Biomedical subjects
D Mulcahy
Publications and source records attributed to D Mulcahy.
The planovalgus rheumatoid foot--is tibialis posterior tendon rupture a factor?
The purpose of this study was to assess gross tibialis posterior tendon (TPT) integrity in a series of patients with a planovalgus foot deformity secondary to rheumatoid arthritis. This was done by means of contrast tenography. Our findings of an intact tendon in all of the seventeen patients studied suggest that complete rupture of the TPT is not the primary aetiology in the planovalgus rheumatoid foot.
Circadian rhythms and the onset of myocardial infarction: clinical implications.
There is much current interest in the development of therapeutic strategies which may alter the circadian pattern of cardiovascular events such as myocardial infarction and sudden cardiac death. It is not known whether manipulating rhythmic processes and providing active medication at the most vulnerable periods during the day or night will protect patients and reduce the risk of death. This review examines the evidence from the limited available data and assess the feasibility of implementing such strategies.
Nitrates in silent ischemia.
In recent years it has become clear that episodes of transient myocardial ischemia commonly occur in patients with coronary artery disease in the absence of chest pain or angina equivalent. These episodes of "silent myocardial ischemia" are particularly well documented during continuous ambulatory electrocardiographic monitoring in daily life. Evidence suggests that these episodes represent true ischemia, and appear to be a marker of unfavorable outcome. While the pathophysiology is not completely understood, it appears as though the mechanisms of angina and silent ischemia are the same. Both forms of ischemia respond to conventional antianginal medication. While long-acting nitrates are effective in reducing or preventing myocardial ischemia, because of their propensity to cause tolerance they should be used intermittently and in association with either beta-blockers or calcium antagonists. Nitrates are safe and comparatively inexpensive, and will continue to play an important role in the treatment and prevention of angina. However, in the light of current knowledge, there is no specific indication for the treatment of silent ischemia by nitrates.
Collateral growth between left internal mammary and left anterior descending coronary arteries following coronary artery bypass surgery.
A case is described in which new collateral vessels grew between the left internal mammary artery and the left anterior descending coronary artery following coronary artery bypass surgery. Collateralization of the coronary arteries by extra-cardiac arteries has not been previously described following bypass surgery and may have implications for the mechanisms of angiogenesis.
Circadian variations in cardiovascular disease: implications for treatment.
This review describes circadian patterns in cardiovascular disease processes and analyses the findings of recent studies. The awareness of an increased incidence of myocardial infarction and sudden cardiac death in the early morning hours, shortly after waking, has stimulated an interest in the relationship of these events and the occurrence of both silent and symptomatic myocardial ischaemia. A number of studies have been reported that examine both the physiological triggers and the underlying causes of these events. Beta-adrenergic blockers have been shown to abolish the early morning peak of myocardial infarction and blunt the morning peak in sudden cardiac death. Newer calcium antagonists, such as amlodipine, have been demonstrated to control angina throughout a 24-hour period. Aspirin is effective in preventing morning infarction. It is a reasonable aim for investigators to extend progress in the treatment of cardiovascular disease to include prevention.
Lasers, burns, cuts, tingles and pumps: a consideration of alternative treatments for intractable angina.
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Asymptomatic ischaemia during daily life in stable coronary disease: relevant or redundant?
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Effects of amlodipine versus diltiazem on morning peak in myocardial ischemic activity in angina pectoris.
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Atenolol or nicardipine alone is as efficacious in stable angina as their combination: a double blind randomised trial.
BACKGROUND: Beta blockers and calcium antagonists are widely used in the management of angina pectoris in the belief that the combination is more efficacious than either drug alone. METHODS: This double blind randomised crossover placebo controlled study compares the effects of nicardipine, atenolol and their combination in 30 patients with chronic stable angina. Each treatment period lasted 6 weeks with dose titration after 3 weeks. Symptom limited treadmill exercise testing and radionuclide ventriculography at rest was carried out at the end of each treatment period. RESULTS: Total exercise duration and time to 1-mm ST-segment depression was significantly prolonged by nicardipine and atenolol when compared to placebo, the combination offered no additional benefit. Time to onset of angina was significantly prolonged by nicardipine and the combination but not by atenolol. Indices of left ventricular function were not significantly affected by any treatment other than an increase in left ventricular end diastolic volume on atenolol and the combination. CONCLUSIONS: Nicardipine and atenolol are equally effective in prolonging exercise duration and time to onset of ischemia in patients with chronic stable angina while the combination appeared to offer no additional benefit. Nicardipine prolonged the time to onset of angina significantly; again there was no further improvement with the combination. Neither drug appears to have an important effect on the parameters of diastolic function studied in patients with chronic stable angina.
Heart rate and blood pressure consequences of an afternoon SIESTA (Snooze-Induced Excitation of Sympathetic Triggered Activity).
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Acute myocardial infarction triggered by emotional stress.
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Long term follow up of severely ill patients who underwent urgent cardiac transplantation.
OBJECTIVE: To assess long term survival (> 5 years) and quality of life in severely ill patients referred for urgent cardiac transplantation. SETTING: Tertiary referral centres: before transplantation at the National Heart Hospital (late 1984 to end 1986); after transplantation at Harefield Hospital. SUBJECTS: Eighteen patients (15 men; three women) who had required intensive support in hospital before cardiac transplantation and were alive at short term follow up. INTERVENTIONS: Intravenous infusions of cardiac drugs (mean 2.2 infusions), intravenous diuretics (17 patients), and many other drugs before transplantation. Intra-aortic balloon counterpulsation (four patients), temporary pacing (two), and resuscitation from cardiac arrest (three). Patients had specialised nursing care on a medical intensive care unit in almost every case. MAIN OUTCOME MEASURES: Long term survival in patients after urgent cardiac transplantation and perceived quality of life. RESULTS: Of 18 patients who were alive at short term follow up (mean (range) 19.4 (10-33) months), 14 were still alive in 1992 (69 (61-83) months). Ten still worked full time, and 11 reported no restrictions in their daily activities. Three of four patients who died in the intervening period survived > 5 years after transplantation. Overall, 17 of 18 patients survived at least 5 years. CONCLUSIONS: In severely ill patients who undergo urgent cardiac transplantation and survive in the short term, long term (5-7 year) survival and quality of life seem good.
Unstable and stable angina.
Treatment of both stable and unstable angina depends on initially defining the pathophysiological mechanisms. The goal of treatment is to prevent the development of angina pectoris and possibly also to improve the prognosis. beta-blockade is effective in treating effort-related angina, as are calcium antagonists, which are also effective in treating coronary spasm. Combination therapy may be synergistic, but evidence to support this is controversial. In unstable angina the main goal of treatment is the prevention of myocardial infarction and death. While calcium antagonists have not been shown to improve the prognosis, there is more evidence to support the use of beta-blockers, particularly in combination with a calcium antagonist. Aspirin and possibly heparin should be considered as routine treatment.
Recurrent parotitis.
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Prognostic significance of transient ST segment changes after coronary artery bypass surgery: a long-term (4-10 year) follow up study.
OBJECTIVE: To assess the long-term (four to 10 years) prognostic significance of transient ST segment changes on ambulatory ST segment monitoring after coronary artery bypass grafting (CABG). PATIENTS AND METHODS: 76 patients (67 men, nine women) underwent CABG between 1982 and 1984 (n = 31) and between 1987 and 1988 (n = 45) and at a mean age of 57. All underwent 48 hours of ambulatory ST segment monitoring at a mean of 19 weeks after surgery. The results were available for assessment. All general practitioners were contacted and patients' notes reviewed. Patients were contacted by telephone. Details were recorded of intervening events (acute myocardial infarction, unstable angina, need for further revascularisation, and deaths). Event free survival curves were produced for those with and without transient ST segment changes during routine postoperative ambulatory ST segment monitoring. RESULTS: During 3213 hours of monitoring after CABG, 21 (27.6%) of 76 patients had transient ST segment changes, of which 70% were silent. Over a mean 70 month follow up period, patients with such ischaemic changes were no more likely to have either an objective (myocardial infarction or cardiac death) or subjective (unstable angina or another revascularisation) event than those patients without ischaemic changes. This finding was the same in patients operated on between 1987 and 1988 and between 1982 and 1984. CONCLUSIONS: Although ambulatory ST segment monitoring is becoming increasingly popular in some countries as a routine investigation for ischaemia in various coronary subgroups, the findings of such an investigation, when performed after CABG, do not help to identify a subgroup more likely to have an adverse outcome during up to 10 years of follow up. There seems to be no reason to perform this investigation after surgery, and particularly to refer patients for reinvestigation because of the detection of predominantly silent ST segment changes of uncertain relevance.
Silent ischaemia--to treat or not to treat?
The authors summarise published data concerning silent myocardial ischaemia: they review the studies showing the poor prognosis of this type of myocardial ischaemia but pose the question of whether this is due to the severity of the lesions causing the ischaemia or to the ischaemia itself. To answer this question, it would be necessary to set up a therapeutic trial showing that treatment preventing the electrocardiographic changes of silent ischaemia is associated with an improved prognosis. In the absence of solid evidence on this point, the authors present the case for and against treatment of silent ischaemia without drawing any formal conclusions.
Effect of simvastatin on high density lipoprotein subfractions and apolipoproteins in type IIa hypercholesterolemia.
Changes in plasma concentrations of high density lipoproteins (HDL) and triglycerides may partly explain the ability of cholesterol-lowering drugs to decrease the incidence of coronary heart disease. We measured the response of fasting plasma lipids, lipoproteins, and apolipoproteins in 46 subjects with Type IIa hypercholesterolemia treated with simvastatin for 3 months. The initial dose of simvastatin (10 mg/day) was subsequently increased up to 40 mg/day if the plasma cholesterol concentration had not fallen below 5.2 mmol/l. Plasma concentrations of HDL cholesterol and of the apolipoproteins AI and AII were increased by simvastatin. The increase in HDL cholesterol (9%) was due to increases in both subfractions (HDL2 17%; HDL3 7%), changes that would be consistent with a beneficial effect on cardiovascular risk. Simvastatin decreased plasma triglyceride concentrations by 25%. Plasma total cholesterol concentrations fell by 35% after 3 months of treatment; this fall was proportional to the initial concentration and was due almost entirely to a 45% fall in low density lipoprotein cholesterol. In contrast, plasma concentrations of lipoprotein Lp(a) were not affected by simvastatin.