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PubMed1991

Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group.

OBJECTIVE: To assess the ability of antihypertensive drug treatment to reduce the risk of nonfatal and fatal (total) stroke in isolated systolic hypertension. DESIGN: Multicenter, randomized, double-blind, placebo-controlled. SETTING: Community-based ambulatory population in tertiary care centers. PARTICIPANTS: 4736 persons (1.06%) from 447,921 screenees aged 60 years and above were randomized (2365 to active treatment, 2371 to placebo). Systolic blood pressure ranged from 160 to 219 mm Hg and diastolic blood pressure was less than 90 mm Hg. Of the participants, 3161 were not receiving antihypertensive medication at initial contact, and 1575 were. The average systolic blood pressure was 170 mm Hg; average diastolic blood pressure, 77 mm Hg. The mean age was 72 years, 57% were women, and 14% were black. INTERVENTIONS: --Participants were stratified by clinical center and by antihypertensive medication status at initial contact. For step 1 of the trial, dose 1 was chlorthalidone, 12.5 mg/d, or matching placebo; dose 2 was 25 mg/d. For step 2, dose 1 was atenolol, 25 mg/d, or matching placebo; dose 2 was 50 mg/d. MAIN OUTCOME MEASURES: Primary. Nonfatal and fatal (total) stroke. Secondary. Cardiovascular and coronary morbidity and mortality, all-cause mortality, and quality of life measures. RESULTS: Average follow-up was 4.5 years. The 5-year average systolic blood pressure was 155 mm Hg for the placebo group and 143 mm Hg for the active treatment group, and the 5-year average diastolic blood pressure was 72 and 68 mm Hg, respectively. The 5-year incidence of total stroke was 5.2 per 100 participants for active treatment and 8.2 per 100 for placebo. The relative risk by proportional hazards regression analysis was 0.64 (P = .0003). For the secondary end point of clinical nonfatal myocardial infarction plus coronary death, the relative risk was 0.73. Major cardiovascular events were reduced (relative risk, 0.68). For deaths from all causes, the relative risk was 0.87. CONCLUSION: In persons aged 60 years and over with isolated systolic hypertension, antihypertensive stepped-care drug treatment with low-dose chlorthalidone as step 1 medication reduced the incidence of total stroke by 36%, with 5-year absolute benefit of 30 events per 1000 participants. Major cardiovascular events were reduced, with 5-year absolute benefit of 55 events per 1000.

Aged↗
PubMed2001

Follow-up of renal function in treated and untreated older patients with isolated systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators.

BACKGROUND: In the outcome trials that provided information on renal function in older hypertensive patients, diuretics and beta-blockers were mostly used as first-line drugs. The long-term renal effects of calcium-channel blockers remain unclear. OBJECTIVE: To compare the changes in renal function in 2,258 treated and 2,148 untreated patients with isolated systolic hypertension, of whom 455 had diabetes mellitus and 390 had proteinuria. METHODS: We performed a post-hoc analysis of the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Active treatment was initiated with nitrendipine (10-40 mg/day) with the possible addition of enalapril (5-20 mg/day), hydrochlorothiazide (12.5-25 mg/day), or both, titrated or combined to reduce the sitting systolic blood pressure by at least 20 mmHg, to less than 150 mmHg. The main outcome measures were serum creatinine concentration and creatinine clearance calculated by the formula of Cockroft and Gault. RESULTS: Serum creatinine concentration at the time when participants were randomly allocated to study groups was less than 176.8 micromol/l (2.0 mg/dl), averaging 88 micromol/l. At the time of the last serum creatinine measurement, the blood pressure difference (P< 0.001) between the two groups was 11.6/4.1 mmHg. In the intention-to-treat analysis (11,427 patient-years), serum creatinine and the calculated creatinine clearance were not influenced by active treatment. However, in the patients assigned randomly to receive active treatment, the incidence of mild renal dysfunction (serum creatinine at least 176.8 mmol/l) decreased by 64% (P= 0.04) and that of proteinuria by 33% (P= 0.03). Active treatment reduced the risk of proteinuria more in diabetic than in non-diabetic patients: by 71%, compared with 20% (P= 0.04). In non-proteinuric patients, active treatment did not influence serum creatinine, whereas in patients with proteinuria at entry to the study, serum creatinine decreased on active treatment (P< 0.001). Furthermore, in on-randomized treatment comparison stratified for risk at baseline, serum creatinine concentration did not change (P= 0.98) in patients continuing to receive monotherapy with nitrendipine, whereas it increased by 6.73 mmol/l (P < 0.001) in patients who received hydrochlorothiazide alone or in combination with other study medication (P < 0.001 for difference in trends). CONCLUSIONS: In older patients with isolated systolic hypertension, antihypertensive treatment starting with the dihydropyridine calcium-channel blocker, nitrendipine, did not decrease blood pressure at the expense of renal function and prevented the development of proteinuria, especially in diabetic patients.

Aged↗
PubMedDate not supplied

End-systolic pressure-volume and end-systolic stress-volume relationships in patients with aortic stenosis and with normal valvular function.

In order to study the effect of left ventricular hypertrophy on the endsystolic pressure-volume relationship, three left ventricular angiograms were performed in ten patients with normal valvular function but with varying left ventricular function (group 1) after 0.15 mg/kg propranolol and 1 mg atropine: at rest, after isosorbide-dinitrate at a decreased afterload and after methoxamine at an enhanced afterload. In eight patients with aortic stenosis (group 2) two left ventricular angiograms were performed: at rest and after isosorbide-dinitrate. Heart rate was kept constant by atrial pacing. Left ventricular mass in group 1 was 89 g/m2 and in group 2 180 g/m2. In group 1 the slope k of the end-systolic pressure-volume relation was related to the ejection fraction (EF) at rest: k = 0.024 . e0.072 EF; r = 0.93. In group 2 this relation was shifted to the left (P less than 0.001): k = 0.135 . e0.057 EF; r = 0.81. The relations, however, between the slope k of the end-systolic stress-volume relation and the ejection fraction were close together in group 1 and in group 2 and crossed at an ejection fraction of 67%. It is concluded: 1. In patients with aortic stenosis the end-systolic pressure-volume relation is steeper than in patients without valvular dysfunction at a given ejection fraction, so the relation between the slope k and the ejection fraction is shifted to the left. 2. The end-systolic stress-volume relationship is not altered in patients with aortic stenosis and seems to be advantageous for the evaluation of left ventricles with substantial hypertrophy due to pressure load.

Adult↗
PubMed1998

Treatment of isolated systolic hypertension in the elderly: further evidence from the systolic hypertension in Europe (Syst-Eur) trial.

The Systolic Hypertension in Europe (Syst-Eur) study investigated whether antihypertensive treatment could decrease the risk of cardiovascular complications in elderly patients with isolated systolic hypertension. Patients > or = 60 years were randomly assigned to treatment with the dihydropyridine calcium antagonist nitrendipine (n = 2,398), with the addition of enalapril and hydrochlorothiazide if needed, or to matching placebo (n = 2,297). In the intent-to-treat analysis, the between-group difference in blood pressure was 10.1/4.5 mm Hg (p < 0.001). Active treatment decreased the total incidence of stroke (the primary endpoint) by 42% (p = 0.003), of all cardiac endpoints by 26% (p = 0.03), and of all cardiovascular endpoints combined by 31% (p < 0.001). Cardiovascular mortality was somewhat lower with active treatment (-27%, p = 0.07); all-cause mortality was not significantly different (-14%; p = 0.22). For total (p = 0.009) and cardiovascular (p = 0.09) mortality, the benefit of antihypertensive treatment weakened with advancing age and for total mortality it decreased with lower systolic blood pressure at entry (p = 0.05). The benefits of active treatment were not independently related to gender or to the presence of cardiovascular complications at entry. Antihypertensive therapy was at least as effective in patients with diabetes as in those without diabetes at entry. Further analyses suggested benefit in patients who were taking nitrendipine as monotherapy. Per-protocol analysis largely confirmed the intent-to-treat results. Active treatment decreased all strokes by 44% (p = 0.004), all cardiac endpoints by 26% (p = 0.05), and all cardiovascular endpoints by 32% (p < 0.001). Total mortality was decreased by 26% (p = 0.05), but the similar reduction in cardiovascular mortality did not reach significance in this analysis. It is concluded that stepwise antihypertensive drug treatment starting with nitrendipine improves prognosis in elderly patients with isolated systolic hypertension.

Adult↗
PubMed1984

Relationship of peak systolic pressure/end systolic volume ratio to standard ejection phase indices and ventricular function curves in coronary disease.

In order to determine the relationship of the peak systolic pressure/end-systolic volume (PSP/ESV) ratio to standard ejection phase indices [ejection fraction (EF), mean normalized systolic ejection rate (MNSER), mean velocity of circumferential fiber shortening (Vcf)], and ventricular function curves (VFC), hemodynamic and angiographic studies were carried out in 38 subjects: 11 normal controls (Group I) and 27 with coronary artery disease (CAD). The CAD patients were subdivided into those without (Group II) and those with (Group III) regional asynergy. EF, MNSER and Vcf were calculated from the ventriculogram using standard formulae. The slope of the left ventricular function curve was constructed by determining left ventricular stroke work index and left ventricular end-diastolic pressure before and after ventriculography, and dividing the change in the left ventricular stroke work index by the change in the left ventricular end-diastolic pressure. Peak systolic left ventricular pressure was determined before left ventriculography; minimal systolic volume was measured from the left ventriculogram. PSP/ESV ratio in the control group (Group I) was 6.4 +/- 2.8. This differed significantly from the ratio in patients (Group II) with CAD but without asynergy (4.7 +/- 2.2 p less than 0.025) and from that in patients (Group III) with CAD and asynergy (2.4 +/- 1.4, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators.

BACKGROUND: The goal of the present study was to assess the effect of antihypertensive therapy on clinic (CBP) and ambulatory (ABP) blood pressures, on ECG voltages, and on the incidence of stroke and cardiovascular events in older patients with sustained and nonsustained systolic hypertension. METHODS AND RESULTS: Patients who were >/=60 years old, with systolic CBP of 160 to 219 mm Hg and diastolic CBP of <95 mm Hg, were randomized into the double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) Trial. Treatment consisted of nitrendipine, with the possible addition of enalapril, hydrochlorothiazide, or both. Patients enrolled in the Ambulatory Blood Pressure Monitoring Side Project were classified according to daytime systolic ABP into 1 of 3 subgroups: nonsustained hypertension (<140 mm Hg), mild sustained hypertension (140 to 159 mm Hg), and moderate sustained hypertension (>/=160 mm Hg). At baseline, patients with nonsustained hypertension had smaller ECG voltages (P<0.001) and, during follow-up, a lower incidence of stroke (P<0.05) and of cardiovascular complications (P=0.01) than other groups. Active treatment reduced ABP and CBP in patients with sustained hypertension but only CBP in patients with nonsustained hypertension (P<0.001). The influence of active treatment on ECG voltages (P<0.05) and on the incidence of stroke (P<0.05) and cardiovascular events (P=0.06) was more favorable than that of placebo only in patients with moderate sustained hypertension. CONCLUSIONS: Patients with sustained hypertension had higher ECG voltages and rates of cardiovascular complications than did patients with nonsustained hypertension. The favorable effects of active treatment on these outcomes were only statistically significant in patients with moderate sustained hypertension.

Aged↗
PubMed1981

Assessment of preoperative left ventricular function in patients with mitral regurgitation: value of the end-systolic wall stress-end-systolic volume ratio.

Twenty-one patients with symptomatic, chronic, severe mitral regurgitation (MR) but without other valvular heart disease or coronary disease were evaluated to determine which hemodynamic and angiographic factors might be prognostic of surgical outcome. Sixteen patients were in New York Heart Association functional classes I or II postoperatively and formed group A. One patient remained in class III postoperatively and four patients died perioperatively; they constitute group B. End-diastolic volume index (EDVI) was less for group A than for group B, 119 +/- 25 ml/m2 vs 170 +/- 28 ml/m2 (p less than 0.001). End-systolic volume index (ESVI) was also lower in group A, 39 +/- 19 ml/m2 vs 72 +/- 32 ml/m2 for group B (p less than 0.01). The ratio of end-systolic wall stress to end-systolic volume index (ESWS/ESVI) was examined in normal persons and in groups A and B. This ratio was significantly lower in both groups than in normal persons, indicating relatively greater end-systolic volume at a given wall stress, suggesting left ventricular dysfunction. The ESWS/ESVI ratio in group B, 2.2 +/- 0.2, was significantly less than in group A, 3.3 +/- 0.4 (p less than 0.001). The variables of age, pulmonary capillary wedge pressure, EDVI, ESVI, ejection fraction and the ESWS/ESVI ratio were subjected to stepwise discriminant multivariate analysis to determine if any were independent predictors of outcome. The only independent predictor determined by this method was the ESWS/ESVI ratio (p less than 0.001). We conclude that the ESWS/ESVI ratio may be helpful in evaluating left ventricular function and operative risk in patients with chronic, symptomatic MR.

Aged↗
PubMed1998

Risk factors for stroke and type of stroke in persons with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group.

BACKGROUND AND PURPOSE: We sought to determine risk factors for stroke and stroke type in persons with isolated systolic hypertension (ISH). METHODS: We performed proportional hazards analyses of data from the Systolic Hypertension in the Elderly Program, a double-blind, randomized, placebo-controlled trial of 4736 persons aged > or =60 years with ISH (systolic blood pressure, 160 to 219 mm Hg; diastolic blood pressure, <90 mm Hg). One treatment group received chlorthalidone (12.5 to 25 mg/d) with step-up to atenolol (25.0 to 50.0 mg/d) or reserpine (0.05 to 0.10 mg/d), if needed. The other treatment group received matching placebo. The main outcome measures were stroke, stroke or transient ischemic attack [TIA], and stroke types: ischemic (including lacunar, atherosclerotic, and embolic) and hemorrhagic. RESULTS: During an average follow-up of 4.5 years, 384 strokes or TIAs and 262 strokes (including 217 ischemic, 66 lacunar, 26 atherosclerotic, and 25 embolic strokes) were documented. In multivariate analyses, placebo treatment, older age, smoking, history of diabetes, higher systolic blood pressure, lower HDL cholesterol, and ECG abnormality were significantly associated (P<0.05) with increased incidence of stroke or TIA, stroke, or ischemic stroke. Greater lacunar stroke risk was significantly related to placebo treatment, older age, history of diabetes (relative risk [RR] = 3.03; 95% confidence interval [CI], 1.70 to 5.40), and smoking (RR = 3.04; 95% CI, 1.73 to 5.37). Greater atherosclerotic and embolic stroke risk were significantly related to presence of carotid bruit (RR = 5.75; 95% CI, 2.50 to 13.24) and older age (RR = 1.65 per 5 years; 95% CI, 1.25 to 2.18), respectively. CONCLUSIONS: In older persons with ISH, history of diabetes and smoking are important risk factors for lacunar stroke, whereas carotid bruit and age are important risk factors for atherosclerotic and embolic stroke, respectively.

Aged↗
PubMed1993

Implications of the systolic hypertension in the elderly program. The Systolic Hypertension in the Elderly Program Cooperative Research Group.

Several imperatives drive the need to establish the merit of treating isolated systolic hypertension in the elderly. These include its higher prevalence with age, the associated excess cardiovascular risks, and the rapid aging of the population. The Systolic Hypertension in the Elderly Program demonstrated a significant reduction in stroke incidence (fatal and nonfatal) (36%, equivalent to preventing 30 strokes per 1,000 participants per 5 years). A 27% reduction in coronary heart disease incidence and a 32% reduction in all major cardiovascular events were also achieved (equivalent to the prevention of 16 and 55 events per 1,000 participants per 5 years, respectively). These results were associated with a treatment regimen in which the primary agent was low-dose chlorthalidone. The benefits accrued to all subgroups identified based on baseline age, race and sex, blood pressure, serum cholesterol levels, and electrocardiographic abnormalities. The reduction in coronary disease is consistent with predictions based on prospective epidemiological studies and is concordant with other recent intervention trials. It is a reasonable inference from the Systolic Hypertension in the Elderly Program findings that middle-aged as well as older people with isolated systolic hypertension, and people with less severe degrees of this condition, particularly when other risk factors are present, would benefit from such therapy. Another reasonable implication of the trial relates to the matter of preferred drug treatment regimens for diastolic hypertension, in middle-aged as well as older people.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1998

Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction.

BACKGROUND: Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI). HYPOTHESIS: The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI. METHODS: The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double-blind, randomized, place-bo-controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow-up period were excluded. RESULTS: At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow-up, AV plane displacement increased in ramipril-treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group. CONCLUSIONS: Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.

Adult↗
PubMed2004

Relation of impaired left ventricular filling to systolic midwall mechanics in hypertensive patients with normal left ventricular systolic chamber function: the Losartan Intervention for Endpoint Reduction in Hypertension (LIFE) study.

BACKGROUND: Patients with hypertensive left ventricular (LV) hypertrophy commonly have diastolic dysfunction with preserved LV ejection fraction. LV systolic midwall shortening (MWS) may be impaired in hypertensive patients with normal LV ejection fraction. However, it is unclear whether impaired LV filling is related to depressed systolic midwall mechanics. METHODS: Echocardiographic measures of LV diastolic filling and systolic performance were compared in 632 unmedicated patients with stage II or III hypertension and LV hypertrophy determined by electrocardiogram, with LV ejection fraction >55% and <2+ mitral regurgitation. RESULTS: Stress-corrected LV MWS, an index of myocardial contractility, was lower in patients with abnormal as opposed to normal LV filling patterns (98% +/- 12% vs 102% +/- 10%, P <.001) and in patients with prolonged as opposed to normal isovolumic relaxation time (IVRT) (98% +/- 13% vs 101% +/- 12%, P =.014). Stress-corrected MWS was <85% of predicted levels in more patients with abnormal LV filling patterns (11.8% vs 6.3%) or with long IVRT (> or =105 msec) (34% vs 21%, both P <.05). In regression analyses, lower stress-corrected MWS and higher LV mass were independent correlates of longer IVRT, while lower stress-corrected MWS was the only independent correlate of prolonged mitral valve deceleration time (P =.017). Higher LV mass had strong, statistically independent relationships to longer IVRT (by 0.3 g/msec) and decreased stress-corrected MWS (by 0.5 g/%; both P <.0001), independent of body size and age. CONCLUSION: In patients with moderate hypertension and target organ damage who have normal LV ejection fraction, impaired early diastolic LV relaxation (abnormal E/A ratio, prolonged IVRT and deceleration time) is associated with impaired LV systolic midwall mechanics independent of higher LV mass.

Aged↗
PubMed1975

Mid-systolic click, late systolic murmur syndrome associated with complete heart block.

A 60 year old woman is presented who had the mid-systolic click, late systolic murmur syndrome, documented by phonocardiogram and left ventricular angiography. During an episode of non-anginal chest pain, advanced heart block was demonstrated and permanent transvenous pacemaker therapy was subsequently instituted. The association of the mid-systolic click, late systolic murmur syndrome and heart block is reviewed. It is suggested that 24-hour continuous electrocardiographic monitoring, as well as exercise stress testing, be included in the evaluation of patients with this syndrome.

Angiocardiography↗
PubMed1977

Systolic time intervals in the syndrome of midsystolic click and late systolic murmur.

Left ventricular function, as measured by systolic time intervals, was studied in 30 subjects with the syndrome of midsystolic click and late systolic murmur (ages, 20 to 53 years; mean, 34 +/- 9 years). Twenty-one were asymptomatic, six had chest pain, two had palpitations, one had shortness of breath, and one had hypotensive episodes. Each patient had the typical auscultatory and echocardiographic findings of the syndrome of midsystolic click and late systolic murmur. In the study the values for the interval between the onset of the QRS complex (Q) and the aortic component of the second heart sound (A2) (377 +/- 42 msec), the Q-A2 index (532 +/- 39 msec), the preejection period (PEP) (97 +/- 17 MSEC), THE PEP index (127 +/- 16 msec), the left ventricular ejection time index (403 +/- 26 msec) and the ratio of PEP to left ventricular ejection time (0.35 +/- 0.01) were not significantly different from the values in 17 controls matched for age. Out study, then, supports the contention that left ventricular function remains well preserved in most patients with the syndrome of midsystolic click and late systolic murmur.

Adult↗
PubMed2003

Preload response in patients after cardiac surgery: a comparison of systolic blood pressure and systolic area variability and initial volume of distribution of glucose.

OBJECTIVE: Estimation of stroke volume variation (e.g. systolic blood pressure and systolic area variability) and central extracellular compartment volume (e.g. initial volume of distribution of glucose, IVDG) may be useful in guiding fluid therapy in mechanically ventilated patients. The reliability of systolic blood pressure (SBP) variability has been well validated, but little is known about systolic area (SA) variability or IVDG. Our aim was to investigate SBP and SA variability and IVDG as predictors of preload responsive hypovolaemia in post-cardiac surgery patients. METHODS: Thirty-four mechanically ventilated patients undergoing preload enhancement post elective cardiac surgery were studied. The maximum-minimum difference and power spectral measurement of SBP and SA variability were derived from the arterial waveform trace and examined before and after rapid volume infusion. IVDG was determined prior to volume infusion from three-minute incremental glucose estimation and (with SBP and SA variability) correlated with subjects classified as hypotensive and preload responsive. RESULTS: Neither IVDG or SA and SBP variability were found to correlate with subjects identified as hypotensive and preload responsive. However, the power spectral measures of SBP and SA variability were significantly reduced (p = 0.007 and p = 0.026, respectively) following preload enhancement in fluid responsive subjects. CONCLUSIONS: Our results indicate that neither IVDG, nor SBP and SA variability are predictive of preload responsive hypotension in post-cardiac surgery patients. Spectral analysis of SBP and SA may be more sensitive at assessing preload responsiveness in this patient group than traditional maximum-minimum measures.

Journal Article↗
PubMed1976

Assessment of the mid systolic click late systolic murmur syndrome by noninvasive methods.

In patients with the mid systolic click/late systolic murmur syndrome (MSC/LSM Sy) a ballooning, billowing or aneurysmal protrusion of one or both mitral leaflets has previously been described in angiographic studies. It is accepted that besides angiography noninvasive methods such as dynamic electrocardiography, phonocardiography, apexcardiography and echocardiography can provide valuable information in the diagnosis of this syndrome. Little is known however about diagnostic value and sensitivity of these methods. The dynamic Ecg, recorded during an average of 10 hours, showed in 8/20 patients (40%) one or several significant arrhythmias such as frequent ventricular premature contractions (VPCs) (greater than 12/min), multifocal VPCs, VPCs in a row or ventricular tachycardia, or 2 degrees SA-block. 12/20 patients (60%) showed in the phonocardiogram a movement of the click toward the first heart sound when the patients' position was changed from supine to sitting. In 40% of the patients a double or triple click was recorded. A late systolic bulge in the apexcardiogram was seen in 13/20 patients (65%). In one patient the recording was not successful. Echocardiographic signs of abnormal posterior movement (prolapse) of one or both mitral leaflets were recorded in 15/20 patients (75%). Five echocardiograms did not show any abnormality, but all these cases demonstrated in their apexcardiogram a late systolic bulge. We believe that in patients with the MSC/LSM Sy a mitral valve abnormality can be documented adequately by noninvasive methods.

Adolescent↗
PubMed1949

Difficulties in evaluating systolic murmurs in children; with special reference to the functional systolic murmur.

As a guide in distinguishing between organic and functional systolic murmurs, five characteristics of a murmur should always be noted, namely, (a) the location of maximal intensity of the murmur; (b) the intensity of the murmur itself; (c) the character of the murmur, that is, whether it is blowing, rumbling, rough or harsh; (d) the transmission of the murmur; and (e) the duration of the murmur and its time within the cardiac cycle. Functional systolic murmurs may be found at any of the "valve areas," are usually faint to moderately loud, are usually soft and blowing in quality, are usually only slightly transmitted, and are usually not heard immediately following the first heart sound. In doubtful cases, those in which history and physical examination alone are not sufficient to make a diagnosis of functional systolic murmur, further studies should be undertaken to determine the presence or absence of organic heart disease. Until a diagnosis of organic heart disease can be made with reasonable certainty, there should be no restriction of activity imposed, because of the likelihood of the development of cardiac neurosis in the patient.

Child↗
PubMed1995

Angiographic and prognostic implications of an exaggerated exercise systolic blood pressure response and rest systolic blood pressure in adults undergoing evaluation for suspected coronary artery disease.

OBJECTIVES: This study was designed to assess the angiographic and prognostic implications of an exaggerated systolic blood pressure response to exercise ("exercise hypertension") in adults undergoing evaluation for suspected coronary artery disease. BACKGROUND: The clinical implications of exercise hypertension are unclear. METHODS: Subjects for this prospective cohort study were derived from a consecutive sample of 9,608 adults who were referred for treadmill testing and who augmented their systolic blood pressure by at least 10 mm Hg. There were 594 subjects who underwent coronary angiography within 90 days of treadmill testing. Exercise hypertension was defined as a peak exercise systolic blood pressure > or = 210 mm Hg in men and > or = 190 mm Hg in women. Severe angiographic coronary disease was defined as left main coronary artery disease (> or = 50% diameter stenosis), three-vessel disease (> or = 70% diameter stenosis) or two-vessel disease with > or = 70% diameter stenosis of the proximal left anterior descending coronary artery. All-cause mortality was assessed during a follow-up period of approximately 2 years. RESULTS: Exercise hypertension was present in 196 subjects (33%). Severe coronary disease was less common in subjects with exercise hypertension (14% vs. 25%, odds ratio 0.51, 95% confidence interval [CI] 0.32 to 0.81, p = 0.004). Exercise hypertension remained associated with a lower rate of severe coronary disease even after adjusting for rest hypertension, age, gender, exercise capacity and other possible confounders. During the follow-up period, there were 23 deaths; only 2 occurred in the group with exercise hypertension. After adjusting for severity of coronary disease, exercise hypertension remained associated with a lower mortality rate (adjusted relative risk 0.20, 95% CI 0.05 to 0.84, p = 0.03). CONCLUSIONS: In adults evaluated for coronary artery disease, exercise hypertension is associated with a lower likelihood of angiographically severe disease and a lower adjusted mortality rate.

Blood Pressure↗
PubMed2006

Severe tricuspid regurgitation shows significant impact in the relationship among peak systolic tricuspid annular velocity, tricuspid annular plane systolic excursion, and right ventricular ejection fraction.

OBJECTIVES: Peak systolic mitral annular velocities correlate with left ventricular ejection fraction (EF) regardless of mitral regurgitation severity. Peak systolic tricuspid annular velocity (RV-Sm) and tricuspid annular plane systolic excursion (TAPSE) are used to assess right ventricular (RV) EF (RVEF). We investigated whether tricuspid regurgitation (TR) affects the relationship among RV-Sm, TAPSE, and RVEF. METHODS: Patients (n = 625) underwent echocardiography and Doppler tissue studies. Left ventricular EF and RVEF were estimated by Simpson's rule. Because of confounding, we excluded patients with diseases that influence mitral annular motion or left ventricular function. We finally enrolled 225 patients: 125 with mild TR, 50 with moderate TR, and 50 with severe TR. Forty study patients (20 with mild TR, 10 with moderate TR, and 10 with severe TR) received radionuclide ventriculography. RESULTS: The RVEF estimated by Simpson's method correlated strongly to that estimated by the radionuclide method (r = 0.793, r2 = 0.629, P < .0001). With mild or moderate TR, RV-Sm correlated well to RVEF (mild TR group: r = 0.765, r2 = 0.59, P < .0001; moderate TR group: r = 0.756, r2 = 0.57, P < .0001). RV-Sm had no significant correlation to RVEF in patients with severe TR (r = 0.212, r2 = 0.05, P = .167). Over a range of TR severities, the relationship between TAPSE and RVEF showed a similar trend to that between RV-Sm and RVEF. CONCLUSION: Severe TR has a significant impact on the relationship between RV-Sm and RVEF and between TAPSE and RVEF. TAPSE and RV-Sm in patients with severe TR show poor correlation to RVEF. When applying Doppler tissue method or TAPSE to assess RV function, severe TR is a significantly confounding factor.

Female↗