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Biomedical subjects

H N Hultgren

Publications and source records attributed to H N Hultgren.

At least 37 records · Page 2Linked to original sources
PubMed1985

The 5 year effect of bypass surgery on relief of angina and exercise performance.

The 5 year effect of medical vs surgical treatment on symptoms and exercise performance was evaluated in patients with stable angina who entered the Veterans Administration Cooperative Study from 1972 to 1974. Severity of angina was evaluated by a physician-administered angina questionnaire and physical working capacity was assessed by exercise testing. Angina was substantially relieved in surgical patients at 1 year, with 78% having mild or no angina compared with only 28% at entry. The corresponding rates in medical patients showed little change: 38% at 1 year and 32% at entry. At 5 years the percentage of surgical patients with mild or absent angina decreased from the 1 year rate of 78% to 64%, whereas the medical group exhibited a small increase from 38% to 49%. Similar results were obtained by evaluating changes in angina compared to entry. At 1 year 49% of surgical patients were markedly improved compared with only 12% of medical patients. At 5 years the percentage of surgical patients who remained markedly improved decreased to 41%, whereas the medical group with marked improvement increased slightly from 12% at 1 year to 17% at 5 years. Medication requirements were markedly reduced in surgical patients with only a slight increase in medical patients. Exclusion of nonadherers from the analysis did not change the results. Exercise testing revealed comparable changes in physical performance. At 1 year surgical patients had fewer tests stopped by angina compared with medical patients (28% vs 64%), a higher estimated oxygen consumption (26 vs 21 ml/kg/min) and treadmill exercise duration (7.3 vs 4.9 min). Other measures of exercise performance were comparably improved.(ABSTRACT TRUNCATED AT 250 WORDS)

Angina Pectoris↗
PubMed1984

Relation of severity of symptoms to prognosis in stable angina pectoris.

To determine if severity of angina is related to the extent of coronary artery disease (CAD) or prognosis, 341 patients were evaluated by a systematic physician-administered angina questionnaire at entry into a large-scale randomized study of medical vs surgical treatment of stable angina pectoris. Severity of angina was numerically scored; scores were based on frequency of pain, rest pain, amount of daily medication, and level of daily activity. Severity scores were separated into mild, moderate and severe groups of approximately equal numbers and correlated with (1) number of coronary arteries narrowed, (2) presence of left main CAD, (3) ejection fraction less than 50%, (4) abnormalities of left ventricular function, (5) 3-vessel CAD with abnormal left ventricular function, (6) increased heart size by chest x-ray, (7) a noninvasive measure of prognosis, and (8) mortality. Severity of angina was not significantly related to any of the above variables except for the presence of left main CAD (p = 0.046) and increased heart size by chest x-ray (p = 0.001), both of which had low prevalence rates. Severity of angina at baseline was not related to 7-year survival in patients treated medically or surgically. Severity of angina at baseline, however, did predict 1- to 2-year survival in medically treated patients. Similarly, the severity of angina at 1 year and severity at 5 years predicted survival in the subsequent 4 years in the medical group.(ABSTRACT TRUNCATED AT 250 WORDS)

Angina Pectoris↗
PubMed1984

Detection of coronary artery disease in aortic stenosis by exercise gated nuclear angiography.

Because the clinical diagnosis of coronary artery disease (CAD) in the presence of aortic stenosis (AS) is difficult, the value of exercise gated nuclear angiography in detecting CAD in 33 patients with AS was assessed. Exercise left ventricular (LV) ejection fraction (EF) and wall motion analysis were evaluated after symptom-limited supine cycle ergometer exercise. Sixteen patients had severe AS (valve area 0.8 cm2 or less). Thirteen had significant associated CAD (50% or greater reduction in luminal diameter of 1 major coronary artery). Twenty patients had normal coronary arteriograms. All 10 patients with mild to moderate AS and normal coronary arteries had normal nuclear studies. Patients with CAD, regardless of the severity of AS, had a decrease in LVEF during exercise (12 of 13 patients) and regional wall motion abnormalities (11 of 13 patients). Abnormal exercise gated nuclear ventriculographic studies occurred in the absence of CAD in 10 of 20 patients, and all had severe AS (mean aortic valve area 0.8 cm2 or less, range 0.4 to 0.8). Ten had an abnormal LVEF response to exercise and 7 had exercise-induced abnormal wall motion. These findings suggest that the presence of an abnormal LVEF, whether in conjunction with an abnormal wall motion analysis, is indicative of further invasive evaluation; conversely, in those patients with a normal response of LVEF and normal wall motion during exertion, invasive studies may be safely deferred.

Adult↗
PubMed1984

Five-year effect of medical and surgical therapy on resting left ventricular function in stable angina: Veterans Administration Cooperative Study.

The effect of coronary artery bypass grafting (CABG) and medical therapy on 5-year resting left ventricular (LV) function was studied in 194 randomized patients with stable angina in the Veterans Administration Study of Coronary Artery Bypass Surgery. LV ejection fraction (EF) was determined in a central laboratory. The 92 medical and 102 surgical patients were comparable at entry with respect to historic, angiographic and electrocardiographic prognostic indicators. Twenty-eight percent of the medical and 30% of the surgical patients had a baseline EF of less than 50%. There was no significant change in mean EF between baseline and 5-year values in either treatment group. The baseline and 5-year values were 56 and 58% in each treatment group. Intervening myocardial infarction (MI) had an adverse effect in medically treated patients (59 to 46%, p less than 0.01) and in surgically treated patients with late MI (58 to 47%, difference not significant). Perioperative MI was not associated with a decrease in EF (56 to 58%, difference not significant). These findings extend the similar results of previous short-term studies of the effect of coronary bypass surgery on resting LV function to 5 years, and provide data in a comparable medical control group.

Angina Pectoris↗
PubMed1984

Characteristics and outcome of medical nonadherers in the Veterans Administration Cooperative Study of Coronary Artery Surgery.

During a 7-year follow-up period in the Veterans Administration Study of Bypass Surgery, 75 (24%) of 311 medically assigned patients without left main disease "crossed over" to surgical treatment. Nineteen baseline, clinical, electrocardiographic and angiographic characteristics of the 75 crossover patients were compared with those of the 236 patients who adhered to medical treatment. At entry into the study, the crossover group contained more patients with severe angina than did the medical adherers group (p less than 0.05) and fewer patients with electrocardiographic evidence of previous myocardial infarction (p less than 0.05). Other entry characteristics were similar in distribution among those in the medical-adherer and crossover groups. The 2 major reasons for crossover were persistence or progression of angina, which occurred in 43 and 37% of the 75 crossover patients, respectively. There was no relation between progression of symptoms and angiographic progression of coronary narrowing. Thus, crossover was not determined by more severe coronary narrowing, but was associated with more severe symptoms and a lower incidence of infarction. The medically randomized patients who later underwent surgery (medical "nonadherers") experienced the same relief of angina 1 year after surgery as did the surgically randomized patients who initially received surgery (surgical "adherers"); however, their overall 7-year survival was lower (77% for medical nonadherers vs 83% for surgical adherers; difference not significant).

Clinical Trials as Topic↗
PubMed1984

Noninvasive evaluation of the severity of aortic stenosis in adult patients.

To determine if a combination of noninvasive variables would be useful in the prediction of the severity of isolated aortic stenosis (AS), 53 patients (mean age 63.4 = 11 years) were evaluated by the following criteria: (1) aortic valve calcification in the plain chest x-ray film; (2) left ventricular hypertrophy by ECG and M-mode echocardiography; (3) faint or absent aortic closure sound; (4) timing of the peak of the systolic murmur; (5) half rise time (T time) of the carotid pulse; and (6) ejection time index. A numeric scoring system and a logistic regression model employing these variables were developed. The total maximum score was 16 points. Sensitivity and specificity for each variable were determined. Patients with clinically evident coronary artery disease (CAD) and significant aortic regurgitation were excluded. All patients underwent hemodynamic studies and coronary arteriography. Thirty-two patients had severe AS (aortic valve area less than 0.75 cm2) and 21 had mild to moderate AS (aortic valve area greater than 0.75 cm2). Significant CAD (greater than or equal to 50% reduction in luminal diameter) was present in 55% of patients. A total score of greater than or equal to 5 occurred in 59% (19 of 32) of patients with severe AS compared to 5% (1 of 21) of patients with mild AS. The presence of subclinical CAD moderately reduced the accuracy of the scoring system principally by its effect upon the timing of the systolic murmur and the ejection time. Combining the scoring system with the presence or absence of symptoms improved the identification of severe AS in patients with a low score.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1983

Left bundle branch block and mechanical events of the cardiac cycle.

Left bundle branch block (LBBB) is associated with a prolongation of the interval from the QRS onset to the onset of left ventricular (LV) ejection. The locus and prevalence of specific sites of delay were examined in 56 patients with complete LBBB using echocardiography, phonocardiography and external pulse recordings. The results were compared with those in 52 control subjects without LBBB. The onset of the QRS complex was used as the initial reference point of measurement of time intervals. The following abnormalities were found in patients with LBBB: (1) delayed mitral valve closure (Q-MC greater than 0.08 second) was the major site of delay in 23% of patients; (2) prolongation of the LV isovolumetric contraction time (greater than 0.06 second) was the major site of delay in 41%; (3) both Q-MC and LV isovolumetric contraction time were prolonged in 18%; and (4) in 26% of patients the onset of ventricular contraction determined by the onset of the increase of the apex impulse was delayed (Q-VC greater than 0.07 second). The most common cause of delayed ejection was a prolonged LV isovolumetric contraction time, which occurred in 59% of patients. A control group of 20 patients with abnormal LV function but without LBBB had a low incidence of the 3 types of delay in LV ejection (0 to 15%). Thus, the major abnormalities in the cardiac cycle in LBBB are due to the conduction defect and not to LV dysfunction. The results of this study suggest the presence of variable abnormalities of conduction in complete LBBB.

Adolescent↗
PubMed1983

Left ventricular function at high altitude examined by systolic time intervals and M-mode echocardiography.

To better understand the effects of high-altitude hypoxia on cardiac performance, healthy lowland-residing volunteers were studied in 2 groups: 10 subjects after acute ascent to 12,500 ft (3,810 m) (acute group) and 9 subjects after chronic exposure for 6 weeks to 17,600 ft (5,365 m) and 11,000 ft (3,353 m) (chronic group). Systolic time intervals and M-mode echocardiograms were recorded at low and high altitudes. Heart rate was 21% greater at high altitude for all subjects. Preejection period/left ventricular ejection time (PEP/LVET) increased by 16% in the acute group and by 22% in the chronic group. Heart size was smaller at high altitude in both groups, with left atrial and left ventricular (LV) diameters decreasing by 10 to 12%. These changes were statistically significant (p less than or equal to 0.01). Despite the increase in PEP/LVET, echocardiographic measurements of LV function (percent fractional shortening and mean normalized velocity of circumferential fiber shortening) remained normal. LV isovolumic contraction time was shorter at high altitude, suggesting heightened, rather than depressed, contractility. LV function does not appear to deteriorate at high altitude. Alterations in systolic time intervals probably result from decreased preload, as reflected by smaller heart size, rather than from heart failure or depressed LV contractility.

Adult↗
PubMed1982

The Veterans Administration Cooperative Study of stable angina: current status.

The current status of the Veterans Administration Cooperative Study of the effect of surgery on survival in patients with stable angina is presented. The outcome in 686 adult males randomly allocated to medical or surgical treatment groups in 1972-1974 was studied in subgroups of patients classified by invasive (arteriographic) and noninvasive risk factors. In 91 patients with left main lesions reducing the luminal diameter 50% or more, surgery significantly improved survival in the two-thirds characterized as middle or high risk by four simple noninvasive predictors of prognosis (New York Heart Association functional classification III or IV, history of myocardial infarction, history of hypertension, and ST-segment depression on the resting baseline ECG as assessed on a centralized reading). Patients with three-vessel disease and no significant disease of the left main coronary artery also had better survival rates when treated surgically. However, this was statistically significant at 6 years only in the 10 hospitals in which the aggregate operative mortality was 3.3%. Patients without left main lesions were also categorized by four noninvasive predictors of risk. Categorizing such patients into roughly equal groups of high, middle, and low risk identified a high-risk group, in which surgery was associated with statistically improved survival, and low- and middle-risk groups in which it was not. The use of both invasive and noninvasive factors to assess risk in patients with chronic stable angina pectoris provided greater predictive power than either angiography or noninvasive factors alone.

Angina Pectoris↗
PubMed1982

Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease.

This report presents the 42-month survival experience of 91 patients with a significant lesion of the left main coronary artery in the Veterans Administration Cooperative Study of Coronary Bypass Surgery. Survival in surgical patients was significantly better than that in the medical group (p = 0.016), even after adjustments were made for two important differences in baseline characteristics--duration of angina and high risk by angiographic criteria--between the two groups (p = 0.019). Subgroups based on severity of left main stenosis and on left ventricular (LV) function showed significant trends in favor of surgery in patients with more than 75% left main stenosis and in those with abnormal LV function. A similar but nonsignificant trend was seen in the two subgroups with 50-75% stenosis or with normal LV function. The surgical benefits were not significantly different between the categories of the subgroups defined separately by stenosis and LV function. Low-, middle- and high-risk subgroups based on four noninvasive clinical predictors also showed significantly improved survival with surgery in the high-risk group. The low-risk groups showed a slight, nonsignificant disadvantage with surgical treatment. These data support the view that patients with left main disease are not a homogeneous group. High- and low-risk subgroups with different outcomes and responses to treatment can be delineated by angiographic or clinical criteria. For most patients with left main disease, coronary artery bypass grafting offers improved longevity.

Adult↗
PubMed1979

Traumatic pulmonary artery--left atrial fistula: an unusual case of cyanosis in an adult.

Eighteen months after sustaining a stab wound to the left upper chest, a 59-year-old man presented with cyanosis and extertional dyspnea. Arterial desaturation due to a central 22 per cent right-to-left shunt was present. A selective pulmonary arteriogram demonstrated a fistula between the main pulmonary artery and the left atrium. At operation the fistula was closed. A laceration of the pulmonic valve and healed pericarditis were present. Marked symptomatic improvement followed the operation, but a murmur of pulmonic valvular regurgitation persisted. The fistula and laceration of the pulmonic valve were probably traumatic in origin.

Cyanosis↗
PubMed1979

Effect of coronary arterial bypass surgery on exercise-induced ventricular arrhythmias. Long-term follow-up of a prospective randomized study.

The effect of coronary arterial bypass surgery on exercise-induced ventricular arrhythmias and their relation to sudden death was examined in 102 patients with stable angina pectoris randomly assigned to medical and surgical therapy (54 and 48 patients, respectively). Symptom-limited treadmill tests were performed at entry and at 1 and 5 years. The surgical group demonstrated significant improvement in exercise performance at 1 year compared with the medical group, and at 5 years exercise-induced ischemia as evidenced by S-T depression and exertional angina remained substantially decreased in the surgical group with little change in the medical group. However, the frequency and severity of exercise-induced ventricular arrhythmias in each group remained unchanged at 1 and 5 years from those at entry. Similar results were obtained from an evaluation of ventricular arrhythmias in the electrocardiogram at rest. With the exception of exercise-induced ventricular tachycardia and fibrillation, no relation was found between ventricular arrhythmias and sudden death. Coronary bypass grafting does not decrease the frequency or severity of exercise-induced or resting ventricular arrhythmias. In patients with stable angina pectoris, with the exception of ventricular tachycardia and fibrillation, exercise-induced ventricular arrhythmias are poor predictors of sudden death. The data suggest that exercise-induced ventricular arrhythmias may not be related to ischemia but to other effects of exercise such as cardiac stimulation by catecholamines or other factors.

Angina Pectoris↗