Cardiac dysfunction in unselected chronic alcoholic patients: noninvasive screening by systolic time intervals

Chronic alcoholism produces abnormal cardiac function even in asymptomatic patients free of other disease. Sixty unselected chronic alcoholics, 52 of whom proved to have symptoms and signs consistent with various disorders (cardiovascular, pulmonary, gastrointestinal, and neurologic), were evaluated by systolic time intervals. Both the group as a whole and separately when subgrouped by associated diseases, showed evidence of cardiac malfunction on the basis of decreased left ventricular ejection time and abnormally increased ratio of pre-ejection time to ejection time.     

Immediate cardiac response to exercise: physiologic investigation by systolic time intervals at graded work loads

Immediate cardiac responses to exercise were investigated in five normal male volunteer subjects by measuring heart rate and systolic intervals from rest through the onset of exertion at three different work loads. Recordings were continued for fifty beats and again at one minute with measurements plotted on a beat-to-beat basis and grouped for statistical analysis. During exercise, heart rate and corrected ejection time increased, pre-ejection period and PEP/LVET decreased, and pulse transmission time remained stable. The heart rate acceleration was sudden, occurring in the first few beats of exercise, a phenomenon also demonstrated by previous investigators. A significant new finding was the equally abrupt major change in each of the other parameters. The immediacy of all responses was independent of load and was consistent with experimental studies showing that changes in both neural activity and venous return at the onset of exercise are virtually instantaneous.     

Systolic and diastolic time intervals in pulsus alternans; significance of alternating isovolumic relaxation

Systolic and diastolic time intervals in 14 cardiac patients with pulsus alternans revealed significant alternation of PEP, IVCT, LVET, ETI, $\text{PEP}\text{LVET}$, and carotid $\text{dD}\text{dt}$, with better functional values in the strong beats. Cycle length, duration of electromechanical systole (EMS), and total diastole (TD) did not alternate. A new observation, alternation of the components of total diastole—i.e., isovolumic relaxation period (IRP) and diastolic filling period (DFP) occurred in 7 out of 8 patients. These diastolic intervals alternated reciprocally such that the IRP of the strong beats encroached upon the DFP of the next (weak) beats.     

Prevalence of the fourth heart sound by phonocardiography in the absence of cardiac disease

A blinded, prospective study of phonocardiograms revealed a fourth heart sound (S₄) in 181 of 245 consecutively examined ambulatory subjects in sinus rhythm aged 50 to 80 years whose clinical status was unknown until all graphic studies were tabulated. An S₄ was demonstrated in 113 (73.1 per cent) of 152 individuals with and 68 (74.3 per cent) of 93 individuals without evidence of cardiovascular disease, statistically an equal prevalence. S₄ in older persons appears to be “normal” phenomenon.     

Determination of systolic intervals utilizing the carotid first derivative

Left ventricular ejection time (LVET) is a useful parameter of cardiac function which may be difficult to measure in restless, dyspneic, and uncooperative patients. Certain well-defined points of the first time derivative of the carotid displacement pulse are suitable to determine LVET and appear more reliable than the corresponding points in the carotid pulse itself under technically adverse situations. Systolic time intervals thus obtained correlate well with those determined by utilizing the undifferentiated carotid pulse wave. Thus the carotid first time derivative (dD/dt) serves as a more versatile and convenient method for such measurements, because of greater freedom from motion artifact and better definition of points.     

The surgical mystique and the double standard: Controlled trials of medical and surgical therapy for cardiac disease: Analysis,hypothesis, proposal

Seventy therapeutic trials reported in specialty journals during 1971 were analyzed for evidence of a controlled design to compare standards employed in evaluating treatments for cardiovascular disease. Nine of 16 qualifying medical trials were controlled. None of 49 surgical trials were controlled. The general “double standard” of acceptability for reports of surgical versus medical therapeutic trials appears to arise from fundamental professional and lay attitudes. It is proposed that medical journals require comparable standards for reporting the results of all kinds of treatment.     

Auscultatory perception of the fourth heart sound: effects of interval form fourth to first sound (S4-S1) and aging.

A clinically heterogeneous group of 48 subjects (aged 19 to 76 years) were searched for a fourth heart sound (S4) by three independent "blind" auscultators. Phonocardiograms recorded immediately after auscultation were measured by another "blind" observer. An S4 was identified in 32 subjects (67 per cent) in phonocardiograms with nominal filter peaks of both 70 and 35 hertz. Results in these subjects revealed two groups by auscultatory performance: those with an "easily heard" and those with an "easily missed" S4. Subjects with an "easily missed" S4 were significantly younger than those with an "easily heard" S4 (31.2 +/- 2.8 years versus 50.0 +/- 4.0 years, P less than 0.001). P-R and P-S4 intervals and relative amplitude of S4 (ratio of fourth to first heart sound [S1] amplitude) were not significantly different in the two groups. Splitting of the first heart sound (S1) was observed more frequently in the phonocardiogram of patients with an "easily missed" S4, but this trend did not reach statistical significance. The interval between S4 and the low frequency component of S1 was significantly short in those with an "easily heard" S4 (49.4 +/- 4.1 msec versus 70.0 +/- 5.0 msec, P less than 0.005). The mean S4-S1 (low frequency component) interval for the group with an "easily heard" S4 approximated 1 cycle length for S4 vibrations, a finding consistent with temporal acoustic summation. An alternate hypothesis is modification of S1.     

Electrocardiogram in acute pericarditis. Distributions of morphologic and axial changes by stages

Among 50 patients with uncomplicated acute pericarditis, 48 showed classic stage 1 S-T segment deviations; stage 3 T wave inversions developed in 32 patients. Electrocardiographic changes during the transitional stages 2 and 4 were recorded in 23 and 32 patients, respectively. Stage 1 orientation of the S-T segment frontal plane mean vector (ÂS-T) corresponded closely to ÂT and ÂQRS. Precordial S-T segment elevations occurred with increasing frequency from leads V₁ to V₆. Subsequent T wave inversions produced a wide dispersion of ÂT in stage 3 between ?50 ° and +100 °; precordial T waves were always inverted in leads V₅ and V₆. Forty-one patients had P-R segment shifts; in 93 percent ÂP-R was concentrated between ?120 ° and ?150 °, directly opposite to ÂP. ÂS-T was oriented to the left and anterior and inferior, representing the generalized subepicardial ventricular myocarditis of acute pericarditis. ÂP-R was oriented to the right and posterior and superior, representing the corresponding generalized atrial injury. The wide dispersion of ÂT in stage 3 is consistent with inhomogeneity of the ventricular recovery process after injury.     

Reticulum-cell sarcoma with intracardiac metastases. Case with angiocardiographic improvement after chemotherapy.

A prospective, multiple observer auscultatory and phonocardiographic study of 100 patients with pericardial friction confirmed the dominant prevalence of triphasic pericardial rubs (56 percent of patients with sinus rhythm). In 9 of 33 patients with various biphasic rub patterns there was summation of the ventricular diastolic rub with the atrial systolic rub, concealing an additional 10 percent of potential triphasic friction. Fourteen of 15 monophasic rubs were audible or recordable only during ventricular systole. Rubs were best heard along the left sternal border in 84 percent of cases and tended to be louder during inspiration than during expiration; in 35 cases there was no respiratory predilection. Twenty-three rubs were palpable. Ten rubs occurred in patients with pericardial effusion, five of whom had tamponade. Extension of the neck did not have a dependable effect on rub intensity.     

Comparative prevalence of the fourth heart sound in hypertensive and matched normal persons

Occurrence of the fourth heart sound (S₄) as a physiologic phenomenon would limit its usefulness as a discriminator of disease. Reports of a high prevalence rate of S₄, as determined by auscultation and by phonocardiography in normal older persons, have provoked support and rebuttal. A blind, randomized phonocardiographic study of 50 normal and 50 age- and sex-matched hypertensive persons (mean age 53.9 ± 6.6 years) drawn from an outpatient screening clinic showed a high and virtually equal prevalence of S₄ (35 instances in each group) or possible S₄ (3 and 5 cases, respectively). It appears that in middleaged persons, as in older persons, there is a high and equal prevalence rate of S₄. Quantitative studies appear to be indicated to determine when this sound can be considered a presystolic gallop.     

Elucidation of physiologic lengthening of left ventricular ejection time during early upright exercise

To elucidate the relationship between heart rate (HR) and left ventricular ejection time (LVET) during early exercise, 30 patients with chest pain were studied at 1 (1′) and 4 minutes (4′). Mean results for control → 1′ exercise: HR 79 to 105 beats per minute, LVET 247 to 260 msec. Thus instead of shortening as predicted by the HR change at 1′ of exercise, LVET rose significantly (p < 0.001). Subsequently LVET fell as HR continued rising, and by 4′ had fallen toward control level. This phenomenon is comparable to the paradoxical decline in LVET as HR decreases early post-exercise and is comparably explained by transiently disproportionate change in determinants of LVET, stroke volume, and ejection rate. Absence of difference in response of exercise-positive (ST depression ≥ 1 mm) and exercise-negative patients, also supports this initial paradoxical lengthening in LVET as a physiologic response.     

Effects of nitroglycerin on isometric exercise

Eight patients with ischemic heart disease performed isometric handgrip of five minutes' duration at 30% of their maximum voluntary contraction, before and after administration of 0.4 mg sublingual nitroglycerin (NTG). Although isometric exercise resulted in similar rise of left ventricular systolic pressure (LVSP) before and after NTG, the level of LVSP during the post NTG effort was lower. Heart rate, cardiac index, stroke index, left ventricular stroke work index, and systemic resistance were not different during the pre- and post NTG exercise. Left ventricular end-diastolic pressure rose to a significantly lower level (18.3 ± 14.4 mm Hg) during the post NTG handgrip than during the pre NTG effort (31.4 ± 17.6 mm Hg, P < 0.005). It is concluded that NTG reduces preload and afterload both at rest and during isometric exercise and improves left ventricular performance during isometric exercise.     

The predictive value of anginal chest pain as an indicator of coronary disease during exercise testing

To determine the significance of anginal chest pain during exercise testing, a series of 302 patients undergoing coronary arteriography with exercise testing was reviewed. Of the 302 patients, 85 had ischemic ECG changes and chest pain (Group I); 87 patients had ischemic ECG changes but no chest pain (Group II); 25 patients had chest pain but no ischemic ECG changes (Group III); 105 patients had neither chest pain nor ischemic ECG changes (Group IV). Coronary artery disease was present in 95 per cent of Group I, 75 per cent of Group II, 72 per cent of Group III, and 28 per cent of Group IV. Of those patients with coronary disease, multiple vessels were involved in 94 per cent of Group I, 51 per cent of Group II, 67 per cent of Group III, and 21 per cent of Group IV. The predictive value for presence and extent of coronary disease showed Group I > Groups II and III > Group IV (p < 0.025). We conclude that (1) anginal chest pain during exercise testing predicts the presence and extent of coronary disease more accurately than its absence; (2) the presence of chest pain even without an ischemic ECG response during exercise testing appears to be as predictive of coronary disease as an ischemic ECG response alone; and (3) the combination of anginal chest pain during exercise testing and an ischemic ECG response is highly predictive of multivessel coronary artery disease.     

Pathophysiologic observations on premature opening of the aortic valve utilizing a technique for multiplane echocardiographic analysis.

The use of a simple technique for multiplane echocardiographic analysis and study of the effect of arrhythmia enabled us to investigate the mechanism of premature opening of the aortic valve in two patients with subacute aortic insufficiency. In one patient, premature opening evolved with the development of left ventricular dilatation and failure. In this case the prematurity of opening in each beat was related to diastolic filling time and was accompanied by septal recoil and by premature closure of the mitral valve. We classified this as the diastolic duration-dependent subgroup. In the second patient, who had a hypertrophied, non-dilated left ventricle, premature opening depended on atrial contraction and was independent of diastolic filling time. This case defined an atrial contraction-dependent subgroup. In the light of these findings we analyzed previously reported cases in patients with acute severe aortic insufficiency. These patients appear to fall into the diastolic duration-dependent subgroup.     

The American Heart Journal: Enhanced service to the cardiovascular community

Seventeen patients presenting with unstable angina pectoris underwent percutaneous transluminal coronary angioplasty (PTCA). Despite vigorous medical therapy, all patients were disabled with 10 experiencing refractory in-hospital angina. PTCA was judged successful in 13 patients and resulted in decreased coronary diameter narrowing from 80 ± 16% to 34 ± 13% and reduced transstenotic pressure gradient from 69 ± 13 to 23 ± 12 mm Hg. Regional coronary blood flow (CBF) and myocardial metabolism were assessed at rest and during pacing tachycardia in six patients with left anterlor descending coronary stenosis. Prior to PTCA, neither regional CBF increased nor coronary vascular resistance declined during rapid pacing; myocardial lactate extraction fell, indicating a shift from aerobic to anerobic metabolism. Following PTCA, however, rapid pacing resulted in increased regional CBF, decreased coronary vascular resistance, and preservation of aerobic metabolism. Following PTCA, successfully dilated patients demonstrated marked relief of angina symptoms, increase in functional capacity, and objective exercise ECG and thallium scintigraphic evidence of relief of previously ischemic myocardium. This investigation demonstrates that PTCA, when combined with medical therapy, can be performed safely and successfully in selected patients who present with otherwise refractory unstable angina, and indicates the procedure deserves further study as a therapeutic alternative in this condition.