Clinical Evidence Of Heart Disease Research Articles

Atrial T (Ta) loop in patients with A-V block: A trial to differentiate normal and abnormal groups

The P and the Ta waves were recorded with high fidelity and high amplification. The P and the Ta loops were constructed from these waves. Human subjects with A-V block were used, so that the Ta waves could be completely visualized. Subjects were separated into two groups: one group with minimal clinical evidence of heart disease and another with more severe disease. There were great and important differences in the Ta loops between the two groups with minimal differences in the P loops. In the patients with minimal heart disease, the Ta loop was always oriented to the right and superiorly. The P-Ta angle was approximately 180 degrees and all patients in this group showed a small spatial atrial gradient oriented to the left and inferiorly. These findings are similar to those found in normal dogs reported separately in the Journal. In the group of four patients with more severe heart disease, the P-Ta angle varied widely and deviated greatly form 180 degree. The satial atrial gradient was very large in three cases. The findings and others such as the direction of the maximum Ta vectors were diagnostically useful in separating the Ta loops of the two patient groups. Results indicate that the Ta loop may be very useful in separating normal from diseased atria in individuals with A-V block. There are some frequency differences between the Ta wave and the QRS complex. If the Ta wave could be extracted from the QRS complex by the use of some kind of filter when A-V block dose not exist, most of the Ta wave could be visualized. This, along with high fidelity recording techniques, may help detect atrial abnormalities in patients without A-V block. Future development of this equipment as a clinical tool is hoped for.

Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease

The incidence, types and patterns of emergence of treadmill exercise-induced ventricular arrhythmias were studied in 482 subjects with and without coronary heart disease. All subjects were free of premature ventricular complexes at rest and were classified into groups on the basis of their clinical status. In Group IA were 141 patients with chest pain and normal coronary arteriograms and in Group IB 144 age-matched subjects free of clinical evidence of heart disease. Group II consisted of 197 patients with chest pain and arteriographically documented coronary artery disease. Patients in Group IA and II exercised to at least 85 percent of their predicted maximal heart rate or until chest pain occurred. Subjects in Group IB underwent maximal exercise testing. The total incidence of exercise-induced ventricular arrhythmias was 16 percent in Group IA, 44 percent in Group IB and 29 percent in Group II. However, when exercise heart rate at the time of appearance of ventricular arrhythmias was taken into account the incidence of exercise-induced ventricular arrhythmias up to a heart rate of 130/min was 27 percent in the patients with documented coronary artery disease (Group II) compared with rates of 9 and 6 percent, respectively, for Groups IA and IB ( P < 0.001). The incidence rates of multifocal ventricular premature complexes, ventricular tachycardia and ventricular premature complexes at a rate of more than 10/min were also significantly greater at submaximal heart rates in the patients with coronary disease. Patients with three vessel coronary artery disease and abnormal left ventricular wall motion had a significantly greater incidence of exercise-induced ventricular arrhythmias. The incidence of exercise-induced ventricular arrhythmias in patients with coronary disease and a positive S-T segment response was not significantly increased.

Preclinical cardiomyopathy in chronic alcoholics: A sex difference

Alcoholic subjects differ in the incidence of cardiomyopathy. Of potential variables, sex may be important since few females are seen with cardiomyopathy, even adjusting for the lower incidence of alcoholism. To examine this question, noninvasive systolic time intervals were measured in 22 males and 14 females of similar age, heart rate, and arterial pressure, without clinical evidence of heart disease or hypertrophy. Duration and intensity of ethanol intake and the interval from last drinking episode were apparently equivalent. In male alcoholics, the left ventricular preejection period and ejection time (PEP/LVET) ratio of 0.410 +/- 0.020 was significantly higher than in the 11 normal males (0.316 +/- 0.007) (P less than 0.001). In female alcoholics, the ratio was 0.322 +/- 0.015, compared to 0.310 +/- 0.01 for 11 normal females, and was significantly less than in the male patients (P +/- 0.001). In addition prolonged intraventricular conduction by high-frequency ECG was more prevalent in the male group. To further ensure equivalency of alcoholism, patients with biopsy-proved cirrhosis were selected. In nine males, PEP/LVET was significantly higher than in the 10 females. Thus, abnormal myocardial function was evident in males but not in females, suggesting that sex is a determinant of the toxic effects of ethanol on myocardium.

Polarcardiographic criteria for myocardial infarction in Chinese men

Polarcardiograms (PCG) derived from xyz leads of the Frank electrocardiogram (ECG) were recorded in the supine position in 1264 initially healthy middle-aged Chinese men who had been under continuing medical surveillance and were re-examined seven years later. Polarcardiographic criteria for myocardial infarction (MI) were demonstrated in 97 men (7.7%), but only 15 of them showed diagnostic Q waves in the electrocardiogram (ECG). Polarcardiographic criteria for MI were independent of age, but ranged from 4.3% in 464 apparently normal men to 38% in 21 men with manifestations of ischemic heart disease. The possible association of polarcardiographic criteria and a history of smoking was limited to those with clinical evidence of heart disease. The "false positive" rate of 4.3% in clinically normal men was similar to that reported in younger Canadians and in Cretan population samples.

Impaired left ventricular function in alcoholic cirrhosis with ascites. Ineffectiveness of ouabain.

Left ventricular function was assessed in 10 patients with alcoholic cirrhosis and ascites without clinical evidence of heart disease. In the resting state pulmonary wedge pressure (PWP) was normal (average 9.7 mm Hg), cardiac output (CO) was elevated (average 9.7 L/min) and systemic vascular resistance (SVR) was low (average 825 dynes-sec-cm –5 ). During infusion of angiotensin in a dose sufficient to raise diastolic arterial pressure 20 mm Hg, SVR increased to 1140 dynes-sec-cm -5 ( P &lt; 0.01) and PWP rose to 19.2 mm Hg ( P &lt; 0.001) with no change in CO. Resting hemodynamics were essentially unchanged in seven patients restudied 45-60 min after intravenous administration of 0.5 mg ouabain. Repeat infusion of angiotensin after ouabain again resulted in a rise in PWP to an average of 17.0 mm Hg ( P &lt; 0.001) with no significant change in CO. In seven additional cirrhotic patients with ascites, systolic time intervals were unchanged by 0.5 mg ouabain whereas in four normal volunteers the same dose resulted in significant shortening of total electromechanical systole, pre-ejection period and left ventricular ejection time. These data indicate that depression of the left ventricular response to an increase in afterload is a uniform finding in alcoholic patients with cirrhosis and ascites. The absence of clinical symptoms of heart disease, therefore, could be attributed to the low systemic vascular resistance characteristic of cirrhosis. Since acute administration of ouabain neither improved left ventricular function nor altered systolic time intervals, digitalis may have a limited place in the therapy of this form of cardiac impairment.

Right bundle-branch block associated with left superior or inferior intraventricular block. Clinical setting, prognosis, and relation to complete heart block.

In an 11-year period 209 cases of partial bilateral bundle-branch block were seen. These included patients with right bundle-branch block and either left superior or left inferior intraventricular block. The majority of patients had evidence of coronary artery disease or hypertension, though a significant number had no clinical evidence of heart disease. The majority of patients had follow-up ECG tracings, with an average follow-up for the whole group of about 2 years. The incidence of complete heart block was 14.4% (30 of 209). Complete heart block developed more than 10 years after the discovery of bilateral bundle-branch block in several patients. It is anticipated that with more complete and longer follow-up the incidence of complete heart block will be even higher.

MYOCARDIAL INFARCTION FOLLOWING SURGICAL OPERATIONS

One hundred and forty-one randomly selected surgical patients, aged 35 years or over, were studied preoperatively, followed through their operative procedures, and reassessed during the first post-operative week for evidence of myocardial ischaemia associated with surgical operations under general anaesthesia. Of these patients 38% were found to have preoperative clinical evidence of heart disease, hypertension, or diabetes; 45% had abnormal preoperative E.C.G. patterns.Three patients experienced myocardial infarction during or within 36 hours of operation, all of the occult type; all were in the preoperative abnormal groups. Non-specific postoperative E.C.G. changes were equally common in the groups of patients with normal or abnormal preoperative electrocardiograms.A relationship existed between a rise in serum lactic dehydrogenase (L.D.H.) concentration and the field of the operation, but the diagnosis of infarction was not confused provided serum L.D.H. isoenzyme patterns and a rise in serum aspartate aminotransferase (S.G.O.T.) levels were consistent with the diagnosis.

Vectorcardiographic analysis of T-wave inversion in the right precordial leads

The transverse plane T loop of 126 subjects with normal QRS complexes and inverted T waves in the right precordial leads were studied and correlated with their clinical diagnoses. The vectorcardiographic analysis included the determination of the direction and magnitude of the maximum T vector, the uniformity of the speed of inscription, and the direction of inscription of the loop. A clockwise and/or a uniformly inscribed T loop were found almost exclusively in patients with clinical evidence of heart disease. It is concluded that the vectorcardiogram may offer additional information permitting separation of patients with or without heart disease whose scalar ECG's show T-wave inversion in the right precordial leads.

Myocardial infarction following surgical operations.

One hundred and forty-one randomly selected surgical patients, aged 35 years or over, were studied preoperatively, followed through their operative procedures, and reassessed during the first post-operative week for evidence of myocardial ischaemia associated with surgical operations under general anaesthesia. Of these patients 38% were found to have preoperative clinical evidence of heart disease, hypertension, or diabetes; 45% had abnormal preoperative E.C.G. patterns.Three patients experienced myocardial infarction during or within 36 hours of operation, all of the occult type; all were in the preoperative abnormal groups. Non-specific postoperative E.C.G. changes were equally common in the groups of patients with normal or abnormal preoperative electrocardiograms.A relationship existed between a rise in serum lactic dehydrogenase (L.D.H.) concentration and the field of the operation, but the diagnosis of infarction was not confused provided serum L.D.H. isoenzyme patterns and a rise in serum aspartate aminotransferase (S.G.O.T.) levels were consistent with the diagnosis.

Electrocardiographic Changes During Routine Sigmoidoscopy

One hundred patients were monitored by telecardiography during routine sigmoidoscopy; 40 patients had heart disease, and 60 patients had no clinical evidence of heart disease. Electrocardiographic changes in rhythm, depolarization, and repolarization occurred in both patients with and without heart disease. There was a significantly greater frequency (40% vs 17%) in the development of or increase in ectopic beats in those patients with heart disease; however, no catastrophic arrhythmias occurred. These findings do not contraindicate sigmoidoscopy either in patients with or without heart disease; however, one must be aware of the potential hazard of cardiac arrhythmias and be prepared for their management.

The cardiomyopathy of progressive muscular dystrophy.

A prospective study was undertaken in order to examine the histories, physical signs, phonocardiograms, electrocardiograms, vectorcardiograms, X-rays, serum enzymes, pulmonary ventilatory findings, and hemodynamics in a group of 55 patients selected solely on the basis of one of the major types of progressive muscular dystrophy (table 9). The classification included: (1) the classic Duchenne type, (2) the limb girdle type, (3) the facioscapulohumeral type, and (4) a group of patients in whom clinical distinction between benign Duchenne dystrophy and limb girdle dystrophy with pseudohypertrophy could not be made. No patient had recognized heart disease prior to selection. Follow-up periods ranged from a few months to 5 years. The pertinent literature was extensively reviewed. In all groups clinical evidence of heart disease had to be interpreted in the context of the influence of the somatic musculoskeletal defects on "cardiac" symptoms, cardiovascular physical signs, and radiological appearance of the heart. On the other hand, convincing evidence of intrinsic heart disease-subtle to overt-was found in each of the major categories of progressive muscular dystrophy. Detection of cardiomyopathy was simplest and most frequent in the classic Duchenne group because of the highly characteristic features of the scalar electrocardiogram which might direct attention to the systemic myopathy prior to its clinical recognition. However, the presence of heart disease in patients with forms of dystrophy other than the classic Duchenne deserves particular emphasis. Evidence of cardiomyopathy in these latter forms varied from subtle quadruple gallop rhythms in the limb girdle and facioscapulohumeral groups to cardiomyopathic death in the benign Duchenne and limb girdle-pseudohypertrophic group. Currently available information on the heart in muscular dystrophy has as a rule depended upon retrospective studies, upon reviews of published reports of incompletely classified cases, upon discussions of individual cardiovascular features, or upon observations of individual types of dystrophy. The present prospective study was undertaken to obviate some of these shortcomings. Comprehensive assessment of a large and carefully classified group of dystrophic subjects has provided additional information regarding the clinical spectrum of dystrophic cardiomyopathy.

Significance of the QX-QT ratio and the QT ratio (QTr) in the exercise electrocardiogram.

Recently, a junctional depression of small amplitude (less than 2 mm.) of the ST segment was considered to be a positive or equivocal result for the electrocardiographic exercise test if the QX/QT ratio was ⪖ 50 per cent or the QTr ⪖ 1.08. In 150 normal, young students with no clinical evidence of heart disease, a junctional depression of the ST segment with a QX/QT ratio ⪖ 50 per cent or a QTr ⪖ 1.08 or both, was observed in 22 per cent. These observations, supported by other published reports concerning the QX/QT ratio and the QTr, indicate that these criteria are not reliable for the determination of a positive electrocardiographic exercise test.

Criteria for the clinical application of the "two-step" exercise test. Obviation of false-negative and false-positive responses.

Significant coronary artery disease may exist in a patient despite a normal resting electrocardiogram and a history. A standardized 2-step exercise is recommended as a simple diagnostic test of ischemic heart disease. This master test was applied to 596 subjects whose resting electrocardiograms were normal. In 277 the electrocardiograms after exercise were classified as normal by criteria developed by the authors, and from 1952 to 1961, 96.8% of this negative group remained free from clinical evidence of heart disease. In the other 319, electrocardiograms after exercise showed various types of depressions of the RS-T segment below the isolectric line. The significance of these changes and other criteria was evaluated. It is concluded that 95% of patients with significant coronary disease show abnormalities of the electrocardiogram after exercise which satisfy the criteria set forth by the authors.

Twenty-Year Studies with the Ballistocardiograph

A group of 211 healthy persons, gathered together from 23 to 17 years ago to provide normal standards for the ballistocardiograms, has been followed to the present time. This study is concerned with the group as a whole, or with subgroups. The study of individuals will appear in later communications. With a few minor exceptions, the group, at the time of the initial test, had ballistocardiograms normal in form. The death rate of the group during the period of the study was much lower than was to be anticipated from standard life expectancy tables for the state of Pennsylvania. Although the ballistocardiograms of this group were normal in form, there was great variation in the amplitude of the records. Since these records were calibrated in terms of force, this can be interpreted as due to differences in the force of the heart's contraction. Those whose hearts contracted with little force at the initial test later suffered from death and cardiac disability, chiefly coronary heart disease, in far greater numbers than those whose hearts contracted strongly. The interpretation of this striking finding is bound up with that of another; in our data, as in that of others, there is strong correlation between the ages of the subjects and the amplitudes of their ballistocardiograms. The heart tends to weaken and beat with less coordination as it grows older. Exact expressions can be given to the "normal" rate of decline of cardiac function with the years by the slope of the regression between age and ballistocardiogram amplitude found in the group of those who remained healthy for 17 years after the test. The normal rate of cardiac decline, as age advances, agrees closely with that calculated for several bodily functions. The cardiac decline seems a little more rapid than that of these other bodily functions, but the difference is small and its significance is doubtful. In our data, among those who later developed undoubted heart disease, there was no significant tendency for the older people to have smaller ballistocardiograms than the younger. From the chronologic age of each subject who later developed undoubted heart disease, and the age-amplitude regression of those who remained healthy, one can calculate for each "cardiac" subject, the amplitude expected if he had been in perfect health. On the average this expected value far exceeds the values found. So most of these hearts were performing abnormally for their age although manitest clinical evidence of heart disease had not yet appeared. When the effect of age is eliminated by pairing the results directly, the relation between the amplitudes of the initial ballistocardiograms and the later development of heart disease remains significant for p = 0.05. Indeed, in such pairs with similar ages, those who later developed heart disease had initial ballistocardiograms that averaged 25 per cent smaller than those of their mates who remained healthy for the next 17 years. This is additional evidence that the hearts of those who were to develop myocardial disease were, at the initial test, like the hearts of much older normal people; that is, the physiologic age of their hearts far exceeded the chronologic age.

Cardiac involvement in coccidioidomycosis

Clinical and pathologic evidence of cardiac involvement was found in six of twenty-two autopsied patients with coccidioidomycosis. Dyspnea and/or orthopnea was present in each of these six patients but was absent in all others, including those with equally severe pulmonary involvement. Coccidioidal pericarditis, with pericardial effusion at some time during the course of the disease, was present in three of the six patients. The pericarditis was symptomatic in all cases. Clinical evidence of pericarditis included chest pain, an enlarged cardiac silhouette, a weak cardiac pulsation at the time of fluoroscopy, S-T segment elevation, low and inverted T waves, ankle edema and cyanosis. A severe myocarditis was present in each of the six patients and may have been important in producing some of the symptoms. Coccidioidal spherules were found in the heart in four of these six patients. In the other two patients chronic non-specific inflammatory lesions were present in all layers of the heart. There was a correlation between the duration of cardiac symptoms and the “age” of microscopic cardiac lesions. Eight other patients without clinical evidence of heart disease also had chronic, non-specific inflammatory lesions in the heart. These lesions, however, were smaller in size and fewer in number. No instance of endocardial involvement by coccidioidal spherules was encountered. However, non-specific inflammatory and scarifying reactions were present in the mural endocardium.

Evaluation of the recumbent esophagogram in the early detection of left atrial enlargement.

The use of the recumbent esophagogram as a means of early detection of an enlarged left atrium has been reported previously (4, 8). It was assumed that such a view might afford an early-possibly the earliest-sign of left atrial enlargement. Demonstration of a straight esophagus with the patient erect is considered by many clinicians to exclude a diagnosis of mitral valvular disease. It has been our experience, however, that in mild cases the esophagus may appear straight (negative) in the upright position but may show some deviation (positive) on the recumbent esophagogram. On the other hand, we are well aware that such a finding may lead to over-reading of roentgenograms, with diagnosis of mitral valvular disease where none is present. Consequently errors in interpretation may occur in both directions (5). In the present study we shall report further experiences with this procedure and evaluate its reliability in a larger series of cases. Method Fluoroscopy of the chest was performed, and postero-anterior teleroentgenograms and left and right anterior oblique films were obtained. The erect esophagogram was taken most often in the right lateral projection, and part of the same film was used for the right lateral recumbent esophagogram. The right lateral view was preferred to the right anterior oblique, since comparison of films is difficult when the angle of obliquity varies even slightly. All esophagograms were obtained under fluoroscopic control, after most of the barium-swallow had passed down the esophagus. The roentgenograms were taken in mid-inspiration, but fluoroscopy was performed both in deep inspiration and expiration. Fluoroscopy in expiration was done to rule out the possibility that changes in the height of the diaphragm in the recumbent position might cause a localized, well defined imprint in the lower third of the esophagus. The presumptive clinical diagnosis was formulated in all cases before the x-ray examination. Material and Results This study is based on 311 cases in which complete clinical and roentgenological data were available, including 173 cases with definite clinical evidence of mitral valvular disease, 17 with probable mitral valvular disease, 7 with various types of congenital heart disease, and a control group of 114 patients without clinical evidence of heart disease of any kind. Among the controls were patients with a high right diaphragm due to various causes, such as pregnancy, kyphoscoliosis, amebiasis of the liver, and phrenic crush. In 105 of this group the erect as well as the recumbent esophagogram showed a straight esophagus, with no localized, well defined indentation. In 18 of these cases a straightening of the left border of the heart, in 2 cases a prominent pulmonary segment, and in 3 straightening of the left heart border together with a prominent pulmonary segment were demonstrable on the postero-anterior and right oblique views (Figs. 1 and 2).

The effect of hyperventilation and pro-banthine on isolated RS-T segment and T-wave abnormalities

Summary o 1. Thirty-four patients (twenty-four Negroes and ten Caucasians) with persistent and unexplained RS-T segment and T-wave changes were seen at the Madison Veterans Administration Hospital between May, 1952, and May, 1954. In none of the patients was there clinical evidence of heart disease. 2. The major electrocardiographic changes consisted of RS-T segment coving and frank T-wave inversion in the mid- and left precordial leads. 3. The administration of a vagal blocking agent (Pro-Banthine) resulted in prompt normalization of these electrocardiographic abnormalities. 4. Hyperventilation performed for ten to twenty seconds consistently reproduced, the original RS-T segment and T-wave changes. This hyperventilation effect was “blocked,” however, during the period of peak Pro-Banthine activity. 5. On the basis of psychosomatic evaluation and the results of psychologic testing, it was demonstrated that these patients had some form of psychiatric or emotional disorder. Regardless of the diagnostic category, however, the combination of vasomotor instability, anxiety, and hypochondriasis was prominently manifested by this group of subjects. 6. The nature and incidence of the “juvenile pattern” is discussed, as is the mechanism and role of emotional stress in ECG abnormalities of this type.

Cardiac output in pregnancy; correlation between Evans blue dye and blood pressure methods.

Cardiac output estimations done by the pulse pressure method were compared to those done simultaneously by the dye method in pregnancy, labor, and in the early puerperium. The subjects selected were young, healthy and without edema or clinical evidence of heart disease. A total of 30 determinations was carried out on 23 subjects. Agreement within 25 per cent of the dye method was attained in 90 per cent of the blood pressure method tests.

The effect of exercise on the electrocardiogram of bundle branch block

A systematic study was undertaken to determine the effect of the exercise test on the electrocardiogram of fifty-six patients with bundle branch block. Of twenty-seven patients with right bundle branch block, four showed a positive test; only two of the four positive reactors had definite evidence of heart disease, while six patients with arteriosclerotic heart disease had negative tests. Of six patients with incomplete right bundle branch block only one had arteriosclerotic heart disease and the exercise test was positive in this case. Of twenty patients with left bundle branch block seven showed positive tests, while five others with arteriosclerotic heart disease had negative tests. All three patients with Wolff-Parkinson-White syndrome had positive tests, despite the absence of other clinical evidence of heart disease in two. The exercise test was positive in approximately 50 per cent of patients with arteriosclerotic heart disease and complete bundle branch block. Presumably false positives occurred in two patients with right bundle branch block and in two with the Wolff-Parkinson-White syndrome, indicating a possible hazard in the evaluation of the effect of exercise in the presence of aberrant conduction.

TRANSIENT RIGHT BUNDLE BRANCH BLOCK, WIDE S WAVE TYPE, IN WHICH NORMAL CONDUCTION OCCURRED BOTH SPONTANEOUSLY AND IN RESPONSE TO VAGAL STIMULATION

Excerpt In routine electrocardiograms taken on healthy young adults without clinical evidence of heart disease, bundle branch block is a rare finding, occurring in less than 1 per cent.1, 2, 3, 4Ap...