[To be a physician 50 years ago].
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Biomedical subjects
Publications and source records attributed to O Storstein.
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Twelve patients with congestive heart failure were monitored with invasive and noninvasive techniques to evaluate the effect of vasodilator treatment. During the 18 hours of strict bed rest before administration of prazosin, the hemodynamics improved substantially while only small and transient heModynamic changes were observed after introduction of prazosin. At 6 weeks' control the effect of vasodilator treatment with prazosin, 3 mg x 4, was lost. The beneficial results often credited to vasodilators in studies on congestive heart failure might in part be due to the concomitant bed rest introduced during the monitoring of the patients.
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Seven hundred and ninety-five consecutive patients with the diagnosis of angina pectoris were studied by coronary angiography and followed for 2-7 years. The prognosis is greatly determined by the extent of coronary artery involvement. Concomitant mitral insufficiency or ventricular aneurysm influence the prognosis adversely. There was no significant difference in prognosis between men and women. As regards patients with three-vessel disease and elevated left ventricular end-diastolic pressure, the prognosis was better in operated than in non-operated patients. The prognosis seems to have improved when angina pectoris materials collected in the 70s are compared with materials from the 60s.
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Angina pectoris is a common symptom in aortic valvular disease. In our study of 100 consecutive patients it was found more commonly in patients with aortic stenosis than in those with aortic insufficiency. Only 21 of 80 patients with angina pectoris had significant narrowing (more that 75%) of one or several coronary arteries. Angina pectoris in aortic valvular disease thus seems to be most often functional due to disproportion between myocardial oxygen supply and demand. On the other hand, 5 of 20 patients without angina pectoris had significant coronary artery stenosis. As coronary artery involvement may jeopardize the results of aortic valve replacement in these patients, coronary angiography should always be carried out in patients evaluated for surgery of aortic vavlular disease. Coronary bypass surgery should be carried out during the same operation if the stenosis is severe and bypass is technically feasible.
During the years 1965--75, 98 patients more than 65 years of age had aortic valve replacement in our hospital, 24 ball valves and 74 disc valves inserted in their aortic orifice. Actuarial analysis of survival in these patients shows that the operative risk is slightly higher in elder than in younger patients. The survival curve for the following years for those who had disc valve implantation runs parallel to that of younger patients, while those who had ball valve implantation showed a more rapid fall in survival after 3 years. After 10 years, only 30% of patients with ball valve transplantation were alive.
A female patient who suffered from atrial tachycardia associated with the ingestion of food or drink was examined in our department. No signs of organic heart disease were discovered, oesophageal motility was normal, but X-ray revealed a small hiatal hernia. The arrhythmia started with an atrial extrasystole arising well outside the functional refractory period of the AV node, and it could be reproduced by inflation of a balloon. It is suggested that the arrhythmia is induced by a mechanical effect of the passage of food on the left atrial wall. Several drugs were tried in order to stop or relieve the complaints. None of them prevented or stopped the atrial tachycardia but verapamil and edrophonium chloride caused 2:1 AV block, and follow-up study has shown that sufficient doses of verapamil are able to relieve the patient's complaints.
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We report on the effect of verapamil in 12 patients suffering from pulmonary hypertension. The drug caused a slight, but statistically significant decrease in mean pulmonary artery pressure and in the work performance by the right ventricle. The mean pressure of the right atrium, the end-diastolic pressure of the right ventricle, the pulmonary arteriolar resistance, the cardiac index and the stroke volume were not significantly changed, however, and there was a wide spread of the values observed. In some patients the drug exerted a marked negative inotropic effect, with a concomitant increase in the pulmonary arteriolar resistance.
A diastolic decrescendo murmur was heard along the left sternal border in 21 patients with advanced renal failure. Eight patients had organic aortic insufficiency. Among the remaining 13 patients, angiocardiography was carried out in 6; aortic regurgitation was demonstrated in 4, while 2 had stenosis of a coronary artery. Two of the 5 patients with positive angiography have died. At autopsy the aortic ostium was normal. The diastolic murmur in these patients is thought to be functional. It disappears during treatment with hemodialysis and renal transplantation.
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Prevention of arterial thromboembolism with acetylsalicylic acid (ASA) was studied in 148 patients with single Starr-Edwards aortic ball-valve prostheses. These patients are suitable for such a study because they have a high incidence of arterial emboli derived mainly from thrombi formed on the valves. They were given either 1 Gm. of ASA daily or placebo in combination with anticoagulants, and were observed for 2 years. Only two emboli occurred in patients receiving ASA, none of them severe. In the placebo group 12 thromboembolic episodes were diagnosed in 10 patients, and three with cerebral emboli died; in one a subdural hematoma unrelated to the embolus was found. In addition, one fatal and the one nonfatal intracranial bleeding occurred in each group, whereas gastrointestinal complications were seen more frequently in patients taking ASA. It is concluded that ASA combined with anticoagulants offered a significantly better protection against arterial thromboembolism than did anticoagulant therapy alone.
In a prospective study of digitalis intoxication in 649 patients on maintenance treatment with digitoxin a low incidence of digitalis toxicity was found, namely, 5.8 per cent. This is mainly due to a more careful use to digitalis glycosides. It is especially important to reduce the dose of digitoxin in the liver and partly excreted metabolized in the liver and partly excreted through the kidneys as metabolities. Serum half-time of digitoxin is shortened in patients with impaired renal function. Patients with reduced renal function may be treated with digitoxin in the same doses as individuals with normal renal function. This is in contrast to patients treated with digoxin. Digitoxin should therefore be the cardiac glycoside of choice in treatment of patients with renal failure. Digitoxin is further rapidly eliminated in patients with reduced liver function in spite of its extensive hepatic metabolism. In this study extracardia symptoms were found equally often as cardiac signs of toxicity. Patients intoxicated usually had several symptoms and signs of toxicity at the same time. The specificity of commonly used symptoms and signs a digitalis intoxication is very low. In this study atrial tachycardia with block, which has been considered to be an important cardiotoxic arrhythmia, very seldom was found in digitalis intoxication. There is an overlap in digitalis serum concentration between toxic and nontoxic patients. The diagnosis of toxicity was made on clinical grounds. Most of the intoxicated patients had high serum concentrations, but some had concentrations in the normal or low range. Apart from being a guide to the diagnosis of digitalis intoxication, serum digitalis levels may further be a guide to underdigitalization of cardiac patients, especially patients in sinus rhythm.