Left ventricular blood flow analysis in patients with and without a thrombus after first Q wave acute anterior myocardial infarction: two-dimensional Doppler echocardiographic study.

The authors studied 80 consecutive patients with a first Q wave anterior myocardial infarction (MI) by 2-dimensional and color Doppler echocardiography (echo), on day 3 and day 10 after admission, to determine whether left ventricular (LV) blood flow dynamics differ between those who develop LV thrombus and those who do not. With pulsed Doppler echo, peak flow velocities were measured in diastole at the inflow tract, at the apex in diastole and systole, and at the outflow tract in systole. There were 11 patients (14%) who had LV thrombosis on day 3. On day 10, no other patient developed a thrombus. There was no difference in the Doppler flow velocities, except for lower apical diastolic velocities (0.23 +/- 0.04 m/s) (+/- SEM) in patients with thrombus as compared with those without it (0.33 +/- 0.01 m/s) (p less than 0.05). All patients with thrombus had apical dyskinesis and 8 (73%) had an anteroapical aneurysm, while 40 (58%) patients without thrombosis had dyskinesis and 11 (16%) had an aneurysm (p less than 0.01). The ejection fraction was lower (25.4 +/- 3.2%), the wall motion score was higher (10.6 +/- 0.7), and mitral regurgitation was seen more frequently (45%) in those with LV thrombus (respective values in no thrombus group patients: 32.9 +/- 1.4%, 7.6 +/- 0.3, 7%). The authors conclude that LV thrombus prediction is difficult by Doppler flow velocity study, whereas dyskinesis and aneurysmal dilatation of the LV apex is significantly associated with thrombus.

Significance of a mitral regurgitation systolic murmur complicating a first acute myocardial infarction in the coronary care unit--assessment by colour Doppler flow imaging.

To determine the prevalence and significance of a systolic mitral murmur heard after a first acute myocardial infarction (MI), we studied 186 consecutive patients in the coronary care unit (CCU) during a one-year period. Fifteen patients had a murmur as a result of mitral regurgitation (MR) (prevalence 8%) documented by colour Doppler flow imaging. It was heard before the third day of hospitalization in 10 (67%) patients, and on the third day itself in the remainder. The severity of MR was graded semi-quantitatively: moderate in 12 (80%) patients, and mild, moderate to severe and severe in three respectively. The direction of the MR jet, determined by colour flow imaging, improved the information obtained by two-dimensional echocardiography (2D echo) that could only diagnose mitral leaflet abnormality in seven (47%) patients. In 10 of 15 (67%) patients, the 2D echo ejection fraction was greater than or equal to 40% and in eight (53%) the wall motion score obtained by analysing 11 left ventricular (LV) segments was less than or equal to 8. Two (13%) patients died in the CCU, four (27%) had LV failure, one angina and eight (53%) remained asymptomatic in the hospital. Of 171 patients without a systolic murmur, 22 (13%) had LV failure, 13 (8%) angina and 25 (15%) died during the in-hospital stay (P-NS for these complications between patients with and without MR murmur). During a follow-up of 12-24 months, one MR patient died, and seven (47%) remained asymptomatic. We conclude that the prevalence of MR systolic murmurs in acute MI patients is low.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of intravenous recombinant tissue-type plasminogen activator therapy on the incidence and associations of left ventricular thrombus in patients with a first acute Q wave anterior myocardial infarction.

Consecutive survivors of a first Q wave anterior myocardial infarction were studied to observe the impact of recombinant tissue-type plasminogen activator (rt-PA) therapy on the incidence and associations of left ventricular thrombus. Fifty-four patients received rt-PA within 4 hours after the onset of cardiac pain, followed by heparin infusion. Forty-four patients who did not qualify for rt-PA therapy but who were anticoagulated with heparin served as a control group. Two-dimensional echocardiography was performed in all patients on days 3 and 7 to detect thrombi and analyze wall motion. Ejection fraction was determined by radionuclide angiography in all patients on day 7. Apical thrombi were detected on day 3 in three patients (5.5%) who received rt-PA and in eight control patients (18%) (p less than 0.05). All patients with a thrombus had apical dyskinesis and 8 of 11 (73%) had an aneurysm. Of the 87 patients without thrombosis, apical dyskinesis and aneurysm were present in 42 (48%) and 11 (13%) patients, respectively (p less than 0.01). Ejection fractions and wall motion scores of patients without a thrombus were significantly better when compared with data from those with a thrombus. There were fewer patients with apical dyskinesis (17 of 54) in the group receiving rt-PA therapy compared with the control group (36 of 44) (p less than 0.01). Ejection fractions and wall motion scores were better in patients who received rt-PA compared with control subjects (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of blood taurine levels in patients with first time acute ischaemic cardiac pain.

We studied blood taurine levels of 91 consecutive patients admitted with first time cardiac pain suggestive of myocardial ischaemia. Blood taurine levels of patients with coronary arterial disease, but without a recent myocardial infarction (n = 36), at rest and after a maximal treadmill stress testing were also determined. The blood taurine level at the time of admission was significantly elevated (P less than 0.001) in patients with an acute myocardial infarction (n = 63) (271 +/- 98 mumol/l) and those with unstable angina (n = 22) [214 +/- 81 mumol/l] compared to that of normal subjects (n = 75) at rest (140 +/- 40 mumol/l). Patients with a myocardial infarction had a higher level than those with unstable angina (P less than 0.01) and non-ischaemic chest pain (n = 6) [P less than 0.05]. The levels peaked after 12-48 hours only in patients with infarction [367 +/- 140 mumol/l] (P less than 0.001) and unstable angina (273 +/- 82 mumol/l) (P less than 0.02). The levels of creatine kinase within the serum at the time of admission did not correlate well with those of blood taurine, but the peak levels of the former did correlate with the latter (P less than 0.02). Patients with known coronary arterial disease had a higher resting [236 +/- 69 mumol/l] level of blood taurine than normal subjects (P less than 0.001), which was further elevated [269 +/- 80 mumol/l] following exercise (P less than 0.001). Thus, an elevated level of taurine in whole blood at the time of admission of patients with an acute cardiac pain suggested the diagnosis of either a myocardial infarction or unstable angina. The level of taurine may be utilised to differentiate the two conditions.

Lipoproteins and apolipoproteins in young nonobese Arab women with NIDDM treated with insulin.

The effects of insulin on the lipid values of nonobese non-insulin-dependent diabetic (NIDDM) Arab women requiring insulin was investigated to find whether these patients have the same coronary artery risk factor related to lipid levels. In this study, 55 NIDDM women on insulin therapy (mean age 28 +/- 8.1 yr and duration of disease 5 +/- 1.2 yr) and 70 control subjects (matched for sex, age, and body mass index) were studied for their plasma levels of lipids, lipoproteins, and apolipoproteins. Concentrations of total cholesterol, very-low-density lipoprotein cholesterol, low-density lipoprotein (LDL) cholesterol, triglyceride (TG), LDL TG, high-density lipoprotein triglyceride (HDL TG), phospholipid, glucose, glycosylated hemoglobin (HbAtc), apolipoprotein B (apoB), LDL-apoB, and apoB/apoAl were significantly elevated in diabetic women compared with control subjects. There was no significant change in the levels of apoAll in plasma and lipoprotein fractions. Concentrations of HDL cholesterol (chol), HDL2-chol, HDL3-chol, plasma apoAl, HDL2-apoAl, HDL3-apoAl, and HDL-apoAl were significantly lower in diabetic women than in control subjects. There was no significant correlation between glucose or HbAtc and most of the lipids, lipoprotein lipids, and apolipoproteins measured. Despite normal body weight and insulin therapy, abnormalities in lipids, lipoprotein lipids, and apoB persisted in NIDDM patients compared with control subjects. Our data may favor an enhanced affinity toward atherosclerosis in these patients.

Brucellosis: atypical presentation with peritonitis and meningitis.

A case of brucellosis associated with peritonitis, intestinal obstruction, granulomatous hepatitis, inappropriate antidiuretic hormone (ADH) secretion and meningitis is reported. Initially, the patient was diagnosed as a case of disseminated tuberculosis and treated accordingly. However, the serologic tests for brucellosis were strongly positive and the patient was subsequently treated as a case of brucellosis and recovered fully. The gastrointestinal manifestations of brucellosis are reviewed.

The effect of a hot dry climate on the haemorrheology of healthy males and patients with acute myocardial infarction.

We studied the influence of an extremely hot dry summer and temperate winter on the haemorrheology of 82 healthy males (controls) and 101 male patients with acute myocardial infarction (AMI). The haematocrit (Hct), blood viscosity (B1V) and Hct/B1V ratio were measured in these subjects working 'outdoors' and in an air-conditioned environment ('indoors'). The 'summer outdoor' controls had a higher B1V and a lower Hct/B1V when compared to the 'winter outdoor' controls (P less than 0.01), and the 'summer indoor' controls had a lower Hct and Hct/B1V when compared to the 'winter indoor' control group (P less than 0.02). The haemorrheology of 'winter indoor' AMI patients was not different from the controls, except for the Hct/B1V. The 'summer indoor' group had a higher Hct (P less than 0.05) and B1V (P less than 0.001) and a lower Hct/B1V (P less than 0.02) when compared to the controls. 'Summer outdoor' AMI patients had the most abnormal haemorrheology of all groups. AMI patients with Hct/B1V less than 7 had a significantly higher prevalence of hypotension and shock syndrome compared to those whose Hct/B1V was greater than or equal to 7 (P less than 0.05). We conclude that in healthy males, there was a seasonal difference in haemorrheology which was due to acclimatization to heat. During summer, AMI patients working outdoors had the most abnormal haemorrheology on admission and the occurrence of complications was also higher in them. We believe that these abnormalities resulted due to inadequate adjustments to heat.

Left ventricular function of survivors of a first complicated acute myocardial infarction. A prehospital discharge cross-sectional echocardiographic study.

To assess the left ventricular function of patients who suffer from post-infarction angina and left ventricular failure in the coronary care unit, 79 consecutive survivors (mean age 48 years) of a first acute myocardial infarction were prospectively studied and followed-up for a mean 18- (10-34) month period. Forty-seven had an uncomplicated infarction, 17 suffered from post-infarction angina and 15 had left ventricular failure. The left ventricular function of these patients prior to discharge from hospital was assessed by cross-sectional echocardiography and radionuclide angiography. Analysis of left ventricular wall motion was performed in all patients using a 11-segment model of the left ventricular. The ejection fraction was determined by echocardiography in 47 patients and by radionuclide angiography in 50. The mean echocardiographic wall motion score of post-infarction angina patients (4.8 +/- 0.8) (+/- SEM) was lower than that of patients with left ventricular failure (9.5 +/- 0.5) (P less than 0.001), but was not different from patients suffering uncomplicated infarctions (4.6 +/- 0.3). The mean echocardiographic ejection fraction was also similar in post-infarction angina (45.3 +/- 4.0; n = 16) and patients with uncomplicated infarction (51.9 +/- 2.7; n = 17), but was lowest in the group of patients with left ventricular failure (35.1 +/- 3.3; n = 14). Similarly, the radionuclide ejection fraction of patients with post-infarction angina (41.4 +/- 3.4; n = 17) and patients with uncomplicated infarction (45.6 +/- 2.7; n = 19) did not differ, but was lower in patients with left ventricular failure (25.9 +/- 2.8; n = 14). The echocardiographic ejection fraction correlated with that obtained by radionuclide angiography in all 46 patients (r = 0.71, P less than 0.001). The wall motion score correlated with the radionuclide ejection fraction in all 50 patients (r = -0.73, P less than 0.001) and with the echocardiographic ejection fraction in 47 patients (r = -0.55, P less than 0.001). During follow-up, 3 (18%) patients suffering post-infarction angina and 2 (13%) with left ventricular failure died. New infarction was seen in 2 (12%) and 1 (7%) patients in these groups, respectively. We conclude that the left ventricular function of patients who suffer from post-infarction angina in the coronary care unit is good, but is impaired in those with even transient left ventricular failure. Echocardiographic assessment of cardiac function prior to hospital discharge was highly successful and may be performed in all such patients.

Abnormal autonomic function in diabetic and nondiabetic patients after first acute myocardial infarction.

We performed autonomic function testing in 68 patients, 34 with diabetes mellitus (group A) and 34 without (group B), at 72 h after a first acute myocardial infarction (MI) to determine the prevalence of autonomic dysfunction in these patients. Heart rate (HR) variation during 6 breaths/min obtained from mean of longest RR interval during expiration(E)/mean of shortest RR interval during inspiration (I) (E:I ratio), immediate HR response to standing = RR at 30th beat/RR at 15th beat (30:15 ratio) and postural fall of blood pressure were evaluated. In group A, 25 (78 percent) of 32 patients had an abnormal expiration-inspiration ratio compared with 28 (85 percent) of 33 in group B. Twenty-six (76 percent) patients in group A and 16 (47 percent) in group B had an abnormal 30:15 ratio. Abnormal postural fall of blood pressure was seen in 16 (47 percent) patients in group A compared with ten (29 percent) in group B. During follow-up, four women in group A with an initial autonomic dysfunction died, and in group B, three patients with a normal autonomic function died. Thus, autonomic dysfunction does not seem to contribute to the high mortality among diabetics after an acute MI.

Seasonal variation in the incidence of unstable angina and acute myocardial infarction: effect of dry hot climate on the occurrence of complications following acute myocardial infarction.

The incidence of unstable angina (UA) and acute myocardial infarction (AMI), and the occurrence of complications following AMI were studied retrospectively by utilizing data of 7859 patients admitted during three consecutive winter and summer periods from 1979 to 1982. In all patients, UA was more frequent during summer than in winter: 58 out of 3819 (1.5%) versus 37 out of 4040 (0.9%) respectively (P less than 0.05). A similar difference was observed for the incidence of AMI: 183 out of 3819 (4.8%) in summer versus 157 out of 4040 (3.9%) in winter (P less than 0.05). This seasonal variation in the incidence of UA and AMI was significant only in male patients (P less than 0.05). Shock and mortality were higher during summer than in winter in all, and in male AMI patients with or without previous infarction. It is suggested that a hot dry summer is an important risk factor for the occurrence of UA and AMI, and the associated serious complications following the latter in males.

Left ventricular thrombosis, wall motion abnormalities, and blood viscosity changes after first transmural anterior myocardial infarction.

Sixty-three consecutive patients with a first transmural anterior myocardial infarction (MI) were studied by serial two-dimensional echocardiography (2D echo) to relate left ventricular (LV) thrombosis with serial changes in blood and plasma viscosity and fibrinogen levels, and wall motion abnormalities at the thrombus site, in order to identify those prone to this complication. The results suggest that an early 2D echo be performed in all patients with acute transmural anterior MI to detect LV thrombi and to identify those at risk of thrombosis.

The role of prehospital discharge two-dimensional echocardiography in determining the prognosis of survivors of first myocardial infarction.

Two-dimensional echocardiography (2DE) was performed in 47 consecutive survivors (mean age 47 years) of a first myocardial infarction (MI), to assess its value in predicting major cardiac complications (MCC) during the posthospital phase. 2DE was undertaken 1 day before hospital discharge (mean 15 days). A wall motion score was derived by analyzing endocardial motion in 11 left ventricular segments. During a mean 17-month follow-up, 17 patients had MCC: eight (47%) had significant angina; two (12%) reinfarcted, and seven (41%) died. Wall motion scores of patients with MCC (9.2 +/- 0.9) (+/- SEM) were significantly higher compared to those without MCC (3.7 +/- 0.4 (p less than 0.005). A wall motion score greater than or equal to 8 was present in 82% (14 of 17) of patients with MCC compared to 7% (2 of 30) who remained asymptomatic. Patients who died had significantly higher wall motion scores compared to those who survived (11.3 +/- 0.9 vs 4.7 +/- 0.5) (p less than 0.005). Stepwise logistic regression and discriminant analysis, by means of age, infarct site, maximal Killip class, cardiac enzymes, and wall motion score, identified wall motion score and Killip class as the most significant predictors of MCC. Thus predischarge 2DE is capable of identifying high-risk patients prone to developing MCC after a first MI.

Significance of early two-dimensional echocardiography after acute myocardial infarction.

We performed serial two-dimensional echocardiography (2D echo) in 35 patients with a first transmural myocardial infarction, to correlate initial left ventricular wall motion abnormalities with subsequent in-hospital cardiac complications, peak total creatine kinase level, and haemodynamic alterations, and to observe serial changes in the left ventricular wall motion. A wall motion score was derived by analysing endocardial motion in 15 left ventricular segments. Left ventricular wall motion could be analysed in 30 patients, 14 without (Group 1) and 16 with complications (Group 2). The initial wall motion score in Group 1 patients was 5.2 +/- 0.7 (+/- SEM) compared to 14.2 +/- 1.2 in Group 2 patients (P less than 0.001). A wall motion score of greater than or equal to 10 correlated with the occurrence of complications in 15 of 16 patients (sensitivity 93%, specificity 92%). Initial wall motion score did not correlate significantly with peak total serum creatine kinase and did not change significantly during the first 72 hr in both the groups. In 12 patients who underwent right heart catheterization together with 2D echo, the average wall motion score was 16.4 +/- 2.0 and cardiac index 2.4 +/- 0.3. Wall motion score correlated inversely with the cardiac index in these patients (r = -0.78; P less than 0.01). Thus, 2D echo performed in first transmural myocardial infarction patients soon after admission can identify those likely to have in-hospital complications. 2D echo wall motion score correlated significantly with the cardiac output in this study.

Early two-dimensional echocardiography in acute myocardial infarction. A study of left ventricular wall motion abnormalities.

Two-dimensional echocardiography (2DE) was utilized in 49 patients with a first transmural myocardial infarction, within 6 hours (+/- 3SD) after admission and again at 48 hours, in order to correlate initial left ventricular wall motion (LVWM) abnormalities with subsequent in-hospital cardiac complications. Analysis of systolic endocardial motion was made in 15 left ventricular segments in each patient and a total wall motion (WM) score was derived as a measure of the extent of myocardial involvement. LVWM abnormalities in relation to Killip class, peak total serum creatine kinase (CK) and serum glutamic oxaloacetic transaminase (SGOT) enzyme levels were also studied. Adequate echocardiograms for LVWM analysis were obtained in 43 patients. Thirteen patients had no infarct-related complications (group I) and 30 had complications (group II). The mean initial WM score in group I patients was 5.7 +/- 2.6 which was significantly lower than the 13.5 +/- 3.9 in group II (p less than 0.0001). A WM score of greater than 10 correlated with the occurrence of complications in 93% of patients. The WM score was significantly higher in admission Killip class 1 and 2 patients in group II compared with group I patients in class 1. However, no difference was noticed between the mean WM score of patients assigned to these 2 classes in group II. Peak CK and SGOT levels showed a poor correlation with the WM score in group I patients. In group II patients, only the peak SGOT levels correlated significantly with this score. We conclude that in patients with acute infarction, 2DE soon after admission can identify those likely to have in-hospital cardiac complications.

Left ventricular thrombi after acute myocardial infarction.

Two-dimensional echocardiography was utilized in a prospective study to find the incidence, characteristics and natural history of left ventricular thrombus in 50 consecutive patients with acute myocardial infarction. The overall incidence of thrombosis was 14%; 19% in anterior and 5% in inferior infarction. The thrombus was detected at the apex in 4, along the ventricular septum in 2 and at both these sites in one patient. It was observed 3-10 days after the infarction. Thrombus at the ventricular septum, seen in this study, has not been reported previously in acute myocardial infarction. Development of apical and septal thrombi was significantly associated with akinesis of these sites. Only 2 patients with protruding thrombi had systemic embolism. We conclude that the apex as well as the septum are common sites for thrombosis in patients with severe wall motion abnormalities following acute anterior infarction. Careful observation of these sites during echocardiography may reveal thrombi prone for embolization.

Echocardiography in infective endocarditis.

Two cases of infective endocarditis are reported. In both, vegetations on the cardiac valves characteristic of endocarditis were documented by echocardiography and confirmed at surgery in one of them. The various features of vegetative endocarditis on the echocardiogram are described. Differentiation of these echoes from those produced by other morbid states is discussed. Echocardiography is considered a useful non-invasive technique in the diagnosis of infective endocarditis. Cardiac surgery is usually found to be necessary in addition to medical therapy, when echoes characteristic of vegetative endocarditis are recorded by echocardiography.

Pernicious anaemia among Arabs in Kuwait.

Addisonian pernicious anaemia is believed to be very rare in Arabs. Three cases are reported. Two were Jordanians of Palestinian origin and one an Egyptian. All had the typical peripheral macrocytosis, a frankly megaloblastic bone marrow, and a Schilling test result in the range of pernicious anaemia. All three improved remarkably on vitamin B(12) therapy and have maintained a normal haemoglobin level. There was no evidence of gastric carcinoma in any of these cases.