% after angioplasty. Detailed geometric and videodensitometric analysis of the postdilatation angiograms of a subset of 96 consecutive patients was carried out. Ischemic complications occurred in 11 patients (11%). Multivariate analysis revealed that the independent correlates of complications, in decreasing order of importance, were the length of the tear or dissection (p = 0.001), diameter stenosis after angioplasty (p = 0.001), cross-sectional area after dilatation measured by videodensitometric methods (p = 0.013), and the presence of extraluminal contrast (p = 0.044). When tear or dissection occurs during otherwise uncomplicated coronary angioplasty, patients at risk of developing delayed ischemic complications can be identified and may benefit from measures designed to minimize this risk. By controlling for the geometric or mechanical factors that result in tear or dissection, it has been possible to identify factors not previously thought associated with ischemic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Bedside diagnosis of systolic murmurs.

The diagnostic accuracy of bedside maneuvers in the evaluation of patients with systolic murmurs has not been assessed objectively. Therefore, we evaluated 50 patients with documented systolic murmurs and compared all standard bedside techniques. Murmurs originating within the right-sided chambers of the heart were best differentiated from all other murmurs by augmentation of their intensity with inspiration (100 percent sensitivity, 88 percent specificity) and diminution of their intensity with expiration (100 percent sensitivity, 88 percent specificity). The murmur of hypertrophic cardiomyopathy was distinguished from all other murmurs by an increase in intensity with the Valsalva maneuver (65 percent sensitivity, 96 percent specificity) and during squatting-to-standing action (95 percent sensitivity, 84 percent specificity), and by a decrease in intensity during standing-to-squatting action (95 percent sensitivity, 85 percent specificity), passive leg elevation (85 percent sensitivity, 91 percent specificity), and handgrip (85 percent sensitivity, 75 percent specificity). The murmurs of mitral regurgitation and ventricular septal defect had parallel responses to all maneuvers, but could be differentiated from other systolic murmurs by augmentation of their intensity with handgrip (68 percent sensitivity, 92 percent specificity) and during transient arterial occlusion (78 percent sensitivity, 100 percent specificity), and by a decrease in their intensity during the inhalation of amyl nitrite (80 percent sensitivity, 90 percent specificity). No single maneuver identified the murmur of aortic stenosis, but the diagnosis could be made by exclusion. Although no single maneuver is 100 percent accurate in diagnosing the cause of a systolic murmur, its origin can be determined accurately at the bedside by observation of the response to a combination of maneuvers.

Mitral valve prolapse in patients with prior rheumatic fever.

It is known that rheumatic heart disease frequently results in isolated mitral regurgitation without concomitant mitral stenosis, especially in countries with a high prevalence of rheumatic fever. However, more recent surgical pathologic data also have demonstrated a high incidence of mitral valve prolapse in cases of rheumatic heart disease, which suggests that rheumatic fever may be a cause of mitral valve prolapse. To determine whether this association of mitral valve prolapse and rheumatic heart disease is present in a stable clinic population, we studied 30 patients who had an apical systolic murmur and a well-documented history of rheumatic fever with dynamic auscultation, two-dimensional echocardiography, and pulsed Doppler examinations. Twenty of the 30 patients (67%) had findings on physical examination consistent with isolated mitral regurgitation and 25 patients (84%) had mitral regurgitation by Doppler examination. Echocardiography demonstrated mitral valve prolapse in 24 patients (80%), whereas only one of the total study group had echocardiographic findings consistent with mitral stenosis. We conclude that (1) the presence of an isolated systolic murmur in patients with a history of rheumatic fever frequently represents pure mitral regurgitation secondary to mitral valve prolapse and (2) postinflammatory changes in valvular tissue resulting from rheumatic fever may be the etiology of mitral valve prolapse in these patients.

Hemodynamically important right ventricular infarction: follow-up evaluation of right ventricular systolic function at rest and during exercise with radionuclide ventriculography and respiratory gas exchange.

The prognosis and recovery of right ventricular systolic function in patients with hemodynamically documented right ventricular myocardial infarction (RVMI) is unclear. Therefore 27 patients who met hemodynamic criteria for RVMI were followed for at least 1 year. Four patients died within 1 year and 23 survived. Postmortem examination performed in three of the four patients showed extensive infarction of the right and left ventricles. Survivors underwent early and late follow-up resting radionuclide ventriculograms and late exercise studies. During long-term follow-up (1 to 4 years) resting radionuclide ventriculography demonstrated a significant improvement in right ventricular ejection fraction (30 +/- 7% to 43 +/- 8%; p less than .001) and right ventricular wall motion index (2.2 +/- 0.4 to 1.5 +/- 0.5; p less than .001) in 18 patients who survived longer than 1 year. Fourteen of these patients underwent upright bicycle exercise while off beta-blocking drugs and peak radionuclide ejection fraction was acquired after anaerobic threshold was achieved. Right ventricular ejection fraction increased significantly from 41 +/- 10% to 47 +/- 12% (p less than .001), as did the left ventricular ejection fraction (55 +/- 15% to 60 +/- 12%; p less than .05). The direction and magnitude of change of the right ventricular ejection fraction correlated significantly with the left ventricular ejection fraction (r = .82, p less than .02). Deviations from this correlation occurred in patients who had a decreased forced expiratory volume in 1 sec and an abnormal ventilatory reserve during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of left-sided regurgitant murmurs by transient arterial occlusion: a new maneuver using blood pressure cuffs.

Transient arterial occlusion of both arms with blood pressure cuffs inflated to 20 to 40 mm Hg above systolic pressure for 20 seconds augmented the intensity of left-sided regurgitant murmurs caused by aortic regurgitation, mitral regurgitation, and ventricular septal defect. We compared this new maneuver with handgrip exercise, squatting, and amyl nitrite inhalation in 30 patients with left-sided regurgitant murmurs and in 30 patients with murmurs not caused by left-sided regurgitation. Transient arterial occlusion increased the intensity of left-sided regurgitant murmurs more than squatting (p = 0.02) and did not statistically differ from isometric handgrip exercise and amyl nitrite inhalation in ability to identify the presence of these murmurs. A false-positive diagnosis of left-sided regurgitant murmur was less likely when using transient arterial occlusion than when using handgrip exercise (p = 0.05) and squatting (p less than 0.001). Thus, transient arterial occlusion works as well as or better than other standard bedside maneuvers for diagnosing or excluding left-sided regurgitant murmurs and can be applied to all patients.