High-dose intravenous beta 1-blockade in patients early after cardiac operations. Negative inotropism versus myocardial oxygen economy.

A high adrenergic strain during reperfusion after ischemia impedes functional recovery. Conversely, adrenergic blockade may be beneficial during reperfusion. Negative inotropic effects may outweigh the expected benefit, however. Against this background hemodynamic and metabolic effects of early postoperative infusion with the beta 1-selective agent metoprolol were studied in 22 patients after coronary operations. During basal postoperative conditions, intravenous metoprolol reduced cardiac index and stroke volume index compared with control patients, while other variables were unaffected. During the higher adrenergic level of a dopamine infusion (7 micrograms/kg per minute), the heart rate, rate pressure product, and myocardial oxygen uptake were attenuated in proportion to the plasma level of metoprolol. Intravenous beta 1-blockade did not affect the cardiac output or stroke volume responses to dopamine (the cardiac output was still, however, 19% lower than in control patients). A release of myocardial creatinine kinase isoenzyme myocardial band was observed during dopamine infusion, suggesting that myocardial ischemia was induced. The release was not influenced by metoprolol, but it correlated with heart rate (r = 0.60; p < 0.01). It is concluded that infusion of metoprolol early after coronary operations depresses myocardial contractility with some 19%, which was without clinical significance in straightforward patients; the increased myocardial metabolic demand during a period of increased adrenergic stress was attenuated by metoprolol. This may be of importance for myocardial recovery.

Influence of beta 1-blockade on myocardial substrates early after a coronary operation.

A high adrenergic strain during reperfusion after ischemia impedes functional recovery. Conversely, adrenergic blockade may be beneficial during reperfusion. This study was undertaken to find out if early postoperative high-dose infusion of the selective beta 1-blocking agent metoprolol tartrate has additional effects on metabolic variables related to myocardial energy supply/demand balance compared with those obtained with a late preoperative oral dose. The study included 21 male patients undergoing coronary bypass grafting. All patients received an oral dose of metoprolol before the operation. After the operation, patients were randomized to a control group or a group receiving intravenous infusion of metoprolol. Myocardial uptake of oxygen and substrates was determined before and during atrial pacing. Metoprolol reduced arterial concentrations of free fatty acids, reduced myocardial uptake of free fatty acids, and enhanced myocardial uptake of lactate. During paced tachycardia, the metoprolol concentration correlated negatively with myocardial uptake of free fatty acids (r = -0.80; p < 0.001) and positively with myocardial uptake of lactate (r = 0.53; p < 0.05). It is concluded that postoperative infusion of metoprolol induces myocardial metabolic changes compatible with an improved energy supply/demand balance.

Prevalences of risk factors and angiopathy in diabetic patients in Uppsala.

The prevalences of risk factors and angiopathy were studied in 260 diabetic patients, 100 females and 160 males, 35-54 years old, in Uppsala. The prevalence, in females and males separately, of hypertension (WHO-criteria) was 46-34%, of hypercholesterolaemia (greater than or equal to 6.7 mmol.l-1) 32-29%, and of obesity (relative BMI greater than or equal to 120%) 25-20%. Those smoking greater than 15 cigarettes/day were 11-20%. Mean HbA1 was 10.6-10.5%. The prevalence of angina pectoris was 11-6%, of possible infarction 4-6%, and of major ECG abnormalities 6-4%. Large vessel (cardiovascular) disease was independently related to HbA1 (strongly), hypertension, cholesterol, age and familial NIDDM. The prevalence of severe retinopathy (blindness, new vessels or large hemorrhage) was 0% with 7-13 years of diabetes duration, and 26% with greater than or equal to 14 years of duration. The prevalence of severe proteinuria was 4% with 7-13 years of diabetes duration, and 15% with greater than or equal to 14 years of duration. Small vessel (retinopathy and nephropathy) disease was independently related to diabetes duration (strongly), HbA1 and hypertension. The data were discussed related to data from the London, Berlin and Tokyo centres of the WHO Multinational Study of Vascular Disease in Diabetics, using the same study protocol in the present study.

Continuous vectorcardiography in cardiac surgery: natural course of vector changes and relationship to myocardial oxygen uptake.

Continuous vectorcardiography was registered before and during the first 18 hours after cardiac surgery in 53 patients. QRS vector changes (QRS-VD) occurred during the operation, but no further changes were observed postoperatively. The ST vector (ST-VM) increased during the operation, and a further slight increase occurred postoperatively. Perioperative myocardial infarction occurred in three patients. Their ST-VM was higher than the average in patients without myocardial infarction, while QRS-VD did not differ from the average pattern. Twelve other patients were studied in pacemaker-induced moderate tachycardia. QRS-VD increased in proportion to heart-rate changes (rs median = 0.93, p less than 0.01). QRS-VD also correlated with myocardial oxygen uptake (rs median = 0.62, p less than 0.05). The ST-VM responses were not uniform. The data suggest that vectorcardiogram variables can provide information related to myocardial energy metabolism.

Myocardial recovery after cardiac surgery: a study of hemodynamic performance and electrophysiology during the first 18 postoperative hours.

Hemodynamic and vectorcardiographic variables were monitored in 23 patients with acquired heart disease, before and during the first 18 postoperative hours of cardiac surgery. The hemodynamic pattern directly after surgery was characterized by left ventricular depression and increased heart rate. Thus, stroke volume index had decreased from the preoperative 29 +/- 1 to 24 +/- 1 mL/beat/m2, and heart rate had increased from 61 +/- 2 to 94 +/- 4 beats/min. During the following hours a gradual normalization of stroke volume occurred, leading to a cardiac index that was adequate after 8 to 10 hours, judging from the mixed venous oxygen saturation (68% +/- 1%). Fourteen patients had an uneventful postoperative course, with no signs of acute myocardial infarction, and did not require inotropic support. These patients had small but consistent vectorcardiographic changes; the QRS vector difference increased moderately, and the ST vector magnitude also increased. No correlation was found between hemodynamic and vectorcardiographic variables, nor between timing of hemodynamic recovery and vectorcardiographic changes. Patients with a perioperative myocardial infarction had a vectorcardiographic pattern that was compatible with acute myocardial infarction. These patients had markedly elevated ST vector magnitude and QRS vector difference values, which were discernible during the first postoperative hours. The present data suggest that the timing of metabolic and electrophysiological recovery of the heart differ, and a computerized vectorcardiographic system may be of value in the early detection of perioperative myocardial infarction.

A study of so-called hypochondriasis.

Twenty-four patients with unexplained somatic complaints were subjected to a thorough somatic examination. Only when the examination proved negative was the patient entered into the study. The patients were clinically appraised according to criteria given in DSM-III. Generalized anxiety disorder (GAD) was diagnosed in 12, somatization disorder (SD) in 8, and hypochondriasis in 4 patients. Seventeen of the 24 patients agreed to participate in biochemical investigations including a TRH load, a dexamethasone test, and a determination of the monoamine metabolites 5-HIAA and HVA in cerebrospinal fluid (CSF). A normal TSH increase and a normal suppression of cortisol were registered. The HVA values correlated significantly with the 5-HIAA values as well as with the alexithymia scores. Concerning alexithymia and maturity level, no difference as to social class was found. The patients filled in a Zung depression chart. The Zung scale and the 5-HIAA values were both inconsistent with depressive illness. In so-called hypochondriasis a long-term relationship, including selected somatic and biochemical examinations and thorough information, was crucial in abating the patient's distrust and thus the need for health care.

Late results after venous valve repair.

Seventeen patients (18 extremities) with primary deep venous insufficiency underwent femoral vein valve repair. Prior to the valvuloplasty the superficial and perforator systems were treated surgically. Dynamic venous pressure measurement and Doppler examination were done for late objective assessment of the valve repair. At early follow-up the reconstructed valves were competent, and all patients showed symptomatical improvement. Significant improvement in pressure reduction and recovery time was observed at postoperative venous pressure measurements. Good or excellent long-term results were obtained in 67% of the extremities after two to five years. Late recurrence of symptoms and incompetence of the reconstructed valve occurred in five extremities. Valve repair may offer good long-term results, but further studies are required to assess the appropriate place of this procedure in the treatment of primary deep venous insufficiency.

Nortriptyline and pituitary-thyroid function in affective disorder.

Twenty out-patients with depressive illness were studied with regard to thyroid hormone concentrations, basal and TRH-stimulated TSH, and prolactin levels before and during treatment with nortriptyline. Concentrations of plasma nortriptyline and 10-hydroxy-nortripyline were analysed while on 75 mg and 150 mg/day. No correlations between clinical outcome and side effects on the one hand and drug concentrations on the other were demonstrated. Provided the age factor was considered, basal and stimulated hormone levels did not differentiate between healthy controls and patients with "endogenous" and those with "exogenous" depression. Nortriptyline treatment did not influence serum hormone levels.

Initial vector rates in differentiation between supraventricular extrasystoles with aberration and ventricular extrasystoles.

A computer method was constructed for analysing vector rates. Initial vector rates of QRS of ventricular extrasystoles (VES) and of aberrant supraventricular extrasystoles were compared. Bundle branch block (BBB) was used as a model for aberration. Spontaneous VES during heart catheterization and VES found by His-bundle recording represented the VES group. The VES were found to contain a longer average "activation time," i.e. the duration from the onset to the spatial amplitude maximum, than the BBB. The maximum amplitudes were similar. A method for calculating initial vector rate distribution was also developed. This showed a significantly higher proportion of fast rate components in BBB than in VES. The calculation of vector rate distribution gave advantages over the calculation of the mean initial vector rate, when considering electrocardiographic abnormalities such as preexcitation QRS or post-infarction Q waves. With a simple discriminatory analysis using initial vector rate distribution values, a 95% precision was obtained in differentiating between VES and BBB. It is concluded that a QRS from a supraventricular impulse focus with aberration has faster initial vector rates than a QRS from a ventricular focus and that this difference is useful in distinguishing between them.

Evaluation of a computer programme for interpretation of 12-lead electrocardiograms.

A 12-lead electrocardiogram (ECG) interpretation programme (Cardionics, Brussels) was treated for computer diagnosis of ECG. The computer performance was evaluated on an ECG population from hospital patients by a method giving results which will allow the clinician to judge the usefulness of the computer diagnosis in clinical practice. Diagnoses made by experienced ECG readers were in essential agreement with the computer diagnoses in 83.5%, of 493 ECGs. Clinically significant disagreements due to differences in criteria occurred in 6.0% of the tracings, whereas such disagreements due to programme errors were found in 10.5%.

A minicomputer system for display and rate analysis in vectorcardiography.

A system has been constructed for recording vectorcardiographic signal with a FM taperecorder. Off-line AD-conversion and analysis of rates and magnitudes of partial vectors are made with a minicomputer. The reason for studying particularly initial vectorrates is that according to our hypothesis these contain valuable information for classification of certain cardiac arrythmias according to supraventricular or ventricular impulse focus. Preliminary results confirm the hypothesis. In vectorcardiography one difficulty is to give an easily comprehensible presentation of the vectorloop. In this study a method for '3-dimensional' display has been developed, using a graphic display processor and varying intensities of the beam. The system is to a high degree man-machine interactive.

Left ventricular function evaluated by videodensitometry in patients with coronary heart disease.

The ejection fraction of the left ventricle was determined by videodensitometry in 121 patients with angina pectoris. The mean value was 31 per cent. This estimation, which is easily performed by the method described, gives important and accurate information on the left ventricular function which, added to other parameters, should increase the reliability of the clinical evaluation of the patient.

Hepatic and pancreatic dysfunction in anorexia nervosa: a report of two cases.

Two patients with anorexia nervosa with evidence of pancreas and liver injury are reported. Both showed evidence of organ dysfunction in the presence of cachexia. Serum amylase, ASAT (GOT), and ALAT (GPT) became normal parallel with body weight. On the basis of reports on the effects of malnutrition on pancreas and liver function, it is suggested that nutritional pancreas and liver dysfunction might represent hitherto unrecognized complications of anorexia nervosa.

Myxedematous madness without myxedema. Selective defect of TSH release on TRF loading in a young woman with a history of severe depressive illness cured with thryoid hormone replacement therapy.

A young woman, whose psychiatric history covered 16 years, has been treated several times as in-patient for psychotic depression, which were finally cured with thyroid replacement therapy. Recent reports of the connection between depression and disturbances in the hypothalamic-pituitary-thyroid axis are discussed. The authors question the suggestion that selective pituitary insufficiency and a defect in TSH release on TRF loading are rare phenomena.

Cerebrospinal fluid levels of chlorpromazine and it metabolites in schizophrenia.

The concentrations of chlorpromazine and some of its metabolites in blood plasma and CSF from chlorpromazine-treated schizophrenics with different therapeutic results were studied. Compared to a good responder a poor responder showed very high levels of the inactive metabolite chlorpromazine sulphoxide in the CSF.