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Because of recent studies suggesting that vasodilators affect ventricular compliance, we studied the effect of sodium nitroprusside and nitroglycerin on the mechanical performance of 21 isolated cat papillary muscles. The muscles were stimulated isometrically at 36 beats/min. Sixteen of the muscles were made hypoxic (95% N2, 5% CO2) for 50 minutes and then reoxygenated. Sodium nitroprusside (10(-5) M) added to four of these muscles prior to hypoxia substantially diminished the tension prolongation (both the time to peak tension, TTP, and time for tension to fall to 1/2 its peak value, RT 1/2) that characterizes recovery from hypoxia. TTP and RT 1/2 measured 2 minutes after reoxygenation were 300 +/- 20 msec and 528 +/- 26 msec for the control muscles compared to 208 +/- 13 msec and 248 +/- 22 msec for the muscles pretreated with nitroprusside. Nitroprusside had no effect on the fall and recovery of peak developed force or on the rise and fall of resting force. Furthermore, nitroprusside had no effect on the above parameters in nonhypoxic muscles. We also found that nitroprusside in concentrations of 10(-7) M and nitroglycerin in concentrations of 10(-5) M had little or no effect on tension prolongation. The results of the study indicate that nitroprusside is capable of blocking the tension prolongation that occurs during recovery from hypoxia and may prevent the incomplete myocardial relaxation thought to characterize this phenomenon. Since nitroglycerin had no effect on tension prolongation, it is possible that other factors also may be important in the apparent increase in left ventricular compliance associated with administration of vasodilators to patients.

This document has been developed as a Clinical Expert Consensus Document (CECD), combining the resources of the American College of Cardiology Foundation (ACCF) and the European Society of Cardiology (ESC). It is intended to provide a perspective on the current state of management of patients with hypertrophic cardiomyopathy. Clinical Expert Consensus Documents are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF and the ESC concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by expert consensus documents are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines process. Often the topic is the subject of considerable ongoing investigation. Thus, the reader should view the CECD as the best attempt of the ACC and the ESC to inform and guide clinical practice in areas where rigorous evidence may not yet be available or the evidence to date is not widely accepted. When feasible, CECDs include indications or contraindications. Some topics covered by CECDs will be addressed subsequently by the ACC/AHA Practice Guidelines Committee. The Task Force on Clinical …

Preamble......1479 The present document is an Expert Consensus Document that includes evidence about the standards for the acquisition, measurement, and reporting of intravascular ultrasound studies (IVUS). This document is intended to inform practitioners, payers, and other interested parties of

Fifty-three patients were studied with combined echo-phonocardiography or phonocardiography alone following prosthetic valve replacement. In sixteen of these patients, clinical deterioration developed, and all subsequently underwent cardiac catheterization and/or surgery. Two patients came to autopsy. Included in this group of sixteen patients were five with obstructed prosthesis, six with paravalvular regurgitation, and five with left ventricular dysfunction. Measurements were made of the time interval from the aortic valve closure sound to the peak opening of the mitral prosthesis determined echocardiographically or to the mitral prosthetic opening click (A2-MVO). Echocardiographic studies of left ventricular wall motion were also performed. The A2-MVO interval was significantly shortened (P less than 0.01) with prosthetic valve obstruction (.05 +/- .02 sec) and paravalvular regurgitation (.05 +/- .01 sec) compared with normally functioning prostheses (Starr-Edwards ball valves .10 +/- .02 sec, Lillehei-Kaster tilting disc prostheses .09 +/- .01 sec). Shortening of this interval was not specific for these conditions because it was sometimes shortened with left ventricular dysfunction. Echocardiographic studies of left ventricular wall motion were helpful in distinguishing among prosthetic valve obstruction, paravalvular regurgitation and left ventricular dysfunction. The combined echo-phonocardiographic technique was especially helpful in detecting malfunction of tilting disc prostheses, because the technique enables measurement of the A2-MVO interval in the absence of an audible opening click.

The effect of sodium nitroprusside on the relationship between left ventricular pressure and volume during diastole was studied in 11 patients with congestive heart failure. Nitroprusside was infused to lower mean arterial pressure approximately 20-30 mm Hg. High fidelity left ventricular pressures were recorded in all patients simultaneously with left ventricular cineangiography (biplane in eight and single plane in three patients), allowing precise measurement of pressure and volume throughout the cardiac cycle. Left ventricular diastolic pressure-volume curves were constructed in each patient from data obtained before and during nitroprusside infusion. In 9 of 11 patients there was a substantial downward displacement of the diastolic pressure-volume curve during nitroprusside infusion, with left ventricular pressure being lower for any given volume with nitroprusside. Serial left ventricular cineangiograms performed 15 min apart in six additional subjects who did not receive sodium nitroprusside showed no shift in the diastolic pressure-volume relation, indicating that the shift seen with nitroprusside was not due to the angiographic procedure itself. A possible explanation for the altered diastolic pressure-volume relationships with nitroprusside might be a direct relaxant effect of nitroprusside on ventricular muscle, similar to its known relaxant effect on vascular smooth muscle. Alternatively, nitroprusside may affect the diastolic pressure-volume curve by affecting viscous properties or by altering one or more of the extrinsic constraints acting upon the left ventricle.

We report the presence of an unusual systolic murmur associated with a traumatic left ventricular pseudoaneurysm. Echophonocardiographic studies showed the murmur to begin at the first heart sound, but end well before the second heart sound. It seems likely that the murmur is caused by the systolic flow of blood from the left ventricle into the relatively noncompliant pseudoaneurysm. The echocardiographic scan of the left ventricle demonstrated a relatively echo-free space posterior to the left ventricular wall, supporting the diagnosis of pseudoaneurysm, which was confirmed with angiographic studies and at surgery. These findings indicate that a combination of noninvasive techniques is useful in establishing this diagnosis.

Acute and follow-up angiograms were analyzed in 75 patients with acute myocardial infarction treated with emergency coronary angioplasty to determine factors that might predict improvement in left ventricular ejection fraction. Ejection fraction improved 8.4 +/- 8.2% in 60 patients who maintained patent infarct vessels at follow-up angiography, compared with -4.1 +/- 6.0% in 15 patients who developed reocclusion (p less than .001). In patients with patent infarct vessels, univariate analysis revealed the following significant predictors of improvement in ejection fraction: initial ejection fraction (r = -.38, p less than .003) subtotal vs total stenosis (12.9 +/- 9.3% vs 6.9 +/- 7.3%, p less than .02), infarct vessel (left anterior descending 11.0 +/- 8.4%, right 6.8 +/- 6.4%, circumflex 2.6 +/- 7.5%, p less than .02), and time to follow-up study (less than or equal to 15 days vs greater than 15 days) (4.8 +/- 5.8% vs 9.8 +/- 8.6%, p less than .03). Reperfusion time (less than or equal to 2 hr vs greater than 2 hr) predicted improvement when subtotal stenoses and stuttering infarctions were excluded (10.6 +/- 7.0% vs 4.9 +/- 6.9, p less than .03). Multivariate analysis showed initial ejection fraction and subtotal vs total stenosis to be independent predictors. Patients with anterior infarctions, low initial ejection fractions, and subtotal stenoses or reperfusion times less than or equal to 2 hr are likely to benefit most from coronary angioplasty for acute myocardial infarction.

The physiologic correlates of ejection sounds have been studied by simultaneous phonocardiograms, echocardiograms and high fidelity pressure tracings. Ejection sounds associated with semilunar valve stenosis or hypertension of the systemic or pulmonary circulation occur at the moment of complete opening of the aortic or pulmonary valve recorded echocardiographically. The start of opening of these valves occurs at the onset of the pressure rise in the corresponding great vessel and completion of valve opening always occurs on the pressure upstroke. The ejection sound in the presence of stenotic valves occurs with checking of the opening motion of the thickened valve cusps. Although the hypertensive ejection sounds also occur at the precise moment of full opening of the valve it remains to be seen whether this relationship is causal or coincidental.

• Emergency coronary angioplasty was performed in 127 patients presenting to a community hospital with acute myocardial infarction. Reperfusion and successful dilatation were performed in 117 patients (92%) at 3.3 ± 1.8 hours from the onset of pain. Eleven patients (8.6%) died, ten patients (7.9%) developed reocclusion, and ten patients (7.9%) required coronary bypass surgery during the initial hospitalization. Late restenosis occurred in 36% (27/76) of patients restudied or 27% (27/100) of patients at risk for restenosis. Ejection fraction improved in patients with patent vs occluded vessels (8.4%± 8.2% vs -4.1%±6.0%) and improved most in anterior vs inferior vs posterolateral infarcts (11.0% ±8.4% vs 6.8% ±6.4% vs 2.6%±7.5%). Posthospitalization follow-up in all patients (mean, 13.4 months) revealed only one late death. Of the patients followed up, 83% had no angina, and 17% of patients had mild angina. Our experience demonstrates that coronary angioplasty for acute myocardial infarction can be performed in the community hospital by an experienced cardiovascular laboratory team with a high success rate, a low reocclusion rate, an improvement in ejection fraction, and an excellent long-term prognosis. The community hospital setting allows early access to patients and creates the potential for early reperfusion and myocardial salvage. ( Arch Intern Med 1987;147:1565-1570)

Results: Angiographic restenosis occured in 44/318 pts and 45/355 lesions (12.7%). BMS use (46% vs 21%, p

Background: In the randomized HORIZONS-AMI trial, implantation of paclitaxel-eluting stents (PES) as compared to bare-metal stents (BMS) in pts with STEMI signiicantly reduced recurrent ischemia, with similar rates of death, reinfarction and stent thrombosis (ST). We assessed the impact of diabetes mellitus (DM) on clinical outcomes at 3 years in this trial. Methods: In HORIZONS-AMI, 3,006 pts were randomized in a 3:1 ratio to receive PES or BMS, stratiied by the presence of DM at the time of admission. Ischemia-driven target lesion (TLR) or target vessel revascularization (TVR), major adverse cardiovascular events (MACE: death, reinfarction, ischemic TVR or stroke) and ST were assessed according to diabetic status at 3 years. Results: Of the 3,006 randomized pts, 478 (15.9%) presented with DM. The 3-year rates of reinfarction (8.9 vs. 6.5%, p=0.09) and ST (6.0% vs. 4.7%, p=0.27) were comparable between DM vs. non-DM pts, whereas death (10.3% vs. 5.0%, p

Reperfusion therapy has been expanded to include elderly pts (EL), and primary angioplasty (PTCA) has been promoted as a preferable alternative to thrombolytic therapy (TT) for acute myocardial infarction (AMI) in the elderly (EL). The purpose of this study was to compare outcomes of EL and non-EL pts considered eligible to receive TI who received PTCA for AMI. Patients with cardiogenic shock, prior bypass, and reperfusion time g 12 hrs were considered ineligible for TT. Of 781 consecutively treated pts eligible for TT, 75 (9.6%) were ≥ 75 yrs, and 706 (90.4%) were l 75 yrs. EL were more likely to be women (50.7 vs 25.1%, P l 0.0001), have prior AMI (32 vs 18.1%, P l 0.01), and to have anterior infarction (64 vs 40.1%, P l 0.0001). Baseline ejection fraction and reperfusion time were similar in both groups. Outcomes are listed below. l75 years (n = 706) ≥75 years (n = 75) P Value Successful PTCA 664 (94.1%) 74 (98.1%) 0.16 Lab Death 8 (1.1%) 2 (2.7%) 0.24 Hospital Mortality 36 (5.1%) 16 (21.3%) 0.00001 Reinfarction 32 (4.6%) 7 (9.5%) 0.11 Recurrent Ischemia 19 (2.7%) 4 (5.3%) 0.40 Stroke 4 (0.6%) 4 (5.3%) 0.004 For pts l65 yrs (n = 522) compared to ≥ 65 yrs (n = 259), hospital mortality was 3.4% vs 13.1%, P l 0.0001. Conclusion Despite a high rate of successful reperfusion, PTCA in elderly TT candidates is associated with considerable mortality and morbidity. Further study is needed to establish the best option for the elderly

High platelet reactivity (HPR) has been associated with an increased coronary atherosclerotic burden. However, plaque morphology has not been evaluated in these studies. ADAPT–DES was a prospective, multicenter, observational study of 8,583 pts undergoing PCI with DES in whom platelet reactivity

Patients with acute coronary syndromes (ACS) who undergo stent implantation have increased on-treatment platelet reactivity (HPR), which has been associated with post-procedural thrombotic events. ADAPT-DES was a prospective multicenter observational study of 8,575 unselected patients undergoing