Anterior Wall Hypokinesis Research Articles

286 A CASE REPORT OF TYPE II KOUNIS SYNDROME

Abstract Case presentation and management A 81-years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre-existing LBBB. HS-T-Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. Complications After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn't show any new ischemic abnormalities in the setting of pre-existing LBBB. The peak CK- MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK-MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre-existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm. Echocardiographic wall motion abnormalities before and after coronary spasm: Take home message We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.

P195 A CASE REPORT OF TYPE TWO KOUNIS SYNDROME

Abstract A 81–years old female presented to the emergency department of our hospital with dyspnea and chest pain. She had a history of chronic kidney disease and left bundle brunch block (LBBB) never further investigated. Non diagnostic ECG was performed in the setting of pre–existing LBBB. HS–T–Troponin level was significantly elevated (986 ng/L). A transthoracic echocardiogram (TTE) revealed inferior and posterior wall hypokinesis. NSTEMI was diagnosed and coronary angiography via the femoral artery revealed subocclusive stenosis of the right coronary artery (RCA) and 80% stenosis of left anterior descending artery (LAD). Coronary stent positioning was performed for the RCA culprit lesion and staged complete revascularization was planned. After two days, the patient experienced sharp pain in the right groin and a femoral pseudoaneurysm was diagnosed by Ultrasound Color Doppler. Subsequently anemia suggested the development of retroperitoneal hematoma but it was excluded by contrast CT. Unfortunately, the patient developed acute chest pain, wheezing and erythematous pruritic rash 10 minutes after injection of contrast medium agent. The ECG didn’t show any new ischemic abnormalities in the setting of pre–existing LBBB. The peak CK–MB level was significantly elevated (87 ng/mL). New onset apical region akinesia and anterior wall hypokinesia were detected on TTE. Acute coronary syndrome (ACS) was suspected consistent with symptoms, new onset wall motion abnormalities and CK–MB elevations. The patient was diagnosed with allergic reaction and coronary vessel spasm secondary to contrast agent injection in pre–existing atherosclerotic plaque. Due to the high probability of an hypersensitivity reaction to the contrast medium agent we did not perform a new coronary angiography to confirm the diagnosis. Promethazine, Urbason and Nitroglicerin were administered with clinical improvement. The next day we observed recovery of the anterior and apex wall motion abnormalities consistent with coronary vessel spasm. Take Home Message We presented the case of an allergic reaction leading to the release of inflammatory mediators responsible of coronary vessel spasm causing acute myocardial infarction. It can also be induced by injection of contrast medium like in the presented case. Therefore, clinicians and radiologist should recognize this rare but critical disease to ensure prevention and appropriate management.

Case Report: Role of Rotational Atherectomy in Complex PCI

Background : One in three patients undergoing percutaneous coronary intervention (PCI) exhibits moderate or severe coronary artery calcification. Coronary calcification remains a major independent predictor of PCI failure and adverse outcomes. PCI of calcified coronary lesions remains challenging, despite significant improvements in the available tools and techniques. Rotational Atherectomy (RA) is a critical component to improve PCI success in these situations by producing lumen enlargement by physical removal of plaque and reduction in plaque rigidity, thus facilitating dilation Case Illustration: A 73-year-old man with exertional angina was referred to our hospital, with a history of hypertension, diabetes mellitus, ex-smoker and dyslipidemia. Physical exam, electrocardiogram, chest x-rays, and laboratory findings were unremarkable, but transthoracic echocardiogram revealed anterior wall hypokinesis. History of cardiac catheterization outside of our center with angiographic result of left anterior descending (LAD) lesion, highly calcified, non-dilatable on first several POBA attempts. Coronary angiography at our center, revealed diffuse calcification from proximal to distal of the LAD artery with about 90% maximum stenosis in mid LAD. RA (Rotablator, Boston) was then performed with A 1.50 mm burr gradually advanced at 150,000 rpm to passed the lesion. After deployments of stents, final angiogram showed well positioned stents with good distal run-off flow. The patient was uneventful during the procedure and was discharged following day. Discussion: In experienced hands, RA is as safe as standard PCI. RA is as a tool to make PCI possible in complex lesions with moderate or severe calcification when clinical variables make PCI appropriate. Rotablator is a catheter-based interventional cardiology procedure using a high-speed rotational device designed to ablate atherosclerotic plaque and restore luminal patency. This help to facilitate stent delivery, avoiding the barotrauma caused by repeated high-pressure balloon inflations that can lead to vessel dissection or perforation. Atherectomy can be performed safely with optimal burr selection and proper ablation techniques, and as a result, complication rates have been significantly minimized, with few changes in the acute complications reported in contemporary studies.

Clinical, Electrocardiographic and Echocardiographic Profile of Ischemic Cardiomyopathy: An analysis of 100 cases.

Background: Ischemic heart disease (IHD) is one of the leading cause of morbidity and mortality worldwide. Ischemic cardiomyopathy (ICM) is a delayed complication of IHD that arises as dilated cardiomyopathy with depressed ventricular function, which cannot be attributed entirely to coronary artery obstruction or ischemic injury.
 Objectives: To evaluate the clinical, electrocardiographic and echocardiographic profile of patients presenting with ischemic cardiomyopathy. Methods: In this cross sectional observational study 100 patients of ischemic cardiomyopathy admitted in hospital or visited OPD in NICVD, Dhaka from March’15 to Sept’15 were studied. Enrollment of the patients were done after fulfilling the inclusion and exclusion criteria. Clinical, electrocardiographic and echocardiographic data were collected then data analysis was done.
 Results: Data analysis of 100 patients was showed age range was 40-80 years and mean age was 61.4±7.9 years. 79% subjects were male. Most common symptoms were dyspnea (93%), chest pain(73%), palpitation (39%) and edema (23%). Most patients were in NYHA functional class lV (43%). 64% cases had history of anterior myocardial infarction (MI), 22% had inferior MI, 25% had H/O PTCA and 7% had CABG. 71% subjects had tachycardia, 65% had lungs basal rales, 56% had systolic blood pressure below 100 mmhg and 25% had edema. ECG findings was as follows sinus rhythm (85%), Sinus tachycardia 71%, AF 15%, LBBB 34%, RBBB 12%, pathological Q in anterior surface 65% and inferior surface 21%, non specific ST-T changes 41% and PVCs was found in 17%.On echocardiography ,anterior wall hypokinesia was seen in 52% and global hypokinesia in 43%. Mean left ventricular ejection fraction (LVEF) was 31±5.9% and mean left ventricular internal diastolic diameter (LVIDd) was 6.5±0.4 cm. (59%) subjects had mitral regurgitation (MR) grade-l and 20% had MR grade-ll.
 Conclusion: The clinical presentation of ischemic cardiomyopathy varies from patient to patient. Severity of symptoms correlates with severity of left ventricular systolic dysfunction, left ventricular diameter and mitral regurgitation grade . Anterior Myocardial infarction has more chance to develop ischemic cardiomyopathy.
 Bangladesh Heart Journal 2020; 35(2) : 121-127

Acute Kidney Injury, Myocardial Infarction and Death Following Brake Fluid Poisoning; A Case Report

Background: Ethylene glycol is a toxic alcohol which is used in brake fluid, antifreeze, coolants, preservatives and chemical solvents. Ethylene glycol poisoning usually results in depression of the central nervous system, renal insufficiency and cardiopulmonary compromise, while laboratory findings include metabolic acidosis, increased anion gap, increased osmolar gap and calcium oxalate crystalluria. Case presentation: A 24-year-old previously healthy person died 13 days after self-ingestion of brake fluid (ethylene glycol). He developed multi-organ failure including acute kidney injury, metabolic acidosis, respiratory failure, myocardial infarction, low Glasgow coma scale, and elevation of liver enzymes. He also developed hypotension for which 3 inotropes were started. He had ST elevation myocardial infarction (STEMI) on day 4 of the poisoning associated with a reduction of ejection fraction of up to 25% with septal anterior wall hypokinesia. He needed intensive care treatment via ventilator and inotropic support. Five cycles of hemodialysis were carried out for acute kidney injury. His autopsy examination revealed sub-endocardial hemorrhages. Discussion: Acute kidney injury and metabolic acidosis are frequently seen following ethylene glycol poisoning from brake fluid ingestion. The cardiotoxic effect of its poisoning could be due to multiple microcalcifications of the myocardium. This clinical report highlights the severity and the sequence of events following ethylene glycol poisoning. Conclusion: STEMI may result following ethylene glycol poisoning in addition to other cardiac effects such as hypotension, tachycardia, myocarditis and ischemic changes in ECG.

Takotsubo after general anesthesia for chronic subdural hematoma: case report

Cardiologia CROATICA The goal: Takotsubo cardiomyopathy is an acute cardiovascular disease generally characterized by reversible wall motion abnormalities of the left ventricle, electrocardiographic changes and clinical presentation that can mimic myocardial infarction in the absence of an obstructive coronary artery disease. It is often precipitated by an intense acute emotional or physical stress. Our goal was to present a patient with Takotsubo cardiomyopathy which developed after the induction of general anesthesia. Patient and Methods: The patient's available medical record was used to present the clinical course of Takotsubo that developed after induction of general anesthesia. Results: We present a case of a 61-year-old woman who developed Takotsubo cardiomyopathy during operation of chronic subdural hematoma. After induction of general endotracheal anesthesia and preparation of the operative field, hemodinamic instability was detected. The ECG lead to suspect on acute myocardial infarction. Coronarography with the left ventriculography was performed indicating development of takotsubo cardiomyopathy. The patient was admitted to the cardiac intensive care unit and treated according to the ongoing hemodynamic disturbances. By the day eight, clinical recovery was observed with anterior wall hypokinesis. The patient was hemodynamically stabile with normal blood pressure and pulse. Conclusion: There are already many case reports presenting numerous possible triggering factors for Takotsubo cardiomyopathy. Severe stress, emotional or physical, can precede this disease. This is an interesting case where iatrogenic stress related to medical procedures causes transient systolic dysfunction of the heart, mimicking myocardial infarction.

Unstable angina pectoris complicated with fatal massive intramyocardial dissecting haemorrhage

A 71-year-old man was admitted with accelerated chest pain for 3 days. There were no history of hypertension, diabetes mellitus, heart failure, coronary artery disease, and trauma. Physical examination was unremarkable. Electrocardiogram showed minimal ST-segment depression in V1–3 derivations. Echocardiogram revealed apical and anterior wall hypokinesia with ejection fraction around 25%. Intramyocardial dissection flap filling with massive …

Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment (Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach …

Myocardial Metabolism Altered by Ischemic Preconditioning and Enflurane in Off-Pump Coronary Artery Surgery

During off-pump coronary artery bypass (OPCAB) surgery, the heart is subjected to ischemia and reperfusion. The authors hypothesized that the volatile anesthetics are as effective as ischemic preconditioning (IPC) in preserving myocardial function during off-pump cardiac surgery, and this effect is because of multiple mechanisms of action. Therefore, the effects of enflurane with its calcium inhibition and antioxidative properties were compared with mechanical IPC in preserving myocardial cellular markers. A prospective, randomized, controlled, and partly blinded study. A tertiary care university hospital. Twenty-five patients undergoing elective single-graft OPCAB surgery. Patients were randomized into 3 groups: (1) control (n = 8), (2) a single 5-minute ischemia/reperfusion interval of IPC before coronary occlusion (n = 9), and (3) 1.6% enflurane anesthesia 15 minutes before and during graft attachment (n = 8). Arterial and coronary sinus venous blood were analyzed for biochemical indices of ischemia and hydroxyl radical generation. Although the hemodynamic changes were small, myocardial lactate production in the control group increased by 120%, whereas in the enflurane group it decreased significantly (p < 0.01) compared with the control and IPC groups. Oxygen utilization in the control group was 44% higher (p < 0.03), and there was also a larger release of the hydroxyl radical-dependent adduct 2,3-dihydroxybenzoic acid (225% increase, p < 0.05) compared with both study groups. During reperfusion, initial anterior wall hypokinesis by TEE was observed, with slow recovery during reperfusion compared with early recovery in both study groups. Coronary occlusion during OPCAB surgery results in increased production of ischemia-related metabolic products. The application of methods such as IPC or volatile anesthesia appears to reduce the metabolic deficit, free-radical production, and physiologic changes.

Trimetazidine Administration Minimizes Myocardial Damage and Improves Left Ventricular Function after Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the administration of trimetazidine, a piperazine derivative, to patients before and after percutaneous coronary intervention (PCI) minimizes the PCI-induced myocardial damage and improves left ventricular function 1 and 3 months after the procedure. Fifty-two patients hospitalized for acute coronary syndromes (ACS) were included in this study. Patients were randomized into two groups: group A (trimetazidine group; n = 27) and group B (placebo group; n = 25). All patients received conventional antianginal therapy. In addition, group A patients received oral trimetazidine 20 mg every 8 hours, starting 15 days before PCI and continuing for 3 months after the procedure. For each patient, serum troponin I and creatinine kinase (CK)-MB levels were measured before PCI, then at 6, 24, and 48 hours after the procedure; a 2D cardiac echocardiogram was performed before PCI and at 1 and 3 months after the procedure. Twenty-four hours after PCI, troponin I levels were >1 ng/mL in 7 of 27 patients (26%) of group A and 11 of 25 patients (44%) in group B. Fourty-eight hours after revascularization troponin levels remained elevated in 15% of patients in group A and in 32% of patients in group B. Twenty-two percent of patients in group A had CK-MB levels >5 ng/mL, 24 hours after PCI, compared with 40% of patients in group B; four patients of group A had high CK-MB levels prior to PCI procedure. Echocardiographic measurements before revascularization revealed that 11 of 27 patients (40%) in group A had an ejection fraction <50% versus 8 of 24 patients (33%) in group B . The number of patients with an ejection fraction <50% was significantly reduced in group A compared with group B at 1 and 3 months after PCI, i.e. 11% versus 16% (p = 0.046) at 1 month and 4% versus 16% (p = 0.017) at 3 months.A significant improvement in regional wall motion was noted after treatment with trimetazidine compared with placebo. One month after PCI, inferior left ventricular (LV) wall hypokinesia had improved in 4 of 6 trimetazidine recipients and in 4 of 14 placebo recipients (p = 0.014, group A vs group B). After 3 months inferior wall hypokinesia improved in four patients in group A versus six patients in group (p = 0.05). Similarly, anterior LV wall motion improved in 3 of 11 patients in group A and in 1 of 6 patients in group B at 1 month. After 3 months anterior wall hypokinesia had improved in eight patients in group A and in two patients in group B (p = 0.04, group A vs group B). The metabolic agent trimetazidine appears to minimize myocardial reperfusion injury during PCI and improves global and regional wall motion at 1 and 3 months after PCI. This study was limited by small patient numbers and further studies are necessary to evaluate exact mechanisms of action and clinical implications of using trimetazidine in conjunction with PCI.

The effect of the Q wave infarct on left ventricular electromechanical function

Objective: To assess the nature of left ventricular (LV) electrical and mechanical dysfunction in Q compared to non-Q anterior myocardial infarction (MI). Subjects: We used ECG and echocardiography to study 54 unselected patients, age 57±15 years, 32 male, with old (>6 months after) anterior MI (39 Q and 15 non-Q), confirmed by enzyme rise and regional wall motion abnormality, and compared them with 21 normals of similar age. Methods: Analysis of resting LV minor and long axis function and 12-lead surface electrocardiogram. Results: Only 10% of normals did not have a normal septal Q wave compared with 46% of non-Q wave MI and 84% Q wave MI ( P<0.001). All patients with Q wave MI had a scarred anteroseptal wall but none of the non-Q wave MI. LV minor axis dimensions were increased only with Q wave MI: 6.0±0.9 vs. 4.9±0.5 cm at end-diastole and 4.5±1.1 vs. 3.3±0.5 cm at end-systole and fractional shortening was reduced 27±8 vs. 33±3% ( P<0.001 for all). Total left ventricular long axis amplitude of motion was reduced at the left, septal and posterior sites only in Q wave MI but was not different from controls in non-Q wave MI. The onset of long axis shortening was delayed by 20 ms at the left and septal sites in non-Q wave MI and by an additional 20 ms at the three sites in Q wave MI. Peak long axis shortening rate was reduced in the two patient groups, with the same distribution as post-ejection shortening (greater than 1 mm), which occurred in 21% of patients with non-Q wave MI and 76% of patients with Q wave MI ( P<0.001). In diastole, the onset of long axis lengthening was delayed by 20 ms at the left and septal sites in non-Q wave MI and at the three sites in Q wave MI ( P<0.001). Peak long axis lengthening rate was reduced with a similar distribution in the two patient groups. Conclusion: Patients with Q wave MI have an increased LV dimension and reduced FS, whereas patients with non-Q wave MI appear to have morphologically normal LV minor axis dimensions and fractional shortening apart from the anterior wall hypokinesis. In the latter, however, long axis function shows significant systolic and diastolic disturbances affecting the anteroseptal and lateral walls. The absence of conduction disturbances in non-Q wave MI suggests intrinsic myocardial dysfunction that may be reversible.

Non-Q-wave myocardial infarction: impaired myocardial energy metabolism in regions with reduced 99mTc-MIBI accumulation.

Reduced regional technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) accumulation in patients with chronic non-Q-wave infarction (NQWI) but without significant coronary artery stenosis indicates non-transmural damage of the myocardial wall. The aim of this study was to characterise cardiac energy metabolism after NQWI using phosphorus-31 magnetic resonance spectroscopy (31P-MRS) and to compare the biochemical remodelling with changes in regional 99mTc-MIBI uptake and with morphological and functional parameters assessed by magnetic resonance imaging (MRI). Fifteen patients with a history of NQWI, exclusion of significant coronary artery stenosis (<50% diameter stenosis) and hypokinesia of the anterior wall (group A) were examined with 31P-MRS to study the effects of NQWI on myocardial energy metabolism. Spectroscopic measurements were performed in the infarct-related myocardial region. Corresponding gradient-echo MR images and myocardial 99mTc-MIBI single-photon emission tomography images were acquired for exact localisation of the infarct region. All examinations were performed at rest under anti-ischaemic medication. Data were compared with those of patients in whom coronary artery disease had been excluded by angiography (group B, n=10). All patients of group A displayed anterior wall hypokinesia in the infarcted area on both ventriculography and MRI, with a reduced myocardial accumulation of 99mTc-MIBI (66.3%+/-11.8% vs 95.6%+/-2.2% in group B). The mean wall thickness during the complete cardiac cycle (9.5+/-1.8 mm vs 13.1+/-1.1 mm in group B, P<0.001), the systolic wall thickening (2.6+/-1.4 mm vs 5.8+/-1.5 mm in group B, P<0.01) and the phosphocreatine/adenosine triphosphate ratio (1.12+/-0.22 vs 1.74+/-0.23 in group B, P<0.01) in the hypokinetic area were all significantly reduced. It is concluded that persisting hypokinetic myocardium after NQWI combined with reduced myocellular uptake of 99mTc-MIBI displays a reduced PCr/ATP ratio. Our results indicate that morphological remodelling after NQWI is accompanied by fundamental changes in cardiac energy metabolism.

Radionuclide Left Ventricular Ejection Fraction in Patients with and without Ventricular Wall Motion Abnormalities

Standard radionuclide determination of left ventricular ejection fraction assumes a constant attenuation throughout the cardiac cycle, implying a proportional relationship between count rate and volume. In this study we examined patients with different contraction patterns of the left ventricle and the impact of the movement of the left ventricular center on calculation of the ejection fraction. Left ventricular depth at end diastole and end systole was assessed in the left lateral projection during a multigated acquisition in 34 patients with and without ventricular wall motion abnormalities due to coronary artery disease. A corrected left ventricular ejection fraction considering changes in the attenuation during the cardiac cycle was calculated and compared with the standard ejection fraction. In patients without impairment of left ventricular wall motion, the left ventricular center moved slightly posteriorly at end systole, and correction for changes in attenuation reduced the radionuclide ejection fractions by 3.0% (95% confidence interval 1.1-4.9%) as compared with the standard calculation. In patients with anterior wall hypokinesia the corrected ejection fractions were 2.7% higher (0.6-4.8%) and in patients with posterior wall hypokinesia 6.5% lower (3.6-9.4%) than the standard ejection fraction. The change in ventricular depth from end diastole and end systole was significantly different in all three patient groups (p < 0.01). These findings suggest that changes in left ventricular depth during contraction result in slight overestimation of the radionuclide multigated left ventricular ejection fraction in patients with normal ventricular function and that wall hypokinesia in some cases may lead to a significant error in the accuracy of the results.

Contribution of Frank ECG measurements to the quantitative estimation of old anterior myocardial infarction

Twenty scalar and vector measurements of the Frank ECG were compared between men categorized as having suffered nontransmural ( n = 47) and transmural anterior myocardial infarction ( n = 124), on the basis of clinical and angiocardiographic findings. Variables which showed significant differences of group means between cases with anterior wall hypokinesis and anterior wall akinesis and/or dyskinesis were submitted to linear discriminant-function analysis. The stepwise selection procedure of Rao's method demonstrated the three most decisive variables for differentiation to be: (1) the angular sum of dorsal displacement of the 5 initial QRS vectors obtained at 0.01 sec intervals (sum of negative azimuth angles); (2) the Q duration in lead Z (anterior force); and (3) the Q duration in lead X (rightward force). The classification routine can identify correctly 81% of the nontransmural and 79% of the transmural anterior infarctions. The high percentages of correctly classified nontransmural and transmural infarctions show significant diagnostic potential for patient management. From the results of discriminant-function analysis, it is apparent that the sum of negative azimuth angles derived from the dorsally directed vectors during the first half of QRS exceeds substantially the scalar variables in their contribution to differentiation of the two conditions.

"Ischemic" Heart Disease in Fire Fighters with Normal Coronary Arteries

Near maximal stress testing conducted on a group (N = 90) of randomly selected Los Angeles City fire fighters (age 40-59 yrs.) revealed that 10% had ischemic ECG changes. These ischemic ECG responses were confirmed during a second test conducted two to four weeks after the initial test. Coronary heart disease (CHD) risk factor analysis revealed that in general the men were not at high risk for CHD. Six of the nine men elected to undergo cardiac catheterization and angiography. One patient had severe triple vessel disease and subsequently underwent aorto-coronary bypass surgery. Another had 50% obstruction in the circumflex branch of the left coronary while the other four men had no visable signs of coronary obstruction. The men with "normal" coronaries, however, did show signs of abnormal cardiac function during atrial pacing. One man had cardiac enlargement, hypokinesis, ischemic ECG and abnormal lactate metabolism. Another had abnormal lactate metabolism and ischemic ECG. A third man had moderate cardiac enlargement with anterior wall hypokinesis. The fourth had ischemic ECG changes with angina but otherwise normal cardiac function. All four of these men had pressures which were within normal limits. These data show that some fire fighters have "ischemic" heart disease with patent coronary arteries. This disease may be due to job related factors (i.e. carbon monoxide and other noxious fumes, catecholamines, etc.) which reduce myocardial oxygen supply or greatly increase myocardial oxygen demands.

201Thalium scintimetry of the heart as a new method for functional assessment in coronary heart disease (author's transl)

201Tl scintimetry of the heart was used for a statistical comparison between normal people (10 individuals) and those with acute anterior wall infarcts (5 patients), anterior wall hypokinesia (5 patients) and dyskinesia (8 patients). Numerical results were obtained by a computer and depended on the relative 201tl storage in the left ventricular myocardium (64 mm2 area) related to mediastinal background uptake. It was found that maximal myocardial uptake, compared with mediastinal activity (about 290%) did not differ between normals and patients with coronary heart disease. Aneurysms of the anterior ventricular wall showed a reduction (with the ventricle perpendicular to the collimator) of 45.8%; in hypokinesia and acute myocardial infarcts, it was 64.2% and 64.6% respectively (normal 82.6%). 201Tl uptake in aneurysms (42.4%) approached background activity (36%) if a projection parallel to the collimator was used. 201Tl scintimetry provides a means of defining functional ability of the myocardium (depdending on myocardial perfusion and mass). Aneurysms and hypokinetic portions of the myocardium can be differentiated statistically from normal 201Tl uptake.