Effects of amlodipine on exercise tolerance, quality of life, and left ventricular function in patients with heart failure from left ventricular systolic dysfunction.

BACKGROUND: A preliminary study suggested that the long-acting late-generation calcium-channel blocker amlodipine has favorable effects on exercise tolerance and is safe to use in heart failure, in contrast to earlier generation agents. The goal of 2 multicenter studies was to assess the effect of adjunctive therapy with amlodipine in addition to standard therapy on exercise capacity, quality of life, left ventricular function, and safety parameters in patients with heart failure and left ventricular systolic dysfunction. METHODS: Two large multicenter trials examining the effects of amlodipine on these parameters over a 12-week period of therapy were undertaken in patients with mild to moderate heart failure and left ventricular systolic dysfunction. A total of 437 patients with stable heart failure were studied in a randomized, double-blind, placebo-controlled prospective design. RESULTS: Amlodipine at a dose of 10 mg/day in addition to standard therapy in such patients was associated with no significant difference in change in exercise tolerance on a Naughton protocol compared with placebo in each trial. Among all patients taking amlodipine, exercise time increased 53 +/- 9 (SE) seconds; exercise time for those taking placebo increased 66 +/- 9 seconds (P = not significant). There were no significant differences in changes of quality of life parameters between amlodipine- and placebo-treated patients, and there were no significant differences in symptom scores or New York Heart Association classification between groups. Left ventricular function (measured as ejection fraction) improved 3. 4% +/- 0.5% in amlodipine-treated patients and 1.5% +/- 0.5% in placebo-treated patients (P =.007). There was no statistically significant excess of important adverse events (episodes of worsening heart failure in 10% amlodipine-treated vs 6.3% of placebo-treated patients) or differences in need for changes in background medication between groups. CONCLUSIONS: The addition of 10 mg of amlodipine per day to standard therapy in patients with heart failure is associated with no significant improvement in exercise time compared with placebo therapy over a 12-week period, and there was no increased incidence of adverse events. These data suggest that the addition of amlodipine to standard therapy in heart failure will not result in additional efficacy per se beyond standard therapy.

Aortic dissection: diagnosis and management.

Acute dissections mandate surgery after the patient has been stabilized medically. Hypertension appears to be a prerequisite in the pathogenesis of aortic dissection, and control of ventricular contraction velocity may be prophylactic.

Pulmonary embolization of papillary fibroelastoma. Arising from the tricuspid valve.

Papillary fibroelastomas are rare, benign tumors of the heart that often are incidental findings at autopsy or cardiac surgery, or during echocardiography. These tumors are predisposed to valvular involvement, and all such lesions detected by echocardiography have occurred in the left side of the heart, except for 3 on the tricuspid valve. Left-sided lesions have been associated with embolic phenomena; however, embolization of right-sided lesions has never been documented. We report a tricuspid valve fibroelastoma detected by 2-dimensional and transesophageal echocardiography, and confirmed by surgical excision and biopsy. To our knowledge, this is the 1st reported case of pulmonary embolization of papillary fibroelastoma arising from the tricuspid valve.

Left atrial and ventricular transseptal catheterization review: losing skills?

Transseptal catheterization has been routinely done at this institution for the past 19 years to evaluate the left heart. Reviewing the last 250 consecutive transseptal heart catheterizations between 1978 and 1986, the left atrium and ventricle were entered in all but six patients. One death occurred with four other major complications. There were 177 males and 73 females ranging from 18 to 84 years of age. Of these 250 studies, 31 were in association with direct left ventricular apical puncture; 42 were in patients with subaortic stenosis; 101 were in aortic stenosis; 26 were in patients with combined aortic and mitral disease; and four were in patients with triple prosthetic valve replacements. No attempts were made to cross the prosthetic mitral valves. A decline in the number of transseptal studies at this institution has been noted over the past 8 years and the technique is not longer taught routinely to Fellows. The reduction is due to increased emphasis on coronary artery anatomy, fewer rheumatic and prosthetic valvular admissions, and improved reevaluation by non-invasive echocardiography and doppler studies. This has resulted in a loss in proficiency among invasive cardiologists. In conclusion, the transseptal technique is potentially hazardous, but continued usage will maintain proficiency and a low major and minor complication rate.

Percutaneous preformed single catheter coronary arteriography and its complications--10,000 cases.

The single preformed catheter has offered an alternative to the conventional approaches to study of the coronary circulation and ventriculography. It has the advantages of being introduced percutaneouly without multiple changes for routine study or for provocative drug testing such as for spasm with Ergonovine maleate or muscular bridges with nitroglycerine. It requires no arteriotomy and has been associated with a low complication rate.

Serial coronary arteriography with 105mm photofluorography: 24-month experience, 2,200 patients.

A 105 mm camera has been used for over 24 mo in evaluation of the coronary circulation for the most part and occasionally the proximal peripheral arteries in 2,200 patients. This photofluorographic technique provides sufficient diagnostic image detail with improved operating convenience and reduced radiation exposure compared to the large film changer. 105 mm serialography is a good adjunct to cine arteriography as a complementary film recording system, and in many cases may supplement large film serialography.