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Repeated measurements of lidocaine serum levels during antiarrhythmic treatment were performed by enzyme-immunoassay (EMIT) in 16 patients with acute myocardial infarction. In 12 cases the frequently employed standard dose (100 mg i.v. followed by infusion of 2 mg/min) was not sufficient to reach optimum lidocaine (2-5 mg/l) during the first 2 hours. In this period 6 patients had persistent ectopic beats and required additional bolus injections and increased infusion rates. Lidocaine elimination was delayed in patients with heart failure, which led to potentially toxic drug accumulation in 3 instances. This study indicates the need for individual adaptation of lidocaine dosage in patients with myocardial infarction, especially where left ventricular function is impaired. Monitoring of serum lidocaine levels by a rapid and reliable assay such as the EMIT system may greatly facilitate this task.

Cardiac tamponade (CT) is a life-threatening complication of pericardial effusion which must be diagnosed and treated as soon as possible. The diagnostic value of the various symptoms and clinical signs, and the problems of pericardial puncture and drainage are reviewed in a group of 50 patients. Dyspnea was the most frequent symptom (92%), while elevated jugular venous pressure and pulsus paradoxus were the dominant findings in all patients. Non-specific enlargement of cardiac shadow on chest x-ray (98%) and low voltage in the electrocardiogram (62%) also provided important diagnostic information. However, echocardiography was the most reliable method of confirming the presence of pericardial fluid and assessing its quantity. The underlying cause of CT was most often malignant tumor (58%), followed by uremia (16%), idiopathic pericarditis (12%) and post-cardiotomy syndrome (10%). Removal of the pericardial fluid resulted in rapid improvement in all cases. Left parasternal drainage under echocardiographic control in 23 patients with a broad (greater than 10 mm) anterior echofree space proved to be a rapid and safe alternative to subxiphoidal puncture or surgical drainage. Longterm prognosis depends on the underlying disease. As might be expected, survival time is usually short in malignant pericarditis; however, even such cases warrant active treatment to relieve subjective symptoms.

Among 40 patients with cardiac tamponade observed over the years 1972--1978, 23 (57.5%) had a neoplasm as primary cause of illness. The most common etiology was bronchial carcinoma (13). In 9 cases cardiac tamponade was the first clinical symptom of the tumor. Evacuation of the pericardial fluid by puncture (3), surgical drainage (6) and left parasternal insertion of a plastic catheter (12) brought rapid relief from symptoms in all cases. Six patients survived 3--6 months, while another two have now been followed up for over 5 years. Diagnostic problems and therapeutic possibilities in malignant pericarditis are discussed.

54 patients with mitral incompetence of varying origin have been studied by echocardiography. Echocardiography was usually not helpful in the diagnosis of pure mitral incompetence of mixed mitral valve lesions. However, it proved to be a sensitive method for recognition of the typical anomaly in "mid systolic click/late systolic murmur syndrome", which is ballooning of one or both leaflets toward the left atrium (17 out of 22 patients). The echo was equally useful for documentation of an abnormal systolic motion of the anterior mitral leaflet toward the septum, which was found in 7 of the 11 studied cases of hypertrophic obstructive cardiomyopathy.

Carotid sinus massage was performed in 100 consecutive patients over the age of 50 years: 63 showed a normal reaction and sinus bradycardia occurred in 12, whereas sinus arrest was registered in 22 and total AV block in 3. With atrial pacing only 2 patients with sick sinus syndrome could be detected. Intravenous administration of atropine did not help to identify them. We conclude that in 1/4 to 1/3 of these elderly people the sinus node reacts in a hypersensitive manner to carotid sinus massage, but this does not imply the diagnosis of sick sinus syndrome.