Carditis In Acute Rheumatic Fever Research Articles

Breastfeeding does not protect against the development of carditis in children with acute rheumatic fever.

Acute rheumatic fever is an autoimmune disease that develops due to streptococcal infection. The positive effect of breastfeeding on the development of the child's immune system is well documented. In this study, we aimed to investigate the effect of breast milk intake period on the development of carditis. Patients (n: 182) who were diagnosed with acute rheumatic fever between 2010 and 2019 were enrolled in the study. The patients were divided into groups according to carditis development. The demographic, socio-economic, and breastfeeding data were compared between groups. The mean age of the patients was 10.5 ± 3.4, and 43.4 % (n: 79) of them were female. Independent predictors of the development of carditis in the first acute rheumatic fever episode were the number of children at home (OR: 1.773, CI 95%: 1.105, 2.845; p: 0.018) and breast milk intake less than 6 months (OR: 0.404, CI 95%: 0.174, 0.934; p: 0.034). Independent predictors of the development of carditis in any of the acute rheumatic fever episodes were the number of children at home (OR: 1.858, CI 95%: 1.100, 3.137; p: 0.021) and female gender (OR: 3.504, CI 95%: 1.227, 10.008; p: 0.019). The only independently predictor of the development of chorea during acute rheumatic fever was female gender (OR: 3.801, CI 95%: 1.463, 9.874; p: 0.006). Although the occurrence of carditis is less common during the first acute rheumatic fever attack in patients with breast milk intake less than six months, this advantage is lost in recurrent attacks. This study showed that breast milk does not have a negative effect on acute rheumatic fever carditis.

Abstract 13147: Non-invasive Identification of Carditis in Acute Rheumatic Fever and Rheumatic Heart Disease

Background: The pathogenesis of acute rheumatic fever (ARF) and its evolution into rheumatic heart disease (RHD) is poorly understood. We aimed to identify carditis in patients with ARF and RHD using cardiac magnetic resonance (CMR) tissue characterisation with T1 mapping. We hypothesised that prolonged native T1 time on CMR, would be present in ARF and RHD patients. Methods: We prospectively recruited 62 patients. We recruited 16 patients fulfilling the Jones Criteria for the diagnosis of ARF, 15 controls with an inflammatory condition and 10 healthy controls. We also recruited 11 patients with echocardiographic evidence of RHD and 10 matched controls. All patients underwent CMR with assessment of non-contrast myocardial T1 mapping. The myocardial T1 time, as an index of myocardial inflammation from carditis, was compared between the groups. All T1 times were converted to Z-scores, to enable comparison with different CMR systems. Findings: Patients with ARF had evidence of carditis demonstrated by markedly elevated mean myocardial T1 times. The mean Z score was 2.76(95% CI 1.34-4.17) for patients with ARF compared to 0.32(95% CI -0.25-0.88) for those with non-cardiac inflammatory conditions and 0.00(95% CI -0.72-0.72) for healthy controls, P=0.004. A myocardial T1 Z score greater than 1.4 showed excellent diagnostic performance as a single test for the diagnosis of ARF (AUC = 0.85[0.67-0.99], P=0.001, sensitivity = 82 %, specificity = 92%, Youden’s J = 0.74). Patients with RHD also demonstrated significantly elevated native T1 time compared to matched controls. The mean Z score for RHD patients was 2.79(95% CI 1.3-4.3) compared to 0.00(95% CI -0.72-0.72) in controls, P=0.002. Interpretation: Patients with ARF and RHD have markedly elevated myocardial T1 Z-scores on CMR, consistent with carditis. Incorporating CMR T1 mapping into the diagnostic algorithm for ARF may improve diagnostic certainty and lead to more effective delivery of secondary penicillin prophylaxis.

Carditis in Acute Rheumatic Fever in a High-Income and Moderate-Risk Country

To describe clinical presentation, electrocardiographic, and echocardiographic characteristics of carditis at the time of diagnosis of acute rheumatic fever (ARF) over a 13-year period. A single-center retrospective chart analysis was conducted involving all consecutive patients diagnosed with ARF between 2003 and 2015. Patient age, sex, clinical characteristics, recent medical history for group A streptococcal pharyngotonsillitis and antibiotic treatment, and laboratory, echocardiographic, and electrocardiographic findings were recorded. Of 98 patients (62 boys, mean age 8.81±3.04years), 59 (60.2%) reported a positive history of pharyngotonsillitis; 48 (49%) had received antibiotic (mean duration of treatment of 5.9±3.1days), and, among these, 28 (58.3%) had carditis. Carditis was the second most frequent finding, subclinical in 27% of patients. Mitral regurgitation was present in 49 of 56 patients (87.5%) and aortic regurgitation in 36/56 (64.3%) no stenosis was documented. ARF is still present in high-income countries and can develop despite primary prophylaxis, especially when given for a short course. Our findings highlight the need for 10days of antistreptococcal treatment to prevent ARF. Echocardiography is important because 27% of cases with carditis were subclinical.

Identification of Carditis in Acute Rheumatic Fever with Myocardial T1 Mapping

Background: The pathogenesis of acute rheumatic fever (ARF) is incompletely understood. Valvulitis is used as part of the diagnostic criteria, while pancarditis has only been demonstrated at autopsy. Purpose: To identify carditis in patients with ARF using T1 mapping on cardiac magnetic resonance (CMR) imaging and echocardiographic global longitudinal strain (GLS). We hypothesised that prolonged native T1 time, consistent with myocardial inflammation, would be present in ARF patients compared to controls. Methods: We prospectively recruited 36 patients; 15 fulfilling the Australian modified Jones Criteria for the diagnosis of ARF, 12 controls with an inflammatory condition without major criteria for ARF and 9 healthy controls. All patients underwent CMR with assessment of non-contrast myocardial T1 mapping as well as echocardiography for GLS. The primary outcome was differences in T1 time between the groups. Results: Patients with ARF had evidence of carditis demonstrated by markedly elevated T1 times [976 (± 167 ms)] compared to those with non-cardiac inflammatory conditions [841 (±50 ms)] and healthy controls [811 (±54 ms)], P = 0.002 (Fig. 1). There was no difference in global longitudinal strain between the groups (−19.4% vs −19.5% vs −20.4%, P = 0.66). Conclusions: Patients with ARF have markedly elevated myocardial T1 times on CMR, consistent with active inflammation from carditis. In contrast, GLS was normal in ARF patients. Incorporating CMR T1 mapping into the diagnostic algorithm for ARF may improve diagnostic certainty and lead to more effective delivery of secondary penicillin prophylaxis.

Identifying Carditis in Acute Rheumatic Fever With Myocardial T1 Mapping

Background: The pathogenesis of acute rheumatic fever (ARF) is incompletely understood. Valvulitis is used as part of the diagnostic criteria, while pancarditis has only been demonstrated at autopsy. Purpose: To identify carditis in patients with ARF using T1 mapping on cardiac magnetic resonance (CMR) imaging and echocardiographic global longitudinal strain (GLS). We hypothesised that prolonged native T1 time, consistent with myocardial inflammation, would be present in ARF patients compared to controls. Methods: We prospectively recruited 36 patients; 15 fulfilling the Australian modified Jones Criteria for the diagnosis of ARF, 12 controls with an inflammatory condition without major criteria for ARF and 9 healthy controls. All patients underwent CMR with assessment of non-contrast myocardial T1 mapping as well as echocardiography for GLS. The primary outcome was differences in T1 time between the groups. Results: Patients with ARF had evidence of carditis demonstrated by markedly elevated T1 times [976(±167 ms)] compared to those with non-cardiac inflammatory conditions [841(±50 ms)] and healthy controls [811(±54 ms)], P = 0.002 (Figure 1). There was no difference in global longitudinal strain between the groups (−19.4% vs −19.5% vs −20.4%, P = 0.66). Conclusions: Patients with ARF have markedly elevated myocardial T1 times on CMR, consistent with active inflammation from carditis. In contrast, GLS was normal in ARF patients. Incorporating CMR T1 mapping into the diagnostic algorithm for ARF may improve diagnostic certainty and lead to more effective delivery of secondary penicillin prophylaxis.

Prevalence of subclinical myocardial involvement among acute rheumatic fever patients without overt clinical carditis in Northern India: An evidence from plasma N-terminal pro-brain natriuretic peptide assessment

Objectives: It is important to diagnose subclinical carditis in acute rheumatic fever (ARF) since it has a bearing on prognosis and duration of prophylaxis. Plasma N-terminal pro-brain natriuretic peptide (NT pro-BNP) has been used as both diagnostic and prognostic tools, and it was hypothesized that it may prove useful in ARF without overt carditis. The study was undertaken to measure the plasma levels of NT pro-BNP in patients of ARF who did not have overt clinical carditis and to correlate the same with echocardiographic (ECHO) parameters of subclinical myocardial involvement. Materials and Methods: A total of 27 ARF patients without overt clinical carditis were enrolled in this prospective follow-up study. Plasma NT pro-BNP levels of these patients were assessed on day 1 of presentation and then after 6 weeks. ECHO was performed and patients were divided into two groups: group I, patients with subclinical carditis (n = 18) and group II, patients without subclinical carditis (n = 9). Results: The mean plasma NT pro-BNP levels were significantly higher in patients with subclinical carditis (509.16 ± 282.9 pg/ml) compared to those without subclinical carditis (109.33 ± 82.95 pg/ml) (P Conclusions: The present study suggests that elevated levels of NT pro-BNP may be used to diagnose subclinical myocardial involvement in patients of ARF without overt clinical carditis.

Anti-inflammatory treatment for carditis in acute rheumatic fever.

Rheumatic heart disease remains an important cause of acquired heart disease in developing countries. Although prevention of rheumatic fever and management of recurrences have been well established, optimal management of active rheumatic carditis remains unclear. This is an update of a review published in 2003, and previously updated in 2009 and 2012. To assess the effects, both harmful and beneficial, of anti-inflammatory agents such as aspirin, corticosteroids and other drugs in preventing or reducing further valvular damage in patients with acute rheumatic fever. We searched the Cochrane Central Register of Controlled Trials (2013, Issue 9 of 12), MEDLINE (Ovid, 1948 to 2013 October Week 1), EMBASE (Ovid, 1980 to 2013 Week 41) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to 17 October 2013). We last searched Index Medicus (1950 to April 2001) in 2001. We checked reference lists of identified studies and applied no language restrictions. Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) versus placebo or controls, or comparing any of the anti-inflammatory agents versus one another, in adults and children with acute rheumatic fever diagnosed according to Jones, or modified Jones, criteria. The presence of cardiac disease one year after treatment was the major outcome criterion selected. Two review authors extracted data and assessed risk of bias using the methodology outlined in the Cochrane Handbook of Systematic Reviews of Interventions. Standard methodological procedures as expected by The Cochrane Collaboration were used. No new studies were included in this update. Eight randomised controlled trials involving 996 people were selected for inclusion in the review. Researchers compared several steroidal agents such as corticotrophin, cortisone, hydrocortisone, dexamethasone, prednisone and intravenous immunoglobulin versus aspirin, placebo or no treatment. Six trials were conducted between 1950 and 1965; one was done in 1990 and the final study was published in 2001. Overall there were no observed significant differences in risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, risk ratio 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, risk ratio 1.13, 95% confidence interval 0.52 to 2.45) compared with aspirin did not reduce the risk of heart disease after one year. Investigators in five studies did not report adverse events. The three studies reporting on adverse events reported substantial adverse events. However, all results should be interpreted with caution because of the age of the studies and the substantial risk of bias. Little evidence of benefit was found when corticosteroids or intravenous immunoglobulins were used to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. In addition, risk of bias was substantial, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever are warranted to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone and the effects of other new anti-inflammatory agents. Advances in echocardiography will allow more objective and precise assessments of cardiac outcomes.

QT and P‐wave dispersions in rheumatic heart disease: Prospective long‐term follow up

Simple electrocardiogram (ECG) markers have been used to evaluate conduction times. Acute rheumatic fever (ARF) is an autoimmune disease that affects these conduction times. The aim of this prospective long-term follow-up study was to evaluate QT, QTc and P-wave dispersions in children with ARF and chronic rheumatic heart disease (CRHD). Sixty-four patients with ARF, 33 patients with CRHD and 41 healthy, age- and sex-matched control subjects were included in the study. The ARF patients were divided into two subgroups: carditis and arthritis. Echocardiographic and ECG measurements at the onset of diagnosis and final evaluation were included. QT, QTc and P-wave dispersions were significantly greater in both the ARF carditis and CRHD groups than the ARF arthritis and control subjects during the initial and final analysis (for all, P < 0.001). There was no significant statistical difference in QT, QTc and P-wave dispersion between the initial and final analysis in each groups. Severity of mitral regurgitation and left atrial enlargement were found to be positively correlated with P-wave dispersion (r = 0.438, P < 0.001; r = 0.127, P < 0.001, respectively). QT, QTc and P-wave dispersion greater than 52, 60 and 57 ms, respectively, had higher sensitivity and specificity for predicting ARF carditis. These ECG measurements can be used in the diagnosis of ARF carditis as minor criteria with modified Jones criteria. In contrast, this increase in the dispersions is permanent in patients with ARF carditis.

Can Soluble Adhesion Molecules Accurately Predict Carditis in Acute Rheumatic Fever?

Can Soluble Adhesion Molecules Accurately Predict Carditis in Acute Rheumatic Fever?

Prediction of Residual Valvular Lesions in Rheumatic Heart Disease: Role of Adhesion Molecules

Rheumatic heart disease (RHD) is a chronic condition characterized by fibrosis and scarring of the cardiac valves and damage to the heart muscle, leading to congestive heart failure and death. This prospective cohort study was conducted to investigate the possible relation between the levels of serum adhesion molecules and acute rheumatic fever (ARF) carditis, valvular insult severity, and residual valvular lesion after improvement of rheumatic activity. Serum levels of intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin were assayed by enzyme-linked immunoassay (ELISA) for 50 children with ARF carditis during activity and after improvement and for 50 healthy children as control subjects. After the acute attack, patients were followed up regularly to detect residual valvular lesion. The serum levels of these adhesion molecules were significantly higher in the patients than in the control group (p<0.001). In addition, the levels of serum adhesion molecules were significantly higher in the patients with severe carditis than in the patients with mild to moderate carditis (p<0.001). Among the severe carditis group, the level of serum adhesion molecules was significantly higher among the patients with heart failure than among the patients without heart failure (p<0.001). Furthermore, the pretreatment serum levels of ICAM-1 and VCAM-1 were significantly higher among the patients with residual valve lesion (p=0.002) than among those without the lesion (p<0.001). The cutoff values were obtained for the prediction of residual valvular lesion (ICAM-1, >1,032.3μg/ml; VCAM-1, >3,662.3μg/ml; E-selectin, >104.8μg/ml). Finally, by combining the three adhesion molecules in a single prediction model, the highest area under the curve (AUC)±standard error (SE) was obtained (0.869±0.052), and the positive likelihood ratio for having a residual valvular lesion was increased (17.33). Levels of serum adhesion molecules could predict residual valvular lesions in RHD patients. The authors recommend that the serum level of adhesion molecules be measured in all cases of ARF carditis.

Can troponin T levels be useful in the diagnosis of rheumatic carditis?

Objective:Acute rheumatic fever (ARF) is an endemic disease observed in children of developing countries. The purpose of this study was to test if it was possible to identify myocardial involvement in cases with rheumatic carditis by the measurement of serum cardiac TnT.Methods:30 patients diagnosed as ARF underwent echocardiography and their cardiac troponin T (cTnT) serum levels were measured. Patients were divided into group 1: Arthritis alone, group 2: carditis, and group 3 carditis with congestive heart failure (CHF).Results:cTnT serum levels were normal in all except one patient with in group 3. Two patients in carditis (group 2) and three patients in CHF (group 3) had dilation in left ventricular end diastolic diameter.Conclusions:Normal cTnT levels in our patient group suggests that inflammation rather than myocardial necrosis is predominant in ARF carditis.

The efficacy of echocardiographic criterions for the diagnosis of carditis in acute rheumatic fever

There is a great need for echocardiographic criterions for accurate diagnosis of carditis in acute rheumatic fever. To test the efficacy of proposed echocardiographic criterions for the diagnosis of carditis. We studied 333 patients suspected of having acute rheumatic fever, undertaking detailed clinical examination, laboratory tests and meticulous echocardiography in each case. We used previously established echocardiographic criterions for the diagnosis of carditis and subclinical valvitis. In 220 cases (66.06%), both the echo criterions, and the Jones' criterions, gave positive results. In 52 cases (15.61%), we found evidence of subclinical carditis, in that clinically no murmur was heard, meaning the Jones' criterions were negative, but the echocardiographic evaluation was positive. In 4 patients clinically diagnosed as having carditis, the Jones' criterions were positive, but echocardiographic evaluation showed them to have congenitally malformed hearts. In another 57 cases (17.11%), the Jones' criterions were negative, as were the results of echocardiographic evaluation. These patients were taken as control subjects. On this basis, the echocardiographic criterions had sensitivity of 81% and specificity of 93%. Using our echocardiographic criterions, it is possible to make a precise diagnosis of carditis or subclinical valvitis. Hence, echocardiography should, in future, be included as a major criterion in the Jones' system.

What is the True Frequency of Carditis in Acute Rheumatic Fever? A Prospective Clinical and Doppler Blind Study of 56 Children with up to 60 Months of Follow-Up Evaluation

This study aimed to evaluate prospectively clinical and echocardiographic findings of patients who had rheumatic fever with and without clinical features of cardiac involvement. For this study, 56 consecutive patients (mean age, 11.4 years) with acute rheumatic fever diagnosed according to the 1992 modified Jones criteria were evaluated at diagnosis, after 3 and 6 months, then at 2 and 5 years. All assessments were performed blindly and included physical and cardiac examination, electrocardiogram, chest X-ray, and two-dimensional color-flow Doppler echocardiography. Initial clinical carditis was observed for 27 patients (48.2%), all of whom had positive echocardiographic abnormalities. Echocardiographic abnormalities were observed in 11 patients who had arthritis or chorea presentation without initial clinical carditis. Persistence of the abnormalities was observed at a late follow-up evaluation in 72.7% of the cases. Sydenham's chorea was present in 8 patients with clinical carditis and in 10 without this disorder, 8 of whom had echocardiographic abnormalities. Patients who had acute rheumatic fever without clinical signs of carditis showed acute and late follow-up echocardiographic abnormalities suggestive of cardiac involvement. Clinicians should be attentive for the presence of cardiac involvement among patients with chorea.

The Malignant Course of Acute Rheumatic Fever in the Modern Era: Implications for Early Surgical Intervention in Cases of Bivalvular Insufficiency With Impaired Ventricular Function

In recent years, the incidence of acute rheumatic fever (ARF) has drastically decreased in the United States while remaining common in developing nations. However, immigration to the United States from developing nations has resulted in the continued prevalence of ARF. Patients with ARF face the potential development of significant valvular insufficiency and rheumatic carditis, which are associated with significant morbidity and mortality. Potentially adverse outcomes may be avoided with advanced interventions such as aortic and/or mitral valve replacement or repair, the use of inotropic agents, and ventricular assist devices for mechanical circulatory support. This report describes a series of three ARF carditis cases. This series serves not only to emphasize proper ARF prevention, but also to demonstrate the need for timely surgical intervention once medical therapy has failed.

Anti-inflammatory treatment for carditis in acute rheumatic fever.

Rheumatic heart disease remains the most important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established the optimal management of active rheumatic carditis is still unclear. To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids and immunoglobulin for preventing or reducing further heart valve damage in patients with acute rheumatic fever. We searched the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1966 to April 2002), EMBASE (1998 to November 2002), LILACS (1998 to November 2002), Index Medicus (1950 to December 2000) and references lists of identified studies. Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in patients with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected. Two reviewers independently extracted data and assessed trial quality. Eight randomised controlled trials involving 996 people were included. Several steroidal agents viz. ACTH, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, whilst the remaining two were done in the last 10 years. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly use of prednisone (relative risk 1.78, 95% confidence interval 0.98 to 3.34) or intravenous immunoglobulins (relative risk 0.87, 95%confidence interval 0.55 to 1.39) when compared to placebo did not reduce the risk of developing heart valve lesions at one year. There is no benefit in using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessment of cardiac outcomes.

Doppler echocardiography and the early diagnosis of carditis in acute rheumatic fever.

The incidence of acute rheumatic fever in New Zealand remains relatively high. Reliable early diagnosis of carditis is difficult and important in management. To determine if Doppler echocardiography contributed to the early diagnosis of carditis in acute rheumatic fever. Forty-seven patients admitted to hospital with suspected acute rheumatic fever and 19 control patients, with a febrile illness due to a documented non-cardiac bacterial infection, were assessed two days and two weeks following admission. Presence or absence of clinical carditis was determined by a cardiologist unaware of the suspected diagnosis, from clinical examination, chest radiograph, electrocardiogram (ECG) and two dimensional echocardiogram. Doppler echocardiography was then performed and interpreted by a second cardiologist unaware of the diagnosis. After completion of the study the Jones criteria were applied, to categorise the patients with suspected acute rheumatic fever into four groups for the final diagnosis: no acute rheumatic fever, possible acute rheumatic fever, definite acute rheumatic fever without carditis, and definite acute rheumatic fever with carditis. In 19 patients with a final diagnosis of acute rheumatic fever and carditis at the baseline assessment carditis was detected by clinical assessment in 15 patients, compared with 19 patients with evidence of significant valve regurgitation by Doppler echocardiography. Following the two week assessment, all 19 patients had both clinical and Doppler evidence of carditis. Five patients with a final clinical diagnosis of possible acute rheumatic fever or definite acute rheumatic fever without carditis, had a Doppler abnormality detected. There was no clinical or Doppler abnormality in the febrile controls. Doppler echocardiography is more sensitive than clinical assessment in the detection of carditis in acute rheumatic fever, and can contribute to earlier diagnosis.

Echocardiographic abnormalities in acute rheumatic fever

The echocardiographic velocity of circumferential fiber shortening and left atrial dimension were measured serially in two groups of children with acute rheumatic fever: Group I, six patients with valve regurgitation without congestive heart failure, and Group II, seven patients with regurgitation and congestive heart failure. In Group I, the initial velocity of circumferential fiber shortening was increased to 1.90 ± 0.31 circumferences per second (circ/sec) (mean ± standard deviation). In Group II, it was decreased (1.18 ± 0.25 circ/sec). In Group I velocity of circumferential fiber shortening subsequently decreased but remained above the normal level; in Group II it increased to exceed the expected normal value. Concurrent changes in left atrial dimension were observed in both groups. The initial left atrial dimension of Group I (2.2 ± 0.75 cm/m 2) was slightly increased and returned to normal (1.70 ± 0.32) on follow-up study. The left atrial dimension of Group II was greatly increased initially (2.70 ± 0.81 cm/m 2) and remained large (2.50 ± 0.67). Three patients in Group II experienced rebound during corticosteroid withdrawal. In each the velocity of circumferential fiber shortening decreased, suggesting impaired cardiac contractility. The echocardiogram thus facilitates serial assessment of the severity of carditis in acute rheumatic fever.

Cardiocirculatory effects of glucagon in patients with congestive heart failure and cardiogenic shock

Cardiocirculatory Effects of Glucagon in Patients with Congestive Heart Failure and Cardiogenic Shock EZRA A. AMSTERDAM, MD/ROBERT ZELIS, MD/JAMES F. SPANN, Jr., MD, FACC EDWARD J. HURLEY, MD, FACC and DEAN T. MASON, MD, FACC Davis, California Although the powerful inotropic property of glucagon is well established in isolated heart muscle and experimentd animals, the efficacy of the agent in patients with severe cardiac malfunction has not been determined. The purpose of this study was to define the cardiocirculatory effects of glucagon in patients with congestive heart failure or cardiogenie shock. Accordingly, the hemodynamic actions of intravenously administered glucagon (50 k there was a small but significant (P < 0.05) rise in heart rate (93 to 99). In the 5 patients of both groups whose cardiac output rose, the maximal increase was 14%. In the 3 patients with cardiogenic shock whose blood pressure increased, the increases were 5, 11 and 30%, respectively. These data suggest that glucagon, as administered in these studies, produces inconsistent hemodynamic improvement in patients with congestive heart failure and cardiogenic shock ahd that when favorable changes occur, they are usually of small magnitude. Signs and Symptoms of the Different Causes of Endocarditis Dr. FELIX ANSCHOTZ Dafmstadt, West Germany Knowledge of the causative inflammable process of the heart valves is important to understanding of the origin, progress, prognosis and treatment of the valvular disease. It is impossible to describe valvular heart disease with the aid of hemodynamic studies alone. The origin of the endocarditis is the central problem because of the consequences in therapy and prophylaxis. The differential diagnosis of endocarditis is described by our own studies in which the signs and symptoms are related in each case to the autopsy findings (137 cases of rheumatic heaxt disease, 85 cases of subacute bacterial endocarditis, 44 cases of acute bacterial endocarditis and 40 cases of rafe causes of endocarditis) . It is easier to recognize carditis in acute rheumatic fever than in cases of chronic valvular disease in which the inflammation doubtless influences the progress of the valvular damage. In these cases other possible explanations of inflammation must be considered. Subacute bacterial endocarditis, too, will be easy to recognize, particularly if the bacterial culture is positive. Often abacterial endocarditis may be hard to diagnose because of its indistinct symptoms. The central problem is to find the strains, which is difficult because many patients have already been given antibiotics. In some cases it is impossible to diagnose the cause of the endocarditis definitely even with the help of the most modern clinical studies. Hemodynamic Effects of Glucagon in Patients with Fixed-Rate Pacemakers WILLIAM W. ASHLEY, MD/DAVID M KAMINSKY, MD/JANET I. LIPSKI, MD ARTHUR C. WEISENSEEL, Jr., MD/EPHRAIM DONOSO, MD, FACC and CHARLES K. FRIEDBERG, MD, FACC New York, New York The effects of glucagon (50 clg/kg) on cardiac output (dye dilution) and brachial arterial pressure were studied in 7 patients, aged 57 to 73, with fixed-rate pacemakers. Mean cardiac index at rest increased 0.8 + 0.07 liters/ min per m2 (9% confidence interval) without significant change in braehial arterial pressures. Exercise performed by 5 patients, without glucagon, increased the cardiac index. During the same amount of exercise with glucagon, there was no aignifioant further increase in cardiac index (0.5 + 0.06 liters/min per m*). One additional patient with congestive heart failure did not show an increased cardiac index with glucagon at rest or during exercise. Isoproterenol administered to 2 patients increased cardiac index by 1.91 and 1.90 liters/min per ma compared to 1.02 and 0.75, respectively, with glucagon. Six of 8 patients experienced nausea and lightheadedness, and in 2 patients ventricular premature systoles developed after administration of glucagon. Mean serum potassium in 9 patients decreased from 82 The Amodem JoounMl of CARDlOLOaY