Determination of the optimal dose of glyceryl trinitrate in the treatment of stable angina

There has been recent controversy over the efficacy of transdermalglyceryl trinitrate (GTN) preparations in the treatment of anginaand their effects on exercise tolerance. To determine the doseof GTN that produces significant anti-anginal effects, symptomlimited exercise testing has been undertaken in seven patientswith stable angina. Doses of 10, 20, 40 and 80 µg min^-1of GTN or placebo were infused during treadmill exercise untilsymptom limiting chest pain or 3 mm ST segment depression occurred.Compared with placebo, total exercise time increased by 47%at 20 µg min^-1 (P<0.05) with no further change at thehigher doses. Duration of exercise before the onset of significantST segment depression increased by 51% at 20 µg min^-1(P<0.05) with no further increase at the higher doses. Thesechanges were accompanied by a 21% increase double product (heartrate x systolic blood pressure) at 20 µg min^-1 (P<0.05)reflecting a higher heart rate achieved as a result of the increasedduration of exercise. These results suggest that 20 µgmin ^-1 may be the optimal dose of GTN to achieve significantantianginal effects as demonstrated by the improved exercisetolerance and reduction of myocardial ischaemia. This impliesthat the dose of GTN delivered by transdermal preparations maybe below the therapeutic level.     

Effects of percutaneous balloon mitral valvuloplasty and exercise training on the kinetics of recovery oxygen consumption after exercise in patients with mitral stenosis

Aims Kinetics of recovery oxygen consumption after exercise playsan important role in determining exer-cise capacity. This studywas performed to assess the kinetics of recovery oxygen consumptionin mitral stenosis and evaluate the effects of percutaneousballoon mitral valvuloplasty and exercise training on the kinetics. Methods and Results Thirty patients with mitral stenosis (valve area 1·0cm²)and same sized age- and size-matched healthy volunteers wereincluded for this study. All subjects performed maximal uprightgraded bicycle exercise. Thirty consecutive patients who underwentsuccessful percutaneous balloon mitral valvuloplasty (valvearea 1·5cm²and mitral regurgitation grade 2), were randomizedto an exercise training group or non-training group. The exercisegroup performed daily exercise training for 3 months. Half-recoverytime of peak oxygen consumption was significantly delayed inmitral stenosis as compared to normal subjects (120±42svs 59±5,P<0·01). Peak oxygen consumption (ml.min^–1.kg^–1)was significantly increased in both the training (16·8±4·9to 25·3±6·9) and non-training groups (16·3±5·1to 19·6±6·0) 3 months after percutaneousballoon mitral valvuloplasty. Half-recovery time of peak oxygenconsumption was significantly shortened in the training group(124±39 to 76±13,P<0·01), but not inthe non-training group (114±46 to 109±44s,P=0·12)at 3 months follow-up. The degrees of symptomatic improvementafter percutaneous balloon mitral valvuloplasty were more closelycorrelated with the changes of the half-recovery time of peakoxygen consumption than those of peak oxygen consumption. Conclusion Kinetics of recovery oxygen consumption was markedly delayedin mitral stenosis, which was improved after exercise trainingbut not after percutaneous balloon mitral valvuloplasty alone.These results suggest that adjunctive exercise training maybe useful for improvement of recovery kinetics and subjectivesymptoms after percutaneous balloon mitral valvuloplasty.     

X综合征女性患者电子束CT测定冠状动脉钙化的临床特点

为探讨X综合征女性患者冠状动脉钙化及临床情况 ,利用电子束CT对 2 6例X综合征女性患者和 2 2例冠状动脉造影及运动试验均正常的女性胸痛者冠状动脉进行检测 ,同时对其冠心病危险因子进行评估 ,测定血脂和血浆氧化型低密度脂蛋白水平 ,对比不同病例的冠状动脉钙化积分及病变血管支数。结果发现 ,有 19例(73% )X综合征女性患者存在冠状动脉钙化 ,而正常组中仅 4例 (18% )存在冠状动脉钙化 ;有冠状动脉钙化的X综合征女性患者冠心病危险因子明显高于正常组 (1.8± 1.3比 1.1± 0 .9,P <0 .0 5 ) ,前者的血浆氧化型低密度脂蛋白浓度也明显高于后者 (5 2 .38± 6 .89比 39.92± 7.87,P <0 .0 5 ) ;其中 13例为绝经期患者。绝经后X综合征患者冠状动脉钙化积分和有冠状动脉钙化的血管支数与非绝经期者相比无明显差异 ,但这两组均较正常组明显增高 (P<0 .0 5 )。结果提示 ,有相当数量的X综合征女性患者存在冠状动脉钙化 ,这种钙化似乎与绝经与否无关 ,有必要对这类患者的临床资料进行评估并作相应治疗     

Left bundle branch block: prevalence, incidence, follow-up and outcome

In a randomly selected population screening study of 8450 menand 9039 women 33 to 71 years of age conducted in Iceland in1967–1977, 27 men and 17 women were found to have leftbundle branch bock (LBBB). The prevalence of LBBB at that timewas 0.43% for men and 0.28% for women. The incidence of LBBBwas 3.2 per 10 000 per year for men and 3.7 per 10 000 per yearfor women.All except one of 37 alive patients with LBBB wereexamined in 1984 including chest X-ray, echocardiography andexercise testing (Bruce protocol). Eight men had had myocardialinfarction (P<0.05), 12 had angina pectoris, 15 had hypertension,7 had cardiomyopathy, 13 had primary conduction disease, and3 had pacemakers. Five men and two women had died in comparisonwith 18 men and 1 woman in an age-matched control group of 176people (P ns). Three of 5 decreased LBBB men had cardiomyopathyat autopsy. Three men died suddenly. The two women died of noncardiaccauses. Only one patient in the control group had cardiomyopathy(P< 0.01). There was no significant difference in other cardiacdiagnoses between the groups. Eleven LBBB women out of thirteenhad a normal exercise duration (6 min) and 11/17 men exercisednormally (7 min). In comparison with the control group, theLBBB patients had an increased LV diameter 2.85±0.38vs 2.58±0.38 cm m^-2 body surface area (P<0.01). Therewas no difference between the groups in left atrial diameteror LV wall thickness.In conclusion, the prevalence of LBBB was0.43% for men and 0.28% for women of middle age. The incidencewas 3.2 per 10 000 per year for men and 3.7 per 10 000 per yearfor women. The prognosis of LBBB is relatively benign apartfrom its association with dilated cardiomyopathy. Few patientsrequire pacemakers. The mean LV diameter is increased in randomlyselected patients with LBBB, but only those with an underlyingdisorder.     

Implications of positive treadmill exercise tests in asymptomatic adult African blacks

Maximal exercise tests in 225 apparently healthy adult Africans(148 men, 77 women) aged 26 to 70 years revealed 35 subjects(18 men and 17 women) with ischaemic ST changes. Out of these,6 men and 4 women developed chest pain that necessitated terminationof the tests. Significant ventricular arrhythmias were observedin 27 patients (20 men and 7 women) all of whom had an otherwisenegative response to exercise tests. During a follow-up period ranging from 6 months to 4 years,2 male positive-responders — both of whom developed chestpain during exercise testing — sustained acute myocardialinfarction. The coronary arteries of both men were found tobe normal at coronary angiography. A third male positive-responder,who also developed chest pain during exercise testing, subsequentlyexperienced repeated attacks of angina with no ECG or serumenzyme changes. Coronary angiography, in this patient, revealedsignificant proximal vessel disease necessitating coronary angioplasty. One female positive responder, who developed chest pain duringexercise-testing, experienced episodes of restrosternal discomfortof considerable duration with no ECG or serum enzyme changes.Her coronary arteries were subsequently shown to be normal. While coronary artery disease would no doubt account for a significantpercentage of positive exercise responses in adult African blacks,it seems likely that non-coronary causes play a dominant role.     

Left bundle branch block: prevalence, incidence, follow-up and outcome

In a randomly selected population screening study of 8450 menand 9039 women 33 to 71 years of age conducted in Iceland in1967–1977, 27 men and 17 women were found to have leftbundle branch bock (LBBB). The prevalence of LBBB at that timewas 0.43% for men and 0.28% for women. The incidence of LBBBwas 3.2 per 10 000 per year for men and 3.7 per 10 000 per yearfor women.All except one of 37 alive patients with LBBB wereexamined in 1984 including chest X-ray, echocardiography andexercise testing (Bruce protocol). Eight men had had myocardialinfarction (P<0.05), 12 had angina pectoris, 15 had hypertension,7 had cardiomyopathy, 13 had primary conduction disease, and3 had pacemakers. Five men and two women had died in comparisonwith 18 men and 1 woman in an age-matched control group of 176people (P ns). Three of 5 decreased LBBB men had cardiomyopathyat autopsy. Three men died suddenly. The two women died of noncardiaccauses. Only one patient in the control group had cardiomyopathy(P< 0.01). There was no significant difference in other cardiacdiagnoses between the groups. Eleven LBBB women out of thirteenhad a normal exercise duration (6 min) and 11/17 men exercisednormally (7 min). In comparison with the control group, theLBBB patients had an increased LV diameter 2.85±0.38vs 2.58±0.38 cm m^-2 body surface area (P<0.01). Therewas no difference between the groups in left atrial diameteror LV wall thickness.In conclusion, the prevalence of LBBB was0.43% for men and 0.28% for women of middle age. The incidencewas 3.2 per 10 000 per year for men and 3.7 per 10 000 per yearfor women. The prognosis of LBBB is relatively benign apartfrom its association with dilated cardiomyopathy. Few patientsrequire pacemakers. The mean LV diameter is increased in randomlyselected patients with LBBB, but only those with an underlyingdisorder.     

Does sublingual 17{beta}-oestradiol have any effects on exercise capacity and myocardial ischaemia in post-menopausal women with stable coronary artery disease?

Background A variety of vascular effects have been ascribed to 17ß-oestradiol.These effects may partially explain the reduced incidence ofcardiovascular disease found in post-menopausal women on oestrogenreplacement therapy. Objectives To evaluate the effects of 2mg sublingual 17ß-oestradiolon exercise capacity, exercise-induced myocardial ischaemiaand circulating levels of endothelin-1 in post-menopausal womenwith stable coronary artery disease. Methods Twelve post-menopausal women, mean age 61 (range 52–72)years, with angiographically verified significant coronary arterydisease, were randomly assigned to 2mg of sublingual 17ß-oestradiol,2·5mg of buccal nitroglycerine and to placebo in a double-blindcross-over study design with at least 2 days between each ofthe study arms. Antianginal medications, with the exceptionof beta-blockers, were discontinued before investigation. Allstudy patients underwent a maximal bicycle exercise test 30minafter drug intake. Blood was withdrawn immediately before andup to 8h after medication for analyses of circulating levelsof oestradiol and endothelin-1. Results The mean serum levels of oestradiol increased from a controllevel of 72±28pmol.l^–1to 3557± 1631pmol.l^–1after30min and to 5028±3971pmol.l^–1after 60min witha gradual decline thereafter. Sublingual 17ß-oestradioldid not induce any improvement in exercise duration when comparedwith nitroglycerin and placebo (500±112s, 505±107s,498±157s), and did not influence time to onset of ST-segmentdepression (358±89s, 436±93s, 384±116s).The plasma levels of endothelin-1 did not change after administrationof 17ß-oestradiol, nitroglycerin or placebo. Conclusions No effects on exercise capacity, exercise-induced acute ischaemia,or plasma levels of endothelin-1 were found after a single doseof 2mg 17ß-oestradiol in post-menopausal women withdocumented coronary artery disease.     

Argument for a Doppler echocardiography during exercise in assessing asymptomatic patients with severe aortic stenosis

Aims: Exercise stress testing (EST) is recommended by guidelines torisk-stratify patients with asymptomatic valvular aortic stenosis(AS), though the role of quantitative exercise-Doppler echocardiographyhas rarely been studied. This prospective study sought to correlatestandard EST results with the haemodynamic measurements madeduring exercise by Doppler echocardiography. Methods and results: We performed rest and semi-supine exercise Doppler echocardiographyin 44 consecutive patients (mean age = 68 ± 12 years)with aortic valve areas 0.6 cm²/m². The effective aortic valvearea (EOA), cardiac output (CO), maximal transvalvular velocity,and pulmonary pressure were monitored over the test. No seriousadverse event was observed. EST was positive in 26 (Group 1)and negative in 18 (Group 2) patients. Baseline echocardiographicmeasurements were similar (EOA 0.77 ± 0.15 vs. 0.78 ±0.14 cm²; CO 5.5 ± 1.6 vs. 5.9 ± 2 L/min) in bothgroups. Exercise-induced changes in CO (+2.9 ± 2 vs.+4.3 ± 1.8 L/min, P = 0.04) and EOA (–0.04 ±0.18 vs. +0.15 ± 0.24 cm², P = 0.015) were significantlygreater in Group 2. A correlation between changes in EOA andchanges in CO during exercise was observed, but significantlyhigher in Group 2 (P = 0.04). Conclusion: In the presence of severe asymptomatic AS, exercise Dopplerechocardiography, assessing the mechanisms behind a positiveEST, appears very promising but further studies with prognosisassessment remain necessary.     

Residual myocardial ischaemia in first non-Q versus Q wave infarction: maximal exercise testing and ambulatory ST-segment monitoring

In a prospective study of 123 consecutive survivors of a firstmyocardial infarction (43 non-Q wave, 80 Q wave), we determinedthe total residual ischaemic burden by use of pre-dischargemaximal exercise testing and post-discharge 36 h ambulatoryST-segment monitoring initiated 11 ± 5 days after theinfarction. The prevalence of exercise-induced ischae-mic manifestations in the infarct types was similar: chest pain 14%vs 16% and ST-segment depression 54% vs 54%. The ischaemic thresholddid not differ either (heart rate at 1 mm of ST-segmnent depression120 ± 27 vs 119 ± 25 beats. min^–1). Duringearly post-discharge daily activities, more patients with non-Qwave infarction demonstrated transient episodes of ST-segmentdepression: 28% vs 14% (ns). Furthermore, ischaemic episodeswere significantly longer (42.5±50.1 vs 22.0 ±20.6 min; p <0.001), and the ischaemic threshold was significantlylower in non-Q wave infarction (heart rate at onset of ST-segmentdepression 84±11 vs 88±9 beats.min^–1; p<0.05). During 3.5±0.9 years of follow-up the proportionof patients with 1 ischaemic event (non-fatal reinfarction,angina pectoris, revascularization) was significantly higherin non-Q wave infarction (51%) as compared to Q wave infarction(31%) (P<005). In both infarct types the presence of ST-segmentdepression on ambulatory recording and exercise testing significantlypredicted the development of future angina pectoris, whereaspatients at increased risk for subsequent non-fatal reinfarctionor cardiac death were not identified.     

Radionuclide assessment of a normal left ventricular response to exercise in patients without evidence of heart disease

The aim of this study was to define normal left ventricularperformance at rest and during supine bicycle exercise withequilibrium radionuclide ventriculography in a normal populationother than young healthy volunteers. Thirty-one patients (meanage 45 years ± 9 SD) with chest pain of varying originandno evidence of heart disease proven by means of noninvasiveand invasive techniques were studied. Left ventricular ejectionfraction (LVEF) at rest averaged 0.64 ± 007 SD and increasedwith peak exercise to 0.73 ± 008 SD (P<0.005). Changein LVEF from rest to maximum exercise ranged within 0–0.19.Six patients (19%) failed to augment LVEF with exercise to morethan 0.05; none of the patients dropped LVEF during exercise.Multivariate analysis revealed no significant predictors ofLVEF response to exercise. However, there was a tendency thatresting LVEF and enddiastolic volume index with exercise mightinfluence LVEF response to exercise. Peak left ventricular ejectionrate (LVER) at rest averaged 3.3s^–1 ± 0.6 SD andincreased to 51 s^–1 ± 11 SD (P<0.005) with exercise.Peak left ventricular early filling rate (LVFR) was 2.8s^–1± 0.6 SD at rest and was measured 5.5 s^–1 ±l.3 SD at maximum exercise (P<0.005). Left ventricular enddiastolicvolume (EDV) did not change significantly from rest to maximumexercise, whereas left ventricular endsystolic volume (ESV)decreased to 79% ± 19 SD (P<0.01) of the value atrest. In conclusion, in a normal population other than healthy youngvolunteers LVEF does not necessarily have to increase with exercise.Moreover, besides an augmentation of heart rate a normal leftventricular response to supine exercise is associated with anincrease of LVER and LVFR, a decrease in ESV and no significantchange in EDV, suggesting augmented contractility and a virtuallynegligible role of the Frank-Starling mechanism during exercise.     

17-beta-estradiol therapy lessens angina in postmenopausal women with syndrome X

Objectives. We sought to investigate the hypothesis that estrogen replacement therapy ameliorates symptoms in postmenopausal women with syndrome X.Background. Syndrome X (angina pectoris, positive findings on exercise electrocardiography and normal results on coronary angiography) frequently occurs in menopausal women. This observation, in conjuction with the known vasoactive properties of estrogens, suggests that estrogen depletion may contribute to the pathogenesis of syndrome X in some women.Methods. Twenty-five postmenopausal patients with syndrome X completed a double-blind, placebo-controlled study of the effect of 17-beta-estradiol cutaneous patches (100 μg/24 h) on the frequency of chest pain and on exercise tolerance. Patients were randomly assigned to receive either placebo or 17-beta-estradiol patches for 8 weeks and were then crossed over to the other treatment.Results. During the placebo phase, patients had a mean of 7.3 episodes of chest pain/10 days. A reduction to 3.7 episodes/10 days was observed during the 17-beta-estradiol phase (p < 0.05). No significant differences were observed between the effects of 17-beta-estradiol and placebo on exercise duration or the results of other cardiologic investigations.Conclusions. Estrogen replacement reduces the frequency of chest pain and may be a useful new therapeutic option for treating postmenopausal women with syndrome X.     

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.     

Improved diastolic function with the calcium antagonist nisoldipine (coat-core) in patients post myocardial infarction: results of the DEFIANT study

A multicentre, randomized, double-blind, placebo-controlled,parallel-group trial was undertaken in 135 patients to determinewhether 4 weeks of treatment with long-acting nisoldipine coat-core(20 mg once a day) could alter diastolic function in patientswith a recent myocardial infarction and with mild left ventriculardysfunction as indicated by a left ventricular ejection fraction50%. The primary endpoint was the change in diastolic fillingparameters assessed by Doppler and two-dimensional echocardiography. The mean time of admission to the study was 20 days (range 7–35)after myocardial infarction. Mean left ventricular ejectionfraction was 41%. The drug increased early diastolic peak velocityat the tips of the mitral leaflet by 0·06 m . s^–1(95% confidence intervals (CI): 0·01, 0·11). Thetime velocity integral was increased by 1·2 cm (95% CI:0·16, 2·27). These findings are indicative ofincreased early diastolic flow across the mitral valve. An importantdeterminant appeared to be a reduced isovolumic relaxation time(by 14·7 ms, 95% CI: -22·5, -6·9). As therewas no change in heart rate, systolic and diastolic blood pressureor cardiac output, after load reduction appeared unlikely asan explanation. Peak workload on exercise was 12 watts higherin the group on nisoldipine (95% CI: 0·8, 23·3).Thus, nisoldipine was shown to improve indices of diastolicventricular function, as well as exercise capacity, in thisgroup of patients. The observed effects of nisoldipine may reflectan anti-ischaemic effect or be due to improved relaxation ofthe myocardium.     

Thallium perfusion and myocardial hypertrophy in transplanted heart recipients with normal or near-normal coronary arteriograms

In patients with hypertrophic cardiomyopathy or systemic hypertension,exercise thallium perfusion defects have been observed but withoutsignificant angiographic stenoses. Hypertension and myocardialhypertrophy are common in transplanted heart recipients, andthe aim of this study was to determine if exercise thalliumscintigraphy false-positives are frequent in transplanted heartrecipients. Thirty-four transplanted heart recipients were evaluated byexercise thallium single emission computed tomography and subsequentlyhad a normal or near normal coronary arteriogram. At the timeof the exercise, the patients (28 men and six women) had a meanage of 48.9 ± 12 years and 29 had been previously treatedfor systemic hypertension. The mean duration between transplantationand the exercise test was 31.6 ± 13 months. In all patientsleft ventricular mass was obtained by echocardiography within3 months of thallium 201 SPECT and was 130g. m^–2 in ninemales and 110 g. m^–2 in four females. M-mode septal+posteriorend-diastolic thickness was >23 mm in 14 patients, all ofwhom had been previously treated for systemic hypertension.These patients were older and endured a longer period duringwhich the heart was kept cold but ischaemic before being grafted(‘cold ischaemia’) but a shorter exercise durationthan patients without left ventricular hypertrophy. During exercisetesting, 26 of 34 patients achieved at least 80% of their maximalpredicted heart rate and two developed significant ECG changes.Exercise and 4 h redistribution thallium perfusions were normalin 33 patients, but one patient with a left ventricular mass= 100 g. m^–2 had a persistent apical defect. We conclude that in transplanted heart recipients with normalor near normal coronary arteriograms, myocardial perfusion evaluatedwith exercise thallium 201 SPECT is usually normal despite ahigh frequency of myocardial hypertrophy.     

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.     

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     

Double balloon aortic valvotomy for rheumatic aortic stenosis; in vitro studies

The manner in which aortic valve area increases after in vitrodouble balloon aortic valvotomy for severe rheumatic aorticstenosis has not been defined. We selected ten intact aorticvalves excised at cardiac surgery from patients (mean age 45± 10 years) with severe rheumatic aortic stenosis, witha valve area cm². In vitro double ballon aortic valvotomy wasattempted on each valve using two Meditech 15 mm diameter ballooncatheters. The balloon catheters were simultaneously inflatedto 4 atm pressure for 10 s. Before and after balloon valvotomythe valve area was calculated with a conical sizer, and radiologicalstudies were also performed to study the effect of balloon valvotomyon calcified aortic commissures. The mean valve area increasedfrom 0.7 ± 0.2 (mean ± SD) to 1.1 ± 0.2cm² (P0.001) after balloon valvotomy, with a mean total commissuralsplit ting for each aortic valve of 9.3 ±6 mm. Overall,63% of the aortic commissures were split, splitting occurringin 81% of non-calcified commissures and 43% of calcified commissures.There was no leaflet tear or calcium fracture either macroscopicallyor radiologically. Commissural splitting of rheumatic aorticstenosis is the manner in which valve area is increased afterdouble balloon aortic valvotomy. The inflated balloon catheterssplit not only non-calcified, but also calcified arotic commissures.The adequate commissural splitting achieved and consequent 57%increase in valve area indicate that the double balloon aorticvalvotomy technique may become a palliative therapeutic procedurefor patients with severe rheumatic aortic stenosis.     

Early exercise testing after coronary care for suspected unstable coronary artery disease -- safety and diagnostic value

The safety of and the diagnostic information provided by a predischargeexercise test performed 2-7 days after admission to the coronarycare unit (CCU) was evaluated in 400 patients less than 65 yearsof age with suspected unstable coronary artery disease, i.e.probable or definite non-transmural myocardial infarction, progressiveangina pectoris or recurring chest pain of recent onset (‘newchest pain’). No serious complications occurred. Signsof ischaemia during exercise tests were more common in olderthan in younger men and more often found in subjects with thanwithout pathological findings in resting ECGs in the CCU. Above45 years of age, more than half of the men with progressiveangina or non-transmural MI had SI depression 2 mm and/or limitingchest pain, whereas men less than 45 years of age had a 10–25%incidence of corresponding findings in the test. In women above55 years with progressive angina or non-transmural MI, 30–35%had ST depression and/or limiting chest pain at the test while20–30% of women below 55 years of age had similar findingsat the test. Beta-adrenoceptor blockade was used by half ofthe patients but did not seem to conceal signs of severe ischaemia.Thus a predischarge exercise test can be performed safely inpatients with suspected unstable coronary artery disease inorder to support or reduce the suspicion of severe disease.     

Normal coronary flow reserve in patients with mitral valve prolapse, a positive exercise test and normal coronary arteries

We studied 12 patients (eight females and four males), ages30–46 years, with echocardiographically documented mitralvalve prolapse and clinical suspicion of coronary artery disease,based on a history of chest pain (five patients), angina-likepain (three patients), a positive exercise stress electrocardiogram(12 patients) and a focally positive thallium-201 stress perfusionscan (three patients), who were referred for cardiac catheterizationand found to have normal coronary arteries. Ten patients withoutevidence of heart disease served as controls. In all mitralvalve prolapse patients, coronary flow velocity reserve wasdetermined successively in the left anterior descending, leftcircumflex and right coronary arteries as the ratio of the maximun(after intracoronary papaverine) to the resting mean coronaryflow velocity. Coronary flow reserve values were fairly similarin the mitral valve prolapse and control patients; all 12 mitralvalve prolapse patients had normal coronary flow reserve (3.5)in all three coronary arteries with no significant differencesamong the arteries tested Mean values ± 1 standard deviationof the coronary flow reserve (mitral valve prolapse vs controlpatients) were 4.7 ± 0.5 vs 4.6 ± 0.6 for theleft anterior descending, 4.6 ± 0.4 vs 4.6 ± 0.3for the left circumflex and 4. ± 0.4 vs 4.4 ±0.5 for the right coronary artery (all P=non-significant). Thesubsets of mitral valve prolapse patients with different clinical‘ischaemic’ manifestations were similar in termsof the calculated coronary flow reserve in all three major epicardialcoronary arteries. In conclusion, this study demonstrated that an inadequate regionalcoronary flow reserve does not account for the clinical manifestationsof myocardial ischaemia and positive exercise tests in patientswith mitral valve prolapse and normal coronary arteries.     

Familial hypertrophic cardiomyopathy. Cardiac ultrasonic abnormalities in genetically affected subjects without echocardiographic evidence of left ventricular hypertrophy

Aims It is not known whether the apparent normality of echocardiographicexamination results, in subjects bearing a mutation for hypertrophiccardiomyopathy but without ultrasonic left ventricular hypertrophy,is due to incomplete phenotypic expression, or inaccurate echocardiographiccriteria. The aim of this study was to search for echocardiographicabnormalities in these patients. Methods and Results Echocardiography was performed in 100 subjects from two familieswith a mutation in the ß-MHC (720) or My-BPC (714)genes. We compared genetically affected subjects with an apparentlynormal left ventricle (thickness <13mm) (20 patients), andnon-affected first-degree relatives (61 normal subjects). (1)Patients had a thicker left ventricular wall (9·7±1·4vs 8·9±1·4mm, P=0·03), a greaterindexed mass (107±18 vs 97±17g.m^–2, P=0·03),a larger left atrium (27±9 vs 23±10mm³, P=0·09)and lower wall stress (78±11 vs 89±15 10³dynes.cm^–2,P=0·002); these differences were highly significant afteradjustment for height, age and systolic blood pressure eitherfor wall thickness (P=0·073503), mass (P=0·005)or atrial volume (P=0·001), and the ventricular systolicdimension appeared smaller (P=0·01); (2) results remainedsignificant (P<0·01) when a lower cut-off value (11mm)or only adults (18 years) were considered; (3) a subanalysisof Family 714 (13 patients, 25 normals matched for sex, ageand height) showed the same trends. Conclusion In familial hypertrophic cardiomyopathy, genetically affectedsubjects with an apparently normal heart by echocardiographyshow slight ultrasonic structural and functional left ventricularmodifications, suggesting that the phenotype of the diseaseis a continuous spectrum from normal structure to typical hypertrophy.