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The mechanism by which angiotensin-converting enzyme inhibitors reduce mortality rates and disease progression in patients with heart failure is likely mediated in part through prevention of adverse ventricular remodeling. This study examined the effects of the angiotensin-converting enzyme inhibitor captopril and the angiotensin II type 1 receptor antagonist losartan on ventricular volumes and function in elderly patients with heart failure and reduced left ventricular ejection fraction (or =40%).Patients underwent radionuclide ventriculograms (RVG) at baseline and were randomized to either captopril (n = 16) or losartan (n = 13). After 48 weeks, another RVG was obtained. Therapy was then withdrawn for at least 5 days, and the RVG was repeated while the patient was not receiving the drug.At 48 weeks both captopril and losartan significantly reduced left ventricular (LV) end-diastolic volume index (135 +/- 26 to 128 +/- 23 mL/m(2) for losartan, P.05 vs baseline; 142 +/- 25 to 131 +/- 20 mL/m(2) for captopril, P.01; mean (SD). Captopril also reduced LV end-systolic volume index (98 +/- 24 to 89 +/- 21 mL/m(2), P.01 vs. baseline), whereas a nonsignificant trend was observed for the losartan group (97 +/- 23 to 90 +/- 16 mL/m(2), P = not significant). The between-group differences in the changes in LV volumes were not statistically significant. After drug withdrawal, LV end-diastolic volume index remained significantly lower than baseline in the captopril group (P.01).Both captopril and losartan prevent LV dilation, representing adverse ventricular remodeling, previously seen with placebo treatment. Reverse remodeling was observed in the captopril group. On the basis of these results, the relative effects on LV remodeling do not provide a rationale for a survival benefit of losartan over captopril.

More than 2 million patients are hospitalized annually in this country because of chest pain suggestive of myocardial ischemia. However, a coronary event is demonstrated in

Tilt-table testing after therapy with beta blockade is frequently used to predict clinical success. This study found that heart rate and blood pressure reductions after beta-blocker therapy did not predict the results of the follow-up tilt-table test, but low blood pressure at rest before the initial test predicts failure of this therapy.

The objective of this multicenter, randomized, double-blind, placebo-controlled study was to determine the safety and efficacy of intravenous diltiazem in the treatment of 37 patients with rapid (ventricular rate, mean +/- SD 142 +/- 17 beats/min) atrial fibrillation or flutter and moderate to severe congestive heart failure (ejection fraction, mean +/- SD 36 +/- 14%; New York Heart Association class III [23 patients], class IV [14 patients]). During the double-blind portion of the study, patients received either intravenous diltiazem, 0.25 mg/kg over 2 minutes, or placebo followed 15 minutes later by diltiazem or placebo, 0.35 mg/kg over 2 minutes, if the first dose was tolerated but ineffective. Placebo nonresponders were given open-label intravenous diltiazem in a similar fashion as in the double-blind portion of the study. In the double-blind part of the study, 21 (18 with 0.25 mg/kg, 3 with an additional 0.35 mg/kg) of the 22 patients (95%) responded to diltiazem, and 0 of 15 patients (0%) responded to placebo (p0.001). All 15 patients (13 with 0.25 mg/kg and 2 with an additional 0.35 mg/kg) who received placebo during the double-blind period had a therapeutic response to diltiazem during open-label therapy. Overall, 36 of 37 patients (97%) had a therapeutic response to intravenous diltiazem. Heart rate response to diltiazem after the 2-minute bolus infusions consisted of aor = 20% decrease in heart rate from baseline in 36 patients; in addition, 17 patients also had heart rates decreased to100 beats/min, whereas no patient had conversion to sinus rhythm.(ABSTRACT TRUNCATED AT 250 WORDS)

4 A 26-year-old man presented with near-syncope and venricular tachycardia (VT) at 270 bpm. The VT morphology was eft bundle branch block with inferior axis pattern. Cardiac agnetic resonance imaging revealed right ventricular (RV) ysplasia as a probable source of the VT. During electrophysilogic testing, two different morphologies of VT were induced y programmed cardiac stimulation. Both VT morphologies xhibited a left bundle branch block, superior axis pattern, onsistent with an RV site of origin. Radiofrequency ablation f two inferior basal right ventricular sites did not ameliorate nducible VT. The patient underwent an RV disarticulation operation. he RV was dissected free along the left anterior descending oronary artery, extending superiorly to just under the pulmoary valve and posteriorly back to the crux of the posterior escending coronary artery. Cryoablation was performed in egions under the tricuspid valve and the moderator band. uring the postoperative period, the patient developed signs of V failure. Normal sinus rhythm apparently was maintained, nd there were no further recurrences of VT (Figure 1). The atient was taken to the electrophysiology laboratory on postperative day 42 to establish the cardiac rhythm in the RV. ultiple RV locations were mapped. Figure 1 shows a repreentative recording of RV electrical activity in one of the ocations. ECG leads I, II, aVF, and V1 demonstrate sinus achycardia with inferior Q waves. The next channel (labeled RV”) demonstrates recordings from a bipolar catheter placed n the right ventricular apex. Open arrows show electrograms ssociated with sinus rhythm recorded from left ventricular yocardium, which was not disconnected during the operation long the RV septum. Closed arrows identify RV electrograms ecorded from the disarticulated RV free wall. The RV elecrograms revealed ongoing RV tachycardia (cycle length 400 s), which persisted even though the remainder of the heart as in sinus rhythm. Moreover, the surface ECG revealed inus rhythm but not VT.

Electrophysiologically guided surgical procedures for the ablation of supraventricular and ventricular dysrhythmias often require prolonged periods of tachycardia to complete intraoperative mapping studies. It is unknown whether tachycardia depletes the myocardium of high-energy compounds or alters subsequent tolerance to ischemia. In the present study, 12 anesthetized dogs were paced from the right ventricle at a cycle length of 250 msec for 60 minutes. In seven animals, drill biopsy specimens were taken from the left ventricular free wall for analysis of adenine nucleotide levels and their breakdown products before and after pacing and after 20 minutes of recovery from pacing. In the remaining five animals, the heart was made totally ischemic immediately after tachycardia and the time to the onset of ischemic contracture was determined and compared to that of five nonpaced control dogs. Acute tachycardia resulted in no significant reduction in adenine nucleotide levels compared to control values. Furthermore, in hearts rendered totally ischemic after tachycardia, the mean time to ischemic contracture was 65.6 +/- 1.3 minutes versus 63.6 +/- 2 minutes in nonpaced control animals (no significant difference). These data show that pacing-induced tachycardia in the normal heart does not decrease adenine nucleotide levels or affect subsequent tolerance to ischemia. These results may be clinically relevant to patients without coronary artery disease who undergo operative procedures necessitating prolonged periods of tachycardia for intraoperative mapping to identify the site of arrhythmogenesis.

The majority of high-energy nucleotides and their catabolites are separated in a single 13-min run using reversed-phase high-performance liquid chromatography. Economical step gradient elution of these compounds with a Nova Pak-A C18, 5-microns, 10 cm X 8 mm column accomplishes this separation with recoveries of 94-100% and sensitivities of 1-5 pmol. Furthermore, the total adenine nucleotide pool can now be quantitated precisely in a simple and easily automated procedure.

A massive embolus of the central retinal artery occurred during cardiac catheterization and selective coronary angiography. Anterior chamber paracentesis and coughing resulted in restoration of retinal blood flow and vision within two hours. In two other cases retinal arteriolar embolization was observed in patients who had minimal or no ocular symptoms after cardiac catheterization.

ObjectivesThis study sought to examine quality of care and warfarin use at discharge in patients with atrial fibrillation (AF) and heart failure (HF).BackgroundAtrial fibrillation is common in HF, and national guidelines recommend discharge on warfarin for stroke prophylaxis. However, the frequency and factors associated with the guideline adherence are poorly described.MethodsWe analyzed 72,534 HF admissions from January 2005 through March 2008 at 255 hospitals participating in the American Heart Association's Get With The Guidelines HF program. Multivariable logistic regression was used to identify independent factors associated with warfarin use at discharge.ResultsIn this HF population, 20.5% (n = 14,901) had AF on admission, whereas another 13.7% (n = 9,918) had a prior history of AF but were in a regular rhythm at admission. Contraindications to warfarin therapy were documented in 9.2%. Among eligible HF patients without contraindications, the median prevalence of warfarin therapy at discharge was 64.9% (interquartile range 55.5 to 73.4) and did not improve during the 3.5 years of study. After adjustment, major factors associated with no warfarin use at discharge included increasing age, nonwhite race, anemia, and treatment in the south. Warfarin use also varied inversely with CHADS2(congestive heart failure, hypertension, age >75, diabetes, and prior stroke or transient ischemic attack) risk (70.9% to 59.5% for CHADS2score 1 to 6, p < 0.0001).ConclusionsGuideline-recommended warfarin use in patients with AF and HF is less than optimal, has not improved over time, and varies significantly according to age, race, risk profile, region, and hospital site.

A 75-year-old woman developed an orbital mass after lacrimal duct probing. Acid-fast bacteria were observed on special stains and Mycobacterium chelonei, subspecies abscessus was isolated. The patient had been taking systemic corticosteroids.

Requirements of the Air Force computed air release point system (CARP), parachute ballistic data input to the CARP solution, airdrop capability of troop carrier aircraft, present and recommended airdrop altitudes, performance capability of existing standard parachute equipment and changes to existing standard parachute equipment having potential for improving its capability for use at lower airdrop altitudes, were reviewed. Minimum airdrop altitudes considered feasible using existing unmodified standard parachute equipment were determined.