John Speer Schroeder, M.D. is a board certified cardiologist who deals with a wide range of cardiovascular diagnostic issues and diseases. His clinical research areas include cardiovascular drugs, coronary artery spasm, chest pain of unclear cause, as well as primary and secondary treatment of coronary artery disease.
He was on the Pioneering First Heart Transplant Team at Stanford and since then has served in multiple administrative roles in the Cardiology Division at Stanford.
Dr. Schroeder also serves as a medicolegal and pharmacologic consultant in the cardiovascular field. He has published over 295 scientifically reviewed research papers and book chapters and published over 8 books.
- Cardiology (Heart)
- Cardiovascular Disease
- Cardiac Advanced Therapies
- Heart Disease Risk Factor Reduction
- Geriatric Cardiology
- Coronary Artery Spasm (Prinzmetal's Angina)
Fellowship:Stanford University School of Medicine Registrar (1969) CA
Residency:Stanford University School of Medicine Registrar (1967) CA
Board Certification: Internal Medicine, American Board of Internal Medicine (1969)
Internship:Stanford University School of Medicine (1963) CA
Board Certification: Cardiovascular Disease, American Board of Internal Medicine (1973)
Medical Education:University of Michigan School of Medicine (1962) MI
Current Research and Scholarly Interests
1. Clinical Pharmocology of Cardiovascular Drugs
(a) Calcium Channel Blockers
(b) Agents for Heart Failure
(c) Anti-atherosclerotic Effects of Cardiovascular Drugs, e.g. Calcium Channel Blockers
2. Cardiac Transplantation/Congestive Heart Failure
3. Coronary Artery Spasm
- Angina with Normal Coronaries (chapter revision of “Variant Angina” chapter). Cardiology An Illustrated Textbook. Philadelphia, JB Lippincott. 2016 Kanu Chatterjee 2016
- Pharmacologic Options for Treatment of Ischemic Disease. Antman Cardiovascular Therapeutics: A Companion to Braunwald’s Heart Disease, 3rd Edition, Elsevier 2012
- Surgical Treatment of Heart Failure, Cardiac Transplantation, and Mechanical Ventricular Support. Hurst's The Heart, 12th Edition, McGraw Hill 2008
- Pharmacologic Options for Treatment of Ischemic Disease. Antman Cardiovascular Therapeutics: A Companion to Braunwald’s Heart Disease, 3rd Edition, Elsevier 2007
Effects of cardiac resynchronization on disease progression in patients with left ventricular systolic dysfunction, an indication for an implantable cardioverter-defibrillator, and mildly symptomatic chronic heart failure
2004; 110 (18): 2864-2868
The effects of cardiac resynchronization therapy (CRT) in patients with mildly symptomatic heart failure have not been fully elucidated.The Multicenter InSync ICD Randomized Clinical Evaluation II (MIRACLE ICD II) was a randomized, double-blind, parallel-controlled clinical trial of CRT in NYHA class II heart failure patients on optimal medical therapy with a left ventricular (LV) ejection fraction < or =35%, a QRS > or =130 ms, and a class I indication for an ICD. One hundred eighty-six patients were randomized: 101 to the control group (ICD activated, CRT off) and 85 to the CRT group (ICD activated, CRT on). End points included peak VO2, VE/CO2, NYHA class, quality of life, 6-minute walk distance, LV volumes and ejection fraction, and composite clinical response. Compared with the control group at 6 months, no significant improvement was noted in peak VO2, yet there were significant improvements in ventricular remodeling indexes, specifically LV diastolic and systolic volumes (P=0.04 and P=0.01, respectively), and LV ejection fraction (P=0.02). CRT patients showed statistically significant improvement in VE/CO2 (P=0.01), NYHA class (P=0.05), and clinical composite response (P=0.01). No significant differences were noted in 6-minute walk distance or quality of life scores.In patients with mild heart failure symptoms on optimal medical therapy with a wide QRS complex and an ICD indication, CRT did not alter exercise capacity but did result in significant improvement in cardiac structure and function and composite clinical response over 6 months.
View details for DOI 10.1161/.01.CIR.0000146336.92331.D1
View details for Web of Science ID 000224835500016
View details for PubMedID 15505095
Emerging therapies for angina: new modalities may offer additional clinical options.
Managed care interface
2004; 17 (4): 45-52
The social and economic burdens of chronic angina are enormous, and the morbidity and mortality associated with its underlying cause, coronary artery disease, are high. For many patients with chronic angina, current drug therapies are contraindicated or ineffective, and surgical procedures too risky or costly. Most newer approaches have not yet been sufficiently evaluated and can be expensive, time-consuming, or both. A new class of antianginal drugs, the metabolic modulators, will soon be available. In controlled clinical trials, these agents have shown promising results in reducing the frequency of angina episodes and lengthening the duration of exercise sessions. They are also well tolerated.
View details for PubMedID 15108760
Glucose intolerance, as reflected by hemoglobin A(1c) level, is associated with the incidence and severity of transplant coronary artery disease
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2004; 43 (6): 1034-1041
The possible effect of plasma hemoglobin A(1c) (HbA(1c)) on the development of transplant coronary artery disease (TxCAD) was investigated.Glucose intolerance is implicated as a risk factor for TxCAD. However, a relationship between HbA(1c) and TxCAD has not been demonstrated.Plasma HbA(1c) was measured in 151 adult patients undergoing routine annual coronary angiography at a mean period of 4.1 years after heart transplantation. Intracoronary ultrasound (ICUS) was also performed in 42 patients. Transplant CAD was graded by angiography as none, mild (stenosis in any vessel < or =30%), moderate (31% to 69%), or severe (> or =70%) and was defined by ICUS as a mean intimal thickness (MIT) > or =0.3 mm in any coronary artery segment. The association between TxCAD and established risk factors was examined.Plasma HbA(1c) increased with the angiographic grade of TxCAD (5.6%, 5.8%, 6.4%, and 6.2% for none, mild, moderate, and severe disease, respectively; p < 0.05 for none vs. moderate or severe) and correlated with disease severity (r = 0.24, p < 0.05). The HbA(1c) level was higher in patients with MIT > or =0.3 mm than in those with MIT <0.3 mm (6.4% vs. 5.7%, p < 0.05). Multivariate logistic regression analysis identified HbA(1c) as an independent predictor of TxCAD, as detected by angiography or ICUS (odds ratios 1.9 and 2.4, 95% confidence intervals 1.5 to 6.3 [p = 0.010] and 1.3 to 4.2 [p < 0.005], respectively).Persistent glucose intolerance, as reflected by plasma HbA(1c), is associated with the occurrence of TxCAD and may play an important role in its pathogenesis.
View details for DOI 10.1016/j.jacc.2003.08.063
View details for Web of Science ID 000220212400018
View details for PubMedID 15028363
- Surgical Treatment of Heart Failure, Cardiac Transplantation, and Mechanical Ventricular Support. Hurst’s The Heart, 11th Edition, McGraw Hill 2004
- Unstable Angina and Non-St Elevation Myocardial Infarction. Cardiology for the Primary Care Physician, 4th Edition 2004
- Multicenter InSync ICD II Study Group. Effects of cardiac resynchronization on disease progression in patients with left ventricular systolic dysfunction, an indication for an implantable cardioverter-defibrillator, and mildly symptomatic chronic heart failure. Circulation 2004; 110: 2864-8.
Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure - The MIRACLE ICD Trial
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2003; 289 (20): 2685-2694
Cardiac resynchronization therapy (CRT) through biventricular pacing is an effective treatment for heart failure (HF) with a wide QRS; however, the outcomes of patients requiring CRT and implantable cardioverter defibrillator (ICD) therapy are unknown.To examine the efficacy and safety of combined CRT and ICD therapy in patients with New York Heart Association (NYHA) class III or IV congestive HF despite appropriate medical management.Randomized, double-blind, parallel-controlled trial conducted from October 1, 1999, to August 31, 2001, of 369 patients with left ventricular ejection fraction of 35% or less, QRS duration of 130 ms, at high risk of life-threatening ventricular arrhythmias, and in NYHA class III (n = 328) or IV (n = 41) despite optimized medical treatment.Of 369 randomized patients who received devices with combined CRT and ICD capabilities, 182 were controls (ICD activated, CRT off) and 187 were in the CRT group (ICD activated, CRT on).The primary double-blind study end points were changes between baseline and 6 months in quality of life, functional class, and distance covered during a 6-minute walk. Additional outcome measures included changes in exercise capacity, plasma neurohormones, left ventricular function, and overall HF status. Survival, incidence of ventricular arrhythmias, and rates of hospitalization were also compared.At 6 months, patients assigned to CRT had a greater improvement in median (95% confidence interval) quality of life score (-17.5 [-21 to -14] vs -11.0 [-16 to -7], P =.02) and functional class (-1 [-1 to -1] vs 0 [-1 to 0], P =.007) than controls but were no different in the change in distance walked in 6 minutes (55 m [44-79] vs 53 m [43-75], P =.36). Peak oxygen consumption increased by 1.1 mL/kg per minute (0.7-1.6) in the CRT group vs 0.1 mL/kg per minute (-0.1 to 0.8) in controls (P =.04), although treadmill exercise duration increased by 56 seconds (30-79) in the CRT group and decreased by 11 seconds (-55 to 12) in controls (P<.001). No significant differences were observed in changes in left ventricular size or function, overall HF status, survival, and rates of hospitalization. No proarrhythmia was observed and arrhythmia termination capabilities were not impaired.Cardiac resynchronization improved quality of life, functional status, and exercise capacity in patients with moderate to severe HF, a wide QRS interval, and life-threatening arrhythmias. These improvements occurred in the context of underlying appropriate medical management without proarrhythmia or compromised ICD function.
View details for Web of Science ID 000183075600027
View details for PubMedID 12771115
Post-transplantation lymphoproliferative disease in heart and heart-lung transplant recipients: 30-year experience at Stanford University
21st Annual Meeting of the International-Society-for-Heart-and-Lung-Transplantation
ELSEVIER SCIENCE INC. 2003: 505–14
Post-transplantation lymphoproliferative disease (PTLD) is an important source of morbidity and mortality in transplant recipients, with a reported incidence of 0.8% to 20%. Risk factors are thought to include immunosuppressive agents and viral infection. This study attempts to evaluate the impact of different immunosuppressive regimens, ganciclovir prophylaxis and other potential risk factors in the development of PTLD.We reviewed the records of 1026 (874 heart, 152 heart-lung) patients who underwent transplantation at Stanford between 1968 and 1997. Of these, 57 heart and 8 heart-lung recipients developed PTLD. During this interval, 4 different immunosuppressive regimens were utilized sequentially. In January 1987, ganciclovir prophylaxis for cytomegalovirus serologic-positive patients was introduced. Other potential risk factors evaluated included age, gender, prior cardiac diagnoses, HLA match, rejection frequency and calcium-channel blockade.No correlation of development of PTLD was found with different immunosuppression regimens consisting of azathioprine, prednisone, cyclosporine, OKT3 induction, tacrolimus and mycophenolate mofetil. A trend suggesting an influence of ganciclovir on the prevention of PTLD was not statistically significant (p = 0.12). Recipient age and rejection frequency, as well as high-dose cyclosporine immunosuppression, were significantly (p < 0.02) associated with PTLD development. The prevalence of PTLD at 13.3 years was 15%.The overall incidence of PTLD was 6.3%. It was not altered by sequential modifications in treatment regimens. Younger recipient age and higher rejection frequency were associated with increased PTLD occurrence. The 15% prevalence of PTLD in 58 long-term survivors was unexpectedly high.
View details for DOI 10.1016/S1053-2498(02)01229-9
View details for PubMedID 12742411
- Combined Cardiac Resynchronization and Implantable Cardioversion Defibrillation in Advanced Chronic Heart Failure. JAMA 2003; 289 (20)
- Accelerated graft arteriosclerosis. Baumgartner WA et al, ed. W.B. Saunders Company 2002: 387-413
- Infectious burden and atherosclerosis Curr Cardiol Rep 2002; 4: 259
Mild hyperhomocysteinemia is not associated with cardiac allograft coronary disease
2001; 15 (4): 247-252
Hyperhomocysteinemia is an independent risk factor for coronary disease and elevated plasma homocysteine levels have been documented in heart transplant recipients. The aim of this study was to test the hypothesis that homocysteine levels are associated with presence or absence of transplant coronary artery disease.Forty-three non-smoking adults were recruited, all of whom had received a heart transplant between 2 and 7 yr previously. All 43 had blood drawn for fasting homocysteine level on the day of presentation. All patients had undergone diagnostic coronary angiography within the past 6 months.For all patients, the average fasting plasma homocysteine level was 17.0+/-SD 6.6 micromol/L with a range from 6.0 to 36.9 micromol/L. Twenty-six patients (60%) had fasting plasma homocysteine levels above 15.0 micromol/L. On the basis of arteriography, patients were categorized as those with angiographically normal (n=22) or abnormal (n=21) coronary arteries. There was no difference in the mean plasma homocysteine level comparing patients with angiographically normal (17.2+/-SD 7.0 micromol/L) to those with abnormal (16.8+/-SD 6.2 micromol/L) coronary arteries. Plasma homocysteine levels increased with increasing plasma creatinine levels (r=0.63, p<0.0001) and with decreasing vitamin B6 levels (r=-0.56, p<0.0001).Mild hyperhomocysteinemia is a consistent finding among heart transplant recipients. This finding was not associated with transplant coronary artery disease in our patients. The combination of renal dysfunction and vitamin B6 deficiency may explain the unusual prevalence of hyperhomocysteinemia in heart transplant recipients.
View details for Web of Science ID 000170338600005
View details for PubMedID 11683818
- Cardiac transplantation Harrison's Principles of Internal Medicine (15th ed). New York, McGraw-Hill, Inc 2001
- Accelerated graft atherosclerosis Heart and Lung Transplant Book (2nd ed) W. B. Saunders 2001: 387-413
- Inhibition of the sodium-hydrogen exchanger with cariporide to prevent myocardial infarction in high-risk ischemic situations: main results of the GUARDIAN trial Circ 2000; 102: 3032-38
- . Design of a trial evaluating myocardial cell protection with cariporide, an inhibitor of the transmembrane sodium-hydrogen exchanger,: the Guard During Ischemia Against Necrosis (GUARDIAN) trial. Curr Control Trials Cardiovasc Med 2000: 59-67
- Unstable angina and non-Q wave myocardial infarction. Cardiology For The Primary Care Physician. (3rd ed.) Mosby-Year Book, Inc., St. Louis 2000: 171-193
Impact of prophylactic immediate posttransplant ganciclovir on development of transplant atherosclerosis - A post hoc analysis of a randomized, placebo-controlled study
1999; 100 (1): 61-66
Coronary artery disease occurs in an accelerated fashion in the donor heart after heart transplantation (TxCAD), but the cause is poorly understood. The risk of developing TxCAD is increased by cytomegalovirus (CMV) infection and decreased by use of calcium blockers. Our group observed that prophylactic administration of ganciclovir early after heart transplantation inhibited CMV illness, and we now propose to determine whether this therapy also prevents TxCAD.One hundred forty-nine consecutive patients (131 men and 18 women aged 48+/-13 years) were randomized to receive either ganciclovir or placebo during the initial 28 days after heart transplantation. Immunosuppression consisted of muromonab-CD3 (OKT-3) prophylaxis and maintenance with cyclosporine, prednisone, and azathioprine. Mean follow-up time was 4.7+/-1.3 years. In a post hoc analysis of this trial designed to assess efficacy of ganciclovir for prevention of CMV disease, we compared the actuarial incidence of TxCAD, defined by annual angiography as the presence of any stenosis. Because calcium blockers have been shown to prevent TxCAD, we analyzed the results by stratifying patients according to use of calcium blockers. TxCAD could not be evaluated in 28 patients because of early death or limited follow-up. Among the evaluable patients, actuarial incidence of TxCAD at follow-up (mean, 4.7 years) in ganciclovir-treated patients (n=62) compared with placebo (n=59) was 43+/-8% versus 60+/-10% (P<0.1). By Cox multivariate analysis, independent predictors of TxCAD were donor age >40 years (relative risk, 2.7; CI, 1.3 to 5.5; P<0.01) and no ganciclovir (relative risk, 2.1; CI, 1.1 to 5.3; P=0.04). Stratification on the basis of calcium blocker use revealed differences in TxCAD incidence when ganciclovir and placebo were compared: no calcium blockers (n=53), 32+/-11% (n=28) for ganciclovir versus 62+/-16% (n=25) for placebo (P<0.03); calcium blockers (n=68), 50+/-14% (n=33) for ganciclovir versus 45+/-12% (n=35) for placebo (P=NS).TxCAD incidence appears to be lower in patients treated with ganciclovir who are not treated with calcium blockers. Given the limitations imposed by post hoc analysis, a randomized clinical trial is required to address this issue.
View details for Web of Science ID 000081279300013
View details for PubMedID 10393682
- Cardiac transplantation In: Harrison's Principles of Internal Medicine 1999; 14th ed.
- Cardiac transplantation In: Harrison's Principles of Internal Medicine 1998; 14th ed., pp. 1298-1300
- Unstable angina and non-Q wave myocardial infarction In: Current Practice of Medicine 1998; 2, 515-20
- Cardiac transplantation, mechanical ventricular support, endomyocardial biopsy In: Hurst's the Heart 1998; 9th ed., pp. 799-824
- HMG-CoA reductase inhibitors reduce transplant coronary artery disease and mortality - Evidence for antigen-independent mechanisms? CIRCULATION 1997; 96 (5): 1370-1373
Relation of donor age and preexisting coronary artery disease on angiography and intracoronary ultrasound to later development of accelerated allograft coronary artery disease
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1997; 29 (3): 623-629
This study assessed the influence of donor age and preexisting donor coronary disease on the later development of allograft coronary artery disease, ischemic events and overall survival.The increasing demand for heart donors has led to a tendency to liberalize age criteria for donor acceptability.A total of 233 consecutive heart transplant recipients who had baseline, early postoperative and follow-up coronary angiograms, as well as a subset of 47 patients with baseline intracoronary ultrasound imaging recordings, were analyzed (mean 3.8 years of follow-up). Patients were subclassified according to the presence of donor coronary artery disease on the baseline angiogram and stratified at age 40 years.patients without evidence of preexisting coronary artery disease on a baseline angiogram (n = 219) were significantly less likely to develop new disease than the 14 patients with preexisting coronary artery disease (p = 0.002). Although older donors exhibited earlier coronary artery disease than younger donors at 3 years of follow-up, there was no difference by 5 years (p = 0.25). There was no difference in survival or probability of developing ischemic events between the groups. Baseline ultrasound imaging revealed substantial disease in 7 of 9 older donated hearts, and in only 7 of 38 younger donated hearts (p = 0.002). Preexisting coronary artery disease, nonuse of calcium channel blocking agents, older donor age, posttransplantation cytomegalovirus infection, elevated very low density lipoprotein levels and previous ischemic heart disease in the recipient were significant predictors of allograft coronary artery disease.Heart donors with angiographic evidence of preexisting coronary artery disease and older donors are more likely to develop new allograft coronary artery disease by 3 years. However, there is no difference in survival or freedom from ischemic events between younger and older donors at a mean follow-up of 3.8 years.
View details for Web of Science ID A1997WL49000023
View details for PubMedID 9060902
Role of compensatory enlargement and shrinkage in transplant coronary artery disease - Serial intravascular ultrasound study
1997; 95 (4): 855-859
Compensatory enlargement of the vessel wall has been described in the early stages of native atherosclerosis. Whether compensatory enlargement plays a role in transplant coronary artery disease is not known. The objective of this study was to determine, by use of serial intravascular ultrasound (IVUS), whether compensatory dilation occurs in transplant coronary artery disease over time.Seventy-five heart transplant recipients with 151 matched coronary segments were selected for the presence of intimal disease progression as detected by serial IVUS examinations 1 to 3 years apart. Intimal disease progression was defined as a > 10% increase in intimal area (IA). IVUS catheter location in follow-up studies was verified angiographically in relation to branch vessels. Luminal area (LA) and total vessel area (TA) were measured at each site. Intimal area (IA = TA-LA) was calculated. Changes in IA (delta IA) and TA (delta TA) between baseline and follow-up IVUS were compared: delta IA, 2.9 +/- 0.2 mm2: delta TA, 2.7 +/- 0.4 mm2. A remodeling index (RI) was defined as RI = delta TA/delta IA. Three subgroups could be distinguished: over compensation (RI > I), partial compensation (RI 0 to 1), and no compensation or shrinkage (RI < or = 0). Seventy-four segments (49%) showed overcompensation, 44 (29%) showed partial compensation, and 33 (22%) showed no compensation or shrinkage.In this study, serial IVUS shows that early after cardiac transplantation, a large proportion of the coronary segments with progression of intimal thickening have compensatory dilation of the vessel wall. However, a substantial number of coronary segments (22%) show no compensatory dilation or shrinkage. The progressive luminal narrowing in transplant patients may be due in part to vessel shrinkage or the lack of compensatory dilation over time.
View details for Web of Science ID A1997WJ28200021
View details for PubMedID 9054742
- New developments in the use of calcium entry blocking drugs in cardiovascular disease In: Cardiology Clinics: Annual of Drug Therapy 1997; I, pp. 11-23
- Heart transplantation in adults and children In: Difficult Cardiology III 1997; pp. 361-399
Prediction of angiographic disease by intracoronary ultrasonographic findings in heart transplant recipients
JOURNAL OF HEART AND LUNG TRANSPLANTATION
1996; 15 (10): 980-987
Intracoronary ultrasonography has proven to be a more sensitive test than angiography for the detection of intimal thickening in transplant recipients. However, the prognostic significance of the intimal thickening detected by intracoronary ultrasonography has not been proven.During a 1-year period, 70 transplant recipients without angiographically apparent coronary artery disease underwent intracoronary ultrasonography examination. For each intracoronary ultrasonography study an intimal index, defined as the ratio of the plaque area to the area within the media, was measured for the most diseased segment imaged. The subsequent annual follow-up angiograms of these 70 patients were reviewed for the development of visually apparent coronary artery disease. The time since transplantation for the 70 patients without angiographically apparent coronary artery disease ranged from 1 to 15 years, with a mean of 4.2 years an median of 3.9 years. Mean duration of angiographic follow-up was 2.0 years (range 1 to 3 years).Angiographically apparent coronary artery disease developed on follow-up angiograms in 13 of the 70 patients, with a mean time to development of 1.5 years. Four of 46 patients (9%) with an intimal index < 0.3 subsequently had angiographically apparent coronary artery disease, whereas of 25 patients (36%) with an intimal index > or = 0.3 subsequently had angiographically apparent coronary artery disease. Odds ratio for future angiographically apparent coronary artery disease between patients with an intimal index > or = and intimal index < 0.3 was 5.9 (p < 0.01 by Fisher's Exact test). In a subgroup of 22 patients more than 5 years after transplantation at the time of intracoronary ultrasonography, 12 had an intimal index < 0.3 and 10 had an intimal index > or = 0.3. In this subgroup none of the 12 patients with an intimal index < 0.3 had angiographically apparent coronary artery disease and only 1 of the 10 with an intimal index > or = 0.3 had angiographically apparent coronary artery disease (difference not significant).The presence of moderate to severe intimal thickening by intracoronary ultrasonography is predictive of the future development of angiographically apparent coronary artery disease among patients more than 1 year and less than 5 years after transplantation. This same degree of intimal thickening may not carry the same prognostic significance among patients greater than 5 years after transplantation without the development of angiographically apparent coronary artery disease.
View details for Web of Science ID A1996VT54800003
View details for PubMedID 8913914
Early development of accelerated graft coronary artery disease: Risk factors and course
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1996; 28 (3): 673-679
This study assessed the time of first appearance of angiographic graft coronary artery disease in relation to clinical and laboratory variables and clinical events in heart transplant recipients.Graft coronary artery disease is the main factor limiting long-term survival after heart transplantation, and it is important to understand its natural history.One hundred thirty-nine consecutive patients who developed angiographic coronary artery disease after heart transplantation were classified according to early (< or = 2 years) versus late (> 2 years) posttransplantation initial detection of coronary artery disease. These subgroups were analyzed for differences in clinical and laboratory demographics, incidence of progression to ischemic events and incidence of antecedent cytomegalovirus infection.The early-onset group (64 patients) had more rapid progression to ischemic events than the late-onset group (75 patients), with 59% of the late group and only 35% of the early group free from ischemic events by 5 years after initial detection (p = 0.02), but there were no significantly correlated clinical or laboratory predictors of ischemic events. The early group had a significantly higher incidence of antecedent cytomegalovirus infection.We conclude that 1) accelerated graft coronary artery disease develops at variable times after heart transplantation; 2) the early appearance of graft coronary artery disease may be a marker of intrinsically more aggressive disease; 3) cytomegalovirus infection is associated with earlier onset of graft coronary artery disease. Patients with early development of graft coronary artery disease should potentially be given priority for interventional strategies as they are developed.
View details for Web of Science ID A1996VE27300019
View details for PubMedID 8772755
Analysis of deaths in patients awaiting heart transplantation: Impact on patient selection criteria
1996; 75 (5): 455-462
To analyse the clinical characteristics of patients who died on the Stanford heart transplant waiting list and to develop a method for risk stratifying status 2 patients (outpatients).Data were reviewed from all patients over 18 years, excluding retransplants, who were accepted for heart transplantation over an eight year period from 1986 to 1994.548 patients were accepted for heart transplantation; 53 died on the waiting list, and 52 survived on the waiting list for over one year. On multivariate analysis only peak oxygen consumption (peak VO2: 11.7 (SD 2.7) v 15.1 (5.2) ml/kg/min, P = 0.02) and cardiac output (3.97 (1.03) v 4.79 (1.06) litres/min, P = 0.04) were found to be independent prognostic risk factors. Peak VO2 and cardiac index (CI) were then analysed in the last 141 consecutive patients accepted for cardiac transplantation. All deaths and 88% of the deteriorations to status 1 on the waiting list occurred in patients with either a CI < 2.0 or a VO2 < 12. In those with a CI < 2.0 and a VO2 < 12, 38% died or deteriorated to status 1 in the first year on the waiting list. Patients with CI > or = 2.0 and a VO2 > or = 12 all survived throughout follow up. Using a Cox's proportional hazards model with CI and peak VO2 as covariates, tables were constructed predicting the chance of surviving for (a) 60 days and (b) 1 year on the waiting list.These data provide a basis for risk stratification of status 2 patients on the heart transplant waiting list.
View details for Web of Science ID A1996UK45400010
View details for PubMedID 8665337
Transplant candidates with severe left ventricular dysfunction managed with medical treatment: Characteristics and survival
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1996; 27 (5): 1192-1197
This study sought to assess the clinical characteristics and survival of patients with symptomatic heart failure who were referred as potential heart transplant candidates, but were selected for medical management.Patients with severe left ventricular dysfunction referred for heart transplantation may be considered too well to be placed immediately on an active waiting transplant list. The clinical characteristics of this patient group and their survival have not been well defined. These patients represent a unique group that are characterized by comparatively low age and freedom from significant comorbid conditions.We studied 116 consecutive patients with symptomatic heart failure, severe left ventricular dysfunction (left ventricular ejection fraction 20 +/- 7% [mean +/- SD]) and duration of symptoms >1 month referred for heart transplantation, who were acceptable candidates for the procedure but who were not listed for transplantation because of relative clinical stability. These patients were followed up closely on optimal medical therapy. A variety of baseline clinical, hemodynamic and exercise variables were assessed to define this patient group and used to predict cardiac death and requirement later for heart transplantation.During a mean follow-up period of 25.0 +/- 14.8 months (follow-up 99% complete), there were eight cardiac deaths (7%) (seven sudden, one acute myocardial infarction). Only nine patients (8%) were listed for heart transplantation. Actuarial 1- and 4-year cardiac survival rates were 98 +/- 1% and 84 +/- 7% (mean +/- SE), respectively, and freedom from listing for transplantation was 95 +/- 2% and 84 +/- 7% (mean +/- SE), respectively. Patients were mainly in New York Heart Association functional class II or III and had a preserved cardiac index (2.4 liters/min.m2), pulmonary capillary wedge pressure of 16 +/- 9 mm Hg (mean +/- SD) and maximal oxygen consumption of 17.4 +/- 4.3 ml/min per kg (mean +/- SD). By logistic regression analysis, there was no predictor for cardiac death. Longer duration of heart failure (p = 0.013) and mean pulmonary artery (p < 0.05) and pulmonary systolic (p = 0.014) and diastolic (p < 0.05) pressures correlated significantly with listing for heart transplantation by univariate logistic regression. By multivariate logistic regression, only pulmonary artery systolic pressure (p < 0.004) and duration of heart failure (p < 0.015) remained as predictors for need for later transplantation.In the current treatment era, prognosis is favorable in a definable group of transplant candidates despite severe left ventricular dysfunction. This patient group can be identified after intensive medical therapy by stable symptoms, a relatively high maximal oxygen uptake at peak exercise and a preserved cardiac output.
View details for Web of Science ID A1996UD65100031
View details for PubMedID 8609341
Coronary artery intimal thickening in the transplanted heart - An in vivo intracoronary ultrasound study of immunologic and metabolic risk factors
1996; 61 (1): 46-53
This study examined the hypothesis that immunologic factors are the major correlates of coronary artery intimal thickening and luminal stenosis. The study population included 116 adult heart transplant recipients with a mean age of 44.7 +/- 12.0 years (89 men and 27 women) undergoing annual coronary angiography and intracoronary ultrasound 3.4 +/- 2.7 (range, 1.0-14.6) years after transplantation. Mean intimal thickness was obtained from several distinct sites along the left anterior descending and/or left circumflex coronary artery by intracoronary ultrasound. Coronary artery stenosis defined by angiography was classified as mild (< 30% luminal stenosis), moderate (> or = 30-70% luminal stenosis), or severe (> 70% luminal stenosis or diffuse pruning of distal vessels). Prevalence of any transplant coronary artery disease (TxCAD) was 85% by intracoronary ultrasound and 15% by angiography. By multiple regression analysis, only average fasting plasma triglyceride level (P < 0.006) and average weight (P < 0.007) were significantly correlated with severity of intimal thickening (R = 0.54, P < 0.0001). Donor age (P < 0.006) and average fasting plasma triglyceride level (P < 0.009) were significantly correlated with stenosis by angiography. Correlation of multiple immunologic and metabolic factors with intimal thickness by univariate analysis suggests a multifactorial etiology for TxCAD. Among the multiple univariate correlates of TxCAD, higher fasting plasma triglyceride levels and body weight are the only independent correlates of TxCAD. The absence of acute rejection as an independent predictor of intimal thickening suggests that mechanisms beyond those mediating typical cellular rejection should be targeted for advancing our understanding of Tx-CAD.
View details for Web of Science ID A1996TQ20100011
View details for PubMedID 8560573
- Unstable angina and non-Q wave myocardial infarction In: Cardiology For The Primary Care Physician 1996; 143-148
- Unstable angina and non-Q wave myocardial infarction In: Current Practice of Medicine 1996; II; pp. 10.1-10.6
PROGNOSTIC IMPORTANCE OF INTIMAL THICKNESS AS MEASURED BY INTRACORONARY ULTRASOUND AFTER CARDIAC TRANSPLANTATION
1995; 92 (12): 3445-3452
Although intracoronary ultrasound (ICUS) has been validated for the early detection of transplant coronary artery disease (TxCAD), the prognostic importance of findings detected by this new imaging technique is unknown.This study examined the relation of clinical outcome in 145 heart transplant recipients (mean age, 45.1 +/- 11.1 years) with the amount of intimal thickness measured by ICUS during routine annual coronary angiography 1 to 10 years (mean, 3.1 +/- 2.2 years) after transplantation. From published autopsy data, a mean intimal thickness of > 0.3 mm was considered significant. During a mean follow-up time of 48.2 +/- 10.2 months, 23 deaths (12 cardiac) occurred, and 6 patients required retransplantation. Angiographic TxCAD developed in 22 of 125 patients (17.6%) in the subgroup with normal angiograms at the time of ICUS and a follow-up annual angiographic study. In the total population and the subgroup, mean intimal thicknesses of > 0.3 and < or = 0.3 mm, respectively, were associated with significantly inferior 4-year actuarial overall survival (73% versus 96%, P = .005; 72% versus 92%, P = .05), cardiac survival (79% versus 96%, P = .005; 80% versus 98%, P = .04), and freedom from cardiac death and retransplantation (74% versus 98%, P < .0001; 70% versus 96%, P = .001). In addition, ICUS predicted freedom from development of subsequent angiographic TxCAD in the subgroup that was initially normal (26% versus 72%, P = .02). A mean intimal thickness by ICUS of > 0.3 mm was associated with inferior clinical outcome regardless of the presence of angiographic TxCAD and predicted the development of subsequent angiographic TxCAD. Despite significantly longer duration after transplantation, higher rejection incidence, and lower average daily cyclosporine dose, none of these covariates were independent risk factors for outcome.These findings confirm the prognostic importance of mean intimal thickening of > 0.3 mm in heart transplant recipients and suggest that these patients should be candidates for early interventional strategies.
View details for Web of Science ID A1995TJ65500018
View details for PubMedID 8521566
- RECENT ADVANCES IN CARDIAC TRANSPLANTATION NEW ENGLAND JOURNAL OF MEDICINE 1995; 333 (10): 660-661
INFLUENCE OF PREEXISTENT DONOR CORONARY-ARTERY DISEASE ON THE PROGRESSION OF TRANSPLANT VASCULOPATHY - AN INTRAVASCULAR ULTRASOUND STUDY
1995; 92 (5): 1126-1132
Transplant vasculopathy (TxCAD) limits longterm survival of allograft recipients. The possibility that preexistent donor coronary disease (PEDD) might accelerate this process is of concern. The serial progression of sites with and without PEDD as assessed by intravascular ultrasonic imaging is explored in this study.Thirty patients with baseline intravascular imaging within 3 weeks of cardiac transplantation who had at least one annual follow-up study were included in this study. Vessel luminal area (LA), total area (TA), intimal index (II = TA - LA/TA), mean intimal thickness (MIT), and Stanford classification were expressed for each image site and for each patient at each study. Progression of sites and of patients with and without PEDD on the baseline study was compared. Patients with PEDD (n = 9) still had significantly more intimal disease than those without PEDD (n = 21) at the first follow-up study (MIT = 0.35 +/- 0.13 versus 0.13 +/- 0.11 mm; II = 0.29 +/- 0.11 versus 0.11 +/- 0.1; class = 3.7 +/- 0.5 versus 2.2 +/- 0.94; P < .001 for all comparisons). However, the increase in intimal thickness during the 1- year interval was not significantly different between the two groups. In 4 patients in whom both types of sites were present, no difference in progression was found. Data were similar for patients and sites studied over > 1 year.PEDD does not accelerate the progression of TxCAD within the first few years after cardiac transplantation. The pathophysiology of TxCAD is most likely immune mediated and does not seem to be accelerated by native coronary artery disease.
View details for Web of Science ID A1995RR27600012
View details for PubMedID 7648656
CALCIUM BLOCKERS AND ATHEROSCLEROSIS - LESSONS FROM THE STANFORD TRANSPLANT CORONARY-ARTERY DISEASE DILTIAZEM TRIAL
CANADIAN JOURNAL OF CARDIOLOGY
1995; 11 (8): 710-715
Accelerated coronary artery disease (TxCAD) in the long term heart transplant patient remains the major limitation to long term survival, with approximately 50% of patients developing an angiographic event of TxCAD by five years post-transplant. This accelerated vasculopathic process is believed to be due to chronic immune injury to the endothelium with coronary intimal proliferation developing rapidly. Subsequent lipid deposition develops in these proliferated areas, leading to a diffuse progressive occlusive CAD which can be seen on serial coronary arteriography as a progressive luminal narrowing. Based on multiple annual studies demonstrating a protective effect of calcium blockers in diet- or injury-induced vascular disease in animals, the authors undertook a randomized trial of diltiazem versus no calcium blocker begun early after heart transplantation in 1986. Serial quantitative coronary arteriographic measurements have demonstrated no significant change in the diltiazem group versus a decrease in mean coronary lumen diameter, from 2.41 +/- 0.27 to 2.19 +/- 0.28 mm, in the no calcium blocker group. These differences persisted at two and three years of follow-up. Freedom from CAD based on qualitative angiographic data confirmed this protective effect of diltiazem. These observations are supported by other reported retrospective studies of calcium blockers post-heart transplantation and in non-TxCAD. Therefore, calcium blockers appear to prevent the early coronary intimal proliferation in response to chronic immune injury, as well as the later lipid deposition. The cardiac transplant patient may serve as a useful model for study of antiatherosclerotic agents in humans.
View details for Web of Science ID A1995RX89100011
View details for PubMedID 7671182
CORRELATION OF DONOR CHARACTERISTICS WITH TRANSPLANT CORONARY-ARTERY DISEASE AS ASSESSED BY INTRACORONARY ULTRASOUND AND CORONARY ANGIOGRAPHY
AMERICAN JOURNAL OF CARDIOLOGY
1995; 76 (5): 340-345
The mechanisms responsible for transplant coronary artery disease (CAD) and its predisposing factors remain incompletely understood. The influence of donor characteristics as predisposing factors has not been studied systematically. We examined the correlation of donor demographic, clinical, and immunologic parameters with transplant CAD assessed by both intracoronary ultrasound (ICUS) and coronary angiography in 116 heart transplant recipients (age 44.7 +/- 12.0 years) studied 3.4 years (range 1.0 to 14.6) after transplantation. Quantitative ultrasound data were obtained by calculating mean intimal thickness from several distinct coronary sites. Coronary angiograms were categorized visually as normal or showing any transplant CAD. By multivariate regression analysis, donor undersize of > 20% of recipient weight (p < 0.02) and duration after transplantation (p < 0.005) were independently correlated with the amount of ICUS intimal thickness (r = 0.36, p = 0.0007), and older donor age with angiographic evidence for the disease (r = 0.34, p < 0.006). In a subgroup analysis of the 39 patients studied 1 year after transplantation, white donor race (p < 0.05), fewer human leukocyte antigen-DR mismatches (p < 0.002), shorter ischemic time (p < 0.04), and donor smoking history (p < 0.02) were independent predictors for severity of ICUS intimal thickening (r = 0.92, p = 0.0009); higher donor age (p < 0.006) and higher arterial partial pressure of oxygen (p < 0.003) were independent predictors for angiographic disease (r = 0.67, p < 0.002). In conclusion, donor characteristics may contribute to the probably multifactorial pathogenesis of transplant CAD.
View details for Web of Science ID A1995RN75900005
View details for PubMedID 7639157
- ACCELERATED GRAFT CORONARY-ARTERY DISEASE IN HEART-TRANSPLANT RECIPIENTS CORONARY ARTERY DISEASE 1995; 6 (3): 226-233
JOURNAL OF HEART AND LUNG TRANSPLANTATION
1995; 14 (2): 394-401
Giant cell myocarditis is a rare and frequently fatal disorder of unknown origin that is defined histopathologically as diffuse myocardial necrosis with multinucleated giant cells in the absence of sarcoidlike granulomata. The clinical and pathologic features of lymphocytic myocarditis have been described in several recent publications, but the features of idiopathic giant cell myocarditis have not been adequately addressed.We describe five patients with idiopathic giant cell myocarditis who were seen at Stanford University over the past 10 years. In each case the onset was subacute congestive heart failure. After diagnosis each patient received immunosuppressive therapy and was evaluated for heart transplantation. Progressive heart failure and ventricular arrhythmias developed in all. Three died rapidly, two of progressive heart failure and one of sudden cause. Two patients underwent orthotopic heart transplantation and are currently alive, one with disease recurrence. Pathologic studies, including endomyocardial biopsy and evaluation of postmortem or explanted material at transplantation were reviewed. The pathologic studies provided additional support that the giant cells derive from a monocytic/histiocytic lineage. Segmental wall motion abnormalities suggest giant cell myocarditis can be a focal, as well as diffuse process at certain stages of its course. This experience is compared with published cases and implications for diagnosis and treatment are discussed.In view of the uniformly fatal nature of the disease, heart transplantation should be a serious consideration, and the patients evaluated once the diagnosis is established. Triple-drug immunosuppressive therapy should be considered at the time of diagnosis.
View details for Web of Science ID A1995QQ92700027
View details for PubMedID 7779862
- Incidence and severity of transplant coronary artery disease early and up to 15 years post transplant as detected by intravascular ultrasound JACC 1995; 25 (1): 171-177
- Distribution and morphological features of coronary artery disease in cardiac allografts: An intracoronary ultrasound study J of the Amer Soc of Echocardiography 1995; 8 (1): 1-8
- Cardiac Transplantation: Complications In: Hurst Jw (ed) Medicine for the Practicing Physician (4th ed) 1995; 1185-89
- Prevention of transplant coronary disease with Diltiazem: Clinical and intravascular findings Drugs of Today 1995; 31 (Suppl. B): 33-36
FEASIBILITY OF SERIAL INTRACORONARY ULTRASOUND IMAGING FOR ASSESSMENT OF PROGRESSION OF INTIMAL PROLIFERATION IN CARDIAC TRANSPLANT RECIPIENTS
1994; 90 (5): 2348-2355
Serial quantitative coronary angiography is used to assess progression of coronary disease; however, pathology studies have demonstrated angiographic insensitivity for determining atheroma. Intracoronary ultrasound (ICUS) can define and measure the components of the arterial wall and offers the potential for precise quantitative assessment of disease progression on serial examinations. The present study was done to test the feasibility of serially assessing intimal proliferation at the same coronary site with ICUS imaging in cardiac transplant recipients.ICUS imaging was done with a 30-MHz, 5F or 4.3F ultrasound imaging catheter at the time of angiography in 70 cardiac allografts (3.8 sites per patient) initially and 1 year later. Mean intimal thickness (IT), luminal area (LA), and total area (TA) of lumen plus intima and an index of intimal thickness (II = TA - LA/TA) were measured at each site. Additionally, vessels were graded using a scale incorporating criteria of intimal thickness and circumferential involvement. Side-by-side comparisons of paired angiograms were performed both to verify the similarity of ICUS imaging site and to detect new angiographic abnormalities. At least one site could be assessed serially by ICUS in 100% of patients, but only 189 of the original 263 coronary sites (72%) (2.7 sites per patient) could be matched satisfactorily on the second study. Thirty-nine patients (56%) had mild IT and 31 patients (44%) had moderate or severe IT on the initial study. Both groups showed the same IT progression the following year (delta = 0.05 +/- 0.13 versus 0.07 +/- 0.15 mm; P = NS). Twenty-seven of the 70 patients (39%) showed progression by ICUS. The 23 patients with ICUS progression and angiographically normal vessels had the same progression in intimal thickening as the 4 patients with ICUS progression but showing angiographic disease (delta = 0.17 +/- 0.13 versus 0.22 +/- 0.10 mm; P = NS).Replication of the intracoronary imaging site by judgment of two observers at an initial study and at a second study 1 year later was possible in at least one vessel site in 100% of the 70 patients and in 72% (189 of 263) of the original imaging sites (2.7 sites per patient). Serial ICUS demonstrates progression of intimal thickening at specific sites in only some cardiac transplant patients. Progression of intimal proliferation can occur in individuals in the presence or absence of initially increased intimal thickening or of angiographic disease at the time of the initial studies. Angiography is insensitive for recognizing early intimal thickening of the coronary vessels.
View details for Web of Science ID A1994PR28600025
View details for PubMedID 7955193
DOES RAPIDITY OF DEVELOPMENT OF TRANSPLANT CORONARY-ARTERY DISEASE PORTEND A WORSE PROGNOSIS
JOURNAL OF HEART AND LUNG TRANSPLANTATION
1994; 13 (6): 1119-1124
We postulated that transplant coronary artery disease with rapid progression to more than 50% stenosis within a 1-year interval may have a different prognosis from transplant coronary artery disease with a more indolent rate of progression. Annual coronary angiograms of 139 consecutive patients who underwent transplantation between January 1968 and February 1990 who survived at least 1 year after transplantation and in whom angiographically apparent transplant coronary artery disease developed were included in the study. Of this group, 45 patients progressed from a normal angiogram to the presence of 50% or greater stenosis in one or more major vessels within 1 year (fulminant group); 94 did not (indolent group). Mean posttransplantation follow-up time was 5.3 +/- 4.1 years for patients with fulminant progression of disease and 6.6 +/- 3.7 years for those with indolent progression. A highly significant difference was found in the time-related incidence of ischemic events (myocardial infarction, congestive heart failure, sudden death, and retransplantation) between the indolent and the fulminant groups after initial detection of transplant coronary artery disease. At 1, 3, and 5 years after initial detection of transplant coronary artery disease, 50%, 33%, and 16% of patients in the fulminant group and 89%, 70%, and 60% of patients in the indolent group were free of ischemic events (p < 0.0001). The fulminant group of patients had a mean of 2.9 +/- 1.5 rejection episodes, and the indolent group a mean of 2.3 +/- 1.4 episodes (p = 0.02) during the first year after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1994PV61100024
View details for PubMedID 7865519
Indications for cardiac transplantation.
Heart disease and stroke : a journal for primary care physicians
1994; 3 (6): 345-349
View details for PubMedID 7850155
CARDIAC TRANSPLANTATION - THE STANFORD EXPERIENCE IN THE CYCLOSPORINE ERA
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
1994; 108 (2): 240-252
We analyzed our experience with 496 patients who underwent primary cardiac transplantation since the introduction of cyclosporine immunosuppression (Dec. 16, 1980, to Jan. 7, 1993). There were 388 male and 108 female patients. Mean recipient age was 40 +/- 16 years (range 0.1 to 70 years, median 44 years). Recipient diagnoses included coronary disease in 188, idiopathic cardiomyopathy in 196, viral cardiomyopathy in 35, and congenital heart disease in 28 patients. Donor age was 25 +/- 10 years (range 1 to 53 years, median 24 years). Graft ischemic time was 148 +/- 57 minutes (range 38 to 495 minutes, median 149 minutes). Operative mortality (hospital death) rate was 7.9% +/- 1.3% (70% confidence intervals). Multivariate logistic regression analysis revealed that (higher) pulmonary vascular resistance and gender (female) were the only independent predictors of hospital death (p < 0.05). Actuarial survival estimates for all patients at 1, 5, and 10 years are 82% +/- 1.7% (83% +/- 1.8% adult, 77% +/- 5.2% pediatric), 61% +/- 2.5% (65% +/- 2.5% adult, 64% +/- 6.6% pediatric), and 41% +/- 3.7% (40% +/- 4% adult, 54% +/- 8.6% pediatric), respectively. For 232 patients treated with triple-drug immunosuppression and induction with OKT3 since 1987, survival estimates at 1 and 5 years are 82% +/- 2.6% and 67% +/- 3.7%, respectively. Causes of death for the entire group were rejection in 29 (14% of deaths), infection in 69 (34%), graft coronary disease in 36 (18%), nonspecific graft failure in 6 (3%), malignancy in 19 (10%), stroke in 6 (3%), pulmonary hypertension in 6 (3%), and other causes in 30 (15%) patients. Actuarial freedom from rejection at 3 months, 1 year, and 5 years was 21% +/- 1.9%, 14% +/- 1.7%, and 7.2% +/- 1.5%, respectively (+/- 1 standard error of the mean). Estimates of freedom from rejection-related death at 1, 5, and 10 years were 96% +/- 1%, 93% +/- 1.4%, and 93% +/- 1.4%, respectively. Actuarial freedom from any infection at 3 months and at 1 and 5 years was 40% +/- 2.3%, 27% +/- 2.1%, and 15% +/- 2.0% and from infection-related death, 95% +/- 1.0%, 93% +/- 1.2%, and 85% +/- 1.9%, respectively. Actuarial freedom from (angiographic or autopsy proved) graft coronary artery disease at 1, 5, and 10 years was 95% +/- 1.2%, 73% +/- 2.7%, and 65% +/- 3.6% and from coronary disease-related death or retransplantation 98% +/- 0.7%, 84% +/- 2.2%, and 66% +/- 4.3%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)
View details for Web of Science ID A1994PB11400006
View details for PubMedID 8041172
METABOLIC RISK-FACTORS FOR ATHEROSCLEROSIS IN HEART-TRANSPLANT RECIPIENTS
AMERICAN HEART JOURNAL
1994; 128 (1): 68-72
Development of coronary artery disease (CAD) in the cardiac allograft limits long-term survival after heart transplantation. Previous studies, focusing on lipoprotein metabolism, have paid little attention to changes in glucose and insulin metabolism that increase the risk of CAD in these patients. To address this issue, plasma glucose and insulin responses to an oral glucose load and lipid and lipoprotein concentrations were measured in male normal volunteers (n = 40) and cardiac transplant recipients with pretransplant diagnoses of either idiopathic cardiomyopathy (n = 24) or ischemic heart disease (n = 28), matched for age and body mass index. Patients with a pretransplant diagnosis of ischemic heart disease had higher plasma glucose and insulin concentrations in response to oral glucose as well as higher fasting plasma triglyceride, cholesterol, and low-density lipoprotein cholesterol concentrations than did the control group (p < 0.005 to p < 0.001). In addition, high-density lipoprotein cholesterol concentrations were lower and the ratio of cholesterol to high-density lipoprotein cholesterol higher than control values in those with a pretransplant diagnosis of ischemic heart disease (p < 0.001). Values for almost all variables were intermediate in patients with a pretransplant diagnosis of idiopathic cardiomyopathy and in most instances were significantly different from both. Thus, male cardiac transplant recipients are dyslipidemic, relatively glucose intolerant, and hyperinsulinemic compared to normal volunteers. These changes, observed in patients with a pretransplant diagnosis of either ischemic heart disease or idiopathic cardiomyopathy, emphasize the important role of immunosuppression in the development of metabolic risk factors for CAD in these individuals.
View details for Web of Science ID A1994NV84000010
View details for PubMedID 8017286
UNUSUAL FORMS OF ISCHEMIC-HEART-DISEASE
CURRENT OPINION IN CARDIOLOGY
1994; 9 (4): 457-464
Unusual forms and causes of ischemic heart disease include angina pectoris in the presence of normal coronary arteries (syndrome X), congenital coronary abnormalities, vasculitic disorders, and graft atherosclerosis after cardiac transplantation. There is now evidence that endothelial dysfunction of coronary resistance vessels can account for abnormalities of the coronary microvasculature and possibly, myocardial ischemia and chest pain. The incidence of syndrome X appears to be higher in women, particularly those who have undergone hysterectomy. An intriguing hypothesis is that low estrogen levels may be associated with reduced expression of nitric oxide (reflecting endothelial dysfunction). The presence of coronary abnormalities in the young should not be underestimated. Syncope and arrhythmias are observed frequently in this patient population and warrant vigorous exploration. Worldwide, cardiac transplantation is now carried out in approximately 4500 patients yearly, with excellent (80% to 90%) 1-year survival due to improved immunosuppression. However, accelerated atherosclerosis develops rapidly postoperatively and is the main cause of late death. The link between cellular rejection of the myocardium and transplant coronary artery disease is not clear. The process of transplant coronary artery disease is believed to be due to chronic immune injury followed by intimal smooth-muscle proliferation and lipid deposition in the vascular wall. By the time it is detected by coronary angiography, the disease is far advanced and not susceptible to routine revascularization procedures. A prospective, randomized study of diltiazem versus no calcium blocker started early after transplantation has documented highly significant reductions in transplant atherosclerosis as measured by lumen narrowing, clinical events, and rates of retransplantation or death due to the process.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1994NX68300008
View details for PubMedID 7919590
- Cardiac transplantation In: Harrison's Principles of Internal Medicine 1994; 13th ed.
- Cardiac transplantation. In Hurst Jw. Current Therapy in Cardiovascular Disease 1994; 4th ed., 285-290
- Cardiac transplantation In: Hurst's the Heart 1994; 8th ed.
- Prevention of transplant coronary artery disease with diltiazem Drugs of Today 1994; 30 (Suppl A) 35-9
INFLUENCE OF GRAFT-REJECTION ON INCIDENCE OF ACCELERATED GRAFT CORONARY-ARTERY DISEASE - A NEW APPROACH TO ANALYSIS
JOURNAL OF HEART AND LUNG TRANSPLANTATION
1993; 12 (6): 1029-1035
Conflicting data exist on the role of graft rejection as a risk factor for later development of accelerated graft coronary artery disease. We analyzed 126 consecutive heart transplant recipients treated with cyclosporine-based immunosuppressive regimens and devised an arbitrary method to incorporate the number, duration, and severity of myocardial rejection episodes during the first postoperative year, resulting in a rejection score for each patient. We then correlated the later incidence (mean follow-up, 4 years) of angiographic accelerated graft coronary artery disease with this rejection score and with its components: number, duration, and severity of rejection; number and duration of untreated rejection; and incidence and duration of delayed rejection therapy. Accelerated graft coronary artery disease developed in 60 patients (48%). The rejection score was 96.7 for patients in the "no accelerated graft coronary artery disease" group and 110.4 for those in the "accelerated graft coronary artery disease" group (p = NS). No significant difference was noted between patients with and without disease in any of the other seven rejection parameters analyzed, and no significant difference in time to occurrence of disease was noted between groups divided at the median rejection score. Donor age was older and fasting triglyceride blood level was higher in patients with accelerated graft coronary artery disease than in those without disease. All other clinical characteristics, including HLA mismatches, ischemic time, blood pressure, lipid profile, and drug therapy, did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1993MP52100021
View details for PubMedID 8312304
IMMEDIATE AND ONE-YEAR SAFETY OF INTRACORONARY ULTRASONIC-IMAGING - EVALUATION WITH SERIAL QUANTITATIVE ANGIOGRAPHY
1993; 88 (4): 1709-1714
Intracoronary ultrasound (ICUS) has the ability to quantitatively evaluate vessel wall morphology and is well suited for serial studies of coronary artery disease regression and progression. However, the potential risk for catheter-induced endothelial damage and accelerated atherosclerosis in instrumented vessels is a concern. The acute effects as well as the 1-year safety of ICUS regarding its impact on the atherosclerotic process were assessed.The acute studies include 240 intracoronary studies performed in 170 cardiac transplant recipients. Patients were systematically heparinized. Only vessels > or = 2 mm in diameter were visualized. Coronary arteries of 38 patients were measured by quantitative coronary angiography in matched angiograms at an interval of 1 year after the initial ICUS examination was performed to assess long-term effects. The angiographic measurements in the previously instrumented and noninstrumented vessels were compared. Forty-nine vessels that had been imaged (IM) in these 38 patients with a 5F ICUS catheter were compared with 61 vessels not previously imaged (NIM) in the same patients. Absolute and percentage change in angiographically measured mean vessel diameters in the ICUS imaged and nonimaged segments were compared. Despite pretreatment with nitroglycerin, 20 patients (8.3%) had angiographically evident coronary spasm. In all cases, this was reversed by giving nitroglycerin. One year after the original imaging study, no difference was noted between imaged and nonimaged vessels in change in absolute vessel diameter (IM, -0.11 +/- 0.28 mm vs NIM, -0.07 +/- 0.22 mm; P = .49) or in percentage change in diameter (IM, -5 +/- 11% vs NIM, -3 +/- 7%; P = .32).Intracoronary ultrasound in cardiac transplant recipients was associated with no clinical morbidity and a low incidence of vessel spasm in large and medium-size coronary arteries. It does not accelerate progression of angiographically quantifiable coronary artery disease. This study suggests that ICUS can be safely used even in coronary arteries not undergoing interventions.
View details for Web of Science ID A1993MA67800033
View details for PubMedID 8403316
A PRELIMINARY-STUDY OF DILTIAZEM IN THE PREVENTION OF CORONARY-ARTERY DISEASE IN HEART-TRANSPLANT RECIPIENTS
NEW ENGLAND JOURNAL OF MEDICINE
1993; 328 (3): 164-170
Accelerated coronary artery disease is a major cause of late morbidity and mortality among heart-transplant recipients. Because calcium-channel blockers can suppress diet-induced atherosclerosis in laboratory animals, we assessed the efficacy of diltiazem in preventing coronary artery disease in transplanted hearts.Consecutive eligible cardiac-transplant recipients were randomly assigned to receive diltiazem (n = 52) or no calcium-channel blocker (n = 54). Coronary angiograms obtained early after cardiac transplantation and annually thereafter were used for the visual assessment of the extent of coronary artery disease. The average diameters of identical coronary artery segments were measured on the angiograms obtained at base line and at the first and second follow-up examinations.In the 57 patients who had all three angiograms, the average coronary artery diameter (+/- SD) 0.27 decreased in the group that received no calcium-channel blocker from 2.41 +/- 0.27 mm at base line to 2.19 +/- 0.28 mm at one year, and to 2.22 +/- 0.26 mm at two years (P < 0.001 for both years). The average diameter in the diltiazem group changed little from the base-line value of 2.32 +/- 0.22 mm (2.32 +/- 0.27 mm at one year and 2.36 +/- 0.22 mm at two years). The average change in the diameter of the segment differed significantly between the two treatment groups (P < 0.001), and the estimated effect of treatment changed only negligibly after adjustment for other relevant clinical variables. New angiographic evidence of coronary artery disease developed in 14 patients not given calcium-channel blockers, as compared with 5 diltiazem-treated patients (P = 0.082). Coronary stenoses greater than 50 percent of the luminal diameter developed in seven patients not given calcium-channel blockers, as compared with two patients given diltiazem; death due to coronary artery disease or retransplantation occurred in five patients in the group that did not receive calcium-channel blockers and none of those who received diltiazem.Our preliminary results suggest that diltiazem can prevent the usual reduction in the diameter of the coronary artery in cardiac-transplant recipients, but further follow-up will be required to determine whether diltiazem can decrease the long-term incidence of symptomatic coronary artery disease.
View details for Web of Science ID A1993KG62500003
View details for PubMedID 8417382
- A Preliminary Study of Diltiazem in the prevention of Coronary Artery Disease in Heart Transplant Recipients Proceedings of the Satellite Symposium of the XIVth Congress of the European Society of Cardiology Drugs of Today 1993; 29 (A): 35-46
THE COUNCIL-FOR-MYOCARDIAL-ISCHEMIA-AND-INFARCTION - ADVISORY GROUP REPORTS ON SILENT-MYOCARDIAL-ISCHEMIA, HEART-RATE CONTROL, AND POST MYOCARDIAL-INFARCTION MANAGEMENT
SYMP ON CORONARY ARTERY DISEASE : MECHANISMS FOR MYOCARDIAL PROTECTION
EXCERPTA MEDICA INC. 1992: F39–F44
View details for Web of Science ID A1992KA16400009
The Council for Myocardial Ischemia and Infarction: advisory group reports on silent myocardial ischemia, heart rate control, and post-myocardial infarction management.
American journal of cardiology
1992; 70 (16): 39F-44F
View details for PubMedID 1442601
IMPACT OF PROXIMAL OR MIDVESSEL DISCRETE CORONARY-ARTERY STENOSES ON SURVIVAL AFTER HEART-TRANSPLANTATION
11TH ANNUAL MEETING AND SCIENTIFIC SESSIONS OF THE INTERNATIONAL SOC FOR HEART AND LUNG TRANSPLANTATION
MOSBY-YEAR BOOK INC. 1992: 892–901
To assess survival after the development of transplant coronary artery disease, annual angiography reports from 353 heart transplant recipients were reviewed. Fifty-four patients who survived beyond 1 year and in whom moderate-to-severe proximal or midvessel coronary artery disease developed were identified. Moderate-to-severe proximal or midvessel coronary disease was defined for this study as a 40% or more stenosis in 1 or more primary or secondary epicardial arteries. Actuarial survival (Kaplan-Meier) from the time of disease detection in those 54 patients was 67% at 1 year, 44% at 2 years, and 17% at 5 years. Actuarial survival was reduced proportionate to disease severity. Survival for single-vessel disease (> or = 40% stenosis) was 64% at 1 year, 36% at 2 years, and 22% at 5 years. Survival was significantly worse with triple-vessel disease (13% at 2 years; p = 0.01) and intermediate for double-vessel disease (41% at 2 years; p = 0.01). Of 19 patients who underwent retransplantation for coronary artery disease, 13 patients (68%) died at a mean of 24 +/- 20 months (range, 1 to 59), and of 15 patients from whom postmortem or angiographic data were available, 11 patients (73%) showed recurrence of significant coronary artery disease in the new graft. Identification of moderate or severe proximal or midvessel coronary disease at angiography predicts an overall mortality rate of more than 50% at 2 years. The poor survival rate in those who underwent retransplantation (around 50% at 4 years) and the high rate of redevelopment of coronary disease suggest that retransplantation should be reserved for selected candidates with angiographically severe disease, if used at all.
View details for Web of Science ID A1992JR77000007
View details for PubMedID 1420237
UNUSUAL FORMS OF ISCHEMIC-HEART-DISEASE
CURRENT OPINION IN CARDIOLOGY
1992; 7 (4): 616-624
View details for Web of Science ID A1992JD86700012
ACCELERATED GRAFT CORONARY-ARTERY DISEASE - DIAGNOSIS AND PREVENTION
CONGRESS ON CURRENT ISSUES IN THORACIC ORGAN TRANSPLANTATION
MOSBY-YEAR BOOK INC. 1992: S258–S266
Accelerated graft coronary artery disease (CAD) has become a major factor limiting survival among long-term heart transplant survivors. Currently 14%, 37%, and 50% of patients treated with triple therapy have angiographically apparent accelerated graft CAD at 1, 3, and 5 years after transplantation. Because cardiac allografts are denervated, transplant recipients generally do not experience angina pectoris. Therefore accelerated graft CAD may present as silent myocardial infarction, congestive heart failure, or ventricular arrhythmia leading to syncope or sudden death. Noninvasive tests for CAD have been insensitive for the detection of accelerated graft CAD because of the diffuse nature of the disease. Coronary arteriographic characteristics of accelerated graft CAD are a mixture of typical focal atherosclerotic lesions and unusual diffuse, concentric, and longitudinal narrowing prominent in middle to distal coronary vessels, with distal vessel obliteration and lack of collateral vessel formation. The presence and severity of accelerated graft CAD may be underestimated by routine angiography because of its diffuse and concentric nature. Quantitative arteriography has become an important technique to assess the progression of accelerated graft CAD. Intravascular ultrasound imaging can detect even earlier development of intimal thickening. CAD risk factor modification has had little impact on the overall incidence. We initiated a randomized study of diltiazem versus no calcium blocker to determine if this may prevent accelerated graft CAD. Patients have undergone early postoperative and annual quantitative coronary angiography since inception of the study.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1992JJ43700019
View details for PubMedID 1515448
- Cost contaminant: coadministration of diltiazem with cyclosporine after heart transplantation J of Heart Lung Transplantation 1992; 1: 1-8
- Intracoronary ultrasound in cardiac transplant recipients: in vivo evidence of "angiographically silent" intimal thickening Circulation 1992; 85: 979-987
- Cardiac transplantation: Complications In: Hurst JW (ed) Medicine for the Practicing Physician (3d ed). 1992; 1185-89
THE INFLUENCE OF PREOPERATIVE PATIENT CHARACTERISTICS ON EARLY AND LATE SURVIVAL FOLLOWING CARDIAC TRANSPLANTATION
1991; 84 (5): 329-337
View details for Web of Science ID A1991GP41600047
CHARACTERISTICS OF SERIAL ELECTROCARDIOGRAMS IN HEART-TRANSPLANT RECIPIENTS
AMERICAN HEART JOURNAL
1991; 122 (3): 771-774
To characterize "normal electrocardiogram patterns" after transplantation, serial surface 12-lead electrocardiograms (ECGs) taken 2 weeks, 1 month, and 1 year postoperatively in a group of 50 heart transplant recipients were analyzed and were correlated with clinical parameters. Some recipient atrial activity was evident in 40% of patients at 2 weeks, but in only 16% at 1 year; donor atrial activity was normal in 90% to 94% of patients at all times. ECG intervals generally were normal and did not change over time. The most prevalent abnormality was the presence of incomplete (IRBBB) or complete right bundle branch block (RBBB) patterns (14% at 2 weeks, 16% at 1 month, and 22% at 1 year). In patients with hemodynamic measurements available approximately at the time of the ECG recording 1 year following transplantation, there was a significant correlation between the presence of IRBBB and RBBB patterns and somewhat higher levels of right atrial mean pressure (6.8 versus 3.9 mm Hg, p = 0.01), pulmonary artery systolic pressure (32.5 versus 24.5 mm Hg, p = 0.001) and diastolic pressure (16.2 versus 11.2 mm Hg, p = 0.004), and right ventricular systolic pressure (31.4 versus 26.9 mm Hg, p = 0.019) and pulmonary artery wedge mean pressure (11.3 versus 7.9 mm Hg, p = 0.010). Repolarization changes were also common but decreased in frequency over time (78% at 2 weeks to 34% at 1 year) and did not correlate with the presence or absence of rejection. We conclude that ECG abnormalities in heart transplant recipients are generally mild and that IRBBB and RBBB patterns correlate with increased right heart pressures.
View details for Web of Science ID A1991GD34100023
View details for PubMedID 1877454
The antiatherogenic effects of calcium antagonists.
American journal of hypertension
1991; 4 (7): 512S-518S
Evidence that calcium antagonists can suppress diet-induced atherosclerosis in the thoracic aorta of animals has existed for a decade. Recently, the results of quantitative angiographic trials of calcium antagonists in humans have become available, confirming their beneficial effect on coronary artery disease. Nifedipine treatment reduces the rate of new lesion development in patients with mild-to-moderate coronary artery disease, reduces disease progression, and, in some cases, induces lesion regression. There is evidence that the use of verapamil may be associated with lesion regression and stenosis prevention, and that nicardipine may influence the progression of minimal coronary lesions. Theoretically, a wide range of explanations for an effect of calcium antagonists on atherogenesis is possible. Potential mechanisms include preventing calcium overload, upregulating LDL receptors with enhanced LDL clearance, inhibiting cell migration into the arterial wall, and antiplatelet effects. The exact mechanism remains unclear, but alteration of serum lipid levels and blood pressure does not appear to be the common pathway. Work with humans is still preliminary, and longer follow-up and further trials are required to determine the appropriate clinical application of calcium timing for their introduction.
View details for PubMedID 1654938
THE ANTIATHEROGENIC EFFECTS OF CALCIUM-ANTAGONISTS
AMERICAN JOURNAL OF HYPERTENSION
1991; 4 (7): S512-S518
View details for Web of Science ID A1991FX09800019
- CHEST PAIN IN HEART-TRANSPLANT RECIPIENTS NEW ENGLAND JOURNAL OF MEDICINE 1991; 324 (25): 1805-1807
- Transplant coronary disease Lewis BS, Kimchi A (eds). Heart Failure-Mechanisms and Management 1991; 466-474
- Historical perspective of Cardiac transplantation In: Kapoor AS, Laks H, Schroeder JS, Yacoub MH, eds. Cardiomyopathies and Heart-Lung Transplantation 1991; 135-139
- Cardiac transplantation. In Hurst JW. Current Therapy in Cardiovascular Disease 1991; 3rd ed. pp. 291-296
- Increased rejection in gender-mismatched grafts: Amelioration by triple therapy J Heart Lung Transplant 1991; 10; 106-110
- Transplant coronary artery disease: Histopatholic correlations with angiographic morphology J Am Coll Cardiol 1991; 17: 449-457
- Plasma lipids and cardiac transplant atherosclerosis in patients treated with cyclosporine or azathioprine Cardiovasc Risk Factors 1991; 1: 454-462
- Cardiac transplantation In: Wilson JD, Braunwald E, Fauci AS, Isselbacher W,Martin JB, Petersdorf RG, Root RC (eds). Harrison's Principles of Internal Medicine 1991; 12th ed. ch. 183, pp. 900-902
- Organization of a cardiac transplant center In: Kapoor AD, Laks H, Schroeder JS, Yacoub MH, eds. Cardiomyopathies and Heart-Lung Transplantation 1991; 141-144
RAPID HISTOLOGICAL-CHANGES IN ENDOMYOCARDIAL BIOPSY SPECIMENS AFTER MYOCARDITIS
BRITISH HEART JOURNAL
1990; 64 (6): 406-408
The course and response to treatment in acute lymphocytic myocarditis are conventionally monitored by endomyocardial biopsy performed every 3-12 weeks. A patient with a short history (five days) of acute myopericarditis of unknown aetiology presented in cardiogenic shock with evidence of severe systolic dysfunction on the echocardiogram. The initial biopsy specimen showed histologically unequivocal myocarditis. Repeat endomyocardial biopsy after four days of treatment with steroids and azathioprine showed substantial histological improvement, a reduction in cellular infiltrate and myocardial necrosis, and interstitial fibrosis. Serial biopsies at 2 weeks and then 1, 2, 4, 5, 8, and 14 months after the initial biopsy showed progressive clearing of cellular infiltrate, increasing interstitial fibrosis, and compensatory myocyte hypertrophy by 4 months. At 14 months scattered lymphocytes persisted but myocyte abnormalities had resolved completely. The patient remained symptom free and systolic function was normal during this recovery period. Early endomyocardial biopsy (within one week of diagnosis) may yield useful histological information on the response to treatment in patients with myocarditis. It may not be necessary to wait the customary 3-4 weeks to repeat the biopsy. This case shows the chronology of histological changes and emphasises that a return to normal myocardial function may precede resolution of the histological abnormalities, which may persist in part or may resolve totally after the acute episode.
View details for Web of Science ID A1990EN55600015
View details for PubMedID 2271352
PROGRESSIVE CORONARY LUMINAL NARROWING AFTER CARDIAC TRANSPLANTATION
1990; 82 (5): 269-275
View details for Web of Science ID A1990EJ51000039
Accelerated transplant coronary artery disease.
Seminars in thoracic and cardiovascular surgery
1990; 2 (3): 241-249
View details for PubMedID 1964396
Arrhythmias and clinical electrophysiology of the transplanted human heart.
Seminars in thoracic and cardiovascular surgery
1990; 2 (3): 271-278
The denervated transplanted heart has given us numerous opportunities to assess normal and abnormal electrophysiology and the influence of the autonomic system on these parameters. Observation of baseline electrophysiology of the denervated heart and its response to various physiologic and pharmacologic stimuli has emphasized the role of the parasympathetic system on heart rate and arrhythmia modulation in the normal population. In the transplant patients, the denervated hearts lack the full spectrum of physiologic responses due to the absence of vagally mediated neurostimuli. This results in a higher resting heart rate, sluggish rate response to exercise, and perhaps inadequate response to some commonly used drugs such as atropine and digitalis. Nevertheless, the heart's overall response to physiologic demands and various pharmacologic maneuvers including beta-antagonists and antagonists remains relatively normal and the patient's overall cardiac performance appears to be quite adequate. Thus, despite its shortcomings, the denervated heart provides near normal functional integrity and overall improved quality of life. Arrhythmias are generally a minor problem in these patients. Although there appears to be a high prevalence of various forms of arrhythmias, most present as isolated and insignificant problems. The more severe arrhythmias consist primarily of atrial tachyarrhythmias that are usually associated with acute rejection, and treatment for these arrhythmias never pose serious difficulty. However, sudden death remains an intriguing issue. Clearly, serious ventricular tachyarrhythmias can occur in these patients, arguing against the concept of a primary role of an intact autonomic nervous system for the generation of arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for PubMedID 2081232
CARDIAC TRANSPLANTATION IN PATIENTS WITH PREEXISTING NEOPLASTIC DISEASES
AMERICAN JOURNAL OF CARDIOLOGY
1990; 65 (7): 501-504
Cardiac transplantation has traditionally been reserved for individuals with end-stage congestive heart failure (CHF) in whom there is no history of other life-threatening systemic disorders. In most transplant centers, patients with a history of malignancy and severe heart failure have not been considered acceptable candidates for cardiac transplantation. In the last 4 years at Stanford University Medical Center, 8 cardiac transplants have been performed in 7 patients with a history of neoplastic disease. Six of these patients had already received treatment for lymphoproliferative disorders and in 1 case, a patient underwent a transplant after treatment for adenocarcinoma of the colon. Six of the 7 patients were discharged from the hospital and in that group, the 1-year posttransplant survival rate was 71%. This was comparable to an overall 1-year survival rate of 80% for patients undergoing a cardiac transplant at our center during the same period of time. At follow-up averaging over 2 years, there has been 1 case of recurrent neoplasia. One patient with evidence of radiation-induced pulmonary damage died of respiratory failure 2 days after transplantation. One patient required retransplantation because of intractable rejection and subsequently died from infectious complications. Immunosuppressive therapy in these patients has not been associated with an increased risk for neoplastic recurrence or for the development of posttransplant lymphoproliferative disorders. The current study demonstrates that in a carefully selected group, previously treated neoplastic disease should not represent a contraindication to cardiac transplantation.
View details for Web of Science ID A1990CN83200019
View details for PubMedID 2305689
A REVIEW OF CALCIUM-ANTAGONISTS AND ATHEROSCLEROSIS
INTERNATIONAL SYMP ON END-ORGAN PROTECTION AND ANTIHYPERTENSIVE THERAPY
LIPPINCOTT-RAVEN PUBL. 1990: S28–S35
Many detailed studies have demonstrated that calcium antagonists can suppress development of diet-induced atherosclerosis in the thoracic aorta of animals. A number of possible mechanisms have been proposed based on in vitro work, but the exact mechanism remains unclear. Alteration of serum lipid levels and blood pressure does not appear to be the common pathway. Differing effects between calcium antagonists of different classes indicate that the voltage-dependent calcium channel-blocking action common to all calcium antagonists is not the sole mechanism. Preliminary results of several major quantitative angiographic studies in human coronary artery disease have recently become available and indicate that calcium antagonists are able to retard the progression of existing lesions in humans also. There is also evidence that calcium antagonists may prevent the development of new lesions and, in some cases, induce lesion regression. Longer follow-up and further trials are required to assess the appropriateness of widespread clinical application of these agents in coronary artery disease, to determine the optimal timing for their introduction, and to define their mechanism of action in influencing the natural history of atherosclerosis.
View details for Web of Science ID A1990ER15200007
View details for PubMedID 1707112
- The use of immunosuppressive and antiinflamatory drugs in cardiology In: Hurst JW, Schlant RC, Rackley CE, Sonneblick EH, Wenger NK (eds). The Heart 1990; Ch. 13, 7th ed.
HEMODYNAMIC AND ADH RESPONSES TO CENTRAL BLOOD-VOLUME SHIFTS IN CARDIAC-DENERVATED HUMANS
1990; 10 (1): 55-67
Haemodynamic responses and antidiuretic hormone (ADH) were measured during body position changes designed to induce blood volume shifts in 10 cardiac transplant recipients to assess the contribution of cardiac and vascular volume receptors in the control of ADH secretion. Each subject underwent 15 min of a control period in the seated posture, then assumed a lying posture for 30 min at 6 degrees head-down tilt (HDT) followed by 30 min of seated recovery. Venous blood samples and cardiac dimensions (echocardiography) were taken at 0 and 15 min before HDT, 5, 15 and 30 min of HDT, and 5, 15 and 30 min of seated recovery. Blood samples were analysed for haematocrit, plasma osmolality, plasma renin activity (PRA) and ADH. Resting plasma volume (PV) was measured by Evans blue dye and per cent changes in PV during posture changes were calculated from changes in haematocrit. Heart rate (HR) and blood pressure (BP) were recorded every 2 min. In the cardiac transplant subjects, mean HR decreased (BP less than 0.05) from 102 b.p.m. pre-HDT to 94 b.p.m. during HDT and returned to 101 b.p.m. in seated recovery while BP was slightly elevated (P less than 0.05). PV was increased by 6.3% (P less than 0.05) by the end of 30 min of HDT but returned to pre-HDT levels following seated recovery. Plasma osmolality was not altered by posture changes. Mean left ventricular end-diastolic volume increased (P less than 0.05) from 90 +/- 5 ml pre-HDT to 105 +/- 4 ml during HDT and returned to 88 +/- 5 ml in seated recovery. Plasma ADH was reduced by 28% (P less than 0.05) by the end of HDT and returned to pre-HDT levels with seated recovery. PRA was also reduced by 28% (P less than 0.05) with HDT. These responses were similar to those of six normal cardiac-innervated control subjects and one heart-lung recipient. Therefore, cardiac volume receptors are not the only mechanism for the control of ADH release during acute blood volume shifts in man.
View details for Web of Science ID A1990CH32400005
View details for PubMedID 2302936
ACUTE MYOCARDIAL-INFARCTION IN CARDIAC TRANSPLANT RECIPIENTS
AMERICAN JOURNAL OF CARDIOLOGY
1989; 64 (18): 1093-1097
To characterize the clinical and pathologic features of acute myocardial infarction (AMI) in cardiac transplant recipients, 22 Stanford patients who had 25 documented infarcts at a mean of 3.86 years after transplantation were reviewed. Symptoms included chest pain (2), arm pain (3), weakness (16), dyspnea (11) and palpitations (8). Three episodes were clinically silent, detected only as new electrocardiographic changes during routine follow-up. Of 18 patients hospitalized with symptoms, only 7 had electrocardiographic changes of typical Q-wave AMI; 5 had nonspecific ST-segment changes and 2 had no documented changes. Two had old Q waves. Twelve of the 18 were misdiagnosed at admission as having infection or congestive heart failure. Serial creatine phosphokinase levels were obtained in 13 patients, and values were elevated in 8. Six of 25 AMI episodes were associated with development of congestive heart failure and 4 others led to development of cardiogenic shock. Seven patients died during the acute phase of infarction, 12 were retransplanted from 2 days to 6 months after infarct and 1 died suddenly after discharge. Two healed myocardial infarctions of unknown duration were found at autopsy or on explantation in patients not clinically suspected of having an AMI. All infarcts occurred in patients known to have angiographic evidence of transplant coronary artery disease, based on annual coronary arteriography. At autopsy or explantation all hearts were found to have characteristic diffuse concentric coronary artery narrowing, and 4 (18%) had an unusual pattern of multiple foci of nontransmural AMI.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1989AZ54800002
View details for PubMedID 2816760
PREVALENCE OF ACCELERATED CORONARY-ARTERY DISEASE IN HEART-TRANSPLANT SURVIVORS - COMPARISON OF CYCLOSPORINE AND AZATHIOPRINE REGIMENS
1989; 80 (5): 100-105
View details for Web of Science ID A1989CB17700017
CARDIOVASCULAR EFFECTS OF DESIPRAMINE IN CHILDREN
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
1989; 28 (3): 376-379
The effect of desipramine hydrochloride was studied in children who were treated for eating disorders (5), attention deficit disorder (13), or affective disturbance (3). Serial heart rate, blood pressure, ECG, and 24-hour ambulatory monitoring were recorded before treatment and at 4 and 8 weeks during treatment. Maximum dose of desipramine was 5 mg/kg/day, average 4.25. A 21% increase in heart rate and 2.5% increase in QTc at 4 weeks were sustained at 8 weeks. No dysrhythmias or clinically significant changes in blood pressure occurred. Desipramine is safe in children who have normal cardiovascular examinations and ECGs when used within the limits of the study design. The cardiovascular effects of desipramine should be kept in mind and monitored when patients are starting tricyclic antidepressant therapy such as desipramine.
View details for Web of Science ID A1989U609000012
View details for PubMedID 2661525
FREQUENCY OF FAMILIAL NATURE OF DILATED CARDIOMYOPATHY AND USEFULNESS OF CARDIAC TRANSPLANTATION IN THIS SUBSET
AMERICAN JOURNAL OF CARDIOLOGY
1989; 63 (13): 959-963
A familial etiology was identified on the basis of family history in 16 (8.75%) of 184 patients undergoing cardiac transplantation at Stanford for endstage dilated cardiomyopathy (DC). These 16 patients, from 11 families, included 5 sibling pairs. To help determine optimal management of such patients, their case histories and posttransplant courses were reviewed. Mean age of patients at presentation was 23 +/- 15 years. In sibling pairs, duration of symptoms from onset to diagnosis was 14 +/- 5 weeks for the first sibling, but only 4 +/- 2 weeks for the second. Progressive cardiac enlargement was documented radiographically in siblings of transplant recipients in 2 families before the onset of symptoms. The posttransplant course with regard to rejection incidence, infectious complications, coronary artery disease and malignancy was similar to that of the 168 patients with nonfamilial DC. Actuarial survival at 5 years after transplantation was 80%. Thirteen patients (including all sibling pairs) are alive 1 to 11 years after transplantation. Sepsis was the cause of death in 3 patients, occurring during the early postoperative period in 2 and following retransplantation for graft atherosclerosis 7 years after the initial transplant in the third patient. Thus, diagnosis of DC in childhood or adolescence mandates evaluation and surveillance of family members, because this disease can progress rapidly. The favorable results of cardiac transplantation for familial DC suggest that it should be promptly considered for such patients with end-stage disease.
View details for Web of Science ID A1989U107900014
View details for PubMedID 2648793
- Managing patients after cardiac transplantation Hospital Practice 1989; 24 (10): 83-100
- Cardiac transplantation and assisted circulation In: Harrison's Principles of Internal Medicine (12th ed) 1989
- The spectrum of coronary artery pathology in human cardiac allografts J Heart Transplant 1989; 8:349-359
- Secondary prevention following myocardial infarction International Symposium, Brussels, Sept. 24, 1988 1989; 122-130
- Cardiac transplantation Intensive Care Med 1989; 15: 283-289
- Cardiovascular effects of desipramine in children with eating disorders for ADD J AM Acad Child & Adol Psych 1989; 28: 376-379
EFFECTS OF ACETYLCHOLINE ON EPICARDIAL CORONARY-ARTERIES AFTER CARDIAC TRANSPLANTATION WITHOUT ANGIOGRAPHIC EVIDENCE OF FIXED GRAFT NARROWING
AMERICAN JOURNAL OF CARDIOLOGY
1988; 62 (16): 1093-1097
The coronary response to acetylcholine was evaluated in 10 patients who had had cardiac transplantation 1 to 8 years earlier and in 4 patients who did not undergo transplantation. All 14 patients had no angiographic evidence of fixed coronary arterial narrowing. Acetylcholine was infused in 10-fold increasing concentrations (10(-6) to 10(-2) M) into the midpoint of the left anterior descending coronary artery by an infusion catheter. Administration was terminated when either vasoconstriction was noted at fluoroscopy or when the maximal acetylcholine concentration was reached. Vascular responses were evaluated by quantitative angiography. All 14 patients had a decrease in coronary lumen size in response to acetylcholine. The mean percentage of vasoconstriction was 37 +/- 24% (p less than 0.001). Combined infusion of nifedipine and the maximal vasoconstricting dose of acetylcholine did not result in a significant reversal of coronary vasoconstriction in all 10 cardiac transplantation patients. It was concluded that acetylcholine is a potent coronary vasoconstrictor in patients who had cardiac transplantation and possibly lacks vasodilating effects in most normal patients without angiographic evidence of coronary artery disease, thus suggesting that acetylcholine might not be a suitable pharmacologic agent for testing endothelial cell integrity.
View details for Web of Science ID A1988Q817800020
View details for PubMedID 3055925
RETRANSPLANTATION FOR SEVERE ACCELERATED CORONARY-ARTERY DISEASE IN HEART-TRANSPLANT RECIPIENTS
AMERICAN JOURNAL OF CARDIOLOGY
1988; 62 (13): 876-881
Development of accelerated coronary artery disease (CAD) in the cardiac allograft is one of the major causes of late graft failure in heart transplant recipients. At the Stanford University Medical Center 356 heart transplant procedures were performed in 329 patients by the end of January 1985. Eighty-nine of these patients developed evidence of transplant CAD. Twenty retransplant procedures, including 2 third transplants, were performed in 19 of the 89 patients because of transplant CAD. The graft survival rates after the second transplant were 55%, 25% and 10% after 1, 2 and 5 years, respectively. Nine of these retransplant patients currently survive, the longest for 5.5 years. To examine potential risk factors for development of severe transplant CAD, these 20 retransplant procedures were compared with 113 transplant recipients who had no evidence of transplant CAD on annual coronary arteriograms. An excess of rejection episodes (3 +/- 2 vs 2 +/- 1 episodes/patient, p = 0.02), elevated total cholesterol (266 +/- 78 vs 225 +/- 47 mg/dl, p = 0.002) and higher low-density lipoprotein levels (176 +/- 88 vs 137 +/- 46 mg/dl, p = 0.009) were noted in the transplant CAD retransplant group. Five of 11 retransplant recipients who survived greater than 1 year again developed transplant CAD. Characteristic morphologic features and rapid progression of CAD in the second graft were similar to those in the primary graft.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1988Q603600006
View details for PubMedID 3052011
ACCELERATED CORONARY VASCULAR-DISEASE IN THE HEART-TRANSPLANT PATIENT - CORONARY ARTERIOGRAPHIC FINDINGS
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1988; 12 (2): 334-340
Annual coronary arteriograms have been obtained from all heart transplant recipients at Stanford University Medical Center since 1969. Angiographic lesions in 81 transplant patients exhibiting coronary vascular disease were classified into three categories: type A, discrete or tubular stenoses; type B, diffuse concentric narrowing; and type C, narrowed irregular vessels with occluded branches. The 81 arteriograms showing transplant coronary vascular disease were contrasted with 32 from nontransplant patients with coronary artery disease analyzed in a similar fashion. The nontransplant angiograms showed 178 lesions, all of type A (discrete or tubular) morphology, 75% of which were located in primary epicardial coronary vessels and 25% in secondary branch vessels. In the patients with transplant coronary vascular disease, 349 (76%) of 461 lesions were type A: 57% in primary vessels, 42% in secondary branches and 1.4% in tertiary branches. Of the 112 type B and C lesions (diffuse narrowing, tapering and obliteration), 25% were in primary vessels, 44% in secondary vessels and 31% in tertiary branches (p less than 0.05 for patients with transplant coronary vascular disease versus patients with nontransplant coronary artery disease). Total vessel occlusion was found in proximal or middle vessel segments in 96% and distally in 4% of patients with "ordinary" coronary artery disease versus 49% distally in patients with transplant coronary disease (p less than 0.002). In the presence of total vessel occlusion, collateral vessels were poor or absent in 92% of transplant versus 7% of nontransplant patients with coronary disease (p less than 0.002). Therefore, coronary artery disease in transplant patients represents a mixture of typical atheromatous lesions and unique transplant-related progressive distal obliterative disease that occurs without collateral vessel development.
View details for Web of Science ID A1988P527800006
View details for PubMedID 3292629
HEMODYNAMIC, RENAL AND ENDOCRINE EFFECTS OF ATRIAL NATRIURETIC PEPTIDE INFUSION IN SEVERE HEART-FAILURE
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1988; 12 (1): 175-186
The cardiac release and total body and renal clearances and the hemodynamic, renal and endocrine effects of increasing doses of atrial natriuretic peptide were investigated in 12 patients with severe chronic congestive heart failure. Immunoreactive arterial plasma levels of atrial natriuretic peptide were 10-fold higher than normal and there was no correlation between aortic atrial natriuretic peptide and cardiac filling pressures. The heart released atrial natriuretic peptide into the coronary sinus. The kidney, though a major clearance site, accounted for only 33% of the total body clearance. Administration of 0.3 micrograms/kg per min atrial natriuretic peptide produced significant changes in heart rate (95 +/- 4 to 85 +/- 4 beats/min) and mean arterial (92 +/- 8 to 77 +/- 9 mm Hg), right atrial (13 +/- 3 to 8 +/- 2 mm Hg) and mean pulmonary artery occluded (27 +/- 3 to 14 +/- 3 mm Hg) pressures. Atrial natriuretic peptide increased cardiac index (2.25 +/- 0.18 to 2.83 +/- 0.3 liters/min per m2) and stroke work index (21 +/- 1.5 to 29 +/- 3.4 g/m2), whereas systemic vascular resistance (1,424 +/- 139 to 1,033 +/- 97 dynes.s.cm(-5)) decreased. Infusion of 0.1 microgram/kg per min atrial natriuretic peptide increased urinary flow 128%, fractional excretion of sodium 133% and fractional excretion of potassium 35%. The filtration fraction increased from 29 +/- 2 to 31 +/- 4%. This represented a disproportionate rise in glomerular filtration rate over renal plasma flow. Plasma aldosterone and norepinephrine decreased whereas plasma renin activity remained unchanged. In association with these hemodynamic, excretory and endocrine changes, the urinary excretion of cyclic guanosine monophosphate doubled. Placebo had no effect. These results showed that, despite high circulating levels of atrial natriuretic peptide, administration of this hormone in heart failure is associated with potentially beneficial hemodynamic, renal and endocrine effects.
View details for Web of Science ID A1988P162200024
View details for PubMedID 2967855
DIAGNOSTIC AND THERAPEUTIC CONSIDERATIONS IN SILENT MYOCARDIAL ISCHEMIA
AMERICAN JOURNAL OF CARDIOLOGY
1988; 61 (12): F41-F47
View details for Web of Science ID A1988N612000009
- Coronary artery spasm Hospital Med 1988; 24:31-48
- Cardiac transplantation: Current role in the management of congestive heart failure Practical Cardiol 1988; 11:79-84
CLINICAL AND LABORATORY CORRELATES OF ACCELERATED CORONARY-ARTERY DISEASE IN THE CARDIAC TRANSPLANT PATIENT
1987; 76 (5): 56-61
View details for Web of Science ID A1987L004500011
POOR SURVIVAL OF PATIENTS WITH IDIOPATHIC CARDIOMYOPATHY CONSIDERED TOO WELL FOR TRANSPLANTATION
AMERICAN JOURNAL OF MEDICINE
1987; 83 (5): 871-876
Although the success of cardiac transplantation has encouraged earlier referral of potential candidates, those with mild symptoms of heart failure are frequently considered "too well" for transplantation. Outcome was investigated for 28 patients with non-ischemic dilated cardiomyopathy and ejection fraction of 25 percent or less who were denied transplantation due to lack of severe symptoms. One-year survival without transplantation was 46 percent. Low stroke volume and history of ventricular arrhythmias were independent predictors of early mortality. High risk, defined as either stroke volume of 40 ml or less or history of ventricular arrhythmia, identified 13 of 14 patients who did not survive one year and only one of 12 one-year survivors (p less than 0.001). Low stroke volume predicted hemodynamic failure (p less than 0.05) whereas arrhythmic history predicted sudden death (p less than 0.001). Clinical status improved in only six patients, all of whom had symptom duration of seven or less months at initial evaluation (p less than 0.001). Thus, patients referred to transplantation for dilated cardiomyopathy with an ejection fraction of 25 percent or less have a poor prognosis even if symptoms are mild. Patients with high hemodynamic risk may require early transplantation, whereas those with high arrhythmia risk may require other aggressive therapy in order to avoid transplantation until symptoms become severe.
View details for Web of Science ID A1987K745100010
View details for PubMedID 3314498
Cardiac sarcoidosis: response to steroids and transplantation.
journal of heart transplantation
1987; 6 (4): 244-250
From 1976 to 1986, six cases of cardiac sarcoidosis have been documented by myocardial biopsy in three of five instances; on examination of the explanted heart after transplantation in two, and at autopsy in one patient. Right ventricular end-diastolic pressure was elevated in all four patients with right ventricular involvement with sarcoidosis. Of three patients treated with steroids, improvement in ventricular function and decrease in arrhythmia occurred in two, whereas failure to respond led to transplantation in the other patient. Two further patients have undergone heart transplantation, one for resistant ventricular arrhythmia and the other for congestive heart failure. No recurrence of sarcoidosis has occurred in the grafts. Because two of five patients had sarcoidosis diagnosed on gross examination, a negative endomyocardial biopsy does not exclude the diagnosis of myocardial sarcoidosis, which should therefore be pursued in the setting of unexplained heart failure, conduction abnormalities, and ventricular arrhythmia, particularly when right ventricular end-diastolic pressure is raised. Steroids may result in improvement in some patients even in the presence of severe morphological damage. Heart transplantation may be performed without increased risk of recurrence of sarcoidosis.
View details for PubMedID 3312535
- Variant angina In: Cardiology 1987
- Efficacy and safety of sustained (48-hour) intravenous infusions of milrinone in patients with severe congestive heart failure: A multicenter study J Am Coll Cardiol 1987; 9:711-722
- Cardiac transplantation: Update 1987 JAMA 1987; 258: 3142-3145
- CARDIAC TRANSPLANTATION - WHERE ARE WE NEW ENGLAND JOURNAL OF MEDICINE 1986; 315 (15): 961-963
CURRENT STATUS OF CARDIAC TRANSPLANTATION
MODERN CONCEPTS OF CARDIOVASCULAR DISEASE
1986; 55 (8): 37-40
View details for Web of Science ID A1986D114700001
DILTIAZEM AND PROPRANOLOL IN COMBINATION - HEMODYNAMIC-EFFECTS FOLLOWING ACUTE INTRAVENOUS ADMINISTRATION
AMERICAN HEART JOURNAL
1986; 111 (3): 489-497
Diltiazem and propranolol are independently useful antianginal agents with common negative chronotropic, dromotropic, and inotropic properties. Concern over the safety of the concurrent use of these two drugs led to an investigation of their intravenous combination in 19 patients with suspected coronary artery disease. Hemodynamics were recorded in both a sinus and atrial paced rhythms at baseline and again following administration of a loading dose of diltiazem (0.25 mg/kg) followed by continuous infusion (0.002 mg/kg/min). Propranolol was then added by intravenous bolus (0.07 mg/kg) and continuous infusion (0.0012 mg/kg/min), with reassessment of hemodynamics once steady state was achieved. Patients were stratified by left ventricular ejection fraction (LVEF): group 1 (LVEF = 62% to 69%), group 2 (LVEF = 49% to 59%), and group 3 (LVEF = 20% to 47%). The combination of drugs resulted in a 15% drop in heart rate (p less than 0.01) and a 15% prolongation in the PR interval (p less than 0.01) for the group of 19 patients. Left ventricular end-diastolic pressure (LVEDP) was not significantly changed by diltiazem or its combination except in group 3. Cardiac output was lowered in all groups following diltiazem and propranolol (p less than 0.05). Untoward reactions included marked vasovagal reactions at the conclusion of the procedure in six patients. The combination of drugs resulted in profound sinus bradycardia with attendant 2:1 atrioventricular (AV) block in one patient. Diltiazem and propranolol were hemodynamically well tolerated in patients with preserved left ventricular function. Because of the additive negative dromotropic activities of these two drugs, ECG monitoring is warranted when they are acutely combined.
View details for Web of Science ID A1986A376900010
View details for PubMedID 3953357
INTRAVENOUS DILTIAZEM FOR THE TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA
1986; 9 (4): 145-149
To determine the effects of diltiazem hydrochloride on patients with paroxysmal supraventricular tachycardia, we administered intravenous diltiazem, 0.25 mg/kg to patients who presented to the Stanford Medical Center Emergency Department with this rhythm. Blood pressure was recorded prior to administration, and monitored for 20 min thereafter. Six of the ten patients converted to sinus rhythm a mean of 7.75 min (+/- 4.4) after drug administration. The remaining four experienced slowing of heart rates from a mean of 177 to 166 beats/min. Systolic blood pressure fell a mean of 12.4 mmHg during treatment, but returned to pretreatment level or higher within 20 min following diltiazem administration. This mean degree of blood pressure reduction compares favorably with effects produced by intravenous verapamil under comparable circumstances. Intravenous diltiazem appears to be a safe and effective drug for the conversion of paroxysmal supraventricular tachycardia.
View details for Web of Science ID A1986A709500004
View details for PubMedID 3720041
- Calcium antagonists for cardiovascular emergencies Topics Emergency Med 1986; 8:37-51
- Clinical experience with esmolol, a short-acting beta-adrenergic blocker in cardiac arrhythmias and myocardial ischemia J Clin Pharmacol 1986; 26 (suppl A): A15-A16
- Comparison of the efficacy and safety of esmolol, a short-acting beta blocker, with placebo in the treatment of supraventricular tachy-arrhythmias Am Heart J 1986; 111:42-48
BLUE-LIGHT ACTIVATES ELECTROGENIC ION PUMPING IN GUARD-CELL PROTOPLASTS OF VICIA-FABA
1985; 318 (6043): 285-287
View details for Web of Science ID A1985AUR1900090
ABSENCE OF REBOUND FROM DILTIAZEM THERAPY IN PRINZMETALS VARIANT ANGINA
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1985; 6 (1): 174-178
To determine the frequency of rebound anginal symptoms on abrupt withdrawal of calcium channel blocking agents, anginal symptoms were retrospectively examined in patients with Prinzmetal's variant angina abruptly withdrawn from diltiazem therapy as part of the design of a placebo-controlled multiple crossover trial. Rebound was defined as a return of anginal symptoms to levels exceeding those of the pretreatment baseline state. Values for daily frequency of angina were compared (after subtracting corresponding baseline values) between placebo periods following diltiazem periods and placebo periods following placebo periods. No intergroup differences existed between mean changes in daily frequency of angina from baseline value (-0.61 for placebo following diltiazem versus -1.10 for placebo following placebo) (p greater than 0.4). Furthermore, in 13 (28%) of 46 occurrences when placebo followed placebo, daily frequency of angina exceeded baseline value in the immediate 3 day period following placebo compared with 17 (21%) of 80 occurrences when placebo followed diltiazem. There was no increased rebound occurrence comparing high dose (240 mg/day) with low dose (120 mg/day) diltiazem therapy. No significant symptoms such as myocardial infarction or unstable angina occurred after withdrawal of diltiazem or placebo. The lack of difference in rebound after diltiazem or placebo withdrawal was consistent using paired and unpaired analyses. In conclusion, there appears to be no evidence that abrupt withdrawal of therapy with diltiazem results in rebound anginal symptoms.
View details for Web of Science ID A1985ALK9200028
View details for PubMedID 3891821
EFFICACY OF DILTIAZEM FOR CORONARY-ARTERY SPASM
ACTA PHARMACOLOGICA ET TOXICOLOGICA
1985; 57: 49-54
The introduction of calcium entry blockers which caused marked vascular smooth muscle relaxation with minimal effects on myocardial contractility have provided a new approach to the patient with angina due to coronary artery spasm. Multiple, double-blinded, randomized studies of diltiazem versus placebo have demonstrated that this agent results in reduction in angina frequency and nitroglycerin consumption by 30% to 70% with a demonstrated dose response. A long-term, open label follow-up study of 18 patients who participated in a 44-week prospective, double-blind crossover trial of 240 mg of diltiazem versus placebo for prophylaxis of angina in patients with coronary artery spasm demonstrated a 75% decrease in angina attacks during the first five months of the study and an 80% decrease compared to the placebo period during the second six months. Both the short- and long-term studies have demonstrated very few adverse side effects, less than 7%. A recent long-term study of 43 patients who took diltiazem regularly and were followed in the Coronary Artery Spasm Clinic at Stanford University Medical Center for a mean of 19.6 months (range 6 to 28.5 months) was analyzed for cardiovascular events in the 19.6 months prior to therapy and the 19.6 months after the initiation of therapy. Cardiovascular events on diltiazem, including sudden cardiac death, myocardial infarction, and hospitalization to rule out myocardial infarction utilizing a binomial distribution showed over a 90% reduction compared to the pre-diltiazem period. Adverse effects were reported in six patients who reported minimal to mild pedal oedema.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1985ARG3800007
View details for PubMedID 3904332
- Absence of rebound from diltiazem therapy in Prinzmetal's variant angina J Am Coll Cardiol 1985; 6:174-178
- The effect of diltiazem and propranolol, alone and in combination, on exercise performance and left ventricular function in patients with stable exertional angina. In: Just H, Schroeder JS (eds). Advances in Clinical Applications of Calcium Antagonist Drugs 1985; 115-123
- Concluding remarks. In: Advances in Clinical Applications of Calcium Antagonist Drugs International Diltiazem Workshop, Dusseldorf 1985; 114-145
- Introduction: Assessment of the clinical effectiveness of diltiazem Advances in clinical Applications of Calcium Antagonist Drugs (International Diltiazem Workship, Dusseldorf, 1984) 1985; 109-114
DILTIAZEM AND PROPRANOLOL, ALONE AND IN COMBINATION, ON EXERCISE PERFORMANCE AND LEFT-VENTRICULAR FUNCTION IN PATIENTS WITH STABLE EFFORT ANGINA - A DOUBLE-BLIND, RANDOMIZED, AND PLACEBO-CONTROLLED STUDY
ACTA PHARMACOLOGICA ET TOXICOLOGICA
1985; 57: 55-60
Diltiazem and propranolol alone and in combination as antianginal agents were compared with placebo in 12 patients with stable exertional angina at Stanford University Medical Center. The patients performed symptom-limited, multi-stage upright bicycle ergometric exercise while undergoing radionuclide angiographic studies every two weeks while being treated with 90 mg of diltiazem four times daily, 60 mg of propranolol four times daily, a combination of 90 mg of diltiazem and 60 mg of propranolol four times daily, and placebo. Diltiazem, propranolol and a combination all significantly increased exercise duration compared to placebo (526 +/- 149, 525 +/- 115, and 549 +/- 129 vs 430 +/- 132 sec.). Although rate pressure product and heart rate decreased with diltiazem therapy at submaximal workloads, these values were unchanged at peak exercise in contrast to propranolol or the combination of propranolol or diltiazem. Diltiazem decreased the sub-maximal and maximal degree of exercise-induced ST segment depression by over 50% compared to placebo (P less than 0.01 vs placebo). Diltiazem resulted in a higher exercise left ventricular ejection fraction compared to placebo, propranolol or the combination of diltiazem or propranolol (all less than P less than 0.05). Sinus bradycardia or orthostatic hypertension occurred in four patients on the high-dose combination therapy and required dose reduction. We concluded that high-dose diltiazem, appeared to be even more effective than moderate-dose propranolol or the combination of diltiazem and propranolol in improving exercise tolerance, electrocardiographic evidence of myocardial ischaemia and left ventricular function in patients with stable effort angina due to occlusive coronary artery disease.
View details for Web of Science ID A1985ARG3800008
View details for PubMedID 4061105
EFFICACY OF DILTIAZEM FOR MEDICALLY REFRACTORY STABLE ANGINA - LONG-TERM FOLLOW-UP
1985; 8 (9): 480-485
To assess the efficacy of long-term diltiazem therapy when added to beta blockers and nitrates, we prospectively studied patients with chronic exertional angina who were determined to have medically refractory angina pectoris which was too severe to enter placebo-controlled studies. The mean follow-up time was 24.6 months (8-47 months) and all patients were seen every 2-4 months. Angina frequency decreased from a prediltiazem frequency of 9.5 episodes per week (1-40 per week) to 3.3 attacks per week (0-21 per week) at 6 months and 3.3 attacks per week (0-40 per week) at the patients's last evaluation. Similar reductions in nitroglycerin consumption were reported. Five patients had an increase in angina frequency during the mean 24.6 months of follow-up, which necessitated coronary bypass surgery, 8, 10, 12, 19, and 23 months after study entry, respectively. Diltiazem daily dosage ranged from 120 to 480 mg/day, the mean daily dose was 298 mg/day. Twenty (65%) patients remained on beta-blocker therapy and 19 (61%) patients on nitrate therapy in an effort to achieve a completely pain-free state. New cardiovascular events were documented in 3 patients during the follow-up period, with one patient having an uncomplicated myocardial infarction at 6 months, one patient hospitalized for prolonged chest pain at 2 months, and one patient dying following cardioversion for unrelated atrial fibrillation at 14 months poststudy entry. Adverse effects were reported during 19 of the 354 patient visits, but no patient had to stop therapy because of these. Sinus bradycardia required reduction of beta-blocker dosage in three patients and prolonged PR interval was observed in two additional patients.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1985APQ8600004
View details for PubMedID 2864152
COMBINATION THERAPY WITH ISOSORBIDE DINITRATE - CURRENT STATUS AND THE FUTURE
AMERICAN HEART JOURNAL
1985; 110 (1): 284-291
The excellent safety and predictable efficacy of isosorbide dinitrate (ISDN) have been demonstrated repeatedly during the past 25 years in a number of studies in which the agent has been used alone or in combination with other antianginal agents. Clinical studies to investigate the additive or synergistic effect of ISDN have been difficult to conduct because of the complexity of protocol design and length of studies required. However, combination therapy is well accepted in the clinical practice of medicine and cardiology and is used to obtain additive therapeutic effects while minimizing the side effects. The addition of ISDN not only to other standard and proven antianginal agents but also to calcium antagonists should prove to be a fruitful area for further clinical research benefiting patients with angina pectoris (caused by either coronary artery spasm or occlusive coronary artery disease), hypertension, and congestive heart failure. Noncardiovascular uses of ISDN may include the treatment of hyperspasticity of other smooth muscle beds, such as esophageal spasm and achalasia.
View details for Web of Science ID A1985ALZ1200018
View details for PubMedID 3893082
ACCELERATED ATHEROSCLEROSIS IN A CARDIAC TRANSPLANT PATIENT
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1985; 6 (1): 243-245
A cardiac transplant patient with rapidly progressive graft atherosclerosis is described. This case demonstrates the accelerated nature of this disease and problems in diagnosis, as well as an unexpected and previously unreported lack of sensitivity of exercise thallium scintigraphy in its investigation. This case also gives further support to the practice of routinely and frequently obtaining coronary arteriograms in the management of these patients.
View details for Web of Science ID A1985ALK9200040
View details for PubMedID 3891822
COMPARISON OF THE ELECTROCARDIOGRAPHIC EFFECT OF DOTHIEPIN AND AMITRIPTYLINE
JOURNAL OF CLINICAL PSYCHIATRY
1984; 45 (7): 291-293
Electrocardiograms of 65 patients treated with dothiepin, a sulphur substituted tricyclic antidepressant, were compared to those of 57 patients receiving amitriptyline and 62 patients given placebo. Amitriptyline produced an average heart rate increase of 10 beats/minute as compared to 5 beats/minute for dothiepin (p less than .02). Amitriptyline also produced a significant prolongation of the corrected QT interval as compared to both dothiepin and placebo (p less than .01 and p less than .001, respectively). Dothiepin had no significant effect on any index of myocardial conduction (PR interval, corrected QT interval, and QRS duration) as compared to placebo.
View details for Web of Science ID A1984TB30000002
View details for PubMedID 6376479
- Provacative testing for coronary artery spasm Schroeder JS (ed). Invasive Cardiology 1984; 83-96
- Antianginal effects of calcium antagonists Sperelakis N, Caulfield JB (eds). Calcium Antagonists: Mechanisms of Action on cardiac Muscle and Vascular Smooth Muscle 1984; 101-110
FUNCTIONAL AND SOCIAL REHABILITATION OF HEART-TRANSPLANT RECIPIENTS UNDER AGE 30
SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
1984; 18 (2): 97-103
In the Stanford Heart transplant program, the functional and social rehabilitation of heart transplant recipients below the age of thirty has been investigated by using data from annual follow-ups with right and left heart catheterization, left ventricular (LV) and coronary angiograms and by a health survey questionnaire investigation. 24 out of 38 patients who received transplants in the period January 1, 1974 to April 1981 were still alive. The actuarial survival rates in this group of patients are: 3 months 74%; 1 year 71%, 3 years 67%, 5 years 50%. The figures are persistently higher than for the total number of heart transplant recipients in the Stanford program. 71% of the fatalities occurred during the critical first 3 months after transplantation. The hemodynamic and angiographic findings were normal in all but 2 patients where progressive coronary artery disease had been diagnosed. 23 out of the 24 patients completed the questionnaire. 9 patients were back at work, 4 went to school as required, 4 were now postgraduate students, 2 studied for self-satisfaction and 4 patients neither worked nor studied. All patients considered themselves able to do some kind of work. All patients were able to walk at least 1 mile and 70% 3 miles. 87% were able to do heavy domestic work. Hardly any restrictions in transportation ability and mostly minor restrictions in the activities of daily living were found. Marital satisfaction and sexual function were good in most of the patients; 57% were very satisfied, 30% moderately satisfied and 13% not really satisfied with their life.(ABSTRACT TRUNCATED AT 250 WORDS)
View details for Web of Science ID A1984SU60100001
View details for PubMedID 6379865
DILTIAZEM - A CLINICAL AND PHARMACOLOGIC PROFILE
JOURNAL OF CARDIOVASCULAR MEDICINE
1983; 8 (1): 41-?
View details for Web of Science ID A1983PY90800003
- Acute hemodynamic effects of betaxolol Morselli PL, Harrison DC, et al (eds) Betaxolol and Other Betal-Adrenoceptor Antagonists 1983; 179-181
- The calcium antagonists: Launching a new era in cardiology (editorial) Drug Therapy 1983; 63-64
The role of coronary artery spasm in unstable angina pectoris.
1983; 14 (1): 71-80
View details for PubMedID 6616514
- Provocation of coronary artery spasm Fowler NO (ed).. Noninvasive Diagnostic Methods in Cardiology 1983; 371-384
ACUTE HEMODYNAMIC-EFFECTS OF NITROGLYCERIN IN PULMONARY-HYPERTENSION
ANNALS OF INTERNAL MEDICINE
1983; 99 (1): 9-13
Therapy of pulmonary hypertension is limited by the low potency and adverse effects of current pulmonary vasodilators. The hemodynamic effects of nitroglycerin in human pulmonary hypertension are not known. We administered nitroglycerin to nine patients with chronic pulmonary hypertension. Nitroglycerin increased cardiac index 40% (p less than 0.01), increased stroke volume 40% (p less than 0.01), decreased pulmonary vascular resistance 40% (p less than 0.01), and decreased mean pulmonary artery pressure 15% (p less than 0.01). Pulmonary vascular resistance decreased more than 25% in eight of the nine patients. In four patients the effects of intravenous nitroglycerin were reproduced by topical nitroglycerin preparations; cardiac index increased 50%, stroke volume increased 48%, pulmonary vascular resistance decreased 43%, and mean pulmonary artery pressure decreased 19%. Five of six patients treated with long-acting nitrates had substantial improvement of their symptoms. We conclude that therapy with nitroglycerin can be effective in patients with severe pulmonary hypertension.
View details for Web of Science ID A1983QY17800002
View details for PubMedID 6407380
MYOCARDIAL-INFARCTION IN PATIENTS WITH CORONARY-ARTERY SPASM DEMONSTRATED BY ANGIOGRAPHY
AMERICAN HEART JOURNAL
1983; 105 (4): 542-547
Twelve cases of myocardial infarction (MI) were documented in 11 of 39 patients who had coronary artery spasm (CAS) that was observed by angiography either before MI (3 patients), after MI (5 patients), or both before and after MI (3 patients). MI corresponded in location to sites of ECG changes of myocardial ischemia during spontaneous angina pectoris in 7 of 7 patients and to the region of myocardium supplied by the vessel in which CAS was observed by angiography in each patient. MI occurred in the distribution of the right coronary artery in 8 patients and of the left coronary artery in 4 patients. Of 12 vessels that supplied infarcted regions of myocardium, 7 vessels had greater than or equal to 50% diameter fixed coronary artery narrowing (CAN), but the remaining 5 vessels had minimal (10%) or no fixed CAN. In those patients who were studied after MI, coronary angiography demonstrated that only 3 of 9 vessels in the distribution of infarcted regions of myocardium were completely occluded. Clinical follow-up for an average of 1.3 years after MI showed that 7 patients continued to have chest pain, 2 patients were asymptomatic, and 2 patients died suddenly 9 weeks and 1 year, respectively, after MI. Therefore, among our patients with CAS demonstrated by angiography, MIs (1) were frequent (28%), (2) occurred in the distribution of observed coronary spasm, (3) were frequently (5 of 12 arteries) in the distribution of vessels having minimal or no fixed narrowing, and (4) were often (6 of 9 arteries) in the distribution of vessels that were demonstrated to be patient after MI.
View details for Web of Science ID A1983QJ63500002
View details for PubMedID 6837408
CALCIUM-ANTAGONISTS SUPPRESS ATHEROGENESIS IN AORTA BUT NOT IN THE INTRAMURAL CORONARY-ARTERIES OF CHOLESTEROL-FED RABBITS
1983; 49 (2): 154-158
We tested the effects of the calcium antagonists lanthanum, diltiazem, and flunarizine on the development of atherosclerosis in rabbits fed a 2% cholesterol diet. The drugs were given orally and were well tolerated. In the cholesterol control animals, 52.2% of the thoracic aortic intimal surface was Sudan IV positive. This was reduced by 37% (p less than 0.05) with lanthanum, 37% (p less than 0.05) with diltiazem, and 34% (p less than or equal to 0.06) with flunarizine. In all cholesterol-fed animals, the intramural, but not subepicardial, coronary arteries were severely diseased. The extent and distribution of this disease were not altered by the various drug interventions. Thus, the calcium antagonists lanthanum, diltiazem, and flunarizine suppress atherogenesis of the rabbit aorta but have no effect on the extent or distribution of atherosclerosis in the intramural coronary arteries.
View details for Web of Science ID A1983RD33900005
View details for PubMedID 6876744
THE SHORT AND LONG-TERM EFFICACY OF DILTIAZEM FOR THE TREATMENT OF VARIANT ANGINA-PECTORIS
ARCHIVES DES MALADIES DU COEUR ET DES VAISSEAUX
1983; 76: 149-152
We studied 42 consecutive patients with coronary artery spasm (CS) who where treated with the Ca2+ entry blocker diltiazem for a mean period of 11 months (range 2-29 months). Patient population consisted of 26 females (age X = 52.1) and 16 males (age X = 59.1). ALl patients had diagnosis of CS confirmed by coronary arteriography (CA) with no patient having 70 per cent CAD. CS was equally distributed between LAD and RCA. 81 per cent of patients were cigarette smokers, 55 per cent had Raynaud's phenomenon, and 9 per cent had a history of migraine, 2 patients had previous MI, 2 previous bypass surgery (CABS), 1 previous angioplasty, 3 syncope with heartblock requiring pacemaker, and 2 with sudden death (VF-resuscitated). All patients were placed on diltiazem 240 or 360 mg/day to achieve pain free state. During follow-up there was no mortality. 2 patients hd uncomplicated inferior MI's. 1 patient had CABS for progressive 90 per cent LAD lesion, and 2 required hospitalization for dose adjustment due to frequent chest pain. No patient has drug-related side effects. Thus, long-term follow-up of patients with CS treated with diltiazem revealed no mortality, low morbidity (12 per cent) and no adverse drug side effects.
View details for Web of Science ID A1983QF81900022
View details for PubMedID 6407438
PREVENTION OF CARDIOVASCULAR EVENTS IN VARIANT ANGINA BY LONG-TERM DILTIAZEM THERAPY
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
1983; 1 (6): 1507-1511
In 43 patients with variant angina, the cardiovascular event rate during diltiazem therapy was compared with that in an equal time period before initiation of therapy. Cardiovascular events, that is, myocardial infarction, sudden death and hospitalization for prolonged angina, were decreased significantly (p less than 0.01) during the initial 6 months and mean 19.6 months of therapy. Based on the binomial principle, there were 22 events during the mean 19.6 months before therapy and 2 events during the equal time period on therapy. No patient died during follow-up. The frequency of angina was decreased by 94%. Diltiazem was well tolerated by all patients and no patient had to discontinue therapy because of adverse effects. It is concluded that long-term diltiazem therapy reduces cardiovascular events in patients with variant angina.
View details for Web of Science ID A1983QR88000020
View details for PubMedID 6853903
LONG-TERM EFFICACY OF DILTIAZEM FOR CONTROL OF SYMPTOMS OF CORONARY-ARTERY SPASM
1983; 52 (2): 153-157
View details for Web of Science ID A1983QN22500021
STUDY OF THE NORMAL AND FAILING ISOLATED HUMAN-HEART - DECREASED RESPONSE OF FAILING HEART TO ISOPROTERENOL
AMERICAN HEART JOURNAL
1983; 106 (3): 535-540
We evaluated the effects of isoproterenol in right ventricular papillary muscles derived from normal and failing isolated human hearts. Basal values for the peak force developed, rate of force development (dF/dt), and time to peak tension (TPT) were similar in both groups. Isoproterenol produced a significantly smaller (p less than 0.05) increase in peak force developed and dF/dt in failing papillary muscles. The half equivalent dose (ED50) of isoproterenol was fivefold higher in failing muscle as compared to normal muscle. We conclude that failing cardiac muscle demonstrates decreased responsiveness to beta-receptor mediated stimulation.
View details for Web of Science ID A1983RE66300016
View details for PubMedID 6308994
- THE EFFECT OF DILTIAZEM AND PROPRANOLOL, ALONE AND IN COMBINATION, ON EXERCISE PERFORMANCE AND LEFT-VENTRICULAR FUNCTION IN PATIENTS WITH STABLE EFFORT ANGINA - A DOUBLE-BLIND, RANDOMIZED, AND PLACEBO-CONTROLLED STUDY CIRCULATION 1983; 68 (3): 560-567
CORRELATION OF AN ABNORMAL REST TL-201 MYOCARDIAL IMAGE - PATHOLOGICAL FINDINGS IN CARDIAC TRANSPLANT RECIPIENTS
EUROPEAN JOURNAL OF NUCLEAR MEDICINE
1982; 7 (6): 243-247
Rest myocardial 201T1 scintigraphy was undertaken in 15 males mean age 39 years (22-54) who had been accepted for cardiac transplantation. Complete pathological correlation was obtained in 14 after transplantation and in 1 who died before a suitable donor heart became available. The average time from scintigraphy to pathological evaluation was 42 days (9-103). All the 201T1 images were grossly abnormal and on the basis of these studies it was not possible to differentiate ischemic from idiopathic cardiomyopathy. Each of the three views of the 201T1 study was divided into three segments, therefore 135 areas were available for comparison (3 x 3 x 15). Eighty-eight of these were abnormal on scan and 78 of these were abnormal pathologically. The right ventricle was seen on all rest images but the degree of uptake bore no relationship to the measured thickness of the right ventricular wall. Structures such as the atrial wall and the enlarged papillary muscle were visualized in some patients. In two patients there was an improvement of the rest 201T1 image in delayed views and histologically these areas showed a mixture of muscle and fibrous tissue. The sensitivity of 201T1 imaging in this study was 89% and there was close correlation of the images with gross and microscopic pathological findings.
View details for Web of Science ID A1982NU10000001
View details for PubMedID 7106150
- Role of CA++ antagonist for acute and chronic therapy of coronary spasm in both Prinzmetal's and stable angina in patients Cardiovasc Med 1982; I:245-251
- One year experience with cyclosporin A in clinical heart transplantation Heart Transplant 1982; 1:285-290
- New approaches to diagnosis and treatment In: Kimura E (ed). Progress in Cardiology 1982; 53-58
- Calcium and beta blockers in ischemic heart disease: When to use which Modern Med 1982; 94-116
- Wirksamkeit von diltiazem bei spasmen der koronarterien-kirzund langzeitstudient Bender F, Grief K (eds). Calciumantagonisten zur Behandlung der Angina Pectoris, Hypertonie und ARrhythmia 1982; 142-159
- The efficacy of diltiazem on symptoms of coronary artery spasm Diethrich EB (ed). Noninvasive Assessment of the Cardiovascular System: Diagnostic Principles and Techniques 1982; 227-231
- Current status of cardiac transplantation J Cardiovasc Med 1982; 1:363-368
- Treatment of coronary artery spasm with calcium blockers-variant angina and unstable angina Calcium-Blockers-Mechanisms of Action and Clinical Applications 1982; 219-230
- Effects of pharmacologic agents on isolated human coronary arteries Santamore WP, Bove AA (eds). Coronary Artery Disease 1982; 103-115
RANDOMIZED DOUBLE-BLIND COMPARISON OF NIFEDIPINE AND ISOSORBIDE DINITRATE THERAPY IN VARIANT ANGINA-PECTORIS DUE TO CORONARY-ARTERY SPASM
AMERICAN HEART JOURNAL
1982; 103 (1): 44-48
Twelve patients were entered prospectively into a randomized double-blind study comparing the efficacy of nifedipine and isosorbide dinitrate (ISDN) in the treatment of variant angina pectoris due to coronary artery spasm. Using the diary technique, both anginal episodes and nitroglycerin tablets consumed were recorded during the pretrial, no drug period, and both active drug phases. During the baseline pretrial period, an average of 1.1 anginal episodes/day occurred with reduction to 0.28/day during nifedipine treatment and 0.39/day during ISDN treatment. Headache was the major side effect during ISDN treatment, occurring in 9 of 11 (81%) patients; and nonheart failure related pedal edema during nifedipine treatment, occurring in 4 of 12 (33%) patients. Intolerable side effects necessitating cessation of treatment occurred in two patients during nifedipine treatment and in three patients during ISDN treatment. Patients preferred nifedipine over ISDN because of increased efficacy and fewer uncomfortable side effects. We conclude that both nifedipine and ISDN are effective therapy for coronary spasm, but that nifedipine was more effective and was preferred by the majority of patients.
View details for Web of Science ID A1982MX22600006
View details for PubMedID 7034513
INTRACARDIAC ELECTROPHYSIOLOGIC STUDY OF INTRAVENOUS DILTIAZEM AND COMBINED DILTIAZEM-DIGOXIN IN PATIENTS
AMERICAN HEART JOURNAL
1982; 103 (1): 57-66
Fifteen patients without sinoatrial (SA) or atrioventricular (AV) node dysfunction underwent electrophysiologic study (EPS) before and after intravenous diltiazem: 0.20 mg/kg bolus followed by 0.0007 mg/kg/min infusion (seven patients) or 0.25 mg/kg bolus followed by 0.0012 mg/kg/min infusion (eight patients). In six patients intravenous digoxin (0.018 mg/kg) was given and 45 minutes later EPS was repeated while the diltiazem infusion continued. Diltiazem prolonged sinus cycle length (+7%, p less than 0.01), lengthened AH conduction time (+22% in constant rate atrial paced rhythm, p less than 0.001), prolonged AV node functional and effective refractory periods (+6%, p less than 0.01 and +16%, p less than 0.05, respectively), lengthened AV node Wenckebach cycle length (+13%, p less than 0.001), shortened atrial functional refractory period (-3%, p less than 0.05), and reduced mean arterial pressure (-8%, p less than 0.005 in constant rate atrial paced rhythm). Subsequently, intravenous digoxin further prolonged sinus cycle length (+12%, p less than 0.05), AH conduction time (+17%, p less than 0.05), AV node Wenckebach cycle length (+9%, p less than 0.05), and AV node functional refractory period (+7%, p less than 0.05), shortened atrial effective refractory period (-7%, p less than 0.05) and ventricular effective refractory period (-6%, p less than 0.05), and increased systolic arterial pressure (+6%, p less than 0.05). Diltiazem and digoxin have additive depressant effects on SA and AV node function without significant adverse effects.
View details for Web of Science ID A1982MX22600009
View details for PubMedID 7055046
MULTICLINIC CONTROLLED TRIAL OF DILTIAZEM FOR PRINZMETALS ANGINA
AMERICAN JOURNAL OF MEDICINE
1982; 72 (2): 227-232
To assess the efficacy of a new calcium entry blocker, diltiazem (Cardizem), for prophylaxis of Prinzmetal's angina, 48 patients were studied in randomized, multiple crossover multiclinic study (2 weeks single-blind, 8 weeks double-blind). Diltiazem dosage in one crossover phase was 120 mg per day; in the other, 240 mg per day. Therapeutic response was measured by patients' diary records of angina frequency and nitroglycerin tablet consumption. Treatment with 120 mg of diltiazem per day reduced angina by 41 percent from the entry placebo period and 20 percent from the paired placebo period (p less than 0.005). Treatment with 240 mg of diltiazem per day reduced angina frequency by 68 percent from the entry placebo period and 43 percent from the paired placebo period (p less than 0.01). There were similar reductions in nitroglycerin consumption. Adverse experiences that may have been related to the medication were noted in only 5 percent of patients. There were no alterations in blood pressure or heart rate. The PR interval increased 3 percent at the 240 mg dosage level. We conclude that diltiazem is an effective and safe agent for control of symptoms of Prinzmetal's angina.
View details for Web of Science ID A1982NB85700009
View details for PubMedID 7036726
THE USE OF DILTIAZEM HYDROCHLORIDE IN CARDIOVASCULAR DISORDERS
1982; 2 (3): 121-133
Diltiazem, a calcium channel blocking agent, has potent cardiovascular effects that are directly related to its influence on vascular smooth muscle, ventricular myocardium, and specialized conducting tissue. It causes coronary and peripheral vasodilation, has a negative chronotropic and dromotropic effect, and little to no negative inotropic effect in patients with normal ventricular function. Diltiazem has potential use in a wide variety of cardiovascular disorders. It has been shown extremely effective in relieving the coronary artery spasm associated with variant angina. When compared with nitrates in patients with exertional angina, diltiazem has similar efficacy. Preliminary work indicates it will have a therapeutic role in the treatment of unstable angina. Because of its ability to improve the balance between myocardial oxygen supply and demand and reduce cellular injury secondary to ischemia, it is likely that diltiazem will be of benefit in the treatment of acutely ischemic myocardium during cardiopulmonary bypass and possibly acute myocardial infarction. It has proven efficacy in treating re-entrant supraventricular tachycardia. Adverse effects are seen in less than 5% of patients, indicating that it is well tolerated.
View details for Web of Science ID A1982NT94900001
View details for PubMedID 6763199
THE EFFECTS OF DILTIAZEM AND REDUCED SERUM IONIZED CALCIUM ON ISCHEMIC VENTRICULAR-FIBRILLATION IN THE DOG
1982; 50 (4): 518-526
Calcium influx blockers reportedly suppress ventricular arrhythmias during acute ischemia. We therefore studied the effects of diltiazem and reduced serum ionized calcium on ventricular fibrillation (VF) in a reversible ligation model. VF was produced at 15-minute intervals by simultaneous occlusion of the left anterior descending and circumflex arteries of 31 dogs. Time from coronary occlusion to onset of VF showed no significant variation during 15 consecutive trials in six dogs that received saline alone. Intravenous infusion of diltiazem (0.02 mg/kg per min) markedly delayed the onset of VF in each of 10 dogs (P less than 0.0001). Mean VF latency increased from 138 to 295 seconds during a 45-minute diltiazem infusion, declined exponentially when the infusion ceased, and was strongly correlated with serum diltiazem concentration (r = 0.96, P less than 10(-6)). In five dogs, hemodynamic measurements, including coronary venous blood flow, were performed during each occlusion. The increase in VF latency by diltiazem was not due to increased coronary flow during occlusion or to reduction of left ventricular (LV) mechanical work. In six dogs, mean serum ionized calcium, [Ca++], was reduced from 1.11 to 0.59 mM by infusion of sodium citrate. Citrate infusion increased mean VF latency from 155 to 243 seconds, and the increase observed in each dog was correlated (r = 0.84, P less than 10(-6)) with the reduction in [Ca++]. VF latency was unaffected by lidocaine in nine dogs. The antifibrillatory effect of diltiazem during global LV ischemia may be an electrophysiological phenomenon related to reduction of cellular calcium influx.
View details for Web of Science ID A1982NM08900009
View details for PubMedID 7067059
DO CALCIUM-DEPENDENT IONIC CURRENTS MEDIATE ISCHEMIC VENTRICULAR-FIBRILLATION
AMERICAN JOURNAL OF CARDIOLOGY
1982; 49 (3): 606-612
Calcium ions mediate the adverse effects of myocardial ischemia and have been implicated in the genesis of arrhythmias. Calcium influx blocking drugs protect against early ventricular arrhythmias during experimental coronary occlusion, and recent studies suggest that this effect is at least partly due to inhibition of myocardial cell calcium influx. Most of the pharmacologic maneuvers used to simulate acute ischemic arrhythmias in vivo also produce intracellular calcium overload. Production of calcium overload in small myocardial cell clusters causes fibrillatory electrical and mechanical activity similar to that recorded from fibrillating hearts. Fibrillation in these cell clusters is mediated not by reentrant conduction, but by the same subcellular processes that give rise to depolarizing afterpotentials and abnormal automaticity. Agents favoring calcium influx, such as beta adrenergic agonists, accentuate these processes, while agents that depress calcium influx inhibit them. Although the relation of these experimental models to clinical ischemic arrhythmias has not been fully delineated, calcium influx blocking drugs may prove useful in reducing the incidence of sudden cardiac death.
View details for Web of Science ID A1982ND14800019
View details for PubMedID 6277181
DILTIAZEM FOR LONG-TERM THERAPY OF CORONARY ARTERIAL SPASM
AMERICAN JOURNAL OF CARDIOLOGY
1982; 49 (3): 533-537
The first 36 patients with coronary arterial spasm treated with diltiazem and followed up at the Stanford University Coronary Artery Spasm Clinic for 6 months or longer are described. There were 13 men and 23 women with a mean age of 50.2 years; the mean duration of angina was 36.1 months. All patients had angina at rest with a good or fail response to sublingual nitroglycerin. During a mean of 17.5 months of diltiazem therapy, the frequency of angina was reduced from a mean of 21.5 to 1.3 attacks/week. This 94 percent reduction in pain frequency occurred when either 240 or 360 mg of diltiazem was administered daily. Sixteen patients required the addition of isosorbide dinitrate to achieve a painfree state. Pain breakthrough occurred a mean of 1.7 times during the 17.5 month follow-up period but tended to be of short duration. Six patients had trace to 1+ pedal edema and no other adverse effects occurred. It is concluded that diltiazem is highly effective and well tolerated for the long-term prophylaxis and treatment of angina in patients with coronary spasm.
View details for Web of Science ID A1982ND14800008
View details for PubMedID 7058764
COMPARATIVE CLINICAL ELECTROPHYSIOLOGIC EFFECTS OF DILTIAZEM, VERAPAMIL AND NIFEDIPINE - A REVIEW
AMERICAN JOURNAL OF CARDIOLOGY
1982; 49 (3): 629-635
The slow channel blocking agents--diltiazem, verapamil and nifedipine--have generated clinical interest for the treatment of a variety of cardiovascular disorders. These agents, despite a similar basic mechanism of action, produce disparate clinical cardiac electrophysiologic effects in human beings. In usual doses, the acute administration of diltiazem slows heart rate. Verapamil and nifedipine, however, increase heart rate. Although diltiazem and verapamil produce equivalent slowing of atrioventricular (A-V) nodal conduction, verapamil prolongs A-V nodal refractoriness to a greater degree. In contrast, nifedipine facilitates A-V nodal conduction and shortens A-V nodal refractoriness. Knowledge of these differences may aid in the appropriate selection of specific slow channel blocking agents in specific clinical situations.
View details for Web of Science ID A1982ND14800022
View details for PubMedID 6277182
CALCIUM-ANTAGONISTS - INCREASING IMPORTANCE
MUNCHENER MEDIZINISCHE WOCHENSCHRIFT
1982; 124 (8): A18-?
View details for Web of Science ID A1982NC62700007
- CALCIUM-ENTRY BLOCKADE, BETA-ADRENERGIC-BLOCKADE AND THE REFLEX CONTROL OF CIRCULATION CIRCULATION 1982; 65 (4): 669-670
HEART LUNG TRANSPLANT - CYCLOSPORIN-A IMPROVES PROGNOSIS
MUNCHENER MEDIZINISCHE WOCHENSCHRIFT
1982; 124 (10): A15-A16
View details for Web of Science ID A1982NE31000007
- CORONARY-ARTERY SPASM - PATHO-PHYSIOLOGY, CLINICAL PRESENTATIONS, DIAGNOSTIC APPROACHES AND RATIONAL TREATMENT WESTERN JOURNAL OF MEDICINE 1982; 136 (5): 398-410
Myocardial infarction ruled out: a high-risk patient group.
1981; 7 (10): 42-45
View details for PubMedID 7297047
Cardiovascular responses to handgrip isometric exercise in patients following cardiac transplantation.
1981; 48 (6): I156-61
The effects of cardiac denervation on the hemodynamic responses to isometric handgrip contraction were studied in patients 1--5 years after allograft cardiac transplantation. The objective of these studies was to determine the role of cardioacceleration and myocardial contractility on the increase in systemic arterial pressure during isometric exercise. Initially, noninvasive measurement of brachial artery pressure and heart rate during 60 seconds of isometric exercise at 50% of maximal voluntary contraction (50% MVC) were recorded in 23 cardiac transplant patients, 18 ischemic heart disease patients, and 15 healthy controls. While the increases in arterial pressure were not significantly different among the three groups and the heart rate response for the healthy controls and ischemic heart disease patients were similar, the transplant patient's heart rate remained essentially unchanged. In an attempt to determine the mechanisms for the increase in arterial pressure, despite any increase in heart rate in transplant patients, we recorded left ventricular volumes before and at the end of 50% MVC using fluoroscopy of tantalum midwall myocardial markers in seven cardiac transplant recipients and seven nontransplant cardiac surgery patients. The rise in arterial pressure during isometric exercise in both groups of patients resulted from a significant increase in peripheral vascular resistance but not in stroke volume or cardiac output. These data demonstrate that the rise in arterial pressure observed during isometric exercise can be achieved by increased peripheral vascular resistance alone in patients who lack the capacity to increase heart rate or stroke volume.
View details for PubMedID 7014021
LONG-TERM SURVIVAL AND FUNCTION AFTER CARDIAC TRANSPLANTATION
ANNALS OF SURGERY
1981; 194 (4): 381-385
Cardiac transplantation now permits prolonged survival for some patients with otherwise fatal heart disease. This report summarizes the hemodynamic and clinical characteristics of 25 patients who have survived five or more years after cardiac replacement. The average age of the patients at the time of operation was 40 +/- 10 (SD) years; 23 were men. The average duration of survival is 6.7 years, and ranges from five to 10.5 years. Annual cardiac catheterization and clinical follow-up were performed to assess systolic cardiac function, coronary anatomy, and quality of extended rehabilitation. We found that among these long-term survivors, the left ventricular ejection fraction remained constant (0.59 +/- 0.08 one year postoperatively, 0.57 +/- 0.09 at most recent study, p = ns). Segmental wall motion measured by fluoroscopic examination of midwall intramyocardial markers also remained normal. Four of 21 (19%) patients with complete longitudinal studies developed significant graft coronary artery disease. Clinical evaluation revealed that the long-term survivors required fewer than one unscheduled admission to the hospital per year. Sixteen of 25 patients (64%) were gainfully employed, and 22 of 25 (88%) enjoyed substantial benefit in terms of extended rehabilitation. These 25 long-term survivors represent 27% of 92 patients transplanted between 1968 and 1975. The actuarial survival rate at five years, of patients transplanted since 1975, is 40 +/- 5%. This increase in survival rate reflects improved techniques of early postoperative management. Cardiac transplantation now offers prolonged survival with good quality of life for selected patients with terminal heart disease.
View details for Web of Science ID A1981ML08000002
View details for PubMedID 7025768
View details for PubMedCentralID PMC1345309
VARIABILITY OF EXERCISE PERFORMANCE DURING LONG-TERM PLACEBO-TREATMENT
CLINICAL PHARMACOLOGY & THERAPEUTICS
1981; 30 (3): 321-327
Although exercise testing is commonly used to determine the efficacy of antianginal drugs, there is little information on the effect of frequent exposure to such testing over periods of long as 6 mo. In or study 10 patients (four men and six women) with stable angina pectoris received placebo for 6 mo. Treadmill testing followed a modified Bruce protocol. All patients exercised to an end point of typical anginal pain and 1 mm or more of ST depression. The first treadmill test for diagnostic purposes was followed by testing every 2 wk for 6 mo. Sublingual nitroglycerin was permitted to abort attacks of angina. Parameters evaluated included heart rate, double product, and duration of exercise. There was no change in the maximal heart rate (mean = 109 at 2 wk and 112 at 6 mo) or double product (mean = 17,002 at 2 wk and 17,249 at 6 mo). On the other hand, duration increased (mean 7.8 min at two wk and 9.9 min at 6 mo). Thus, although treadmill testing showed reproducible measurements of maximal heart rate and double product over 6 mo, exercise duration increased progressively.
View details for Web of Science ID A1981MG76700007
View details for PubMedID 6791867
- Transplantation and the heart Less of MH (ed). Immunology of Cardiovascular Disease 1981; 339-360
- Variability of exercise treatment during long-term placebo treatment Clin Pharm & Therapeutics 1981; 30:321-327
- Response of cardiac transplant recipients to static and dynamic exercise: A review Heart Transplant 1981; 1:72-79
- Myocardial infarction ruled out: What is the prognosis and approach? Primary Cardiol 1981; 109-117
APPLICATION AND SAFETY OF OUTPATIENT ERGONOVINE TESTING IN ACCURATELY DETECTING CORONARY SPASM IN PATIENTS WITH POSSIBLE VARIANT ANGINA
AMERICAN HEART JOURNAL
1981; 102 (4): 698-702
We analyzed the results of 61 consecutive outpatient ergonovine provocation tests to determine the safety and efficacy of such outpatient testing for detecting coronary artery spasm (CAS). Criteria for outpatient testing included: clinical history suggestive of variant angina, noncritical coronary artery disease documented by coronary arteriography, normal exercise treadmill test, no symptomatic arrhythmias, and no history of recent myocardial infarction. All antianginal medications were tapered and stopped. Ergonovine maleate was given as a bolus at 3-minute intervals in consecutive doses of 0.05, 0.10, and 0.25 mg. A positive test was defined as chest pain accompanied by greater than 0.1 mV ST segment elevation of 12-lead ECG. If pain and ST-segment elevation occurred, intravenous and sublingual nitroglycerin were immediately administered for relief of myocardial ischemia. Of the 61 patients studied, 10 had positive tests; there were no complications. Follow-up the 51 patients with negative studies has not revealed cardiac etiology for their chest pain. We conclude that outpatient ergonovine testing is a safe and accurate diagnostic test for identifying CAS in a highly selected population of patients with possible variant angina when performed under carefully controlled conditions.
View details for Web of Science ID A1981MJ59000007
View details for PubMedID 7282514
CLINICAL COURSE OF PATIENTS FOLLOWING THE DEMONSTRATION OF CORONARY-ARTERY SPASM BY ANGIOGRAPHY
AMERICAN HEART JOURNAL
1981; 101 (2): 127-134
The clinical course of 25 patients was determined during an average of 2.7 years following the angiographic demonstration of coronary artery spasm (CAS). Seventeen patients received medical treatment after the demonstration of coronary spasm and six patients had cardiac surgery. Twenty-three patients were living and two patients had died at the time of follow-up. Twenty-one of the 23 surviving patients has either no chest pain or markedly reduced symptoms. However, the demonstration of CAS by angiography was associated with a high incidence of subsequent cardiac complications, which included myocardial infarct (four patients), cardiac arrest (four patients), and death (two patients). We concluded from this study that after the demonstration of CAS by angiography: (1) the clinical course was variable, with most patients (21 of 25 patients, 84%) having improvement of symptoms at the time of follow-up; (2) major cardiac complications were frequent (11 out of 25 patients, 44%) and; (3) although clinical and coronary angiographic features were of limited use in predicting major cardiac complications, most of the patients who had an uncomplicated course (11 of 14 patients, 79%) had either less than 50% fixed coronary artery luminal diameter narrowing (CAN) or coronary artery bypass graft operations, the majority of patients with less than 50% CAN (8 of 11 patients, 73%) had no major cardiac complications, and myocardial infarction or death usually occurred during periods of increased angina pectoris.
View details for Web of Science ID A1981LB33700001
View details for PubMedID 7468413
- Obstructive sleep apnea syndrome and tracheostomy: Long-term follow-up and experience Arch Int Med 1981; 141:985-988
ABNORMALITIES OF PULMONARY-ARTERY WEDGE PRESSURES IN SLEEP-INDUCED APNEA
INTERNATIONAL JOURNAL OF CARDIOLOGY
1981; 1 (1): 67-74
Six patients with sleep apnea syndrome were studied with continuous hemodynamic monitoring during sleep. Sleep apnea had been previously documented with an average number of apneas per hour of sleep ranging from 23 to 93 ((mean 63). There was significant decrease in heart rate during sleep (82 +/- 5 to 69 +/- 6, P less than 0.01). There was a significant rise in systemic blood pressure (103 +/- 2 mn Hg to 116 +/- 6 mm Hg, P less than 0.05) and pulmonary artery pressure (20 +/- 1 mm Hg to 32 +/- 5 mm Hg) during sleep. In addition, pulmonary artery wedge pressure increased (12 +/- 2 mm Hg to 20 +/- 3 mm Hg, P less than 0.05) during sleep and 5 of the 6 patients developed an abnormal pulmonary wedge pressure. There was a significant decrease in PO2 during sleep (71 +/- 3 mm Hg to 49 +/- 2 mm Hg, P less than 0.005). These findings suggest that increases in pulmonary wedge pressures may be contributing to increase in pulmonary artery pressures in these patients during sleep.
View details for Web of Science ID A1981MQ04400008
View details for PubMedID 7333716
CORONARY-ARTERY SPASM IN THE DENERVATED TRANSPLANTED HUMAN-HEART - A CLUE TO UNDERLYING MECHANISMS
AMERICAN JOURNAL OF MEDICINE
1981; 70 (5): 1144-1149
The mechanism of coronary artery spasm has been poorly understood but there has been some suggestion that cardiac autonomic innervation may play an important role. We report coronary artery spasm in a 43 year old man two years after he had received a transplant. Provocative pharmacologic testing suggested functional denervation of the patient's heart. Thus, coronary artery spasm can occur in the transplanted, denervated human heart. Autonomic innervation of the heart is not essential in all cases of coronary spasm, and circulating catecholamines and/or metabolic of hormonal products may play an important role.
View details for Web of Science ID A1981LP92100027
View details for PubMedID 7015853
CARDIOVASCULAR-RESPONSES TO HANDGRIP ISOMETRIC-EXERCISE IN PATIENTS FOLLOWING CARDIAC TRANSPLANTATION
1981; 48 (6): 156-161
View details for Web of Science ID A1981LR85000021
UNSTABLE ANGINA-PECTORIS - NATIONAL COOPERATIVE STUDY-GROUP TO COMPARE MEDICAL AND SURGICAL THERAPY .4. RESULTS IN PATIENTS WITH LEFT ANTERIOR DESCENDING CORONARY-ARTERY DISEASE
AMERICAN JOURNAL OF CARDIOLOGY
1981; 48 (3): 517-524
View details for Web of Science ID A1981MG28900018
LONG-TERM TRANSTELEPHONIC ELECTROCARDIOGRAPHIC MONITORING IN THE DETECTION AND EVALUATION OF VARIANT ANGINA
AMERICAN HEART JOURNAL
1981; 102 (2): 196-201
To facilitate the outpatient diagnosis of variant angina by documenting transient ST segment evaluation during chest pain, we studied the feasibility of transtelephonic ECG monitoring during angina episodes. Eight patients with known coronary artery spasm underwent simultaneous continuous ambulatory and transtelephonic ECG monitoring during a 24-hour period. Five patients (62%) had transient diagnostic ST segment shifts on both continuous ambulatory and transtelephonic monitoring. Another eight patients with coronary spasm underwent 24-hour continuous ambulatory monitoring and separate 14-day period of transtelephonic monitoring. The addition of this longer monitoring period provided diagnostic ST segment shifts in three patients. We conclude that transtelephonic monitoring in patients with suspected coronary artery spasm can provide important additional diagnostic information to continuous ambulatory monitoring, particularly in the patient with infrequent or predictable chest pain.
View details for Web of Science ID A1981MB29100009
View details for PubMedID 7258093
AFTER A TIME, ARRHYTHMIAS
1980; 12 (3): 34-?
View details for Web of Science ID A1980JE11500005
ALBUMINURIA AND THE PERMSELECTIVE PROPERTIES OF THE GLOMERULUS IN CARDIAC-FAILURE
1980; 17 (4): 507-514
Fractional dextran clearances (theta D) were used to ascertain whether the albuminuria accompanying cardiac failure (CF) has a hemodynamic basis. In 17 patients with grade-IV CF in whom GFR and effective renal plasma flow (ERPF) were depressed to 58 +/- 7 and 215 +/- 20 ml/min/1.73 m2, respectively, theta D was elevated relative to normal control subjects over the Stokes-Einstein radius (r) interval of 28 to 46 Angstrom. For dextran of equivalent size to albumin (r = 36 Angstrom), the rate of urinary excretion (UD36V) was not increased because elevated theta D36 was offset by the depressed GFR. In contrast, urinary albumin excretion (UalbV) was increased to 82 +/- 35 microgram/min. Thus, for albuminuria in CF to have the hemodynamic basis suggested by elevation of theta D requires that (I) the fractional clearance for anionic albumin be disproportionately enhanced relative to uncharged dextran by reduced glomerular plasma flow and/or (2) that glomerular electrostatic barrier function be impaired in CF. In seven patients with minimal change nephropathy, UD36V was similar to that in CF, but UalbV was 40 times greater than that in CF. Thus, if glomerular electrostatic barrier function is impaired in CF, such dysfunction is trivial by comparison with minimal change nephropathy.
View details for Web of Science ID A1980JS30700010
View details for PubMedID 7392424
- Use of propranolol in management of cardiac arrhythmias. In: Kattus AA Jr, Ross G, Hall VE (eds). Cardiovascular Beta Adrenergic Responses 1980; 205:173-190
- Rule out myocardial infarction Fries JF, Ehrlich GE (eds). Prognosis: Contemporary Outcomes of Disease 1980; 272-274
- Long-term results of coronary artery bypass for unstable angina: Incidence of mortality, myocardial infarction and angina resumption Clin Cardiol 1980; 3:297-302
- Cardiotoxicity of lithium salts Bristow MR (ed). Drug-Induced Heart Disease. Specific Disease States 1980; 5:293-304
- Congestive heart failure Fries JF, Ehrlich GE (eds). Prognosis: Contemporary Outcomes of Disease 1980; 278-279
- Coronary artery spasm: Approach to diagnosis and treatment Practical Cardiol 1980; 6(9):62-82
- Clinical assessment of external pressure circulatory assistance in acute myocardial infarction: A cooperative study Am J Cardiol 1980; 45:349-56
CARDIORESPIRATORY RESPONSES OF CARDIAC TRANSPLANT PATIENTS TO GRADED, SYMPTOM-LIMITED EXERCISE
1980; 62 (1): 55-60
The electrocardiographic and ventilatory responses of 15 denervated heart patients who had undergone cardiac transplantation and 14 age-matched, normally innervated men were compared to assess the pattern of response to graded treadmill exercise. A 5-minute postexercise venous lactate sample was also obtained. Respiratory exchange ratio and ventilation (Ve) were higher in denervated patients than in normals during submaximal exercise. Peak values (normals vs denervated) for heart rate (172 vs 159 beats/min), blood pressure (189 vs 167 mm Hg), oxygen uptake (37 vs 25 ml/kg/min), oxygen pulse (0.22 vs 0.16 ml/kg/beat) and work time (26.2 vs 18.0 minutes) were higher in normals than in cardiac transplant recipients. Peak ventilatory equivalent (2.14 vs 3.13 l/ml/kg) and lactate values were higher for transplants than for normal subjects, but there were no significant intergroup differences in peak Ve or in the respiratory exchange ratio. In cardiac transplant recipients, work time correlated inversely with a measure of rejection history (r = -0.59, p less than 0.01). The response of cardiac transplant recipients to treadmill work differs from that of normal men and reflects a diminished ability to meet the oxygen demands of the exercising periphery.
View details for Web of Science ID A1980JX59200009
View details for PubMedID 6991158
DO PATIENTS IN WHOM MYOCARDIAL-INFARCTION HAS BEEN RULED OUT HAVE A BETTER PROGNOSIS AFTER HOSPITALIZATION THAN THOSE SURVIVING INFARCTION
NEW ENGLAND JOURNAL OF MEDICINE
1980; 303 (1): 1-5
To determine the prognosis after hospitalization of patients hospitalized with acute chest pain in a coronary-care unit, we undertook a prospective study of 211 consecutive admissions to the Stanford Coronary Care Unit. On the basis of predetermined criteria, 16 patients were found to have noncardiac chest pain, and myocardial infarction was ruled out in 89, one of whom died in the hospital. Infarction was documented in 84 others, six of whom died in the hospital. Prospective follow-up after hospitalization was carried out in the 88 patients in whom infarction was ruled out and in the 78 patients who survived infarction. The rate of myocardial infarction or death was 8.0 per cent at six months and 21.6 per cent at a mean of 27.8 months of follow-up for patients who had infarction ruled out, as compared with 7.7 per cent at six months and 21.8 per cent at a mean of 27.8 months of follow-up for those who had a documented infarction during the initial hospitalization. Cardiomegaly, congestive heart failure, and angina after discharge from the hospital tended to increase the risk of morbidity and mortality in both groups. The patient hospitalized with acute ischemic chest pain without evolution of a myocardial infarction has a six to 24-month prognosis similar to that of the patient hospitalized with an acute infarction, and therefore requires similar diagnostic and therapeutic assessment.
View details for Web of Science ID A1980JX57100001
View details for PubMedID 7374727
EFFICACY OF DILTIAZEM FOR CONTROL OF SYMPTOMS OF CORONARY ARTERIAL SPASM
AMERICAN JOURNAL OF CARDIOLOGY
1980; 46 (6): 1027-1032
To evaluate the efficacy of the calcium antagonist diltiazem for therapy of active coronary arterial spasm, 13 patients with clinical variant angina attributed to documented coronary arterial spasm completed a prospective randomized double-blind crossover trial of diltiazem (120 and 240 mg/day) versus placebo. Response was assessed with the diary technique measuring frequency of angina, consumption of nitroglycerin and percent of pain-free days. When 120 mg of diltiazem/day was compared with the paired placebo period there was a significant increase in percent of pain-free days (from 43 to 71 percent [p = 0.03]), but no significant decrease in frequency of angina (p = 0.06) or consumption of nitroglycerin (p = 0.32). When 240 mg of diltiazem/day was compared with the paired placebo period there was a significant increase in percent of pain-free days (from 50 to 79 percent [p = 0.03]) and a significant decrease in both frequency of angina (from 1.6 to 0.4 episodes/day [p = 0.03]) and consumption of nitroglycerin (from 1.3 to 0.4/day [p = 0.01]). Diltiazem was found to be a highly effective drug for control of symptoms of active coronary arterial spasm, without side effects and with excellent patient tolerance.
View details for Web of Science ID A1980KT61100019
View details for PubMedID 6778197
LEFT-VENTRICULAR RESPONSE TO ISOMETRIC-EXERCISE IN PATIENTS WITH DENERVATED AND INNERVATED HEARTS
1980; 61 (5): 897-901
Patients with cardiac denervation resulting from allograft transplantation have been observed to increase their diastolic and systolic blood pressure during isometric exercise without concomitant cardioacceleration. To determine the mechanism for the blood pressure increase, heart rate, blood pressure, and ventricular volumes (measured using fluoroscopy of tantalum midwall myocardial markers) were recorded before and after a 50% maximal voluntary contraction. Seven cardiac transplant recipients (denervated heart) and seven nontransplant patients (innervated heart) were studied. Innervated and denervated heart patients increased systolic blood pressure by 16% and 21% and total peripheral resistance by 20% and 12%, respectively. The percentage responses were not significantly different between groups, except for heart rate, which increased 17% in innervated heart patients and 2% in denervated heart patients (p less than 0.05). Neither group had enhanced contractility or increases in cardiac output, suggesting that the blood pressure increases resulted in both groups from increased peripheral resistance.
View details for Web of Science ID A1980JP65500006
View details for PubMedID 6988102
UNSTABLE ANGINA-PECTORIS - NATIONAL COOPERATIVE STUDY-GROUP TO COMPARE SURGICAL AND MEDICAL THERAPY .3. RESULTS IN PATIENTS WITH S-T SEGMENT ELEVATION DURING PAIN
AMERICAN JOURNAL OF CARDIOLOGY
1980; 45 (4): 819-824
View details for Web of Science ID A1980JN03200014
CALCIUM, CALCIUM-ANTAGONISTS, AND CARDIOVASCULAR-DISEASE
1980; 78 (1): 122-122
View details for Web of Science ID A1980KF18900002
EFFECT OF DILTIAZEM HYDROCHLORIDE CAPSULES ON CARDIAC HEMODYNAMIC AND ELECTROCARDIOGRAPHIC FUNCTION
CURRENT THERAPEUTIC RESEARCH-CLINICAL AND EXPERIMENTAL
1980; 28 (3): 319-325
View details for Web of Science ID A1980KK58600004
MEDICAL THERAPY OF PRINZMETAL VARIANT ANGINA
1980; 78 (1): 231-233
Medical therapy for Prinzmetal's variant angina has been treatment of the acute attack with sublingual nitroglycerin. Prophylactic therapy has been more difficult, utilizing long-acting vasodilators that are limited because of their short half-life and side effects when therapeutic doses are used. Alpha-adrenergic blockade has been effective in some patients but is frequently associated with intolerable side effects or apparent development of tolerance to the drug. Preliminary experience from a randomized double-blind trial of diltiazem, a new calcium antagonist, has demonstrated a 90% reduction in pain episodes, with many patients becoming pain-free on the 240-mg daily dose. These data and the lack of adverse side effects demonstrate a dramatically effective therapy for patients with coronary artery spasm.
View details for Web of Science ID A1980KF18900017
View details for PubMedID 6772386
- EXERCISE RESPONSE OF THE DENERVATED HEART IN LONG-TERM CARDIAC TRANSPLANT RECIPIENTS AMERICAN JOURNAL OF CARDIOLOGY 1980; 46 (2): 213-218
SPONTANEOUS PHASIC ACTIVITY OF ISOLATED HUMAN CORONARY-ARTERIES
1980; 14 (10): 613-618
The functional behaviour and pharmacological responses of ring segments of large coronary arteries removed from five patients undergoing cardiac transplantation were studied in vitro. All segments showed spontaneous rhythmic contractions which were markedly dependent on external calcium and were rapidly abolished in calcium-free solutions and by verapamil. The contractions were inhibited by cooling and by anoxia. Phasic activity was enhanced by increasing the external potassium concentration over the range 5 to 20 mmol.litre-1 but was abolished by 120 mmol.litre-1 potassium. Noradrenaline and ergonovine enhanced or induced phasic activity. The behaviour of human coronary arteries resembles that of the portal-mesenteric veins of many species and our results suggest that the activation mechanisms of these two tissues may be similar.
View details for Web of Science ID A1980KR90700009
View details for PubMedID 6783306
Prodromal characteristics as indicators of cardiac events in patients hospitalized for chest pain.
1979; 2 (1): 33-39
In an effort to determine the usefulness of prodromata for predicting a myocardial infarction, a prospective analysis was made of 211 consecutive patients with chest pain who were admitted to the Stanford University Medical Center Coronary Care Unit. In their subsequent course, 91 patients had a myocardial infarction, 102 had a myocardial infarction ruled-out, and 18 had a noncardiac etiology for their chest pain. Prodromal chest pain in the previous six months had occurred in 65% of patients and unstable angina in 61%. Infarction versus noninfarction patient groups could not be identified on the basis of prodromal ill health, chest pain, unstable angina, typical versus atypical nature of the chest pain, or activity at the onset of pain. Complaints of preceding fatigue and increased perceived stress were common in both groups. Activity at the onset of the admission chest pain was strenuous in 15% of the infarction patients and 12% of the noninfarction patients. We conclude that prodromal symptoms are common in both infarction and noninfarction patients. Although chest pain probably remains the single most frequent identifier of a new cardiac event, it is common in noninfarction patients and cannot be used alone to predict infarction or death.
View details for PubMedID 498604
- CURRENT STATUS OF CARDIAC TRANSPLANTATION, 1978 JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 1979; 241 (19): 2069-2071
- Sudden death: Identification of high risk patients and its prevention Anand MP, Shah SJ (eds). Progressive Cardio-Pulmonary Diseases 1979; 20-25
- Unstable angina pectoris: National Cooperative Study Group to Compare Surgical and Medical Therapy. Medical or surgical therapy for unstable angina pectoris? Cardiovasc Med 1979; 4:1059-78
EFFECTS OF PROBUCOL ON HYPERLIPIDEMIC PATIENTS WITH CARDIAC ALLOGRAFTS
JOURNAL OF CARDIOVASCULAR PHARMACOLOGY
1979; 1 (3): 353-365
Probucol, a well-tolerated new drug with moderate hypocholesterolemic effect in the general population, was evaluated in hypercholesterolemic (greater than 300 mg/dl) cardiac transplant recipients. Nine patients received probucol, 500 mg twice daily, in a single-blind, placebo-controlled trial lasting 20 weeks. Six patients responded with cholesterol falls of -20% (mean, -13.2%), and 1 patient showed minimal change. One patient developed cardiac rejection and was excluded, and another responded paradoxically and was returned to previous therapy. In 1 patient, probucol was readministered, and a similar favorable response occurred, which has been sustained for over 6 months. For the group completing the study, low-density lipoprotein (LDL) cholesterol fell by 15.4%, accounting for the major portion of overall change in plasma cholesterol. High-density lipoprotein (HDL) cholesterol also fell (-15.6%), and the LDL/HDL ratio was unchanged. Triglycerides and very low density lipoprotein cholesterol showed variable responses with no overall change. Probucol was universally well tolerated, without adverse clinical or laboratory effects. In conclusion, probucol may effect a moderate hypocholesterolemic response in hyperlipidemic recipients of cardiac transplantation, despite long-term maintenance therapy with corticosteroids. However, efficacy should be individually documented. The long-term effect of probucol on the natural history of coronary artery disease in these patients remains to be determined, particularly in view of its effects on HDL cholesterol.
View details for Web of Science ID A1979GX97200007
View details for PubMedID 94402
- Hemodynamic studies in sleep apnea Guilleminault C, Dement WC (eds). Sleep Apnea Syndromes 1979; 177-186
- The physical work performance of heart-transplant patients Rossi P (ed). Functional Evaluation and Rehabilitation of Cardiac Patients 1979; 133-143
- Medical and surgical treatment of Prinzmetal's angina. Proceedings of International Symposium Commemorating a Generation of Coronary Arteriography Cleveland Clinic Foundation and Cleveland Clinic International Center for Specialty Studies, sponsors 1979
- HEMODYNAMIC PERFORMANCE OF THE HUMAN TRANSPLANTED HEART TRANSPLANTATION PROCEEDINGS 1979; 11 (1): 304-308
TRACHEOSTOMY AND HEMODYNAMIC CHANGES IN SLEEP-INDUCED APNEA
ANNALS OF INTERNAL MEDICINE
1978; 89 (4): 454-458
Because pulmonary hypertension and systemic hypertension occur during sleep-induced obstructive apnea, six patients underwent overnight hemodynamic monitoring before and after tracheostomy. Variables studied included heart rate, pulmonary artery pressure, femoral artery pressure, and arterial oxygen tension (Po2). After tracheostomy, significant reductions were noted during sleep in mean pulmonary artery pressure from 45 +/- 6 mm Hg (mean +/- SEM) to 22 +/- 2 mm Hg (P less than 0.05) and in mean femoral artery pressure from 137 +/- 6 mm Hg to 97 +/- 3 mm Hg (P less than 0.005). There was also a significant increase for the group in arterial Po2 recorded during the apneic episodes from 38 +/- 3 mm Hg before tracheostomy to 71 +/- 2 mm Hg (P less than 0.001) after tracheostomy. We conclude that tracheostomy improves the hemodynamic abnormalities and hypoxemia that occur during sleep in patients with sleep-induced obstructive apnea.
View details for Web of Science ID A1978FR76800003
View details for PubMedID 697223
- Unstable angina pectoris: Diagnosis and management of "preinfarction angina" Mason DT (ed). Cardiac Emergencies 1978; 84-94
- Cardiac transplantation: The Stanford experience Anand MP, Goyal BK (eds). Progress in Vascular Diseases 1978; 71-76
- Sleep apnea and cardiovascular abnormalities Primary Cardiol 1978; 84-86
- Clinical course of patients with chest pain and without myocardial infarction Practical Cardiol 1978; 63-79
- Holter monitoring, PVC's, and antiarrhythmic therapy Jacobsen NK, Robertson MK, Yarnall SR (eds). The Scope of Ambulatory Monitoring in Ischemic Heart Disease 1978; 7-14
- Effects of cardiac denervation on cardiac arrhythmias and electrophysiology Br Heart J 1978; 40:17-23
- Unstable angina pectoris: National Cooperative Study Group to Compare Surgical and Medical Therapy. II. In-hospital experience and initial follow-up results in patients with one-, two-, and three-vessel disease Am J Cardiol 1978; 42:839-848
- NEWER ANTIARRHYTHMIC AGENTS FOR PATIENTS WITH CORONARY-ARTERY DISEASE ANGIOLOGY 1978; 29 (1): 22-32
- PREHOSPITAL COURSE OF PATIENTS WITH CHEST PAIN - ANALYSIS OF PRODROMAL, SYMPTOMATIC, DECISION-MAKING, TRANSPORTATION AND EMERGENCY ROOM PERIODS AMERICAN JOURNAL OF MEDICINE 1978; 64 (5): 742-748
SLEEP APNEA SYNDROME IN A PATIENT WITH SHY-DRAGER SYNDROME
ARCHIVES OF INTERNAL MEDICINE
1978; 138 (2): 206-209
A patient with autonomic insufficiency and extrapyramidal signs (Shy-Drager syndrome) and sleep apnea syndrome (SAS) underwent hemodynamic studies. In comparison to patients with SAS and intact autonomic reflexes, systemic hypertension was absent and marked sinus arrhythmia during sleep was blunted. Cyclical pulmonary hypertension associated with frequent apneic episodes during sleep persisted, reflecting a minor role of autonomic reflexes in the generation of this abnormality. Autopsy confirmed the Shy-Drager syndrome and multiple areas of degeneration were observed in areas of the CNS outside the medullary respiratory centers, suggesting their importance in the origin of the respiratory abnormalities in SAS.
View details for Web of Science ID A1978EV05400008
View details for PubMedID 626549
SUCCESSFUL RETRANSPLANTATION OF HUMAN HEART
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
1977; 73 (2): 242-247
Cardiac retransplantation has been performed in five patients at Stanford University Medical Center. Long-term survival and rehabilitation have been achieved in two cases. In the first case retransplantation was performed 57 days after the initial procedure because of persistent acute graft rejection. The second patient underwent retransplantation 27 months postoperatively because of documented accelerated graft atherosclerosis. The major indications for cardiac retransplantation consist of intractable acute rejection and late postoperative graft atherosclerosis. These complications should prompt consideration of cardiac retransplantation in carefully selected cases.
View details for Web of Science ID A1977CV61800014
View details for PubMedID 319302
PROPRANOLOL FOR PATIENTS WITH MITRAL-VALVE PROLAPSE
AMERICAN HEART JOURNAL
1977; 93 (4): 422-427
This study evaluates propranolol's effect on symptoms, arrhythmias, and exercise tolerance in 16 patients with mitral valve prolapse. Three patients (19 per cent) experienced symptomatic deterioration with propranolol therapy, seven (44 per cent) were unchanged, and six (37 per cent) noted an over-all symptomatic improvement, primarily due to a reduction in palpitation. Symptomatic improvement continues in these six patients an average of 12.5 months after beginning propranolol therapy. Treatment with propranolol alleviated chest pain in only two of eight patients and it did not improve the ability to perform treadmill exercise. Fatigue did not improve, and in three patients appeared for the first time during propranolol therapy. Premature ventricular contractions were reduced by at least 75 per cent in five of nin patients (56 per cent), and paroxysmal ventricular tachycardia was eliminated in three of four patients. We conclude that propranolol is not uniformly effective in patients with mitral vale prolapse. A trial of propranolol may be instituted fro patients with mitral valve prolapse who have severe symptoms and/or arrhythmias, but the drug should only be continued in those who demonstrate clinical and/or antiarrhythmic response.
View details for Web of Science ID A1977DA54500003
View details for PubMedID 842437
- Cardiac transplantation: Review of seven years experience Davila JC (ed). 2d Henry Ford Hospital International Symposium on Cardiac Surgery 1977; 675-678
CHARACTERISTICS OF VENTRICULAR TACHYCARDIA IN AMBULATORY PATIENTS
AMERICAN JOURNAL OF CARDIOLOGY
1977; 39 (4): 487-492
This study analyzes 94 episodes of the ventricular tachycardia recorded in the ambulatory electrocardiograms of 23 patients with stable cardiac disease. The episodes were asymptomatic in 19 patients, and only one episode resulted in ventricular fibrillation. Eighty-five percent of the episodes occurred when the underlying heart rate was less than 100 beats/min, and 17 percent occurred during sleep. The rate of the ventricular tachycardia was between 120 and 180 beats/min in 78 percent of the episodes and showed a modest correlation with the underlying heart rate (r = 0.59, P less than 0.001). Only 14 of the 94 episodes were initiated by R on T premature ventricular contractions, and the mean prematurity index (+/- standard deviation) (R-R'/Q-T) for all episodes was 1.31 +/- 0.28. Episodes of ventricular tachycardia recorded during ambulatory electrocardiographic monitoring are usually self-limited and asymptomatic. They occur during ordinary nonexertional activity and are frequently initiated by late couples premature ventricular contractions.
View details for Web of Science ID A1977DB12200002
View details for PubMedID 557893
Should premature ventricular beats be treated in the ambulatory patient? A protagonist's view.
1977; 8 (1): 171-180
View details for PubMedID 66096
- Patients admitted to the coronary care unit for chest pain: High risk subgroup for subsequent cardiovascular death Am J Cardiol 1977; 39: 829-832
- Sudden death Comprehensive Therapy 1977; 3:16-23
PROVOCATION OF CORONARY SPASM WITH ERGONOVINE MALEATE - NEW TEST WITH RESULTS IN 57 PATIENTS UNDERGOING CORONARY ARTERIOGRAPHY
AMERICAN JOURNAL OF CARDIOLOGY
1977; 40 (4): 487-491
Ergonovine maleate (Ergotrate) was given to 57 patients undergoing coronary arteriography for investigation of angina occurring at rest or without provocation when routine study showed normal arteries or insufficient occlusive disease to explain their symptoms. This provocative test induced coronary arterial spasm in 13 patients, 10 of whom had definite Prinzmetal's angina. The spasm was easily reversed with sublingually administered nitroglycerin. The spasm was occlusive or nearly occlusive in nine patients, and there was associated reproduction of the chest pain and S-T elevation similar to the spontaneous episodes. One patient with Prinzmetal's angina had S-T depression rather than elevation in association with the chest pain. The other three patients without Prinzmetal's angina had focal narrowing without coronary occlusion, reproduction of the chest pain or electrocardiographic changes. Of the 44 patients who did not demonstrate coronary spasm in response to ergonovine, 29 had normal coronary arteries and 15 had various degrees of atherosclerotic occlusive disease. We conclude that cautious administration of ergonovine maleate during coronary arteriography can be safely used to elicit coronary spasm in some patients who have insufficient fixed occlusive disease to explain their symptoms.
View details for Web of Science ID A1977DX64200001
View details for PubMedID 910712
HEMODYNAMIC CHANGES AT ONSET OF SPONTANEOUS VERSUS PACING-INDUCED ANGINA
AMERICAN JOURNAL OF CARDIOLOGY
1977; 39 (6): 784-788
To determine the origin of angina pectoris at rest hemodynamic monitoring was performed for 24 to 72 hours in 25 patients with unstable angina who had pacing-induced angina during cardiac catheterization. During the monitoring period, seven patients had spontaneous epidsodes of angina at rest that could be compared with the pain-free periods and periods of pacing-induced angina. At the onset of spontaneous angina, the patients had a significantly lower mean double product (P is less than 0.005) and triple product (P is less than 0.025) than at the onset of pacing-induced angina. The mean double product (heart rate x systolic blood pressure) was 9,411 +/- 2,815 mm Hg/min during pain-free rest, 10,635 +/- 2,587 at the onset of spontaneous angina and 16,623 +/- 3,904 during pacing-induced angina. The mean resting pain-free triple product (heart rate x systolic blood pressure x ejection time) was 3,023 +/- 703 and 3,536 +/- 931 mm Hg/sec per min during, respectively, pain-free rest and spontaneous angina, and 4,350 +/- 938 mm Hg/sec per min during pacing-induced angina. These marked differences in the double and triple products were associated with a mean increase in pulmonary arterial diastolic pressure (from 10.7 mm Hg at rest to 14 mm Hg) at the onset of both spontaneous and pacing-induced angina. Although indirect, these data suggest that transient changes in coronary blood flow, rather than changes in myocardial work, may be primarily responsible for spontaneous angina at rest in certain patients with the syndrome of unstable angina.
View details for Web of Science ID A1977DH82100003
View details for PubMedID 860691
CORONARY-BYPASS SURGERY FOR UNSTABLE ANGINA-PECTORIS - LONG-TERM SURVIVAL AND FUNCTION
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
1977; 237 (24): 2609-2612
The first 81 patients to undergo coronary artery bypass surgery for unstable angina pectoris at Standford Hospital have been observed for a mean of 40.8 months. Surgical mortality was 8.5%, and perioperative incidence of myocardial infection was 16%. The mean 18-month follow-up showed two early cardiac deaths and 12 additional myocardial infarctions. Sixty-seven percent of the patients were angina-free, and the condition of none was worse. After a mean of 40.8 months, two late cardiac deaths and two myocardial infarctions had occurred. Complete relief of angina was present in 51%;22% had unstable or worsening angina. The probability of survival from time of operation to four months after surgery was 88.8% +/- 3.5%, and this remained unchanged until the two late deaths, which decreased survival probability to 83.8% +/- 4.8% at 43 months. The two late cardiac deaths and the 22% incidence of patients with worsening angina may reflect progression of the atherosclerotic process, late graft occlusion, or both.
View details for Web of Science ID A1977DH96700014
View details for PubMedID 300813
SLEEP-INDUCED APNEA SYNDROME - PREVALENCE OF CARDIAC-ARRHYTHMIAS AND THEIR REVERSAL AFTER TRACHEOSTOMY
AMERICAN JOURNAL OF MEDICINE
1977; 63 (3): 348-358
Cardiac arrhythmias during wakefulness and sleep in 15 patients with sleep-induced obstructive apnea, and the effect of atropine and tracheostomy on these arrhythmias were studied by continuous overnight Holter electrocardiographic, respiratory and electroencephalographic recordings. Sleep was characterized by marked sinus arrhythmia in 14, extreme sinus bradycardia ( less than 30 beats/minute) in six, asystole of 2.5 to 6.3 seconds in five, second degree atrioventricular (A-V) block in two, and ventricular arrhythmias--complex premature ventricular beats in 10 and ventricular tachycardia in two. Arrhythmias during wakefulness were limited to premature ventricular beats in six. Atropine administration was partially and tracheostomy highly effective in preventing the majority of these arrhythmias during sleep. Marked sinus arrhythmia during sleep is characteristic of the syndrome of obstructive sleep apnea and is frequently accompanied by potentially life-threatening tachy- and bradyarrhythmias. Possible mechanism of production of these arrhythmias, the mode of action of tracheostomy and atropine, and the probable role of similar arrhythmias in the sudden infant death syndrome are discussed.
View details for Web of Science ID A1977DV42100005
View details for PubMedID 331948
Does cardiac transplantation prolong life and improve its quality? An updated report.
1976; 54 (6): III56-60
The current status of the human cardiac transplant experience at Stanford University Medical Center is presented in order to reassess its role in the treatment of end-stage cardiac disease. Of 109 patients undergoing transplantation at Stanford between January 1968 and August 1976, 44 were still alive as of August 1, 1976. The overall 1- and 2-year survival rates for the series are 52% and 43%, respectively. Sixty-nine patients have survived more than 3 months, and their overall 1- and 2-year survival rates are 80% and 66%, respectively. Of the 3-month survivors, 62 (90%) returned to functional Class I New York Heart Association cardiac status and most of these returned to their pre-illness activities. Of 40 patients selected for transplantation for whom a donor did not become available, 38 were dead in less than 6 months. Complications related to immunosuppression with steroids are currently the major barrier to longer survival and improved rehabilitation postransplantation. On the basis of these data we conclude that cardiac transplantation not only prolongs survival, but can return carefully selected recipients to an active life.
View details for PubMedID 45827
CARDIOVASCULAR EFFECTS OF LITHIUM IN MAN - REVIEW OF LITERATURE
AMERICAN JOURNAL OF MEDICINE
1976; 61 (5): 665-670
The medical literature since 1900 has been reviewed to determine the nature of lithium's cardiovascular effects. In therapeutic doses, lithium produces reversible T wave flattening and inversion in the electrocardiogram: rarely, it may cause sinus node dysfunction or ventricular arrhythmias. Patients with lithium toxicity almost always present with neurologic signs and symptoms. "Hypotension and cardiovascular collapse," alleged cardiotoxic manifestations of lithium, invariably follow days of coma. Given the possible cardiotoxic effect other psychopharmacologic agents and the hazards of withholding effective therapy in mania, it is concluded that lithium may be used safely in patients with cardiac disease if the dose is adjusted to the rate of lithium excretion and if serum levels of lithium are followed carefully. When used in patients with cardiac arrhythmias, frequent electrocardiographic monitoring is advised.
View details for Web of Science ID A1976CL02900011
View details for PubMedID 790953
- Sleep-related arrhythmias Jacobsen NK, Higgins S, Yarnall SR (eds). Clnical and Research Uses of Ambulatory Monitoring 1976; 10-1 to 10-11
- Cardiac transplantation: Review of seven years' experience Transplant Proc 1976; 8:5-8
CHRONIC THROMBOEMBOLIC OCCLUSION OF MAIN PULMONARY-ARTERY OR PRIMARY BRANCHES - CASE-REPORT AND REVIEW OF LITERATURE
AMERICAN JOURNAL OF MEDICINE
1976; 60 (4): 563-570
Chronic thromboembolic occlusion of the left pulmonary artery in a 36 year old woman is described, and similar cases reported in the past 15 years are discussed. On review, this disease remains a rare entity. In the majority of cases, the etiology is thrombophlebitis and acute pulmonary embolism. Associated cardiopulmonary disease is uncommon. The most common presenting symptom is unexplained dyspnea, and the majority of patients have past histories of hemoptysis. Acute cardiovascular collapse is distinctly rare. Most physical signs and laboratory tests are normal or nonspecific. The perfusion lung scan, although nonspecific, is the best screening test. Antemortem diagnosis, with rare exception, is established by pulmonary angiography. Eleven patients have been operated on: thromboembolectomy in nine, saphenous vein graft in one and pneumonectomy in one. Operative mortality was 36 per cent (four of 11), definite improvement was seen in 46 per cent (five of 11), and 18 per cent (two of 11) survived the operation with no improvement. The role of medical therapy in this disease is considered.
View details for Web of Science ID A1976BN07300014
View details for PubMedID 1274991
EFFECT OF LITHIUM ON CARDIOVASCULAR PERFORMANCE - REPORT ON EXTENDED AMBULATORY MONITORING AND EXERCISE TESTING BEFORE AND DURING LITHIUM-THERAPY
AMERICAN JOURNAL OF CARDIOLOGY
1976; 38 (6): 701-708
To assess the effect of long-term lithium therapy on cardiac arrhythmias and cardiovascular performance, extended ambulatory electrocardiographic monitoring was performed in 12 patients, and rest and exercise electrocardiograms in 10 of 12, before and during lithium therapy. Lithium increased the frequency of premature ventricular contractions in three patients, decreased it in one, and produced no change in eight. Three of four patients with atrial arrhythmias showed improvement during lithium therapy. Exercise performance was unchanged. Although 7 of the 12 patients manifested T wave flattening in the resting electrocardiogram, none had S-T segment displacement at rest or on treadmill exercise. Before lithium therapy, arrhythmias on exercise included premature atrial contractions in four patients, ventricular arrhythmias in four (premature ventricular contractions in four, with couplets in two and with ventricular tachycardia in one). During lithium therapy, exercise did not provoke premature atrial contractions or ventricular tachycardia in any of the patients, but three patients had premature ventricular contractions (with couplets in one case). We conclude that lithium at therapeutic levels may precipitate or aggravate ventricular arrhythmias. When administered to patients with heart disease, factors that interfere with renal clearance of lithium (heart failure, salt restriction, long-term diuretic therapy) must be recognized and doses must be adjusted accordingly. Careful follow-up and electrocardiographic monitoring are advisable if lithium is to be used in the presence of ventricular arrhythmias. Cardiovascular performance as assessed by treadmill exercise testing was not affected by long-term lithium therapy.
View details for Web of Science ID A1976CM63900005
View details for PubMedID 998508
HEMODYNAMICS IN SLEEP-INDUCED APNEA - STUDIES DURING WAKEFULNESS AND SLEEP
ANNALS OF INTERNAL MEDICINE
1976; 85 (6): 714-719
Twelve patients with predominantly obstructive type sleep apnea underwent cardiac catheterization, hemodynamic monitoring, and arterial blood gas analysis during wakefulness and sleep. Abnormalities during wakefulness included systemic hypertension in four of 12, exercise-induced mild pulmonary hypertension in five of 12, and alveolar hypoventilation in one. During sleep nine patients had cyclic elevations of arterial pressure with each apneic episode, exceeding 200 mm Hg systolic in three of 12. Pulmonary artery pressures increased in 10 of 12, exceeding 60 mm Hg systolic in five. Marked degrees of hypoxemia (arterial P02, less than 50 mm Hg in eight of 12) and moderate hypercapnia with respiratory acidosis were associated with these hemodynamic changes. Cyclic upper airway obstruction during sleep may result in hypercapnia, acidosis, and pronounced hypoxemia, which can lead to hemodynamic abnormalities during sleep. Sustained pulmonary hypertension and possibly systemic hypertension may follow. Tracheostomy is an effective therapy and is recommended to symptomatic patients who have predominantly obstructive apnea but no relievable anatomic cause of upper airway obstruction.
View details for Web of Science ID A1976CP46600002
View details for PubMedID 999107
SPONTANEOUSLY AND PHARMACOLOGICALLY PROVOKED CORONARY ARTERIAL SPASM IN PRINZMETAL VARIANT ANGINA
1976; 119 (3): 521-527
Eleven of 21 consecutive patients with Prinzmetal angina (PMA) exhibited no significant fixed stenoses of the coronary arteries. Spontaneous coronary arterial spasm was demonstrated in 3 patients. Ergonovine maleate produced near-total occlusion of a major vessel in 3 of 4 other patients with PMA, but did not provoke spasm in 10 without PMA. The current study documents spasm as the mechanism of myocardial ischemia in some patients with normal coronary arteries and provides initial and favorable diagnostic results with provocative pharmacoangiography in this entity.
View details for Web of Science ID A1976BR92300002
View details for PubMedID 935383
CLINICAL AND ARTERIOGRAPHIC FEATURES OF PRINZMETALS VARIANT ANGINA - DOCUMENTATION OF ETIOLOGIC FACTORS
AMERICAN JOURNAL OF CARDIOLOGY
1976; 37 (6): 831-839
Coronary arteriography performed in 17 patients with Prinzmetal's variant angina demonstrated high grade fixed obstructions in 9 patients (Group I) and insignificant or no fixed lesions in 8 patients (Group II). Group I consisted mostly of middle-aged or elderly men with S-T segment elevations in various sites; Group II included five younger women with S-T segment elevations in inferior electrocardiographic leads. In Group I patients, arteriography revealed a discrete high grade lesion located proximally in a major coronary artery in four patients and multivessel involvement in five patients. In Group II patients, spontaneous spasm was documented in three patients and spasm was pharmacologically provoked in two others during arteriography. The current study indicates that spasm is the responsible pathogenetic mechanism of myocardial ischemia in some patients with Prinzmetal angina and that this mechanism may be suspected from the clinical characteristics of these patients.
View details for Web of Science ID A1976BQ73700002
View details for PubMedID 1266748
INFECTIONS AFTER CARDIAC TRANSPLANTATION - RELATION TO REJECTION THERAPY
ANNALS OF INTERNAL MEDICINE
1976; 85 (1): 69-72
We have analyzed the relation of the treatment of 76 acute graft rejection episodes in 45 late postoperative cardiac transplant patients to the 56 infections occurring in these patients. Intensification of immunosuppressive therapy for acute rejection greatly increased the occurrence of infection from a control incidence of 1.3 infections per 1000 patient-days to a posttreatment incidence of 3.6. Two modes of treatment, increased oral prednisone and high-dose methylprednisolone plus antithymocyte globulin, were further analyzed. Actuarial analysis of infections after these two treatment modes showed that the treatment-related increase in infection was nearly exclusively due to the latter form of therapy. Invasive cardiac procedures did not appear to be causally related to infections in these immunocompromised patients.
View details for Web of Science ID A1976BX00200014
View details for PubMedID 779572
UNSTABLE ANGINA-PECTORIS - NATIONAL COOPERATIVE STUDY-GROUP TO COMPARE MEDICAL AND SURGICAL THERAPY .1. REPORT OF PROTOCOL AND PATIENT POPULATION
AMERICAN JOURNAL OF CARDIOLOGY
1976; 37 (6): 896-902
View details for Web of Science ID A1976BQ73700012
- AMBULATORY ELECTROCARDIOGRAPHIC MONITORING - TECHNIQUE AND CLINICAL INDICATIONS JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 1976; 236 (5): 494-495
Indications and techniques for ambulatory electrocardiogram monitoring.
Heart & lung
1975; 4 (4): 540-545
The development of the ability to record a patient's ECG during a full 24-hour day of normal activities has resulted in improved arrhythmia detection and potential for treatment. Improved methods of ECG data processing, using computer techniques, now allows quantitation of PVC frequency and improved correlation of the arrhythmia with events occurring during the period of recording. Knowledge of the natural occurrence and variability of ambulatory arrhythmias permits appropriate choice and timing of antiarrhythmic therapy.
View details for PubMedID 1042008
DIAGNOSIS AND QUANTIFICATION OF ARRHYTHMIAS IN AMBULATORY PATIENTS USING AN IMPROVED R-R INTERVAL PLOTTING SYSTEM
AMERICAN JOURNAL OF CARDIOLOGY
1975; 35 (6): 816-823
An improved technique for identification, diagnosis and quantification of arrhythmias during rest or ambulatory electrocardiographic recording is described. With simultaneous plotting of the R-R interval and the QRS duration and QRS vector measurement of each beat versus time, all periods of arrhythmias or abnormal complexes can be identified and characterized. Analog electrocardiographic samplings are used to confirm the diagnosis of the arrhythmia and to exclude artifact. The availability of a permanent record for the characterization of each QRS complex enables the physician to check the technician's analysis of the recording and to relate all events to the patient's heart rate and clinical symptoms. This technique also provides data for quantification of ventricular arrhythmias.
View details for Web of Science ID A1975AE53700008
View details for PubMedID 48334
- Detection of high-risk patients for sudden death Vogel JHK (ed). Advances in Cardiology 1975; 15:25-36
- Should premature beats be treated in the ambulatory patient? A patient's view Cardiovasc Clinics 1975; 52:894-900
- Hemodynamic effects of procainamide and quinidine and the influence of beta-blockade before and after experimental myocardial infarction Proc Soc Exp Biol 1975; 149:958-967
- Comparison of 24 vs. 12 hours of ambulatory ECG monitoring Chest 1975; 67:269-273
Perioperative myocardial infarction during cardiac surgery. Diagnosis, ECG and enzyme testing.
Advances in cardiology
1975; 15: 179-184
The detection of perioperative myocardial infarction is complicated by the variety of electrocardiographic changes normally seen concomitantly with cardiac surgery. Unequivocal electrocardiographic diagnoses based on new Q wave development and evolution of ST and T segments are virtually always confirmed by inappropriately high postoperative enzyme test results. For those patients exhibiting nondiagnostic but suggestive electrocardiographic changes, enzyme testing provides a valuable adjunct in determining whether infarction has indeed taken place. Enzyme testing, similarly, in and of itself, cannot provide the dichotomous situation between those patients experiencing infarction and those who are not. SGOT and LDH appear the most reliable indicators of infarction. CPK is quite volatile with sporadic occurrences of high enzyme elevations without obvious clinical or electrocardiographic explanation. The Ck isoenzymes provide a highly specific test for myocardial damage. However, their sensitivity is sufficiently great that a relatively minor cardiac manipulation may result in uninterpretable results.
View details for PubMedID 1155241
- Indications for surgery in patients with impending myocardial infarction (unstable angina pectoris) Vogel JHK (ed). Advances in Cardiology, 1975; 15:48-58
- Clinical and anatomical aspects West J Med 1975; 122:187-193
ARRHYTHMIAS IN PATIENTS WITH MITRAL-VALVE PROLAPSE
1975; 52 (1): 73-81
Resting ECGs, exercise treadmill tests and 24-hour ambulatory ECGs were recorded and analyzed in 24 unselected patients with mitral valve prolapse. Arrhythmias were frequent. There were three distinct groups of patients, defined on the basis of total number of premature ventricular contractions (PVCs) during the 24 hours; there were no PVCs in 25%, and frequent PVCs in 50%. Complex ventricular arrhythmias, including ventricular tachycardia in five patients, were found almost exclusively in the group with frequent PVCs. Fifteen of the 24 patients demonstrated atrial premature contractions (APCs) during the 24 hours. Complex atrial arrhythmias were found among patients with infrequent, as well as those with frequent, APCs. Supraventricular tachycardia was detected in seven of these patients. The incidence of ACPs decreased during sleep in 67% of the patients and showed no change during sleep in 33%. A poor correlation was found between symptoms recorded in patient diaries and changes noted on 24-hour ECG recordings. The peak PVCs/15 min and peak ACPs/15 min during a 24-hour period of monitoring was found to be an excellent guide to the total number of PVCs and APCs occurring during that period. This permits an accurate prediction of the total number of PVCs in 24 hours after performing an exact PVC count on only 15 minutes of ECG data. Finally, the 24-hour ambulatory ECG was sensitive than the treadmill test and both were superior to the 12-lead ECG for detecting arrhythmias in these patients.
View details for Web of Science ID A1975AG90500010
View details for PubMedID 1132123
STATUS OF CARDIAC TRANSPLANTATION, 1975
1975; 52 (4): 531-539
Since December 1967, 263 human cardiac transplant operations have been performed throughout the world. Eighty-two of these were performed at Stanford University Medical Center, In 1974, 27 such operations were performed, 15 at Stanford Survival rates for the entire Standford series are 48% at one year and 25% at three years; survival rates at one and three years for patients surviving the first three critical months after transplantation are 77% and 42%, respectively. Recipients under the age of 55 years, with New York Heart Association Class IV cardiac disability, are selected for transplant procedures according to criteria dictated by experience over the past seven years. A routine immunsuppressive regimen for organ transplantation, incorporating prednisone, azathioprine, and antithymocyte globulin is employed early postoperatively, and prednisone and azathioprine are used for indefinite maintenance therapy. Acute cardiac graft rejection in nearly all recipients is diagnosed by clinical signs, electrocardiographic changes, and percutaneous transvenous endomyocardial biopsy. Ninety-five percent of acute rejection episodes are reversible with appropriate immunosuppressive treatment, but infectious complications are common and have accounted for 56% of all postoperative deaths. The Stanford experience in cardiac transplantation has demonstrated the potential therapeutic value of this procedure. Maximum survival now extends beyond five years. Satisfactory graft function has been documented in long-term surviving patients, the majority of whom have enjoyed a high degree of social and physical rehabilitation.
View details for Web of Science ID A1975AR26400002
View details for PubMedID 1098809
CORONARY-BYPASS SURGERY FOR UNSTABLE ANGINA-PECTORIS - CLINICAL FOLLOW-UP AND RESULTS OF POSTOPERATIVE TREADMILL ELECTROCARDIOGRAMS
AMERICAN JOURNAL OF MEDICINE
1975; 58 (2): 171-176
The first 81 patients who underwent coronary artery bypass surgery at Stanford University Hospital for unstable angina pectoris have been followed up for an average of 18 months. The over-all surgical mortality was 8.6 per cent (seven patients). There have been no operative deaths in last 32 patients, which may be due to over 75 per cent of these patients being stabilized on intensive medical therapy from 24 to 72 hours before study or surgery. There was a 16 per cent (13 patients) perioperative and 15 per cent (12 patients) late incidence of myocardial infarction. Of 74 patients who survived the initial operation 2 died 2 and 3 months postoperatively. Good or complete relief from pain was obtained in 94 per cent (70 patients) of the survivors. Of 57 longterm survivors tested, 49 per cent (28 patients) had a definite ischemic response to treadmill exercise testing. This may reflect the severe nature of the occlusive coronary disease or mechanisms other than increased coronary flow being responsible for the relief of pain. Although coronary bypass surgery appears to be effective in relieving the pain of patients with unstable angina pectoris, the 18 month average follow-up indicates that the incidence of myocardial infarction in surgically treated patients is comparable to that in medically treated patients.
View details for Web of Science ID A1975V553800004
View details for PubMedID 1078752
VENTRICULAR ARRHYTHMIAS DURING UNSTABLE ANGINA-PECTORIS
ARCHIVES OF INTERNAL MEDICINE
1975; 135 (12): 1548-1553
In order to study the occurrence and frequency of ischemia-induced ventricular arrhythmias, we analyzed 105 episodes of spontaneous angina pectoris occurring at rest in 28 hospitalized patients with unstable angina pectoris and proved coronary artery disease. Of 24 patients with serious ventricular arrhythmias during pain, 17 (57%) were arrhythmia-free during monitoring. In the other four patients, 17 of 29 (59%) pain episodes were associated with serious ventricular arrhythmias, and three of these four had serious ventricular arrhythmias during pain-free periods. Each patient tended to manifest the same type of arrhythmia during repeat episodes of pain. It appears that continuous electrocardiogram (ECG) monitoring is important during the initial hospitalization of the patient with unstable angina. The presence of ventricular arrhythmias during pain-free periods indicates a high risk for serious ventricular arrhythmias during episodes of spontaneous pain. These patients should be considered for continued ECG monitoring and antiarrhythmic therapy.
View details for Web of Science ID A1975AZ11300002
View details for PubMedID 54051
CARDIAC AMYLOIDOSIS - DIAGNOSIS BY TRANSVENOUS ENDOMYOCARDIAL BIOPSY
AMERICAN JOURNAL OF MEDICINE
1975; 59 (2): 269-273
Endomyocardial tissue, obtained from two patients presenting with restrictive cardiomyopathies, demonstrated amyloid infiltration. The percutaneous transvenous cardiac biopsy technic, using a modified Konno-Sakakibara cardiac bioptome, was safe and quick. Physical examination and catheterization data may not provide a definite differential diagnosis between restrictive and constrictive myocardial disease. Confirmation by biopsy of the cardiac amyloidosis assisted in providing optimum diagnostic and therapeutic care for these patients.
View details for Web of Science ID A1975AM28400015
View details for PubMedID 1098458
OSTIUM PRIMUM DEFECT IN ADULT - POSTOPERATIVE FOLLOW-UP STUDIES
1975; 67 (2): 185-189
Twelve adult patients with ostium primum atrial septal defects (incomplete endocardial cushion defect) who underwent surgical repair of their lesions were evaluated in the late postoperative period. All had closure of the low-lying atrial septal defect, with suturing of the mitral valve cleft in 11 patients. Although the patients benefited symptomatically from the surgery, all had residual cardiac murmurs. Postoperative cardiac catheterization and left ventriculography in eight revealed successful closure of the atrial septla defect, but three demonstrated residual mitral insufficiency. In spite of the successful surgical repair in these patients, bacterial indocarditis prophylaxis should be continued in view of the residual murmurs and valvular abnormalities.
View details for Web of Science ID A1975V416900013
View details for PubMedID 123190
- RIGHT CORONARY ARTERIAL SPASM CAUSING PRINZMETALS VARIANT ANGINA CHEST 1974; 65 (5): 573-577
- LEFT-VENTRICULAR ANGIOGRAPHIC ANATOMY OF OSTIUM PRIMUM DEFECT IN ADULT AMERICAN JOURNAL OF ROENTGENOLOGY 1974; 121 (3): 597-605
- ACUTE REJECTION IN LONG-TERM CARDIAC TRANSPLANT SURVIVOR - CLINICAL DIAGNOSIS, TREATMENT AND SIGNIFICANCE CIRCULATION 1974; 49 (2): 361-366
- ARRHYTHMIAS AFTER CARDIAC TRANSPLANTATION AMERICAN JOURNAL OF CARDIOLOGY 1974; 33 (5): 604-607
- Thrombo-embolic complications with the indwelling balloon-tipped pulmonary arterial catheter N Engl J Med 1974; 291: 777
- Acute rejection in the long-term cardiac transplant survivor. Clinical diagnosis, treatment and significance Circ 1974; 49:361-366
- Left ventricular angiographic anatomy of ostium primum defect in the adult Am J Roent 1974; 121:597-605
- HEMODYNAMIC OBSERVATIONS IN PATIENTS WITH UNSTABLE ANGINA-PECTORIS AMERICAN JOURNAL OF CARDIOLOGY 1974; 33 (1): 17-22
- Studies on circulatory response to hypoxia in the denervated transplanted human heart Am J Med 1974; 56:477-481
- Prognosis in coronary care unitnoninfarction cases JAMA 1974; 288:1558-1562
- Right coronary artery spasm causing Prinzmetal's variant angina Chest 1974; 65:573-577
- Arrhythmias after cardiac transplantation Am J Cardiol 1974; 33:604-607
- THROMBOEMBOLIC COMPLICATIONS WITH INDWELLING BALLOON-TIPPED PULMONARY ARTERIAL CATHETER NEW ENGLAND JOURNAL OF MEDICINE 1974; 291 (15): 777-777
Does cardiac transplantation significantly prolong life and improve its quality?
1973; 48 (1): III116-9
View details for PubMedID 4578661
Arrhythmias in the denervated transplanted human heart.
1973; 48 (1): III112-5
View details for PubMedID 4124489
Cardiac transplantation in man. Review of first three years' experience.
American journal of medicine
1973; 54 (5): 563-576
View details for PubMedID 4573819
- Clinical and hemodynamic follow-up of patients receiving homograft mitral valve replacement New Zealand Med J 1973; 77(27):23-27
- CLINICAL AND HEMODYNAMIC FOLLOWUP OF PATIENTS RECEIVING HOMOGRAFT REPLACEMENT OF MITRAL-VALVE NEW ZEALAND MEDICAL JOURNAL 1973; 77 (488): 23-27
- SAPHENOUS VEIN CORONARY-ARTERY BYPASS IN PATIENTS WITH PREINFARCTION ANGINA CIRCULATION 1973; 47 (2): 234-241
CARDIAC TRANSPLANTATION IN MAN - REVIEW OF FIRST 3 YEARS EXPERIENCE
AMERICAN JOURNAL OF MEDICINE
1973; 54 (5): 563-576
View details for Web of Science ID A1973P615600002
- The epidemic of sudden death Stanford MD 1973; 12(4):12-13
- The antiarrhythmic effect of lithium chloride for experimental ouabain-induced arrhythmias Proc Soc Exp Biol Med 1973; 142:1200-1204
- Saphenous vein coronary artery bypass in patients with "preinfarction angina" Circ 1973; 37:234-241
- HEMODYNAMIC INTERACTION OF PROCAINAMIDE AND LIDOCAINE AFTER EXPERIMENTAL MYOCARDIAL-INFARCTION AMERICAN JOURNAL OF CARDIOLOGY 1973; 32 (7): 937-942
Observations on the behavior of recipient atria after cardiac transplantation in man.
American journal of cardiology
1972; 30 (6): 615-622
View details for PubMedID 4563213
Long-term follow-up studies after homograft replacement of the mitral valve.
Canadian Medical Association journal
1972; 107 (6): 516-519
Follow-up studies on 132 patients who have received fresh aortic homograft replacement of the mitral valve since May 1967 indicate good long-term function of the valve. Clinically the majority of patients are greatly improved and are free from the risks of long-term anticoagulant therapy. Hemodynamic studies performed on 13 patients at 25 to 41 months postoperatively showed a significant decrease in left atrial and pulmonary artery pressures with a small increase in cardiac output. Late deterioration of the homograft produced severe insufficiency in four cases and organic stenosis in two cases. Reasons for isolated deterioration are suggested.
View details for PubMedID 5057008
Hemodynamic observations one and two years after cardiac transplantation in man.
1972; 45 (6): 1183-1194
View details for PubMedID 4555848
- Pathophysiology of acute infarction Harrison DC (ed). Management of Acute Myocardial Infarction 1972; 11-21
- Papillary muscle dysfunction due to non-penetrating chest trauma: Recognition in a potential donor Br Heart J 1972; 34:645-647
- ULTRASONIC STUDIES FOR EARLY DETECTION OF ACUTE CARDIAC REJECTION TRANSPLANTATION 1971; 11 (6): 543-?
- Clinical and hemodynamic studies in patients with homograft mitral valve replacement Circ 1971; 44:334-342
- Correlation of histocompatibility matching with graft rejection and survival after cardiac transplantation in man Lancet 1971; 2:459-462
- Cardiac transplantation in man. VI. Prognosis of patients selected for cardiac transplantation Ann Int Med 1971; 75:15-21
- Ultrasound in the early detection and study of post-transplantation cardiac rejection Rand E (ed). Recent Advances in Diagnostic Ultrasound 1971; 24-33
Experience with cardiac transplantation in fourteen patients.
1970; 41 (2): 125-129
View details for PubMedID 4929478
- Cardiac transplantation in four patients: hemodynamic function in the immediate postoperative period J Thorac & Cardiovasc Surg 1970; 59:155-167
- Repeated cardioversion during pregnancy: Treatment for refractory PAT during three successive pregnancies Am J Cardiol 1970; 27:445-446
- The effects of respiratory acidosis on the circulation response to isoproterenol Am J Physiol 1970; 218:448-452
- Selection of patients for cardiac transplantation Heart Bull 1969; 18(4):65-67
- The hemodynamic response to dopamine in experimental myocardial infarction Am J Physiol 1969; 217(6):1716-1720
- Cardiac transplantation in man. IV. Early results Ann Surg 1969; 170:588-592
- Cardiac transplantation in man. I. Early rejection. JAMA 1969; 207:2233-2242
- Acute rejection following cardiac transplantation Phonocardiographic and ultrasound observations Circ 1969; 40:155-164
- Initial clinical experience with cardiac transplantation Am J Cardiol 1968; 22:791-803
- Further studies on the mechanism whereby nephrectomy augments the pressor response to renin Can Med Assoc J 1964; 90:227
- Effect of bilateral nephrectomy on pressor response to renin Am J Physiol 1962; 203:339-343
- Simplified screening for cystic fibrosis of the pancreas JAMA 1959; 169:1279