Severe infective endocarditis due to Neisseria sicca: case report and review of literature.

We report a case of infective endocarditis (IE) caused by an unusual micro-organism in a previously healthy young man. Our patient presented with meningo-encephalitis and embolic signs due to IE caused by Neisseria sicca. Risk factors for IE due to Neisseria sicca, such as intravenous drug use and pre-existing heart disease were absent. The patient recovered well after mitral valve surgery and antimicrobial therapy. IE due to Neisseria spp. is associated with embolic manifestations and valve destruction. However, no deaths have been reported in patients who are treated with appropriate antimicrobial and surgical therapy.

Cardiopulmonary exercise parameters in relation to all-cause mortality in patients with chronic heart failure.

In this study we analysed the all-cause mortality over a period of maximal 6 years in 60 male patients (age: 63.4+/-8.3 years, mean+/-S.D.), suffering from chronic heart failure with resting left ventricular ejection fraction and E/O2 slope as independent factors. We assessed functional NYHA class (II: n=36, III: n=24), radionuclide left ventricular ejection fraction (29.2+/-10.4%) and peak values of heart rate, O2, CO2, E, anaerobic threshold and exercise duration with an incremental work load test on the treadmill. O2 relative to E was based on the individual slopes of the regression of O2 on E during the first 6 min of exercise. These slopes with other exercise-related variables and factors such as etiology, medication, and NYHA class were analysed with a Cox's Regression Method. A survival time analysis (Kaplan-Meier survival curve) was done to establish the influence of E/O2 slope and left ventricular ejection fraction (both split into above and below median values), as well as their interaction, on survival. From all investigated exercise-related variables. E/O2 slope is the most powerful variable regarding prediction of all-cause mortality in our group of chronic heart failure patients. Concerning risk stratification, the subgroup (n=18) with a relatively high left ventricular ejection fraction (>28%) and flat E/O2 slope (<27.6) had most survivors (77.8%) after about 3 years, while the subgroup (n=12) with a relatively high left ventricular ejection fraction (>28%), but a steep E/O2 slope (>27.6) had least survivors (33.3%). This difference in percentage is highly significant (P=0.0025). The fact that E/O2 slope and left ventricular ejection fraction show comparable main and interaction effects between measures of exercise tolerance (e.g., anaerobic threshold, peak O2, exercise duration) on the one hand, and all-cause mortality on the other, suggests the existence of common sources of variance. Based on our analysis, it is unlikely that effects on all-cause mortality are mediated through phenomena related to exercise tolerance. Therefore, we hypothesize that the effects on exercise tolerance and all-cause mortality both depend on common factors, which cause both cardiac and peripheral organ (c.q. muscular) dysfunctions. Moreover, this study clearly shows that E/O2 slope during incremental exercise is an important prognostic marker for risk stratification in chronic heart failure patients, NYHA class II and III.

Safety and effects of physical training in chronic heart failure. Results of the Chronic Heart Failure and Graded Exercise study (CHANGE)

AIMS: Physical training is considered to be safe and beneficial as part of the treatment in heart failure patients. Prospective, sufficiently large studies are still needed to confirm this hypothesis. METHODS: In a prospective study, 80 patients with chronic heart failure class II and III (age, 56.6+/-8.3 years; left ventricular ejection fraction, 26.5+/-9.6%) were randomized to an endurance training group or to a control group with continuation of optimal pharmacological treatment. RESULTS: No training-related adverse event was reported, implying that the training programme was safe for these groups of chronic heart failure patients. Between-group comparison of changes revealed that training increased exercise time (from 608+/-35 to 738+/-40 s, P<0.0001), anaerobic threshold (from 10.5+/-0.4 to 11.8+/-0.3 ml x kg-1 min-1, P<0.05), and decreased the ventilatory equivalent for carbon dioxide at submaximal exercise level (from 2.8+/-0.1 to 2.7+/-0.1, P<0.05). Training did not increase peak oxygen consumption (15.2+/-0.5 to 16. 6+/-0.5 ml x kg-1 min-1, ns). An improvement in patients' assessment of quality of life was observed. There was a significant correlation between physiological and psychological improvements. Training was not effective in patients whose exercise test at entry had a duration of less than 7 min. None of the other baseline data could predict an effective training response. CONCLUSION: Physical training in chronic heart failure patients class II and III is safe and results in significant improvements in exercise time, anaerobic threshold, ventilatory equivalent for carbon dioxide at submaximal exercise level and quality of life.

Effect of exercise training on quality of life in patients with chronic heart failure.

The effect of exercise training on quality of life and exercise capacity was studied in 67 patients with mild to moderate chronic heart failure (CHF; age: 65.6+/-8.3 years; left ventricular ejection fraction: 26.5+/-9.6%). Patients were randomly allocated to either a training group or to a control group. After intervention a significantly larger decrease in Feelings of Being Disabled (a subscale of the Heart Patients Psychological Questionnaire) and a significantly larger increase in the Self-Assessment of General Well-Being (SAGWB) were observed in the training group. Exercise time and anaerobic threshold were increased in the training group only. The increase in exercise time was related to both Feelings of Being Disabled and SAGWB. We conclude that supervised exercise training improves both quality of life and exercise capacity and can be safely performed by chronic heart failure patients.

Exercise training in elderly patients with chronic heart failure.

BACKGROUND: Physical training currently constitutes an important part of treatment of heart failure patients. So far, no data are available on the effects of regular exercise in elderly (aged > 65 years) heart failure patients. METHODS: In a prospective trial, patients with chronic heart failure (New York Heart Association class II and III) were randomly assigned to a training group and a control group. Patients in the training group performed additional exercises three times a week, while patients in the control group continued regular treatment. To analyse the influence of age, both groups were subdivided into subjects younger than and older than 65 years. The effect of training on exercise parameters was evaluated by means of a treadmill test. Quality of life aspects were evaluated with the help of the Heart Patients Psychological Questionnaire and a single-question Self Awareness of General Well-Being test. RESULTS: Comparison of changes between groups revealed that training increased the duration of the exercise test and improved aspects of quality of life in the trained patients aged both younger than and older than 65 years. CONCLUSION: Exercise training is equally effective in patients aged younger than and older than 65 years.

Left ventricular wall motion score as an early predictor of left ventricular dilation and mortality after first anterior infarction treated with thrombolysis. The CATS Investigators Group.

To recognize patients prone to subsequent left ventricular dilation after the acute phase of a myocardial infarction treated with thrombolysis, we studied 233 patients with a first anterior infarction, treated with thrombolysis, with 2-dimensional echocardiography within 12 hours after admission and 3 months later. A wall motion score index (WMSI) and left ventricular volumes were assessed, and enzymatic infarct size was expressed as cumulative alphahydroxybutyrate dehydrogenase determined in the first 72 hours after infarction. Patients who died (17 of 233, 7%) after a mean follow-up of 517 days had a significantly higher acute WMSI (2.1 +/- 0.3, mean +/- SD) than those who survived (1.9 +/- 0.4)(p=0.006). With use of this cutoff value for 2 WMSI, ventricles with an acute WMSI < or = 2 (62%) showed no increase in end-diastolic volume index (EDVI) or end-systolic volume index (ESVI), whereas ventricles with an acute WMSI >2 (38%) showed a significant increase in ESVI (6.1 +/- 12.2 ml/m2) and in EDVI (10.3 +/- 16.6 ml/m2) in the first 3 months. Using a cutoff value of 1,000 U/L for cumulative alphahydroxybutytrate dehydrogenase, only infarcts with a value of >1,000 U/L (52%) caused a significant increase in EDVI (10.8 +/- 14.3 ml/m2) and ESVI (6.5 +/- 10.0 ml/m2) in the first 3 months. Thus, acutely assessed WMSI of >2 can readily predict subsequent dilation in patients with a first anterior infarction treated with streptokinase and is a good predictor of mortality. Enzymatic infarct size also is a predictor of dilation, although not available until 3 days after infarction.

Additional antiischemic effects of long-term L-propionylcarnitine in anginal patients treated with conventional antianginal therapy.

Cardiac L-carnitine content, essential for mitochondrial fatty acid transport and ATP-ADP exchange, decreases during ischemia. In animal models, administration of the natural derivative, L-propionylcarnitine, may reduce ischemia and improve cardiac function. To evaluate possible antiischemic effects of L-propionylcarnitine was compared with placebo in a randomized, double-blind, parallel design, in addition to preexisting therapy. Patients with > or = 2 anginal attacks per week and objective signs of ischemia with angina during bicycle exercise testing were included. After an initial 2-week, single-blind placebo phase, 37 patients received 500 mg L-propionylcarnitine tid, and 37 patients received placebo for 6 weeks. Both groups were comparable at baseline. Three patients discontinued the study while on placebo (two because of noncompliance, one because of palpitations) and one while on L-propionylcarnitine (noncompliance). Although heart rate, blood pressure at rest, and maximal exercise were not affected, L-propionylcarnitine increased the time to 0.1 mV ST-segment depression [44 +/- 3 vs. 8 +/- 2 seconds (mean +/- SEM) in the placebo group; p = 0.05], and exercise duration improved by 5% compared with placebo. Anginal attacks and the consumption of nitroglycerin were not affected in either group. Thus, following a 6 week treatment period, L-propionylcarnitine induced additional, albeit marginal, antiischemic effects in anginal patients who were still symptomatic despite maximal conventional antianginal therapy. It is questionable whether in these patients this form of metabolic treatment will achieve great benefit, although in some improvement can be expected.

Comparison between felodipine and isosorbide mononitrate as adjunct to beta blockade in patients > 65 years of age with angina pectoris.

Coronary artery disease is an increasingly common medical problem in the elderly, and relatively few studies investigating drug therapy focus on this population. To assess the efficacy and safety of the calcium channel blocker, felodipine, and isosorbide mononitrate (ISMN), as adjunct to optimal beta-blocker therapy in elderly patients, a placebo-controlled, double-blind study was conducted in 46 patients, aged between 65 and 80 years, with documented stress-induced angina pectoris and myocardial ischemia. With use of a latin-square design, with 3 periods of 4 weeks each, exercise testing was performed after each period. Felodipine, 5 mg once daily, significantly improved both time to ischemic threshold and pain threshold (p = 0.02 and p = 0.003, respectively, vs placebo), and tended to increase total exercise time (p = 0.06 vs placebo). In contrast, ISMN, 20 mg twice daily, did not significantly affect these parameters. Comparison of the 2 active treatment arms showed that, overall, felodipine was more effective than ISMN, with a statistically significant difference for time to ischemic threshold (p = 0.02). With regard to safety, felodipine was also better tolerated than ISMN, which led to more patients discontinuing study medication with ISMN (p < 0.05 between ISMN and felodipine). It is concluded that in elderly patients who are treated with optimal beta blockade, felodipine, but not ISMN, leads to an additional significant reduction in ischemic parameters during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute intervention with captopril during thrombolysis in patients with first anterior myocardial infarction. Results from the Captopril and Thrombolysis Study (CATS).

The study was designed to examine the safety and efficacy of acute interventional use of captopril on left ventricular volumes, ventricular arrhythmias and neurohormones during thrombolysis in patients with a first anterior myocardial infarction, within 6 h of onset of symptoms. Left ventricular dysfunction and prognosis after myocardial infarction can be improved by angiotensin converting enzyme inhibition started after the ischaemic phase. Experimental evidence suggests that intervention during thrombolysis may lead to even further benefit. In a randomized, double-blind placebo-controlled trial, 298 patients with a first anterior myocardial infarction, eligible for thrombolytic therapy were treated with captopril 6.25 mg or placebo, started immediately upon streptokinase infusion and titrated to 25 mg t.i.d.. The efficacy of captopril by an intention-to-treat-analysis to reduce left ventricular volumes, ventricular arrhythmias, neurohumoral activation and enzymatic infarct size was measured. During dose titration, mean blood pressure and heart rate were similar in both groups. However, hypotension after the first dose was reported in 18 patients on placebo and 31 patients on captopril (P < 0.05). At discharge, 80% of patients were on study medication. Left ventricular volumes were significantly increased in both groups at 3 months, but they tended to be lower in the captopril group; however, the differences were not statistically significant. The incidence of accelerated idioventricular rhythm and non-sustained ventricular tachycardia in captopril patients was lower than in placebo patients (P < 0.05), parallelled by transiently lower norepinephrine levels (P < 0.05) upon thrombolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal wall movements of the right ventricle and both atria in patients with pericardial effusion as indicators of cardiac tamponade.

A retrospective study on 126 patients with pericardial effusion showed cardiac tamponade to be present in 39 patients and absent in 87. We evaluated the distribution of the pericardial effusion as well as the effect of hydrodynamic compression on the different heart chambers. Small to large volumes of pericardial fluid were found in both groups of patients. Abnormal wall movements were only present if pericardial effusion was adjacent. Hydrodynamic compression signs consisted of abnormal wall movements of both atria at end-diastole continuing into systole, and of the right ventricle in early- and mid-diastole. Most of the patients with cardiac tamponade showed an abnormal motion pattern of both right atrium and ventricle (13 patients) or of the right atrial wall alone (12 patients). Abnormal motion of the right ventricle alone was seen in 6 patients, of both atria and right ventricle in 4 and of the left atrium alone in 1 patient. False-negative diagnoses of cardiac tamponade occurred in 3 of the 39 patients and false-positives in 2 of the 87 (sensitivity 92%, specificity 98%). Measurements of the duration of the inversion of both atria increased the specificity of these abnormal wall movements to 100%. Echocardiography can help to identify those patients who are clinically at risk and need pericardial drainage.