Relation of therapeutic response to nifedipine to coronary anatomy and motion of S-T segment during unstable angina pectoris

Of 77 patients hospitalized for unstable angina pectoris and failure of oral, dermal, or intravenous nitrates and/or beta blockade, 81 percent with negligible or single-vessel disease and 55 percent with two- or three-vessel disease showed response (p < 0.05) to nifedipine therapy. Patients with either S-T elevation or no change during pain responded better (31 of 45) than those with any S-T depression (16 of 32; p < 0.05). Patients with negligible or singlevessel disease had a higher prevalence of S-T elevation ( 13 of 16) than patients with two- or three-vessel disease (15 of 31; p = 0.004). S-T motion did not predict response in patients with two- or three-vessel disease, but did predict response in patients with negligible or single-vessel disease. On follow-up study at 9 ± 8 (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. Five who showed response had elective bypass surgery. The addition of nifedipine abolished or reduced pain episodes by more than 50 percent in 61 percent of patients with refractory unstable angina pectoris. Patients with negligible or single-vessel disease with S-T elevation benefit most. In patients with two- or three-vessel disease, the type of S-T motion did not predict response. Follow-up of all those with response indicated sustained amelioration by nifedipine therapy. Failure of nifedipine therapy should not be accepted until a dose of 120 mg per day has been achieved, or until intolerable side effects appear.     

Methodologic problems of exercise testing for coronary artery disease: Groups,analysis and bias

To determine why exercise testing remains controversial as a diagnostic test for coronary artery disease, a methodologic review was undertaken of 33 studies comprising 7,501 patients who had undergone both exercise tests and coronary angiography. Of seven methodologic standards for research design, only one received general compliance: the requirement for an adequate variety of anatomic lesions. Less than half of the studies complied with any of the remaining six standards: adequate identification of the groups selected for study; adequate analysis for relevant chest paln syndromes; avoidance of a limited challenge group; and avoidance of work-up bias, diagnostic review bias and test review bias. Only one study met as many as five standards.These methodologic problems may explain the wide range of sensitivity (35 to 88 percent) and specificity (41 to 100 percent) found for exercise testing, because the variations could not be attributed to the usual explanations: definition of anatomic abnormality, stress test technique or definition of an abnormal test. Determining the true value of exercise testing requires methodologic improvements in patient selection, data collection and data analysis.     

Intravascular papillary endothelial hyperplasia: Multiple lesions simulating Kaposi's sarcoma

We describe a 69-year-old woman who developed multiple violaceous papules and nodules on both lower extremities. The clinical impression was Kaposi's sarcoma, but the lesions proved to represent multiple ectatic venules that contained papillary endothelial hyperplasia and small foci of an unorganized thrombus. The lesions persisted during a 6-month period of observation. Intravascular papillary endothelial hyperplasia can be observed as an unusual pattern of organization of arterial and venous thrombi or as a focal, incidental microscopic finding in hemangiomas. When lesions of intravascular papillary endothelial hyperplasia cause clinical signs, they characteristically appear as solitary, slowly growing nodules, usually on the upper extremities or head. Intravascular papillary endothelial hyperplasia has not previously been noted to simulate Kaposi's sarcoma.