Biomedical subjects
Publications and source records attributed to C L Bray.
Infection is a rare complication of cardiac mural thrombus and may prove difficult to diagnose and treat. We describe a patient with infected thrombus associated with a left ventricular aneurysm, involving Salmonella typhimurium. Cross-sectional echocardiography proved helpful in establishing the diagnosis.
A patient with a dissecting thoracic aortic aneurysm presented with acute low output cardiac failure due to right atrial obstruction. Five years earlier she had had her aortic valve replaced because of aortic regurgitation. Obstruction of the superior vena cava and pulmonary artery has been reported elsewhere as a complication of compression by thoracic aortic dissecting aneurysm. This case was unusual in presenting as right atrial obstruction.
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The association between extent and duration of smoking habit and severity of coronary atheroma was examined in 387 patients undergoing routine coronary ateriography before valve replacement surgery. Total number of cigarettes smoked in life correlated significantly with severity of coronary artery disease (p less than 0.001) and number of coronary arteries with stenoses of 50% or more (p less than 0.001). Severity of coronary artery disease in current smokers was similar to that in former smokers. Multiple regression analysis showed diastolic blood pressure, cigarette consumption, age, ratio of total cholesterol to high density lipoprotein cholesterol, and history of angina to be the important predictors of severity of coronary artery disease. An estimate of the number of cigarettes smoked in life can be useful in identifying patients with coronary artery disease if used in conjunction with data on other important risk factors.
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Several prognostic indices for predicting various aspects of coronary artery disease were significantly improved by the inclusion of psychosocial factors. 218 patients with valvular heart disease who had undergone routine coronary arteriography before valve replacement were studied in terms of cigarettes smoked, family history of ischaemic heart disease, HDL:cholesterol ratio, angina, sex, blood pressure and four psychosocial characteristics (i.e. social support, work stress, life events and Type A behavior). It was found that the psychosocial factors improved the preoperative predictive power of significant coronary artery disease on four criteria: previous history of hypertension, previous history of myocardial infarction, signs of peripheral vascular disease and ECG evidence of myocardial infarction.
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The relationship between coronary risk factors and coronary artery disease in patients with valvular heart disease was studied prospectively in 387 consecutive patients undergoing routine coronary arteriography prior to valve replacement. Coronary artery disease was as common in patients with mitral valve disease (31.9%) as in those with aortic valve disease (26.8%). Although it occurs more frequently in patients with angina (45.7%) significant coronary artery disease is found in 19.2% (47 of 245) of those without angina (P less than 0.001), suggesting that the presence of angina alone is an unreliable indicator of significant coronary disease. The prevalence and severity of significant coronary artery disease increases progressively as the number of coronary risk factors also increase (P less than 0.001) but the prevalence is low (3%) in patients in whom both angina and coronary risk factors are absent. These findings suggest that preoperative coronary arteriography might be omitted in this latter group of patients.
We have studied the effects of four doses of atenolol in 11 patients with stable angina pectoris using a symptom-limited exercise test and angina diaries. The doses 100 mg twice daily and 50 mg, 100 mg and 200 mg once daily were given double-blind and randomised within patients following run-in on placebo. Measurements were made 12 hours after the last twice daily dose and 24 hours after the last once daily dose. Exercise tolerance was improved by 40-74% and exercise duration before the onset of angina by 61-94% (P less than 0.01). Maximal heart rate was reduced further by a total daily dose of 200 mg than by lower doses, but no extra benefit was derived by giving the drug twice daily. The largest increase in exercise tolerance was obtained during treatment with 50 mg once daily. Atenolol was shown to be an effective anti-anginal agent when given once daily, and there were no major differences between the doses studied.
The data of 50 consecutive patients treated for postinfarction ventricular septal defect were reviewed. Cardiac catheterization was carried out in all patients and surgical repair was undertaken in 32 patients. The main factors affecting surgical outcome were the site of infarction and the extent of right ventricular damage. Anterior myocardial infarction carried a better hospital survival rate than inferior infarction (67 and 31%, respectively). Poor right ventricular free wall contraction, present in 44% of anterior infarctions and 71% of inferior infarctions carried a high mortality. Eighty per cent (12/15) of patients with good right ventricular contraction survived operation compared to only 24% (4/17) of patients with poor right ventricular contraction. Surgery within 24 h to 14 days of infarction carried a survival rate of 50% (7/14), similar to that in patients operated on more than two weeks following infarction (9/18). Seventeen out of 18 patients who did not undergo surgery either died suddenly before scheduled operation or were considered too poor a surgical risk. Of these, 12 patients died within one week of infarction and five patients survived between two weeks and three months. Early surgical repair should therefore be considered in all patients with postinfarction ventricular septal defect, the prognosis in patients with good right ventricular contraction being excellent.
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A prognostic index for predicting significant coronary artery disease was established using multiple logistic regression analysis of clinical data from 643 patients with valvular heart disease who had undergone routine coronary arteriography before valve replacement. The index or equation obtained incorporated the presence of angina, a family history of ischaemic heart disease, age, cigarette smoking habits, mitral valve disease, sex, and electrocardiographic evidence of myocardial infarction. The equation was validated using prospective data from 387 patients with valvular disease and shown to enable almost a third of routine coronary arteriograms to be omitted while maintaining 95% sensitivity for patients with coronary artery disease. Similar analysis of the more detailed prospective data produced a second discriminant function incorporating diastolic blood pressure, total cigarettes smoked in life, the severity of angina, family history of ischaemic heart disease, age, current cigarette smoking habits, and the ratio of total to high density lipoprotein cholesterol. This method improved the discrimination between patients with and without coronary artery disease, allowing omission of 30% of routine coronary arteriograms with 100% sensitivity for patients with coronary disease and omission of 41% with a 96% sensitivity level.
Pain relief in acute myocardial infarction (AMI) by the beta-adrenoceptor antagonist, atenolol, was demonstrated by three separate studies. First, 18 patients were randomized to double-blind intravenous atenolol (5 mg) or saline immediately after admission, followed by oral atenolol (50 mg) or placebo 10 minutes later. In patients receiving atenolol, pain relief coincided with reduction in heart rate (HR), systolic blood pressure (SBP), and HR X SBP product (p less than 0.05); however, pain and these parameters were unchanged by placebo. The degree of pain relief was related to the reduction in cardiac work achieved (r = 0.725; p less than 0.001). A second open study involving 22 patients receiving intravenous atenolol (5 to 15 mg) early after AMI showed ischemic pain relief in 17 patients. They achieved a more significant reduction in HR X SBP product than those whose pain remained unchanged (p = 0.004). Finally, a retrospective study of 163 patients randomized to either atenolol or no beta blockade early after AMI revealed that patients receiving atenolol needed less opiate analgesia after admission (p less than 0.001). The safety of this therapy was illustrated by a decreased incidence of left heart failure and atrial fibrillation and no tendency to second- and third-degree heart block.
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Explore the source record for details and available documents.
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The investigative findings of patients considered to have possible hypertrophic cardiomyopathy were examined, and 31 of these fulfilling defined criteria for the disease were reviewed in detail, with emphasis on thyroid abnormalities. Four patients had a history of thyroid disease (13%). Explanations considered for the apparent association were the effects of hyperthyroidism on normal, or more probably, incipiently abnormal myocardium.