Autonomic balance in patients with angina and a normal coronary angiogram

The pathophysiology of angina pectoris in patients with a normalcoronary angiogram is not clear. Furthermore, the pathophysiologicalimpact of ST changes in syndrome X is controversial. The purposeof this study was to investigate cardiac autonomic function,by measuring 24 h heart rate variability, in patients with andwithout electrocardiographic evidence of ischaemia during exercise. Thirty-two patients with angina pectoris, a normal coronaryangiogram, echocardiogram, hyperventilation test and gastro-oesophagealinvestigation were studied. Fourteen healthy subjects servedas controls. Fifteen patients had significant ST segment depressionduring stress testing, whereas 17 had no electrocardiographicsigns of ischaemia. Heart rate variability was calculated as(1) mean RR= mean of all normal RR intervals, (2) the differencein mean RR level between when awake and when asleep (mean RRwake-sleep)—a tentative index of sympathetic activation,(3) the standard deviation (SD)—a broad band measure ofautonomic balance, and (4) a percentage of successive RR intervaldifferences 6% (pNN6%)—an index of vagal modulation. Thecoronary vascular resistance was measured at rest and duringpacing. Mean RR and autonomic indexes did not differ between patientswith a positive exercise test and controls (831/884 m 24 h SD125/134 m pNN6% 6.715.4%, respectively). Patients with a normalexercise test had shorter mean RR (758 ms vs 844 m P<0.05)and significantly reduced 24-h SD (103 ms vs 134 m P<0.05)than controls, whereas values for vagal index (6.5% vs 5.4%)did not differ from healthy controls. Mean RR wake-sleep alsotended to be lower in patients with a normal exercise test (–125 ms vs – 173 ms) compared to controls (P<0.1). Patientswith a positive exercise test had a significantly attenuatedreduction in coronary vascular resistance during pacing in comparisonto patients with a normal exercise test (–0.131–0.26mmHg x min. ml^{– 1}; P<0.05). The findings suggest the occurrence of general elevated sympatheticactivation in angina patients with a normal exercise test. Patientswith a positive exercise test exhibited no signs of autonomicdysfunction although these patients had altered coronary vascularresistance indicating microvascular angina. This supports thesuggestion that patients with a normal exercise test constitutean independent pathophysiological entity.     

Submaximal early exercise test compared to clinical findings for evaluation of short- and long-term prognosis after the first myocardial infarction

Clinical and ergometric data were derived from 1098 consecutiveexercise tests in patients with a first acute myocardial infarctionbetween 1974–1983. In 1992 a follow-up was performed inorder to analyse the importance of a submaximal early exercisetest, in combination with clinical data, for the predictionof short- and long-term prognosis of cardiovascular death. The relative value of 20 clinical variables, including medicalhistory, markers of infarction size, medication etc., and 28variables at exercise test were studied. Univariate, multivariateand survival analysis, for estimation of prognosis and independentprediction of cardiovascular death was used. Independent clinical risk factors for cardiovascular death were(1) Within 1 year: relative heart volume (ml.m^–2 bodysurface area) on chest X-ray. (2) Long-term mortality: maximumheart rate and relative heart volume, diabetes, age and digitalismedication. Independent exercise risk factors were: (1) Within1 year: heart rate, ventricular arrhythmia and ST depression 1 mm before exercise, diastolic blood pressure at maximum exerciseand target heart rate. (2) Long-term mortality: angina pectorisand/or ST depression 1 mm at maximum exercise. In subgroupsof patients with clinical risk factors, mortality risk increasedif there were signs of angina pectoris and/or ST depression 1 mm during exercise. The risk increased 100% in diabetics,91% with age >70 years, 58% with relative heart volume 500ml.m^–2 body surface area, 42% with heart rate 100 atadmission, and 34% with digitalis medication. No increase wasfound in the subgroup of patients without clinical risk factors. Thus, submaximal early exercise stress testing provides importantinformation for short- and long-term prognosis in patients afterthe first acute myocardial infarction compared to clinical evaluationalone.     

Good exercise capacity at hospital discharge predicts recovery of baroreflex sensitivity after myocardial infarction

Myocardial infarction results in depressed baroreflex sensitivity,which has been shown to be associated with increased risk ofventricular arrhythmias and sudden death. We measured baroreflexsensitivity in 37 patients with acute myocardial infarctionbefore hospital discharge and 3 months after the infarctionto find out whether the baroreflex sensitivity recovers duringthat period. In addition, baroreflex sensitivity was assessedin 15 healthy controls. Baroreflex sensitivity was assessedfrom the regression line relating the change in R-R intervalto the change in systolic blood pressure following an intravenousbolus injection of phenylephrine. There was a wide inter-individualvariation in the change of baroreflex sensitivity (Abaroreflexsensitivity) in infarction patients, but the average baroreflexsensitivity showed no significant change during the 3-monthfollow-up (10.2 +5.6 to 11.8 ± 7.5 ms. mmHg ^–1,ns) and remained lower than the baroreflex sensitivity of thecontrols (16.4 ± 9.7 ms. mmHg^–1, P<0.05). Baroreflexsensitivity correlated significantly with exercise capacitymeasured before hospital discharge. When the patients were dividedinto tertiles according to the baroreflex sensitivity ( –3.3 ± 1.5 ms. mmHg^–1 in the lowest tertile, 1.0± 1.0 ms. mmHg^–1 in the middle tertile and 7.5± 40 ms. mmHg^–1 in the highest tertile) the exercisecapacity was found to increase from the lowest to the highesttertile (exercise time 357 ± 115 s, 418 ± 126s and 461 ± 141 s, respectively; P<0.05 lowest vshighest tertile). Patients with a low exercise tolerance (exercisetime <360 s) showed a significantly smaller Abaroreflex sensitivitythan patients with a good exercise tolerance (exercise time480s) ( – 0.5±4.4 vs 5.3 ± 5.4ms. mmHg^–1,P<0.05), respectively. Baroreflex sensitivity was not relatedto the location or type of infarction, thrombolytic therapy,presence of angina pectoris or left ventricular function atthe time of discharge. In conclusion, exercise capacity assessedbefore hospital discharge seems to be a predictor of baroreflexsensitivity recovery in patients with a recent myocardial infarction.     

Haemodynamic findings in experimental right ventricular ischaemia after right coronary arterial ligation

Acute ischaemia limited to the free wall of the right ventriclewas produced by right coronary arterial ligation (RCAL) in 20dogs. Contrast M-mode and cross-sectional echocardiography wasperformed in 7 cases to investigate the presence of tricuspidinsufficiency. The haemodynamic findings obtained with an openpericardium at 15 to 30 min showed increases in right (l.20.5to 2.70.7 mmHg, P0.01) andleft (5.0 0.8 to 6.60.9 mmHg, P005)ventricular end-diastolic pressures, and decreases in heartrate (1394.9 to 1195.1 bpm, P0.01), cardiac index (1066.6 to817.3 ml min^–1 kg^–1, P001), stroke index (79 6 to72 8 ml x 100 beat^–1 kg^–1, P0.02), right (23.8l.5to 19.41.5 mmHg, P0.01) and left (1097.2 to 958.2 mmHg, P005)ventricular systolic pressures and right ventricular strokework index (18.32.4 to 11.41.8 g m kg^–1, P0.01). In 6of 15 cases the 'y' descent became deeper than the 'x' descentin right atrial pressure (RAP). Tricuspid insufficiency gradeI–II/IV was present in 3 of 7 cases, 2 of them with a'y'>'x' in RAP. Right ventricular mechanical alternans, probablysecondary to a decrease in contractility, appeared in 10 of20 cases after RCAL. Closure of the pericardium exaggeratedthe haemodynamic alterations and a dip-plateau appeared in 2cases on the right ventricular pressure curve. We conclude thatsignificant aemodynamic alterations in right ventricular functionare produced by RCAL in dogs, and they are exaggerated afterclosing the pericardium.     

Lack of correlation between haemodynamic and cardiopulmonary exercise capacity improvement after catheter-balloon mitral valvuloplasty

The long-term effects of percutaneous transvenous mitral commissurotomyon exercise capacity and ventilation were investigated to determinewhether a dissociation between haemodynamic improvement andexercise capacity increase occurs in patients with mitral stenosis.Eighteen patients aged 45 ± 12.3 years (mean ±SD) with symptomatic mitral stenosis performed a symptom-limitedbicycle exercise test while respiratory gases were measuredbefore and 6 months after percutaneous transvenous mitral commissurotomy.The mitral valve area increased from 1.07 ±0.22 to 1.98±0.67 cm². P<0.0001 and the mean mitral gradient decreasedfrom 12.9 ±4.5 to 5.3±4.8mmHg, P<0.001, withouta significant increase in cardiac output index (from 2.64 ±0.55 to 2.77 ± 0.56 l. min_{– 1}. m_{– 2}, P= ns).This haemodynamic improvement was still present at the 6-monthfollow-up catheterization. Mean exercise workload and peak oxygenuptake increased 6 months after percutaneous transvenous mitralcommissurotomy from 88.3 ± 28.1 to 97.8 ± 25.1watts, P= 0.01, and from 18.1 ± 5.3 to 19.9 ±4.8 ml. kg_{– 1}.min_{– 1}, P<0.05. Total ventilation,ventilatory equivalents and oxygen pulse at the end of the exercisetest remained unchanged Correlations between peak oxygen orexercise capacity improvement and mitral valve area increasewere poor (r= 0.27, P= ns, r= 0.24, P=ns). This clear dissociationbetween haemodynamic improvement and improvements in minor exercisecapacity after percutaneous transvenous mitral commissurotomysuggests that peripheral alterations persist. Future studiesin which patients are trained after valvuloplasty may be helpful.     

Peak oxygen uptake during exercise in mitral stenosis with sinus rhythm or atrial fibrillation: lack of correlation with valve area: A study in 70 patients

Although the haemodynamic response during submaximal supineexercise in mitral stenosis has been well described, the determinantsof peak oxygen uptake during maximal upright exercise are poorlycharacterized and may differ in sinus rhythm and atrial fibrillation.Seventy patients with isolated mitral stenosis underwent Doppler-echocardiographyand bicycle exercise with respiratory gas analysis. Forty-twopatients were in sinus rhythm (Group I) and 28 in atrial fibrillation(Group II). Peak oxygen uptake it was 21·3±5·6ml. min^–1 kg^–1 in group I and 18·1 ±5·1 ml min^–1 kg^–1 in group II (P<0·05).There was no significant correlation between indices of exercisetolerance (exercise duration, ventilatory threshold, peak oxygenuptake, indexed peak oxygen uptake, peak oxygen pulse) and valvearea or gradient in either group. Indexed peak oxygen uptakewas not correlated to oxygen pulse but was linearly related(r=0·43) to heart rate ( heart rate =peak heart rate=restheart rate) in Group I but not in Group II. Thus, in patientswith mitral stenosis, no correlation was found between the mitralvalve area or the gradient at rest and maximal upright exercisetolerance, suggesting that peripheral adaptation and, in sinusrhythm, chronotropic reserve, are important compensatory mechanisms.     

Left ventricular hypertrophy and myocardial ischaemia in hypertension: The THAMES Study

A multicentre epidemiological study to detect the prevalenceof myocardial ischaemia in hypertensive left ventricular hypertrophy(LVH) was performed in 188 asymptomatic male hypertensives (131treated). The mean age was 55 (range 40–82) years withblood pressure (BP) 160/100 mmHg or a systolic BP 180 mmHg.The participants were screened with echocardiography, and leftventricular hypertrophy (LVH), defined as LV mass index (LVMI) 130 g . m^–2, was found in 127 (68%), of whom 95 wereon antihypertensive treatment. Patients with LVH underwent amaximal bicycle ergometer exercise test and significant ST depression,indicating possible stress-induced ischaemia was found in 29men (23%). These subjects were subjected to exercise thallium-201scintigraphy, which was normal in 14 but showed reversible perfusiondefects in 15. Thus, a high prevalence of LVH (70%) was detected in male hypertensivesselected only on age and BP. In addition, although chest painon exertion excluded patients from entry, a substantial portionhad signs of ischaemia (23% on exercise ECG alone, and in 52%confirmed by thallium scan). The prevalence of these risk factorsshould be considered when evaluating hyper tensive patients.     

Evaluation and prognostic significance of left ventricular diastolic function assessed by Doppler echocardiography in the early phase of a first acute myocardial infarction

AIM: To study the prognostic significance of left ventricular diastolicfunction evaluated by transmitral and pulmonary venous flowvelocities obtained in the early phase of a first acute myocardialinfarction in relation to later development of congestive heartfailure. METHODS: Pulsed Doppler echocardiography of transmitral and pulmonaryvenous flow was assessed in 65 consecutive patients with a firstmyocardial infarction within 1 h of arrival in the coronarycare unit. RESULTS: A univariate regression analysis identified age, left ventricularejection fraction 45%, mitral E deceleration time 130 ms, E/Aratio >1·5, peak pulmonary venous atrial flow velocity30 cm . s^–1 and a difference between mitral and pulmonaryvenous atrial flow duration >0 ms as variables significantlyrelated to the development of congestive heart failure. However,in a multivariate analysis only mitral E deceleration time 130ms and age were significant independent variables related tothe development of congestive heart failure during the firstweek following a first acute myocardial infarction. CONCLUSION: Assessment of left ventricular diastolic function complementsmeasurements of systolic function in the evaluation of cardiacfunction, and mitral deceleration 130 ms best identifies patientsat risk of development of congestive heart failure followingacute myocardial infarction.     

Early administration of captopril and nitroglycerin in combination after acute myocardial infarction: an invasive haemodynamic study

The combination of captopril and nitroglycerin early after acutemyocardial infarction (AMI) could lead to a dangerous decreasein blood pressure coronary perfusion. To evaluate the safetyaspects and haemodynamic effects of this combination, we studied36 first ‘Q wave’ thrombolysed anterior wall AMIpatients during the 24 h following the onset of symptoms. Afterwards, thrombolysis patients received a continuous infusionof nitroglycerin and were submitted to pulmonary artery catheterization.Those patients with mean arterial pressure (MAP) 70 mmHg, cardiacindex 2.21. min^–1.m^–2, and wedge pressure 10 mmHgwere included and randomized to receive 6.25 mg of captoprilevery 6 h on the first day and 12.5 mg qid on the second f MAP 70mmHg (group 1). A second group (group 2) received a placebo.Haemodynamic parameters were determined after 1, 6 and thenevery 6 h up to 48 h after basal measurements. Significant differenceswere observed only for the MAP and the rate-pressure product(reduction in group 1 values, P <0.05). However, MAP wasmaintained within acceptable limits. Our data support the factthat the combination of captopril and nitroglycerin in the earlyhours of a non-complicated anterior wall AMI is safe, and couldguarantee its use in large clinical trials to determine theeffects on left ventricle remodelling and survival after AMI.     

Exercise training in heart failure improves quality of life and exercise capacity

Aims Benefit from exercise training in heart failure has mainly beenshown in men with ischaemic disease. We aimed to examine theeffects of exercise training in heart failure patients 75 yearsold of both sexes and with various aetiology. Methods and Results Fifty-four patients with stable mild-to-moderate heart failurewere randomized to exercise or control, and 49 completed thestudy (49% 65 years; 29% women; 24% non-ischaemic aetiology;training, n=22; controls, n=27). The exercise programme consistedof bicycle training at 80% of maximal intensity over a periodof 4 months.Improvements vs controls were found regarding maximalexercise capacity (6±12 vs –4±12% [mean±SD],P<0·01)and global quality-of-life (2 [1] vs 0 [1] units [median {inter-quartilerange}],P<0·01), but not regarding maximal oxygenconsumption or the dyspnoea–fatigue index. All of thesefour variables significantly improved in men with ischaemicaetiology compared with controls (n=11). However, none of thesevariables improved in women with ischaemic aetiology (n=5),or in patients with non-ischaemic aetiology (n=6). The trainingresponse was independent of age, left ventricular systolic function,and maximal oxygen consumption. No training-related adverseeffects were reported. Conclusion Supervised exercise training was safe and beneficial in heartfailure patients 75 years, especially in men with ischaemicaetiology. The effects of exercise training in women and patientswith non-ischaemic aetiology should be further examined.     

Cardiac responses to hypoxia and hypercapnia in spinal man

The purpose of this study was to evaluate the effect of interruptionof the descending supraspinal sympathetic outflow on heart ratecontrol during exposures to chemical stimuli. We investigatedthe heart rate responses to progressive isocapnic hypoxia andhyperoxic hypercapnia using the rebreathing technique and quantifiedthe relationship between heart rate (HR), oxygen saturation(SaO₂), alveolar PCO₂ (P_ACO₂), and minute ventilation (V_E) in16 chronic tetraplegic subjects with low cervical spinal cordtransection. The HR responses were determined from the linearslopes of HR on SaO₂ and HR on P_ACO₂. We found that mean restingheart rate was within normal range; 66 ±3 (SEM) beatsmin^–1. HR increased as oxygenation fell or CO₂ tensionrose. The mean tetraplegic HR/SaO₂ was 0.83 ± 0.14 beatsmin^–1 per 1% fall in SaO₂ and that of HR/P_ACO₂ was 0.30± 0.13 beats min^–1 per mmHG rise in P_ACO₂. TheHR and V_E responses to either hypoxia or hypercapnia were relatedin the tetraplegic subjects. We conclude that the stimulatoryHR reponses to chemical stimuli are not suppressed by cervicalspinal cord transection. Thus, the descending sympathetic activitydoes not underlie the HR acceleration by chemical stimuli.     

Antihypertensive treatment with felodipine but not with a diuretic reduces episodes of myocardial ischaemia in elderly patients with hypertension

Episodes of transient myocardial ischaemia can frequently beobserved in hypertensive patients. To assess the effects ofantihypertensive treatment with the calcium antagonist felodipineor the diuretic combination hydrochlorothiazidel triamtereneon episodes of ischaemic-type ST-segment depression (ST-D),simultaneous ambulatory electrocardio-graphic and blood pressure(BP) monitoring was performed in 42 elderly hypertensives withoutmanifest coronary artery disease. All patients (mean age 79± 6 years, office BP 160/95 mmHg) were evaluated offany antihypertensive or anti-ischaemic therapy and after 3 monthstreatment with either felodipine or the diuretic (randomized,double-blind study) for episodes of significant ST-D (0.1 mV,duration 1 min, interval 1 min). The reduction in office BPand daytime ambulatory BP was similar for both agents, as wasa significant reduction in the heart rate x systolic BP product(DP) over 24 h (felodipine: 12 441 ±2076 vs 11 643 ±1953 mmHg. min^–1; P=0.048; diuretic: 12 366 ± 2782vs 11 062 ± 2012 mmHg. min^–1; P=0.003). While felodipinesignificantly decreased the total number of ST-D (from 40 tosix episodes; P=0.03), the total number of ST-D remained unchangedwith the diuretic (non-significant increase from 31 to 45 episodes;P=0.24). The same trend was observed for the number of patientswith ST-D. The ischaemic threshold, defined as DP at the onsetof the episodes of ST-D, increased with felodipine (12 171 ±340vs 13 770 ± 138 mmHg. min^–1) and decreased withthe diuretic (16 210 ±312 vs 14 092 ± 319 mmHg.min^–1). In conclusion, antihypertensive treatment withfelodipine reduces blood pressure and episodes of transientmyocardial ischaemia in elderly hypertensive patients, whilehydrochlorothiazidel triamterene increases these episodes despitea similar BP reduction. Felodipine may influence structuraland functional factors at the coronary micro circulation level.These mechanisms improve coronary blood flow and increase theischaemic threshold.     

Coronary artery disease after heart transplantation: non-invasive evaluation with exercise thallium scintigraphy

In order to assess the value of exercise thallium scintigraphyfor the detection and prognosis of graft coronary artery disease,50 heart transplant patients (mean age 46.7 ± 11.5 years)were studied within 48 h of their scheduled yearly coronaryangiography and subsequently followed up for a mean of 13 ±3 months. Angiography revealed normal coronary arteries in 35patients, and coronary artery disease in 15 (two with type Alesions, seven with type B lesions and six with both). Sevenpatients had one or more stenoses 50%. Exercise thallium scintigraphywas negative in all patients with normal coronary arteries (100%specificity), and abnormal in 10 of 15 patients with coronaryartery disease (67% sensitivity). Fixed defects were seen insix cases, transient defects in two and both in two, the resultsof the test were abnormal in all seven patients with 50% lesions. During follow-up, none of the patients with a normal exercisethallium scintigraphy experienced any cardiac event; in thegroup with abnormal results, four cardiac events occurred. Althoughfurther studies are needed to confirm these results, exercisethallium scintigraphy seems to be useful in evaluating post-transplantcoronary artery disease: it is accurate in detecting the mostsevere stenoses and provides some prognostic information.     

Heart failure: are we neglecting the silent majority?

In the last decade, seminal studies from Europe, the USA, andAustralasia have defined the epidemiology of heart failure andleft ventricular systolic dysfunction in the population.^1–3One of those studies, the aptly named Echocardiographic Heartof England Screening study (ECHOES), enrolled over 6000 individuals40 years, living in the West Midlands region of England.⁴ Hobbsand Colleagues provide further important and incremental insightsinto the epidemiology of heart failure from their study. First, they report the number of cases of heart failure     

Effects of positive inotropic stimulation (post-extrasystolic potentiation) on non-uniformity of left ventricular contraction in patients with coronary artery disease

In patients with chronic coronary artery disease, post-extrasystolicpotentiation (PESP) slightly worsens relaxation, increasingthe constant of ventricular pressure decay. However, it doesnot negatively influence left ventricular (LV) diastolic filling.To our knowledge, no data are available on the effects of PESPon segmental relaxation in chronic coronary artery disease. The effects of PESP on the LV pressure–volume (P/V) relationshipand on segmental pressure–length loops (P/L) were studiedin eight patients with coronary artery disease submitted toLV angiography. P/V loops were constructed by means of frame-to-frame analysisof ventriculograms and simultaneous high-fidelity LV pressuretracings; P/L loops were calculated by the endocardial movementof 45 chords intersecting the LV outline (centreline method).PESP was produced by programmed stimulation during ventriculography.P/V and P/L loops were studied in basal conditions and afterPESP. Results showed enhanced LV pump function (ejection fractionfrom 0.45 ± 0.14 to 0.54 ± 0.13, P<0.01; LVstroke work index from 62±29 to 79±28 g. m^–1.m^–2,P<0.01; the LV end-systolic pressure–volume relationfrom 2.9±1 to 3.2±2 mmHg.ml^–1, P<0.05)associated with impaired relaxation (time constant _w, from 40±9to 48±8 ms, P<0.01; time constant _m from 53±11to 61±10 ms, P<0.05;peak filling rate from 3.7 ±1 to 2.3 ± 1 EDV.s^–1, P<0.01; minimal diastolicpressure from 6±6 to 7.5±6 mmHg, P<0.05) andwith increased preload (EDVI from 97±27 to 106±27ml.m^–2, P<0.01; LVEDP from 16 ± 9 to 19 ±7 mmHg, P<0.01). P/L loops showed increased non-unformityof LV relaxation after PESP. The effects were more evident inthe segments showing P/L loops inclined to the left, where PESPincreased or caused the appearance of post-systolic shortening.PESP showed only slight or no effect in the segments showingP/L loops inclined towards the right. PESP slightly impaired early left ventricular filling by decreasingthe rate of fall of intraventricular pressure and increasingthe non-unformity of contraction and relaxation. However, itdid not change the isovolumic phases of pressure–lengthloops of normal segments, while worsened relaxation of hypokinetic(probably ischaemic) segments with the appearance of post-systolicshortening in the loops inclined to the left.     

EUROASPIRE: A European Society of Cardiology survey of secondary prevention of coronary heart disease: Principal results

BACKGROUND: The three major European scientific societies in cardiovascularmedicine—the European Society of Cardiology (ESC), theEuropean Atherosclerosis Society and the European Society ofHypertension—published in October 1994 joint recommendationson prevention of coronary heart disease in clinical practice.Patients with established coronary heart disease, or other majoratherosclerotic disease, were deemed to be the top priorityfor prevention. A European survey (EUROASPIRE) was thereforeconducted under the auspices of the ESC to describe currentclinical practice in relation to secondary prevention of coronaryheart disease. AIMS: The aims of EUROASPIRE were (i) to determine whether the majorrisk factors for coronary heart disease are recorded in patientsmedical records; (ii) to measure the modifiable risk factorsand describe their current management following hospitalization,and (ii) to determine whether first degree blood relatives havebeen screened. MEHTODS: The survey was conducted in selected geographical areas andhospitals in nine European countries. Consecutive patients (70 years) were identified retrospectively with the followingdiagnoses: coronary artery bypass grafting, percutaneous transluminalcoronary angioplasty, acute myocardial infarction and acutemyocardial ischaemia without infarction. Data collection wasbased on a retrospective review of hospital medical recordsand a prospective interview and examination of the patients. RESULTS: 4863 medical records were reviewed of whom 25% were women, and3569 patients were interviewed (adjusted response rate 85%)with an average age of 61 years. Nineteen percent of patientssmoked cigarettes, 25% were overweight (BMI 30 kg. m^–2),53% had raised blood pressure (systolic BP 140 and/or diastolicBP 90 mmHg), 44% had raised total plasma cholesterol (totalcholesterol 5·5 mmol . l^–1) and 18% were diabetic.Reported medication at interview was: antiplatelet drugs 81%,beta-blockers, 54% (58% in post-infarction patients). ACE inhibitors30% (38% in post infarction patients) and lipid lowering drugs32%. Of the patients receiving blood pressure lowering drugs(not always prescribed for the treatment of hypertension) 50%had a systolic BP <140 mmHg and 21% <160 mmHg, and ofthose receiving lipid lowering drugs, 49% had plasma total cholesterol<5·5 mmol. l^–1 and 13% <6·5 mmol.l^–1. Thirty-seven percent of patients had a family historyof premature coronary heart disease in a first-degree bloodrelative, but only 21% of patients reported being advised tohave their relatives screened for coronary risk factors. CONCLUSIONS: This European survey has demonstrated a high prevalence of modifiablerisk factors in coronary heart disease patients. There is considerablepotential for cardiologists and physicians to further reducecoronary heart disease morbidity and mortality and improve patientschances of survival     

Physical responses to different modes of interval exercise in patients with chronic heart failure--application to exercise training

METHOD: In exercise training with chronic heart failure patients, workingmuscles should be stressed with high intensity stimuli withoutcausing cardiac overstraining. This is possible using intervalmethod exercise. In this study, three interval exercise modeswith different ratios of work/recovery phases (30/60 s, 15/60s and 10/60 s) and different work rates were compared duringcycle ergometer exercise in heart failure patients. Work ratefor the three interval modes was 50% (30/60 s), 70% (15/60 s)and 80% (10/60 s) of the maximum achieved during a steep ramptest (increments of 25 w/l0s) corresponding to 71, 98 and 111watts on average. Metabolic and cardiac responses to the threeinterval exercises were then examined including catecholaminelevels and perceived exertion. Parameters measured during intervalexercise were compared with an intensity level of 75% peak VO₂,determined during an ordinary ramp exercise test (incrementsof l2·5 W. min^–1). RESULTS: () (1) In all three interval modes, VO₂, ventilation and lactate did not increase significantlyduring the course of exercise. Mean values during the last workphase were between 754 ± 30 and 803 ± 46 ml. min^–1for VO₂, between 26 ± 3 and 28 ± 11. min^–1for ventilation and between 1·24 ±0·14and l·29 ± 0·10 mmol.1^–1 for lactate.(2) In mode 10/60 s, heart rate and systolic blood pressureincreased significantly (82 ± 485 ± 4 beats. min^–1;124 ± 5134 ± 5 mmHg; P<0·05 each), whilein mode 15/60 s catecholamines increased significantly (norepinephrine0·804 ± 0·0891·135 ± 0·094nmol. 1^–1; P<0·008; epinephrine 0·136± 0·012 0 193 ± 0·019 nmol. 1^–1;P<0·005). (3) In all three modes, rating of leg fatigueand dyspnoea increased significantly during exercise but remainedwithin the range of values considered ‘very light to fairlylight’ on the Borg scale. (4) Compared to an intensitylevel of 75% peak VO₂, work rate durrng interval work phaseswas between 143 and 221%, while cardiac stress (rate-pressureproduct) was significantly lower (83–88%). CONCLUSION: All three interval modes resulted in physical response in anacceptable range of values, and thus can be recommended.     

Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme

Aims The principal aim of the second EUROASPIRE survey was todetermine in patients with established coronary heart diseasewhether the Joint European Societies' recommendations on coronaryprevention are being followed in clinical practice. Methods This survey was undertaken in 1999–2000 in 15European countries: Belgium, Czech Republic, Finland, France,Germany, Greece, Hungary, Ireland, Italy, the Netherlands, Poland,Slovenia, Sweden, Spain and the U.K., in selected geographicalareas and 47 centres. Consecutive patients, men and women 70years were identified retrospectively with the following diagnoses:coronary artery bypass graft, percutaneous transluminal coronaryangioplasty, acute myocardial infarction and myocardial ischaemia.Data collection was based on a review of medical records andinterview and risk assessment at least 6 months after hospitaladmission. Results 8181 medical records (25% women) were reviewed and 5556patients (adjusted participation rate 76%) interviewed. Recordingof risk factor history and risk factor measurement in hospitalnotes was incomplete, particularly for discharge documents.At interview (median time 1·4 years after hospital discharge),21% of patients smoked cigarettes, 31% were obese, 50% had raisedblood pressure (systolic blood pressure 140mmHg and/or diastolicblood pressure 90mmHg), 58% had elevated serum total cholesterol(total cholesterol 5mmol.l^–1) and 20% reported a medicalhistory of diabetes. Glucose control in these diabetic patientswas poor with 87% having plasma glucose >6·0mmol.l^–1and72% 7·0mmol.l^–1. Among the patients interviewedthe use of prophylactic drug therapies on admission, at dischargeand at interview was as follows: aspirin or other antiplateletsdrugs 47%, 90% and 86%; beta-blockers 44%, 66% and 63%; ACEinhibitors 24%, 38% and 38%; and lipid-lowering drugs 26%, 43%and 61%, respectively. With the exception of antiplatelet drugs,wide variations in the use of prophylactic drug therapies existbetween countries. Conclusions This European survey of coronary patients showsa high prevalence of unhealthy lifestyles, modifiable risk factorsand inadequate use of drug therapies to achieve blood pressureand lipid goals. There is considerable potential throughoutEurope to raise the standard of preventive cardiology throughmore effective lifestyle intervention, control of other riskfactors and optimal use of prophylactic drug therapies in orderto reduce coronary morbidity and mortality.     

Coarctation of the aorta: review of 362 operated patients. Long-term follow-up and assessment of prognostic variables

362 patients operated upon for coarctation of the aorta from1961–1980 were analyzed retrospectively. Age at operationwas <2 years in 74 (group A ) and 2 years in 288 patients(group B). Associated cardiovascular malformations were common,especially in group A patients. Early mortality was 12-2% forgroup A and 1-4% for group B patients. 336 patients were followedfor 6 months to 21 years (mean 8.9 years). Late mortality was0.8% per patient year. Associated cardiac defects and postoperativehypertension were responsible formost of the late deaths. Latereoperations were performed because of aortic valve disease,residual coarctation (with persistent hypertension) and aorticaneurysms at the site of anastomosis. The incidence of hypertensiondecreased from 82.5% preoperatively to 33.5% at discharge fromthe hospital. It decreased further during follow-up in patientsoperated <10 years of age, but remained constant in the olderpatients.In conclusion, morbidity and mortality after operativerepair of coarctation are determined mainly by (1) associatedcardiac malformations, and (2) postoperative hypertension. Patientswith isolated coarctation and postoperative normal blood pressurehave an excellent prognosis. Patients operated upon from between2–9 years of age carry the lowest risk for residual coarctationand late postoperative hypertension.