Nocturnal Angina Research Articles

Topical nitroglycerin for ischemic heart disease

THE MAINSTAY of medical management of angina pectoris continues to be β-blocking agents and nitrates. Used initially in the treatment of Raynaud's disease,¹nitroglycerin ointment was first introduced for the treatment of angina pectoris in 1955, but at that time it did not receive widespread clinical application. In the past few years, topical nitroglycerin has enjoyed a revival as a therapeutic agent, especially for patients with unstable or nocturnal angina. We compared the physiological and clinical effectiveness of sublingual and topical nitroglycerin (Nitrol Ointment) when used in patients with ischemic heart disease. <h3>Mechanism of Action of Nitroglycerin</h3> Myocardial ischemia is the result of an imbalance between myocardial oxygen demand and myocardial oxygen supply. Although nitroglycerin has been shown to be clinically effective in the therapy of this condition, its exact mechanism of action is still uncertain. At the present time it seems prudent to consider that nitroglycerin alters the

Allergic contact dermatitis secondary to topical nitroglycerin

To the Editor.— Physicians have long been looking for a practical, longacting nitrate product for prophylaxis of exertional and nocturnal angina pectoris. Sustained nitrate effects from cutaneously absorbed nitroglycerin have long been known to industry. 1 Topically applied nitroglycerin ointment was introduced in 1955 but never achieved clinical acceptance. 2 In an editorial Vaisrub (236:292, 1976) reviewed the current status and effectiveness of topically applied nitroglycerin and stated, Barring an unexpected fly, glycerin ointment promises to be a useful addition to the therapeutic unguentarium. This report of allergic contact dermatitis caused by topically applied nitroglycerin ointment may well be a small fly in the ointment. Report of a Case.— A 60-year-old man was treated with nitroglycerin (Nitrol) ointment for angina prophylaxis. The patient stated that he was experiencing relief of his exertional angina using 1.27 cm of the ointment applied twice daily to various areas of his trunk. After approximately

Decrease in myocardial oxygen supply as a mechanism in resting and nocturnal angina with ST depression: Hemodynamic evidence

Decrease in myocardial oxygen supply as a mechanism in resting and nocturnal angina with ST depression: Hemodynamic evidence

Significance and treatment of nocturnal angina preceding myocardial infarction

The presence of nocturnal angina and congestive heart failure within the month prior to admission was evaluated in the 174 patients with acute myocardial infarction. Heart size was evaluated radiographically at the time of admission. Twenty-three patients (13 per cent) experienced nocturnal angina. The incidence of nocturnal angina was significantly higher in those with anterior myocardial infarction (p less than 0.005) and subendocardial infarction (p less than 0.02) when compared with patients with inferior MI. Congestive heart failure was more common prior to admission in those with nocturnal angina (9/23) as opposed to those without (3/141) (p less than 0.001). Cardiomegaly was seen in 9/23 patients with nocturnal angina and 22/141 without (p less than 0.02). We conclude that the presence of nocturnal angina in those who develop MI increases the likelihood that the infarction will be either anterior or subendocardial rather than inferior. The association of nocturnal angina and congestive heart failure to anterior myocardial infarction is probably due to more severe and probably significant left coronary artery disease.

Severe papillary muscle dysfunction substantiated by atrial pacing during cardiac catheterization

A patient experienced episodic pulmonary edema accompanying nocturnal angina pectoris. The symptoms were provoked at cardiac catheterization by atrial pacing. Simultaneous onset of chest pain, shortness of breath, and sudden appearance of a large V wave in the pulmonary artery wedge pressure contour confirmed acute mitral valve regurgitation. Rapid reversal of these changes after nitroglycerin administration supported "papillary muscle dysfunction" as the explanation for these hemodynamic changes.

Treatment of angina pectoris. Pharmacologic approaches.

The short-acting nitrite sublingual nitroglycerin is the cornerstone of drug treatment of angina pectoris. It is most useful when given two to three minutes before activity that may precipitate an anginal attack. If disabling angina persists despite medical management and there is no contraindication, the beta-adrenergic blocking agent propranolol should be tried before coronary artery surgery is considered. Newer bera-adrenergic blocking agents do not appear to be more effective than propranolol. Digitalis may be beneficial in patients with congestive heart failure or with cardiac arrhythmias responsive to digitalis and in some patients with radiographic evidence of left ventricular enlargement or with nocturnal angina resulting from increased left ventricular end-diastolic volume. If bypass graft surgery is done, medical management must be continued postoperatively.

Expectoration of Bronchogenic Tumor Tissue

BRONCHOGENIC carcinoma can present itself in a variety of ways. Some patients with this disease may have an abnormal chest roentgenogram but no symptoms. Others may have manifestations of metastatic disease. Although cough and hemoptysis are common, expectoration of tumor tissue as a part of the presenting complaint is extremely rare. Report of a Case A 78-year-old man came to the emergency room complaining of hemoptysis for the past 12 hours. Bleeding was initially brisk but had steadily decreased in amount. He had noted an irritative cough for about three months that did not respond to antibiotics, expectorants, or bronchodilators. The patient denied any acute dyspnea, sputum production, orthopnea, paroxysmal nocturnal dyspnea, angina, ankle edema, pleuritic pain, bone pain, or weight loss. He had a myocardial infarction at 51 years of age. He was being treated for chronic atrial fibrillation, with digoxin, 0.25 mg daily. He worked 42 years in

Salve for the Aching Heart

After 20 years of undeserved neglect, nitroglycerin ointment is now coming into its own. The need for it is obvious. Sublingually administered nitroglycerin, with its fleeting effect, is inadequate for unstable nocturnal or variant angina. Long-acting nitroglycerin preparations for oral administration lose much of their effectiveness through inactivation of nitrate in the liver. In bypassing the portal circulation, nitroglycerin ointment offers a logical alternative. That the alternative is also practical has been confirmed by recent clinical trials. Reichek and associates 1 reported gratifying subjective and objective results with the use of this ointment. Not only was angina forestalled in the 14 patients they studied, but there was a substantial enhancement of exercise capacity, lowering of systolic blood pressure, increase in heart rate, and diminution of exerciseinduced ST segment depression. These effects, which lasted three to five hours, were undiminished after a three-month trial in six of these patients. No evidence

Psychological and physiopathological study on coronary patients.

In this paper the AA have tried to define the relationship between psychopathological characteristics or symptoms and angina attacks in coronary patients. The research plan was agreed upon and carried out as a collaborative program between psychiatrists and internists with the goal of reaching a more comprehensive approach to the psychosomatic patient. In 20 patients suffering from nocturnal angina attacks the polygraphic sleep recording was performed; 10 of them received psychodiagnostic examination (MMPI). In 8 cases during sleep recordings hemodynamic monitoring was also performed. The MMPI data were compared with 82 other individuals who had myocardial infarction (56 ss) and diurnal angina (26 ss) and 34 control subjects without cardiac disease. The results show that the sleep patterns were strongly affected and the most relevant alterations were recorded during the nights with ischemic episodes. No significant correlations were found between ischemic episodes and sleep stages. In no instance did the hemodynamic monitoring show an increase in the parameters related to myocardial oxygen consumption. The psychological data showed that the most severe symptomatology was observed in the nocturnal angina patients where the disease seems to be mostly related to a functional pathogenic mechanism.

Sleep Research and Clinical Practice

This book contains three essays commissioned by the American College of Psychiatrists to introduce practicing psychiatrists to clinical sleep research. In the first essay Dement and Mitler define terminology and review recent studies of animal sleep. Williams and Karacan in the second chapter discuss a wide array of sleep-related symptoms and diseases including narcolepsy, cataplexy, nightmares, insomnia, snoring, sleepwalking, sleeptalking, depression, schizophrenia, hypothyroidism, uremia, asthma, and emphysema, as well as nocturnal seizures, tooth-grinding, angina, headache, dyspnea, and hemoglobinuria. Though each of these problems is only briefly considered, the broad scope of this essay written by psychiatrists for psychiatrists demonstrates how sleep research is helping to reintegrate psychiatry into general medicine. This chapter concludes with 220 references to the original literature. In the final essay the Drs. Kales review their own experience with various sleep disorders with emphasis on insomnia. They find that most patients with chronic insomnia are depressed and

Angina pectoris induced by intravenous administration of 50 per cent glucose.

Frequent tracings of ECG during attacks of the nocturnal angina pectoris of a 69-year-old man failed to show any evidence of angina pectoris electrocardiographically. Angina pectoris was, however, induced by an intravenous administration of 50% glucose unexpectedly, and relieved by sublingual nitroglycerin and oxygen inhalation. The mechanism of this unusual phenomenon was discussed in relation to the serum-potassium, plasma-insulin, and the spasm of the coronary artery.

Digitalis as an Antianginal Agent

The effect of a 0.25 mg daily digoxin dose was evaluated in a double-blind crossover study in 17 anginal patients with a normal sized heart, 9 of whom had nocturnal angina. The frequency of anginal episodes was decreased at least 50 percent in 2 of 17 patients (12 percent) and increased at least 100 percent in 2 of 17 patients (12 percent) on digoxin compared to placebo. The frequency of nocturnal angina decreased at least 50 percent in four of nine patients (44 percent) and increased at least 100 percent in three of nine patients (33 percent) on digoxin compared to placebo. Exercise performance until angina was significantly decreased in one of eight patients (12 percent) without nocturnal angina and significantly improved in three of nine patients (33 percent) with nocturnal angina on digoxin compared to placebo. These results indicate that digitalis is of no benefit in anginal patients with a normal sized heart without nocturnal angina but should be given a therapeutic trial in patients with nocturnal angina.

Direct arterial pressure and the electrocardiogram in unrestricted patients with angina pectoris.

Direct arterial pressure and electrocardiogram have been recorded over a 24 hr period in 8 males with angina pectoris who were completely unrestricted throughout the study. Twenty-five separate episodes of angina occurred, precipitated by exertion, eating, smoking, and anxiety, in addition to 2 spontaneous attacks and 2 episodes of nocturnal angina. All but 2 angina episodes were accompanied by a rise in both arterial pressure and heart rate. In the cases of spontaneous and nocturnal angina these pressure and rate changes began 10-15 min before the pain. In exertional angina these changes were related to the degree of activity involved, while in other instances there was a brief surge of pressure and rate occurring at the time of onset of pain. In each patient pain tended to occur at approximately the same level of pressure-rate product. ST-segment changes in the electrocardiogram showed no consistent pattern, occurring before or after the onset of pain, while in some episodes there was no significant change. A limited number of observations were made on the effect of glyceryl trinitrate and β-adrenergic receptor blocking drugs.

Nocturnal Angina Pectoris With Disease of a Single Coronary Artery

A premenopausal woman with nocturnal angina pectoris and severe, focal, single-vessel coronary artery (left anterior descending) disease was successfully treated with coronary artery bypass surgery. A possible cause of the angina decubitus in this case was redistribution of fluid, with consequent left ventricular failure.

All-night polygraphic studies of nocturnal angina pectoris.

In 12 patients with nocturnal angina pectoris, all-night continuous polygraphic recordings were made, including electroencephalogram, electrooculogram, electromyogram, impedance pneumogram and electrocardiogram, and ECG was analyzed in relation to heart rate and sleep stages. Out of 58 episodes of ischemic ST, T changes which were recorded with the peak frequency between 4:00 and 6:00a.m., 24 were REM-associated and 21 occurred in awake state.The number of attacks per hour in individual sleep stages was most prominent in REM sleep stage. In 3 cases episodes were seen only in awake period, and in 1 case in NREM sleep stages alone.The analyses of ECG and heart rate during sleep disclosed that the attacks were not likely to be induced by REM-associated increase of heart rate and, in individual episodes, heart rate increase did not precede the ST, T changes. The triggering mechanism of attacks remains to be investigated.Two representative cases were presented.

Noncoronary Factors in the Anginal Syndrome

Of 253 consecutive subjects examined prospectively for gallbladder disease, hiatus hernia and cervical-spine disease during hospitalization for coronary angiographic studies, 170 had all three examinations and formed the major subgroup for analysis. There was no significant increase in the prevalence of any of these disorders either in the coronary patients with prandial angina or in those with nocturnal chest pain. Fifty-one subjects exhibiting classic angina pectoris but with normal coronary arteriograms were similarly studied. No differences were found in the prevalence of gallbladder disease, hiatus hernia or cervical-spine disease in this group. The noncardiac factors mentioned showed no consistent association with coronary heart disease, nor did they appear to contribute significantly to the genesis of prandial or nocturnal angina or to the syndrome of angina pectoris with normal coronary arteriograms.

Evaluation, Diagnosis, and Treatment of Clinical Conditions Related to Sleep

Specific sleep stages are associated with or altered by clinical conditions such as aging, disease states, sleep disorders, and drug use. Gastric acid secretion in patients with duodenal ulcers and nocturnal angina attacks in patients with coronary disease are associated with rapid eye movement (REM) sleep. Sleepwalking and night terrors occur predominantly during stage 4 sleep, while attacks of dyspnea in asthmatic children occur in all stages except stage 4. Enuretic episodes occur predominantly in nonrapid eye movement (NREM) sleep. In treating insomnia, drugs which are effective in the sleep laboratory are recommended. Following the withdrawal of REM suppressant hypnotics, insomnia, increased dreaming, and nightmares may occur and lead to drug dependence. If these drugs are withdrawn, very gradual withdrawal is recommended as well as informing the patient of possible increases in dream frequency and intensity.

Evaluation, diagnosis, and treatment of clinical conditions related to sleep

Specific sleep stages are associated with or altered by clinical conditions such as aging, disease states, sleep disorders, and drug use. Gastric acid secretion in patients with duodenal ulcers and nocturnal angina attacks in patients with coronary disease are associated with rapid eye movement (REM) sleep. Sleepwalking and night terrors occur predominantly during stage 4 sleep, while attacks of dyspnea in asthmatic children occur in all stages except stage 4. Enuretic episodes occur predominantly in nonrapid eye movement (NREM) sleep. In treating insomnia, drugs which are effective in the sleep laboratory are recommended. Following the withdrawal of REM suppressant hypnotics, insomnia, increased dreaming, and nightmares may occur and lead to drug dependence. If these drugs are withdrawn, very gradual withdrawal is recommended as well as informing the patient of possible increases in dream frequency and intensity.

Reconstitution of Coronary Blood Flow Using Autogenous Vein Bypass Grafts.

Meeting Abstracts1 May 1970Reconstitution of Coronary Blood Flow Using Autogenous Vein Bypass Grafts.William L. Winters Jr., M.D., F.A.C.P., Paul K. Peterson, M.D., F.A.C.P., George C. Morris, M.D., Jimmy Howell, M.D., George Reul, M.D., H. Liston Beazley, M.D., F.A.C.P., Don W. Chapman, M.D., F.A.C.P.William L. Winters Jr., M.D., F.A.C.P.Search for more papers by this author, Paul K. Peterson, M.D., F.A.C.P.Search for more papers by this author, George C. Morris, M.D.Search for more papers by this author, Jimmy Howell, M.D.Search for more papers by this author, George Reul, M.D.Search for more papers by this author, H. Liston Beazley, M.D., F.A.C.P.Search for more papers by this author, Don W. Chapman, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-72-5-781_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptOur group's extensive successful use of autogenous vein grafts in bypass and reconstruction of small arterial vessels in extremities prompted use of similar bypass grafts in the coronary circulation. The first 75 patients so treated are reported. There were 65 men and 10 women with ages ranging from 30 to 72 years. All experienced exertional angina, 50% with rest or nocturnal angina. All were under medical coronary programs with incomplete control of symptoms. Duration of symptoms ranged from 3 months to 6 years. One third had ECG evidence of a prior myocardial infarction. One third had elevated left ventricular end-diastolic... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Houston, Tex. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 May 1970Volume 72, Issue 5Page: 781-781KeywordsAnginaBlood flowMyocardial infarctionVeins Issue Published: 1 May 1970 PDF DownloadLoading ...

Nocturnal Angina Pectoris

To the Editor:— A major precipitating factor in nocturnal angina pectoris has not been stressed. I am impressed that angina occurring during sleep is the result of the tremendous physiologic response to dreams. Several authors have noted increases and irregularity of heart rate, respiration, and arterial pressure occurring in nearly all instances of D-sleep (sleep associated with dreaming). 1,2 Shifts in the blood pressure might be dangerous to a cardiac patient, and as early as 1921, it had been suggested that sudden death during sleep of patients with heart disease was probably caused by blood pressure changes associated with dreaming. 3 I have recently had occasion to see a 68-year-old woman with a two-month history of nocturnal angina. The patient had already been receiving long-acting nitrates, she eats lightly, and has no upper- gastrointestinal tract problems. The patient awakens with chest pain, walks around the room, and has dreamed of