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The tendency of oral diltiazem (a calcium entry blocking agent and a negative inotrope) to induce or exacerbate congestive heart failure when used for the long term management of myocardial ischaemia in patients with poor left ventricular function has not been investigated before. Twenty two patients (aged 42-73 years) with pretreatment left ventricular ejection fraction ranging from 0.11 to 0.39 were given open label oral diltiazem (120-360 mg/24 h (mean 254 mg)) for two weeks to 16 months (mean 7.5 months, median 6.2 months). There was a weight change of greater than 3 lb (1.35 kg) in nine patients--five gained weight and four lost it. Diltiazem treatment did not alter the mean (SD) cardiothoracic ratio on chest x ray (0.47 (0.06) before vs 0.48 (0.05) after) or the left ventricular ejection fraction at rest (0.28 (0.09) before vs 0.26 (0.08) after). Diltiazem was discontinued in one patient because of symptoms indicative of worsening congestive heart failure. No patient required admission to hospital for treatment of symptoms resulting from further left ventricular decompensation. Diltiazem was discontinued in six other patients for other reasons. Long term administration of oral diltiazem was not regularly associated with a deterioration in clinical, radiographic, or radionuclide ventriculographic estimates of left ventricular function, even in patients with poor baseline left ventricular systolic performance. [ABSTRACT FROM PUBLISHER]

Two dimensional echocardiographic criteria for bicuspid aortic valve recognition have greater specificity than previously proposed M-mode echocardiographic criteria. The potential clinical use of the two dimensional technique is, however, limited by the technical inability to image adequately the aortic valve leaflets in many patients. One hundred consecutive adult patients undergoing two dimensional echocardiography were prospectively studied. Valve cusp number could not be determined because of dense calcification in eight patients. A bicuspid aortic valve was diagnosed in a single subject. A parasternal short axis view disclosed three commissures (diastolic "Y" configuration) in only 26 patients. Technically adequate parasternal short axis imaging was more likely in younger patients and in non-smokers. In patients not successfully imaged from the parasternal approach, an anteriorly tilted apical four chamber view showed a diastolic "Y" configuration in an additional eight cases. Considering the high prevalence in our population of incomplete two dimensional echocardiographic aortic valve leaflet imaging, angiographic and/or pathological studies must be performed to establish the correlation between these incomplete echocardiographic patterns and aortic valve anatomy if two dimensional echocardiography is to have widespread application in the diagnosis of the congenital bicuspid aortic valve. [ABSTRACT FROM PUBLISHER]

Thirty-seven patients were evaluated before cardiac catheterisation by bedside physical examination, including Valsalva manoeuvre, to assess the value of the sphygmomanometrically determined arterial pressure responses during the Valsalva manoeuvre and to compare its sensitivity, specificity, and predictive accuracy in the detection of left ventricular dysfunction with that of the commonly used diagnostic signs including the chest x-ray. Patients not on beta-blockade treatment could be separated into three distinct arterial pressure responses detectable at the bedside which corresponded well to three statistically different groups with regard to left ventricular ejection fraction (0.29 +/0 0.11, 0.48 +/0 0.15, 0.69 +/0 0.11) and left ventricular end-diastolic pressure (38 +/- 5 mmHg, 24 +/- 10 mmHg, 14 +/- 5 mmHg) at subsequent cardiac catheterisation. In patients not on beta-blockade it was shown for the first time that (1) the height of the systolic arterial pressure overshoot was directly related to left ventricular ejection fraction and inversely related to left ventricular end-diastolic pressure, and that (2) the bedside sphygmomanometrically determined arterial pressure response during Valsalva manoeuvre provided a semiquantitative estimate of left ventricular function and was unsurpassed in its ability to do so by any of the standard diagnostic signs including the chest x-ray film. [ABSTRACT FROM PUBLISHER]