[Attitude of general practitioners to the importance of gender and diet in disease prevention]. / Praktiserende laegers holdning til kønnets og kostens betydning ved sygdomsforebyggelse.

Three hundred and seventy-four general practitioners (GPs) in Denmark filled in a questionnaire on attitudes to include information on gender and diet in the strategy for prevention of coronary heart disease, cancer, osteoporosis, and overweight/underweight. Risk factors for disease in general were ranked as follows: smoking, alcohol, stress, diet, physical exercise, heredity and hygiene. The patients' lack of motivation, insufficient time for each patient, and inadequate knowledge about nutrition were stated as barriers to dietary counselling. The GPs stated that the gender of the patient was important only to the counselling on osteoporosis. Lack of time and insufficient knowledge were perceived as barriers for including gender specific issues in prevention. It is concluded that GPs consider dietary counselling important but lack time and knowledge. The results point at a need for better pre- and postgraduate training in nutrition, and for a better reimbursement system for time spent on prevention.

[Prevention in general practice. Are female and male patients treated the same way? A questionnaire study]. / Sygdomsforebyggelse i almen praksis. Gøres der forskel på kvinder og maend? En spørgeskemaundersøgelse.

Three hundred and seventy-four general practitioners (GPs) in Denmark filled in a questionnaire on practices regarding prevention of coronary heart disease (CHD), cancer, osteoporosis, and overweight/underweight. Half of the GPs were questioned about the issue of prevention based upon female case stories and the other half on male case stories with identical wording. The GPs more often in relation to: Prevention of CHD gave dietary counselling and recommended weight loss to slightly overweight male than female patients. Prevention of cancers gave dietary counselling and recommended weight loss and increase of exercise to female than to male patients. Prevention of osteoporosis recommended a supplement of calcium and vitamin D to female than to male patients. Treatment of underweight recommended weight gain and discussion of psycho-social issues to underweight female than male patients. In conclusion, GPs distinguish between men and women in relation to prevention strategies in general practice. There is a need for well-described prevention and action strategies with relevant gender differentiation for use in general practice.

[Treatment of acute apoplexy at a medical department with a specialized rehabilitation unit]. / Behandling af akut apopleksi på medicinsk afdeling med et specialiseret genoptraeningsafsnit.

The aim of this retrospective study was to describe the occurrence of acute stroke and the effect of treatment measured as mortality, length of hospital stay and discharge to the home in a medical department with a specialized rehabilitation unit. During the period 1.9.1992-31.5.1995 110 patients were discharged to their own home after transient cerebral ischaemia, 23 after subarachnoid haemorrhage, 62 after documented intracerebral haemorrhage and 574 after acute stroke due to infarction or unknown cause. The 636 patients in the last two groups had an in hospital mortality of 18%, a 30-day mortality 18% and a six month mortality of 25%. In the same group the length of hospital stay was 25.6 days and 68% were discharged to their own home. In conclusion the results of treatment of acute stroke in a medical department with a specialized rehabilitation unit were similar to those reported from acute stroke units in Denmark and abroad, but the patients admitted to our department were younger and fewer were single, which may itself reduce mortality and length of hospital stay.

Improved recovery after cold crystalloid cardioplegia using low-dose glutamate enrichment during reperfusion after aortic unclamping: a study in isolated blood-perfused pig hearts.

Increased glutamate utilization is a part of the metabolic adaptation to oxygen deprivation by the heart. The effect of low-dose L-glutamate (2 mmol/L) during continuous reperfusion after aortic unclamping on postcardioplegic recovery was studied in pig hearts similar in size, anatomy, and function to the human adult heart. After cold crystalloid cardioplegic arrest (CCC) with Bretschneider solution no 3, hearts were excised from pigs weighing 70-80 kgs (heart weight, average +/- SEM: 308 +/- 4 grams), and reperfused in an isolated blood-perfused heart model for 120 minutes. Three groups of hearts were compared. One group of hearts was subjected to 30 minutes of CCC only (30 min group; n = 9), another group of hearts to 90 minutes of CCC and storage (Control group: n = 16), and a third group to 90 minutes of CCC and storage, but with L-glutamate added to the blood reperfusate (2 mmol/L) (Glutamate group: n = 18). In the Control group 14 of 16 hearts (88%) needed electrical defibrillation after start of reperfusion, significantly more (p < 0.05) than the 8 of 18 (44%) in the Glutamate group; the difference between the 30-min (2 of 9 [22%]) and the Glutamate group was not significant (p = 0.48). Developed left-ventricular pressure (DLVP) and positive dP/dtmax (+dP/dtmax) was significantly higher in the Glutamate group than in the Control group during early reperfusion (DLVP: p < 0.05: +dP/dtmax: p < 0.01) and the entire reperfusion (DLVP and +dP/dtmax: p < 0.05), while reperfusion responses in the Glutamate and 30-min groups were not significantly different. Furthermore, myocardial oxygen uptake was significantly higher in the Glutamate group than in the Control group (p < 0.001), but not higher than that in the 30-min group. Decreased lactate release was found in the Glutamate group compared to the Control group during early reperfusion (p < 0.01), and the entire reperfusion (p < 0.001). No differences were found between the Control and Glutamate groups in alanine exchange. Thus, L-glutamate has a beneficial effect in pig hearts on both functional and metabolic recovery after cold crystalloid cardioplegia and storage when present in a concentration even as low as 2 mmol/L during continuous reperfusion after aortic unclamping. A possible mechanism is a glutamate-induced stimulation of the malate-aspartate shuttle leading to increased intramyocardial lactate utilization.

Applicability of small endomyocardial biopsies for evaluation of high energy phosphates and glycogen in the heart.

To evaluate variability of biochemical determination of energy stores in endomyocardial biopsies, we compared myocardial contents of high energy phosphates and glycogen in endomyocardial and transmural myocardial biopsies from 12 75-kg pigs before, during, and after cardioplegia. Before cardioplegia, comparable amounts of adenine nucleotides and glycogen were found in left and right ventricular endomyocardial and left ventricular transmural biopsies. Phosphocreatine levels were lower in endomyocardial than in transmural biopsies. Significant correlations were observed between endomyocardial and transmural adenine nucleotide and glycogen contents but not phosphocreatine content. During cardioplegia, myocardial ATP and phosphocreatine contents increased and glycogen concentration tended to decrease. During reperfusion, ATP and glycogen levels decreased, whereas phosphocreatine levels increased remarkably. Transmural changes in left ventricular adenine nucleotide and glycogen levels were reflected in endomyocardial biopsies but those in phosphocreatine were not. By increasing the number of endomyocardial biopsies from one to three, within-subject variance was reduced from 33-47% to 14-23% of total variance whereas four or more biopsies only added minor further reduction in variability. In conclusion, endomyocardial biopsies yield representative estimates of the average myocardial content of adenine nucleotides and glycogen but not of phosphocreatine in the normal heart. Endomyocardial biopsies offer a sensitive estimate of the changes in myocardial adenine nucleotides and glycogen induced by cardioplegia and reperfusion. However, metabolite content in endomyocardial biopsies shows a high variability. Three or more endomyocardial biopsies are necessary to reduce variability to acceptable levels.

Determination of high energy phosphates and glycogen in cardiac and skeletal muscle biopsies, with special reference to influence of biopsy technique and delayed freezing.

OBJECTIVE: The aim was to clarify the influence of biopsy technique and the effects of temporal delay between sampling and freezing on tissue contents of labile metabolites. METHODS: Cardiac and skeletal muscle concentrations of adenine nucleotides, phosphocreatine, creatine, and glycogen in pigs were determined in endomyocardial and transmural myocardial biopsies and in skeletal muscle biopsies obtained with either endomyocardial bioptome or Tru-cut needle. The influence of the temporal delay between biopsy sampling and freezing was evaluated by keeping the biopsies at room temperature for varying intervals up to 300 s before freezing. RESULTS: Skeletal muscle showed higher concentrations of creatine compounds and lower contents of ADP and AMP than cardiac muscle, whereas ATP, total adenine nucleotide pool, and glycogen were similar. Lower phosphocreatine contents were found both in endomyocardial biopsies and in skeletal muscle biopsies obtained with bioptome compared to transmural myocardial biopsies and skeletal muscle biopsies obtained with Tru-cut needle, respectively. Other metabolites were unaffected by the biopsy technique. With extended delays between biopsy sampling and freezing, an increase in skeletal muscle phosphocreatine averaging 26% after 5 min was observed. In the heart, a decrease in glycogen content averaging 42% after 5 min was found. These changes were not related to the biopsy procedure and were not observed within the period usually required to freeze biopsies in experimental as well as clinical settings. CONCLUSIONS: There are essential metabolic differences between cardiac and skeletal muscle. Low endomyocardial phosphocreatine levels are influenced by the biopsy technique, compromising the use of endomyocardial biopsies for establishing myocardial phosphocreatine content. Reliable measurements of adenine nucleotides and glycogen can be obtained with endomyocardial biopsies.

[Cardiac risk in surgery. A review and guidelines for risk evaluation and reduction of cardiac risk in general surgery]. / Kardial risiko ved operation. En oversigt og vejledende retningslinier for vurdering og reduktion af kardial risiko ved almenkirurgiske indgreb.

Cardiac complications occur with an incidence of 2-6% and are a main cause (15-20%) of mortality after non-cardiac surgery. Cardiac risk should be determined and reduced by treatment preoperatively and by an intraoperative and postoperative care that has been adjusted to the increased risk. This review provides recommendations concerning risk evaluation and management.

Comparison of non-collagen protein and total creatine as reference for determination of energy stores in endomyocardial biopsies.

OBJECTIVE: The aim was to establish a reliable reference system for biochemical measurements in endomyocardial biopsies. METHODS: Myocardial tissue samples were obtained from pigs before and after cardioplegic arrest and reperfusion. Non-collagen protein content was evaluated as a non-specific reference system and compared with total creatine content representing a specific myocardial reference system. The influence of base strength, extraction temperature, and extraction time on protein yields was determined in tissue precipitates redissolved in NaOH. Interference from protein of collagenous origin was excluded by hydroxyproline determinations. Variability of myocardial ATP content in relation to non-collagen protein and total creatine was compared in endomyocardial biopsies taken before and after cardioplegic arrest and reperfusion. RESULTS: The two methods showed comparable analytical precision. Apart from an interference in 1.0 mol.litre-1 NaOH for extended extraction periods at high temperatures, myocardial protein yields increased with increasing base strength, extraction temperature, and extraction time. During cardioplegic arrest and reperfusion heart weight increased due to oedema. Simultaneously, myocardial non-collagen protein content decreased. No change in total creatine was found during cardioplegic arrest but there was a significant loss of creatine after reperfusion. Comparison of variability in myocardial ATP content with non-collagen protein or total creatine as reference systems revealed no difference. CONCLUSIONS: Determination of non-collagen protein can be optimised with standardised conditions for protein extraction in tissue precipitates. Employment of total creatine as a reference system does not reduce variability of myocardial metabolite determinations in endomyocardial biopsies compared with non-collagen protein. Loss of myocardial creatine may in itself provide additional information about myocardial injury but this makes it unsuitable as a reference system for measuring metabolic changes during reperfusion. Multiple biopsies seem necessary for estimation of myocardial energy stores.

Myocardial loss of glutamate after cold chemical cardioplegia and storage in isolated blood-perfused pig hearts.

Metabolic adaptation of the ischemic human heart includes release of lactate, augmented uptake of glucose and glutamate, together with increased release of citrate and alanine. In the present study exchanges of these metabolites were examined in relation to left ventricular function (LVF) in pig hearts during reperfusion after hypothermic cardioplegic-induced global ischemia and storage. Three groups of pig hearts were studied. Group I consisted of 11 hearts subjected to 9 minutes of warm ischemia prior to cold chemical cardioplegia with Bretschneider's cardioplegic solution (CCC), and hypothermic storage (HS), for a total of 180 minutes. Groups II and III, 8 hearts in each, were subjected to 90 and 180 minutes of CCC and HS, without precardioplegic warm ischemia. All hearts were reperfused in an isolated blood-perfused Langendorff model. Myocardial oxygen uptake and LVF were two-fold depressed in Group I compared to Groups II and III during the first 25 minutes of reperfusion. An increased uptake of glucose (p < 0.05) and augmented release of lactate (p < 0.01) and citrate (p < 0.001) were found during the reperfusion period in the hearts subjected to precardioplegic warm ischemia, indicating an increased total ischemic burden compared to Groups II and III. No significant changes in LVF or myocardial metabolism were noted between Groups II and III during reperfusion. In all three heart groups a substantial release or loss of glutamate was found at start of reperfusion, although in the preischemic state prior to cardioplegia pig hearts were found to extract glutamate from the circulation to an extent similar to that of the human heart.(ABSTRACT TRUNCATED AT 250 WORDS)

Aneurysm of the left anterior descending coronary artery after chest trauma.

A 28-year old man developed transmural anterior wall myocardial infarction after a car accident despite the absence of external signs of chest trauma. Coronary angiography one month after the accident demonstrated an aneurysm of the left anterior descending artery. Angiography five and eleven months afterwards showed almost total regression of the aneurysm. The man remained asymptomatic with no signs of residual ischaemia one year after the accident. Blunt trauma to the chest is a well-known cause of cardiac damage including myocardial contusion, rupture of the ventricular wall, septum, papillary muscles or chordae tendineae. Myocardial infarction secondary to distinct injury to a coronary artery has only seldom been described. Visualization of a localized lesion in a coronary artery of an otherwise non-atherosclerotic coronary tree supports the traumatic origin of a myocardial infarction.

Hemodynamic and cardiac metabolic changes during nicardipine-induced myocardial ischemia.

After 10 mg nicardipine IV a patient with stable angina developed chest pain and ST-segment depression accompanied by excessive tachycardia, low arterial blood pressure, and initially decreased coronary sinus blood flow. Measurements of arterial concentrations and cardiac exchanges of lactate, glucose, free fatty acids, glutamate, and alanine showed alterations indicative of severe ischemia.

Atrial natriuretic peptide during pacing in controls and patients with coronary arterial disease.

At rest, during cardiac catheterization, aortic plasma levels of immunoreactive atrial natriuretic peptide did not differ between 10 controls with atypical chest pains and normal coronary arteries and 9 patients with stable angina pectoris and coronary arterial disease (55.2 +/- 19.8 vs. 64.8 +/- 19.8 pg/ml, NS). Nor did atrial natriuretic peptide values differ between the two groups during or after atrial pacing (150 beats/minute), which induced electrocardiographic and metabolic signs of acute myocardial ischaemia in the patients with coronary arterial disease but in none of the controls. Pacing, when carried out for more than 300 seconds, induced an increase of plasma atrial natriuretic peptide that correlated with duration of pacing (r = 0.80, P less than 0.001), and similarly in controls and patients with coronary arterial disease. In a second part of the study, which included 2 controls and 2 patients with coronary arterial disease, post-pacing coronary sinus concentrations of atrial natriuretic peptide were 10-20 times higher than peripheral levels (415- greater than 890 pg/ml). The concentration of atrial natriuretic peptide rose as blood from the caval veins (34 +/- 7 pg/ml) entered the right atrium (56 +/- 24 pg/ml), but thereafter was unchanged in the pulmonary artery (51 +/- 3 pg/ml) and the aorta (46 +/- 9 pg/ml). In conclusion, the results gave no evidence for ischaemic heart disease without congestive cardiac failure to be associated with altered levels of atrial natriuretic peptide. It was confirmed that atrial pacing stimulates the secretion of atrial natriuretic peptide which is produced by the heart and released via the coronary sinus into the circulation.

Whole blood versus plasma measurements of glutamate and alanine across the human myocardium.

Comparison of whole blood and plasma aorto-coronary sinus concentration differences of glutamate and alanine were made before, during and after coronary sinus pacing in seven patients with normal and six patients with stenotic coronary arteries. Mean differences between duplicate analyses were greater in whole blood than plasma both of glutamate (7.5 +/- 5.8 vs. 3.3 +/- 3.0 mumol/l, p less than 0.001) and of alanine (7.9 +/- 7.0 vs. 3.8 +/- 3.4 mumol/l, p less than 0.001). Concentrations of glutamate were 3.4 and of alanine 1.4 times higher in whole blood than in plasma. Blood cells were calculated to be responsible for about 20% of glutamate and alanine blood exchanges across the heart. Plasma and whole blood fluxes were closely positively correlated (glutamate:r = 0.81, alanine:r = 0.88) and had always the same direction. Differences in myocardial exchanges of amino acids between the patients with and without coronary artery disease, as well as rapid changes during pacing, could be demonstrated in plasma analyses but were not significantly reflected in whole blood glutamate determinations. This seemed to be due to the greater variations in whole blood analysis. In conclusion, differences in aorto-coronary sinus plasma concentrations reflected, although underestimated, whole blood fluxes. Because of considerable gains in precision of analysis, plasma should be preferred to whole blood for evaluations of glutamate and alanine exchanges across the human heart.

Dose-related haemodynamic effects of nicardipine during rest and exercise and variable anti-anginal effects in patients with chronic stable angina.

The effects of increasing doses of i.v. nicardipine (2.5, 5.0 and 7.5 or 10.0 mg) on blood pressure, heart rate and exercise performance were studied in 12 patients with chronic effort angina. Plasma nicardipine concentrations correlated closely with the infused doses (r = 0.90). Resting haemodynamic changes after nicardipine included a dose-related fall in systolic (5%, 13%, 15%) and diastolic (0%, 6%, 8%) blood pressure and a rise in heart rate (10%, 19%, 30%). Rate-pressure product was slightly increased after the highest dose (10%). During exercise, maximal systolic blood pressure decreased (3%, 9%, 9%) and heart rate increased (2%, 4%, 9%) but the rate-pressure product remained unchanged. Exercise tolerance improved in 10 patients as indicated by prolonged exercise duration in all, delayed appearance of ST-segment depression in 6, decreased maximal ST-segment depression in 5, and abolished (N = 3) or diminished (N = 4) anginal pain at the end of exercise after optimal nicardipine dose. Five of the 10 patients obtained maximum benefit after the highest dose. The other five patients improved after 2.5 or 5.0 mg but deteriorated (N = 4) or had no further benefit when the dose was increased (N = 1). One patient deteriorated even after the lowest dose, whereas one patient neither improved nor deteriorated after any dose. The patients who deteriorated after low or high doses tended to be more severely diseased than those who tolerated the maximal dose well. The results stress the importance of individual dose titration of nicardipine to ensure maximum benefit in patients with chronic effort angina.

Altered plasma concentrations of glutamate, alanine and citrate in the early phase of acute myocardial infarction in man.

Plasma levels of glutamate, alanine, free fatty acids (FFA), citrate, glucose, insulin, lactate, creatine kinase and aspartate aminotransferase were determined frequently during the first 2-48 h after onset of chest pain in 10 patients who developed acute myocardial infarction (AMI) and in 8 who did not (non-AMI). An initial decrease in plasma glutamate and increase in alanine was found in AMI compared to non-AMI patients. The AMI group showed early, moderate rises of plasma FFA and citrate concentrations, positively related to the initial ST-segment elevation and to the enzymatic estimated infarct size. The AMI patients were continuously hyperglycaemic, but their relative insulin response i.e. plasma glucose/insulin ratio was identical to that of non-AMI patients. Lactate values did not differ between the two groups. Via participation in the malate-aspartate shuttle and by shunting pyruvate to alanine instead of lactate, glutamate is of importance for maintaining myocardial glucose utilization. Our finding of initial low plasma glutamate concentrations after onset of myocardial infarction suggests insufficient glutamate supply to the ischaemic myocardium. On basis of this and animal experiments, an external supply of glutamate might be a 'metabolic' treatment of AMI, alternative or additional to glucose-insulin-potassium infusion in order to promote myocardial glucose oxidation.

Myocardial exchanges of glutamate, alanine and citrate in controls and patients with coronary artery disease.

1. Myocardial exchanges of plasma alanine, glutamate, citrate, lactate, glucose and free fatty acids were determined in 17 patients with coronary artery disease and in seven control subjects during rest, atrial pacing and recovery. 2. Myocardial release of alanine was demonstrated in all subjects. The amount released was higher in patients with coronary artery disease than in controls. In the patients alanine release was related to severity of coronary artery stenosis. 3. All subjects showed myocardial uptake of glutamate, higher in patients than in controls at rest and during recovery. During atrial pacing myocardial glutamate extraction remained unchanged in controls but decreased in patients. 4. Citrate was released by the heart in all controls and patients. During recovery citrate output was higher in patients than in controls. 5. Myocardial alanine and citrate release during recovery were positively correlated. Both were positively related to myocardial uptake of glutamate during recovery and to the decrease in glutamate extraction during pacing. 6. The results indicate changed myocardial citrate and amino acid metabolism in coronary artery disease. Measurement of myocardial exchanges of glutamate, alanine and citrate in addition to lactate is suggested as a sensitive biochemical test in assessing myocardial ischaemia in man.