Predictive value of electrocardiographic patterns in localizing left ventricular asynergy in coronary artery disease.

Transmural myocardial infarction by ECG (ECG-MI) was correlated with left ventricular asynergy by biplane left cineventriculography in 200 patients with coronary artery disease. The ability of individual ECG-MI patterns to predict and correctly localize asynergy was: anterior--98 per cent (43 of 44), inferior--82 per cent (36 of 44), true posterior--73 per cent (11 of 15). Of various combinations of criteria for true posterior ECG-MI, the pattern of an R wave and upright T wave in Lead V1 was most predictive of posterior asynergy--80 per cent (8 of 10). The LAO projection demonstrated a wall motion abnormality not appreciated in the RAO in 8 per cent (10 of 122) of cases of inferoposterior asynergy and enhanced assessment of asynergy in 30 per cent (36 of 122) of cases. It is concluded that: (1) ECG-MI has a high predictive accuracy for left ventricular asynergy, (2) an R-wave and upright T wave in Lead V1 is the best ECG predictor of posterior asynergy, and (3) the LAO projection makes an important contribution to the assessment of regional asynergy in coronary artery dieseas.     

The prognostic value of the P wave morphology in the discharge ECG in a 5-year follow-up study after myocardial infarction.

The discharge ECG's of 641 patients with acute myocardial infarction (AMI) (WHO categories "definite" and "possible" AMI) were studied to assess the prognostic value of P wave morphology as an index of left ventricular dysfunction. Of 69 patients with abnormal P terminal force (PTF), i.e., --0.03 mm.sec. or more negative, 53.6 per cent died within the next 5 years of ischemic heart disease, compared with 20.4 per cent of 558 patients with normal PTF. The odds ratio (age-corrected risk to die, Mantel-Haenszel test) was 4.1 (95 per cent confidence limits 2.4 to 7.0). The mortality curve of patients with normal PTF was linear whereas there was an abrupt rise in mortality rate during the first six months if PTF was abnormal. Of a group of 15 patients with the frontal axis of the terminal P wave --30 degrees or more negative, 8 died (Odds ratio 4.7; 1.3 to 17.1). Ten patients had atrial fibrillation, and five of them died (Odds ratio 2.; 0.5 to 12.9). In 14 cases the duration of the P wave in Lead II was 0.12 sec. but it showed no relationship to mortality (p less than 0.10). The significance of the P wave morphology on the discharge ECG to long-term survival after MI has been demonstrated. These simple ECG variables, related to left ventricular failure, can easily be put to clinical use to differentiate MI patients who are in greater risk of dying during the chronic phase.     

Morphologic significance of left atrial involvement

Left atrial involvement, defined as the terminal negativity of the P wave in Lead V₁ of 1 mm. or more in depth and a duration of 0.04 second or more, was evaluated in 270 autopsied cases with the use of a chamber dissection technique for the determination of atrial and ventricular hypertrophy. Left atrial involvement was present in the following: 35 (44.3 per cent) of 79 hearts with left atrial hypertrophy, 31 (34.8 per cent) of 89 hearts with right atrial hypertrophy, 32 (22.4 per cent) of 143 hearts without atrial hypertrophy, 52 (44.4 per cent) of 117 hearts with left ventricular hypertrophy, 17 (34.7 per cent) of 49 hearts with right ventricular hypertrophy, 9 (11.5 per cent) of 78 hearts without anatomic evidence of atrial or ventricular hypertrophy, and 3 (3.8 per cent) of 78 hearts without anatomic evidence of atrial or ventricular hypertrophy or any clinical or postmortem findings of cardiopulmonary disease. Left atrial involvement has a significant correlation with left atrial hypertrophy (p < 0.01) and left ventricular hypertrophy (p < 0.001). Left atrial involvement was frequently noted to be transient. The presence of left atrial involvement on the ECG appears to be the result of many factors including left-sided heart disease, left atrial hypertrophy, left ventricular hypertrophy, increases in left atrial volume or pressure, and possibly intra-atrial conduction delays.     

Local characteristics of the normal and asynergic left ventricle in man

The significance of ventricular asynergy in determining medical prognosis and surgical risk in patients with coronary artery disease and its delineation by ventriculography have been of increasing interest. To determine the underlying histopathologic and electrographic features of left ventricular asynergy, 39 patients undergoing open heart surgery were studied. Thirty-six histopathologic specimens were obtained in 31 patients (26 as transmural needle biopsies and 10 as aneurysm resections). In four normally contracting areas and 12 hypokinetic areas, neither fibrosis nor early changes of myocardial damage was evident. In contrast, of eight akinetic areas there was more than 50 per cent muscle loss in four and from 30 to 35 per cent muscle loss in three, in only one area was there less than 10 per cent muscle loss. Of 12 dyskinetic zones there was more than 75 per cent muscle loss in 10 zones, 35 per cent in one and no pathologic abnormalities in one.Epicardial electrograms were obtained from 35 areas in 29 patients. Of 10 normally contracting ventricles, in one, pathologic Q waves were demonstrated only over the inferior area. Progressive increases in the severity of asynergy were associated with a progressive increase in frequency of initial abnormal Q waves. In only one of nine hypokinetic areas were epicardial Q waves exhibited, but they were present in six of 10 akinetic and five of six dyskinetic areas.Both histopathologic and electrographic data were available from 20 asynergic areas in 16 patients. Initial epicardial R waves were associated with normal biopsy specimens in seven of eight hypokinetic areas. Of seven akinetic areas, initial R waves were associated with 30 to 35 per cent muscle loss in three; of four areas with initial Q waves, there was a 35 per cent muscle loss in one and more than 50 per cent muscle loss in three. Similarly, of five dyskinetic segments, a QS pattern was associated with more than 75 per cent fibrosis in four. In one dyskinetic area there was an initial R wave in association with a normal appearing biopsy specimen.In summary, a good correlation exists between the severity of asynergy by ventriculography, the degree of muscle loss and the presence of epicardial Q waves. However, a significant amount of histologically and electrographically normal myocardium may be present even in severely asynergic areas.     

Changes in the QRS complex and ST segment in transmural and subendocardial myocardial infarctions. A clinicopathologic study.

The QRS complex and ST segment in the ECGs of 80 patients who died of an acute myocardial infarction (MI) were studied in relation to the extent of the MI (subendocardial vs. transmural). Changes in the QRS complex developed in nine out of the 15 cases with an acute subendocardial MI. Five of these cases fulfilled the conventional QRS criteria for a myocardial infarction. A definite ST segment depression (a J point depression of 2 mm. or more in at least one lead, and a horizontal or downward sloping ST segment with a minimum duration of 0.08 sec.) occurred most frequently in connection with a circumferential subendocardial MI (88 per cent), but it was also found in a regional subendocardial (43 per cent) and transmural MI (43 per cent). In 17 per cent of the cases with a transmural MI, this was the only ECG abnormality. It is concluded that cases with a subendocardial MI cannot always be distinguished from transmural MI on the basis of the presence or absence of the QRS changes, and that an ST segment depression, as defined in this study, can give additional information in the evaluation of an acute phase of an MI.     

The electrocardiogram and cardiac state in active sickle-cell anemia

The problem of sickle-cell anemia heart disease was studied in twenty-five carefully chosen cases of active sickle-cell anemia. The pathologic changes were studied in nine others. The problem of heart disease in patients with sicklecell anemia was discussed from the clinical, pathologic, and electrocardiographic points of view.The electrocardiograms were analyzed in the routine manner.The disease occurred in young adults, and it was frequently confounded with rheumatic or congenital heart disease.An outstanding feature of the cardiac disease was cardiac enlargement, which occurred in 95 per cent of the cases. The enlargement involved for the most part the left ventricle, the right ventricle, and the pulmonary conus. In no instance was undue enlargement of the left auricle observed.Systolic and diastolic murmurs occurred at the aortic, pulmonic, and mitral areas. A thrill occurred in one case.Dyspnea on exertion was a frequent complaint, but orthopnea was uncommon. The pathologic specimens showed arteritis of the pulmonary, pericardial, and coronary arteries in one case, and mild pulmonary thrombosis in six of the nine subjects autopsied.Routine analysis of the electrocardiogram showed nothing characteristic of sickle-cell anemia heart disease. Significant changes in the electrocardiogram were seen in 20 per cent of the cases when single electrocardiograms were studied in the routine manner. Serial electrocardiograms showed very few changes over periods of approximately four years.Definite right axis deviation occurred in only one case, although enlargement of the pulmonary conus or right ventricle was encountered in 73 and 88 per cent of the cases, respectively.Premature beats were encountered in only two cases. No other cardiac arrhythmias, other than sinus arrhythmia, were seen.The P waves shoed about the same degree of notching as is encountered among normal subjects.The P-R interval surpassed the upper limit of normal in 12 per cent of the cases. Complete A-V block and bundle branch block were not present in this series.Only 4 per cent of the patients had a low T wave in Lead I.     

Significance of site of origin of premature ventricular contractions.

One hundred and sixty-five inpatients with premature ventricular contractions (PVC's) were clinically evaluated in regard to the presence (130 patients) or absence (35 patients) of organic heart disease. PVC's were classified based on QRS morphology (bundle branch block pattern) in Lead V₁ as being either left ventricular (66 patients), right ventricular (71 patients), or of both ventricles (28 patients). The incidence of organic heart disease was significantly greater in patients with left ventricualr PVC's 60 of 66 (91 per cent) and biventricular PVC's 25 of 28 (89 per cent) than in patients with right ventricular PVC's 45 of 71 (63 per cent) (p < 0.001). Of the 130 patients with organic heart disease, 60 (46 per cent) had left ventricular PVC's, 25 (19 per cent) had biventricular PVC's, and 45 (35 per cent) had right ventricular PVC's. of the 35 patients without organic heart disease, six (17 per cent) had left ventricualr PVC's, four (9 per cent) had biventricular PVC's, and 26 (74 per cent) had right ventricular PVC's.These data suggest the following conclusions regarding inpatients with PVC's: (1) Organic heart disease is frequent in patients with right ventricular PVC's and almost universally present in patients with left ventricular and biventricular PVC's. (2) Patients without organic heart disease primarily have PVC's of right ventricular origin. The mechanism of the latter association is unknown.     

Perioperative myocardial infarct following aortocoronary bypass. Clinical aspects, causes, consequences

Perioperative infarction is a significant factor of morbidity of coronary bypass surgery. The aim of this study was to review peri-operative infarction and its complications over a 10 year period (1974 to 1984) and to determine its consequences on left ventricular function and life expectancy. The material included 514 patients who underwent coronary bypass surgery. Perioperative infarction was defined as the association of a postoperative Q wave and increase in creatinine phosphokinase after the 24th postoperative hour: this diagnosis was made in 31 cases (Group A), 6 per cent of the series; 483 patients (Group B) had no signs of infarction. The necrosis involved the revascularised zone in 26 cases and other zones in 5 cases. The acute phase of infarction was associated with major complications in 9 patients of Group A. In 22 patients (70 per cent of cases) the initial evolution was uncomplicated. There was no significant difference in the number of patients with unstable angina between Groups A and B (52 per cent vs 67 per cent), with single vessel disease (25 per cent vs 28 per cent), double vessel disease (45 per cent vs 34 per cent) or with triple vessel disease (30 per cent vs 38 per cent). The average number of bypasses was higher in Group A (2.06 per cent vs 1.4 per cent, p less than 0.05), as was the duration of cardiopulmonary bypass (117 min vs 91 min, p less than 0.05) and of aortic clamping (45 min vs 31 min, p. less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Computer analysis of the orthogonal electrocardiogram and vectorcardiogram in 939 cases with hypertensive cardiovascular disease

Orthogonal ECG's (Frank system) were recorded from 939 male patients with hypertensive cardiovascular disease (HCVD) and were compared with records from 229 normal subjects, matched for age, race, and sex. The hypertensive subjects were divided into three clinical groups: (1) patients without cardiac enlargement by chest x-ray and no history of congestive heart failure (CHF), (2) patients with cardiac enlargement but without past or present CHF, and (3) patients with cardiac enlargement and one or more episodes of CHF. A sustained blood pressure level of $\text{150}\text{90}\text{mm. Hg}$ or more was present in all cases.First an attempt was made to identify optimal scalar and vectorial ECG measurements for discriminating between HCVD and normal, testing a total of 333 variables. With four scalar measurements at a specificity level of 95 per cent, 24 per cent of Group 1, 37 per cent of Group 2, and 44 per cent of Group 3 could be correctly classified. Vector measurements were found mostly redundant.Using linear discriminant function analysis and a likelihood ratio test with 13 different ECG variables at a level of specificity of 95 per cent, it was possible to identify correctly 53 per cent, 75 per cent, and 87 per cent of Groups 1, 2, and 3, respectively.Comparison of results with other reports on ECG changes caused by left ventricular overload (LVO) suggested that the degree of LVO in HCVD, even in the most advanced Group 3, was considerably less than that reported in patients with valvular heart disease with the only exception of terminal cases with HCVD who had come to autopsy. Antihypertensive therapy was considered as one factor which might have contributed to this finding.Multivariate ECG analysis was found an efficient means for diagnostic classification, leading to results which equalled those reported for multiple dipole analysis. As compared to scalar or vector measurements, either used individually or in combination, the multivariate technique exceeded all of these methods for LVO diagnosis by a wide margin when specificity was kept at a constant level.     

Interpretation of RSR' in pulmonic stenosis

An RSR′ pattern in Lead V₁ (with R′ the dominant positive deflection) was found in 108 of 539 patients (20 per cent) with valvular pulmonic stenosis admitted to a national co-operative study of congenital heart defects. On the average, patients with an RSR′ pattern showed lower right ventricular-to-pulmonary artery pressure gradients (mean = 55 mm. Hg) than patients with a QR, R, or RS pattern (mean = 70 mm. Hg). Moreover, an R′-wave of a given voltage was associated with generally lower right ventricular systolic pressures and gradients than an R-wave of equal amplitude. Quantitatively, these data suggest that in patients with an RSR′ complex in Lead V₁, the R′ voltage has the same severity implication as a “pure R” of magnitude (0.5) R′ + 2 mm.     

Left auricular dilatation in calcified aortic stenosis in adults

Two groups of patients of comparable age, one comprising 12 subjects without detectable cardiac disease and the other comprising 38 patients with calcific aortic stenosis (CAS) underwent clinical, electrocardiographic, echocardiographic and haemodynamic studies to assess the degree and significance of left atrial hypertrophies in CAS. The volume of the left atrium (LA) was globally increased in CAS (maximum volume 68 per cent: 26/38) and LA ejection fraction was decreased in 60 per cent of patients (23/38). However, the maximum volume was only moderately greater than that of normal subjects (+38 per cent). The most specific non-invasive investigation for left atrial assessment is echocardiography. There was a linear relationship between LA angiographic volume and echocardiographic antero-posterior dimension (r = 0.43; p less than 1 x 10(-2)). The duration of the P wave in S2 was a specific (75 per cent) but relatively insensitive (27 per cent) sign of LA dilatation in pure CAS. On the other hand, the Morris index based on the surface of the P terminal force in V1 was quite sensitive (77 per cent) but not very specific (25 per cent). The maximum LA volume was not related to left ventricular volume, the severity of CAS, diastolic indices of compliance or left ventricular mass. However, the minimum LA volume (after atrial systole) was related to left ventricular end diastolic (r = 0.35, p less than 0.05) and end systolic volume (r = 0.34, p less than 0.05). The LA ejection fraction was inversely related to mean pulmonary capillary pressure (r = 0.34, p less than 5 x 10(-2).(ABSTRACT TRUNCATED AT 250 WORDS)     

The clinical course, early prognosis and coronary anatomy of subendocardial infarction.

The following prospective study was undertaken to observe the clinical course, early prognosis and coronary anatomy of patients with subendocardial infarction. Subendocardial infarction was defined as typical chest apin (greater than 15 minutes), serum enzyme elevation and persistent (greater than 48 hours) new T wave inversion and/or S-T segment depression in the absence of new pathologic Q waves. Fifty consecutive patients were defined, followed in a prospective manner and subjected to early coronary arteriography. A prior history of unstable angina was found in 33 patients (66 per cent); 22 patients (44 per cent) had significant dysrhythmias during the acute hospital phase, and seven patients (14 per cent) had evidence of mild left ventricular failure. Coronary arteriography demonstrated significant lesions (greater than 75 per cent narrowing in at least one vessel) in all 50 patients, with 30 patients (60 per cent) having either double- or triple-vessel disease. Follow-up (mean 10.6 months) revealed that 15 patients (30 per cent) had stable angina, 23 patients (46 per cent) unstable angina and only 12 patients (24 per cent) remained free of angina. Of 28 patients in a medically treated group, acute transmural infarctions developed in six (21 per cent) and one died (3 per cent). We conclude that subendocardial infarction is symptomatically an unstable entity, is associated with severe coronary artery disease and, in a medically treated group, is followed by a significant incidence of early transmural myocardial infarction (21 per cent). Therefore, these patients require in-hospital monitoring, careful follow-up and consideration for early coronary arteriography.     

Chronic thromboembolic occlusion of main pulmonary artery or primary branches. Case report and review of the literature.

Chronic thromboembolic occlusion of the left pulmonary artery in a 36 year old woman is described, and similar cases reported in the past 15 years are discussed. On review, this disease remains a rare entity. In the majority of cases, the etiology is thrombophlebitis and acute pulmonary embolism. Associated cardiopulmonary disease is uncommon. The most common presenting symptom is unexplained dyspnea, and the majority of patients have past histories of hemoptysis. Acute cardiovascular collapse is distinctly rare. Most physical signs and laboratory tests are normal or nonspecific. The perfusion lung scan, although nonspecific, is the best screening test. Antemortem diagnosis, with rare exception, is established by pulmonary angiography. Eleven patients have been operated on: thromboembolectomy in nine, saphenous vein graft in one and pneumonectomy in one. Operative mortality was 36 per cent (four of 11), definite improvement was seen in 46 per cent (five of 11), and 18 per cent (two of 11) survived the operation with no improvement. The role of medical therapy in this disease is considered.     

The use of the augmented unipolar left leg lead in the differentiation of the normal from abnormal Q wave in standard lead III

An attempt was made to evaluate the diagnostic significance of the QRS pattern in the augmented, unipolar left leg lead (Lead aV_F) as a means of establishing or excluding the diagnosis of posterior infarction. Forty-nine patients were selected for study because of the presence of a prominent Q wave in standard Lead III. One additional patient with posterior infarction was included. This patient did not have Q waves but exhibited the classical ST-T wave changes in Lead III.Multiple precordial and unipolar extremity leads were taken on every subject and esophageal leads were taken on forty-four of the fifty subjects. The presence of a posterior infarct was established in a total of twenty-five subjects, in four of these by autopsy, and in the remaining twenty-one by typical esophageal leads. The infarct was months or years old in all but four cases. Posterior infarction was excluded in a total of twenty-five subjects, in three by autopsy and in the remaining twenty-two by negative esophageal leads.In all cases where posterior infarction was excluded, a prominent Q₃ or QS₃ was present. This amounted to 25 per cent or more of the tallest R in twenty-three of the twenty-five cases; from an examination of the standard leads alone, many of these cases could not be distinguished from cases proved to have old posterior infarction. The pattern of the QRS in Lead aV_F proved to be of considerable help in this differentiation.A QaV_F which was 25 per cent or more of RaV_F was found in twenty-two of the twenty-five subjects proved to have posterior infarct, and in only three of the twenty-five subjects in whom the diagnosis of posterior infarction had been excluded. In both cases of posterior infarct which had a Q₃ but failed to show QaV_F, esophageal leads suggested that the infarct was located high on the posterior wall, near the auricular margin. The voltage of the QRS wave in Lead aV_F was low in two of the three uninfarcted controls which showed a $\text{Q}\text{R}$ ratio exceeding 25 per cent in this lead. In the remaining case, the deep Q wave was present in Lead aV_F when the patient was recumbent, but disappeared when the curve was taken with the patient in the erect posture.The mechanism of production of the Q wave in standard Lead III has been discussed separately for (a) that associated with posterior myocardial infarction, (b) that occurring in uninfarcted hearts with a horizontal or semihorizontal electrical axis, and (c) that occurring in uninfarcted hearts with a vertical electrical axis.     

Calcific aortic insufficiency—a review of 26 patients

Twenty-six patients, 8.3 per cent of all patients with aortic valve disease, and 10.7 per cent of all patients with any degree of aortic insufficiency detected in our catheterization laboratory, had pure calcific aortic insufficiency (no associated stenosis). Nineteen (73 per cent) males and seven (27 per cent) females ranged in age from 25 to 75 years of age (mean 51). Twenty-three per cent were younger than 40. Sixteen (62 per cent) had rheumatic heart disease, one had luetic aortic valve disease, one had congenital bicuspid valve, and eight (31 per cent) had aortic insufficiency of undetermined etiology. Twenty-three patients (89 per cent) had an aortic systolic ejection murmur, and seven (28 per cent) had an aortic ejection click. Aortic valve calcification was detected by plain chest films in only four patients (16 per cent), and by routine image intensification fluoroscopy (before catheterization) in fifteen patients (68 per cent). The remaining 32 per cent had the calcification of the aortic valve detected during catheterization.Aortic valve calcification was severe in nine patients (35 per cent), moderate in eleven patients (42 per cent), and minimal in six patients (22 per cent). Aortic insufficiency was severe in twenty patients (77 per cent), moderate in five patients (19 per cent), and minimal in one patient (4 per cent). Nineteen patients (77 per cent) had reduced left ventricular contractility. Sixteen patients (67 per cent) had low cardiac index. Eighteen patients had normal coronary arteries and three patients had obstructive coronary artery disease. Aortic stenosis was misdiagnosed as the predominant lesion in fourteen patients (54 per cent)—prior to catheterization. This series demonstrates that all patients with calcified aortic valve disease and with ejection murmurs do not necessarily have aortic stenosis. Pure calcific aortic insufficiency is a distinct entity, more common than previously suspected.     

Ischemic myocardial injury during cardiopulmonary bypass surgery

ECG's and serum levels of SGOT, LDH, and CPK were examined during the immediate postoperative period in 126 patients who had cardiac surgery during cardiopulmonary bypass. None had coronary disease and valve replacement was performed in 97 patients. Miscellaneous procedures not involving the coronary arteries were performed in 29. In surviving patients, ECG signs of acute myocardial infarction appeared in 8 (7 per cent) and changes compatible with acute ischemic injury were seen in 38 (30 per cent). Elevation of SGOT exceeding 90 units occurred in 32 per cent of patients and LDH levels over 900 units occurred in 37 per cent. In patients with ECG evidence of postoperative infarction or ischemia, 70 per cent had abnormal SGOT levels and 70 per cent had abnormal LDH levels. In 40 patients with SGOT levels exceeding 90 units, 80 per cent had ECG evidence of acute infarction or ischemia. In 80 patients without ECG changes, only 10 per cent had SGOT levels exceeding 90 units. CPK levels correlated poorly with ECG evidence of ischemia or infarction. Patients who demonstrated ECG and serum enzyme evidence of ischemic injury or myocardial infarction had longer total perfusion times during surgery (P < 0.001) but no relationship to aortic cross clamp time was observed. ECG evidence of acute myocardial ischemia with elevation of serum enzymes is frequently observed following cardiopulmonary bypass surgery. Serial ECG's and measurements of postoperative serum enzymes provide useful information regarding myocardial injury and the effectiveness of bypass perfusion in protecting the myocardium during cardiopulmonary bypass sugery.     

Cystic fibrosis in adults. 75 cases and a review of 232 cases in the literature.

Cystic fibrosis is now the most common cause of chronic obstructive pulmonary disease (COPD) and of pancreatic insufficiency in the first three decades of life in the United States. In this report we describe 75 patients with cystic fibrosis aged 18 to 47 years and review another 232 cases reported in the literature. All of these 307 patients had elevated sweat chloride and sodium levels, which proved excellent discriminants for cystic fibrosis even in patients in the older age group. COPD, present in 97 per cent, was the major cause of morbidity and mortality, and differed from COPD of other etiologies. The progressive downhill course in these patients was punctuated by recurrent symptomatic exacerbations of chronic bacterial bronchitis caused by Pseudomonas aeruginosa and Staphyloccocus aureus, and terminated in pulmonary insufficiency, cor pulmonale and death. COPD was complicated by minor hemoptysis in 60 per cent, massive hemoptysis in 7 per cent and pneumothorax in 16 per cent, problems rare in children. Sinusitis was present in all those examined roentgenographically, and 48 per cent had nasal polyposis. Pancreatic insufficiency was present in 95 per cent of the patients, but in contrast to younger patients it was seldom symptomatic although steatorrhea and azotorrhea were still massive. Intussusception and meconium ileus equivalent (fecal accumulation) are frequent in adults (21 per cent) but rare in children, and they require immediate diagnostic and therapeutic intervention with enemas of diatrizoate sodium. Glycosuria, biliary cirrhosis, cholelithiasis and aspermia were among other complications. Height and weight were usually within the lower limits of normal, but 17 per cent of the men were above 180 cm in height and 7 per cent were overweight. Therefore, a high index of suspicion is needed to make the diagnosis, because older patients with cystic fibrosis may look quite well.     

Occurrence and significance of electrocardiograms displaying large Q-waves in Lead III

Three hundred cases in which there were electrocardiograms with large Q-waves in Lead III, according to the criteria of Pardee, are presented. The majority of these records (268 or 89.3 per cent) were obtained in examination of patients who had one of the following conditions: hypertensive heart disease, the anginal syndrome, hypertensive heart disease accompanied by the anginal syndrome, or arteriosclerotic heart disease not accompanied by the anginal syndrome or hypertension. The remaining thirty-two patients (10.7 per cent) had miscellaneous conditions, but the majority of them had diseases that exert their influence chiefly on the left ventricle. Only three cases (1 per cent) in which the patients apparently had normal hearts were found. In 198 cases (66 per cent of 300) the large Q-wave in Lead III was the only significant electrocardiographic feature present, permitting the conclusion that this abnormality may be considered as an additional diagnostic sign. In the composite group of 977 normal persons studied by various observers there were only two cases (0.2 per cent) in which large Q-waves occurred in Lead III.     

Plasma tocopherol levels in cardiac patients

1.

1. The average plasma tocopherol level in sixty-two patients with heart disease was 0.94 mg. per cent, a value which was significantly lower than the mean of 1.09 mg. per cent found in twenty-one healthy young adults. In addition, there was a greater incidence of very low levels among the cardiac patients.     

Correlation of abnormal Q waves, coronary pathology, and ventricular contractility.

Four hundred and ninety-two patients with coronary artery disease underwent analysis of their electrocardiograms, coronary arteriograms, and ventriculograms. Significant Q-waves were correlated with critical coronary occlusions (greater than or equal 75 per cent obstruction) and ventricular contractility. It was found that Q-waves correlate equally well with ventriculographic abnormalities and critical coronary occlusions. The Q-wave correlation varied from 77 to 87 per cent, depending on the area of myocardium under consideration, except for true posterior myocardial infarction, which correlated 55 per cent with ventriculographic abnormalities and 55 per cent with critical coronary occlusions. Significant Q-waves in Leads II, III, and aVF are better indicators of ventriculographic abnormality than in Leads III and aVF alone, whereas Q-waves in the latter two leads are more definitive than in Lead III alone. Patients who have critical coronary occlusions and normal electrocardiograms have normal ventriculograms in 71 to 78 per cent of the cases, again depending on the area of the myocardium under consideration. Thus, the normal electrocardiogram correlates better with the ventriculogram than with coronary pathology. The abnormal electrocardiogram correlates equally well with both.