Biomedical subjects
Publications and source records attributed to M A Famularo.
Thrombolytic dissolution of coronary artery thrombus has added new dimensions to early myocardial infarction treatment. Reperfusion via streptokinase infusion has been shown to be beneficial; however, adverse effects are being noted. We present the case of a patient so treated who subsequently developed left ventricular free wall rupture.
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Septal Q-wave amplitudes were studied in lead CM5 to evaluate its utility in predicting segmental coronary artery pathoanatomy. Q-wave amplitudes were measured in 41 patients with coronary artery disease (CAD) before and immediately after treadmill exercise. All patients studied had either significant single-vessel CAD (greater than 70% diameter reduction) or normal coronary anatomy; 13 had left anterior descending (LAD) CAD, 8 had right coronary occlusions, 8 had left circumflex (LC) CAD, and 12 had angiographically normal coronary arteries. Septal Q-wave amplitude measurements at rest and during peak exercise were recorded in 0.5 mm increments and classified as increasing in 20 patients, decreasing in 8, and no change in 13 with exercise. All 13 patients with isolated LAD narrowing had either no change (5 patients) or a decrease (8 patients) in the septal Q wave with exercise. Statistical analysis revealed 62% sensitivity and 100% specificity for single LAD narrowing if a decreasing Q wave was noted with exercise. Patients with isolated right or LC CAD or normal coronary anatomy had mixed septal Q-wave responses to exercise. Only patients with LAD narrowing had reductions in Q-wave amplitude with treadmill exercise. This finding suggests that low Q-wave voltage and its failure to increase after exercise imply abnormal septal activation, reflecting loss of contraction associated with ischemia from LAD narrowing.
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Exercise testing, after having established the indication (Tables 1 and 2) is not only an important method for detection of coronary artery disease, it also enables delineation of exercise capacity and permits assessment of medical and surgical treatment. A subnormal increase in heart rate or blood pressure, or even a decrease in blood pressure, during exercise may frequently be found in patients with known coronary artery disease or in those at high risk of developing subsequent coronary events. Downsloping ST segment depression is highly specific for the presence of coronary artery disease; the specificity of upsloping ST segment depression can be increased on requiring this pattern to consist of a 2 mm depression 0.08 s beyond the J point. Consideration of the QTc interval may also be useful in patients with upsloping ST segment depression. Marked ST segment depression and early onset of ST segment depression during exercise is related to increasing severity of the disease while the duration of ST segment depression bears no certain relevance. ST segment elevation may be associated with transmural myocardial ischemia, left ventricular aneurysm or variant angina. An increase in the R wave amplitude appears indicative of multiple vessel disease, while a reduction in septal Q wave amplitude is suggestive of left anterior descending coronary artery occlusion. The current concept of testing asymptomatic patients for coronary artery disease has low predictive value. Post-myocardial infarction exercise testing is an objective method for evaluation of prognosis and guiding management. In the assessment of the results of aorto-coronary bypass surgery, the finding of persistent angina and/or ST segment depression during exercise is indicative of residual ischemia; normalization of the exercise ECG in the presence of a high-level exercise capacity is usually associated with good coronary perfusion. In order to provide maximum diagnostic utility, exercise testing must take into consideration other clinical findings as well as the prevalence of disease in the respective population. With respect to the coronary angiographic findings as well as the incidence of coronary events, the predictive value of exercise testing may be notably increased on consideration of multiple clinical and exercise variables. The exercise test has evolved into a clinically important noninvasive method for the evaluation of the functional aspects of the heart.