Six cases of acute myocardial infarction with blood in the pericardial sac are described. In one case rapid death followed myocardial rupture leaving no time for the possibility of intervention. Of two other cases acute symptoms developing after myocardial rupture, one was operated on promptly and the other, whose condition improved on pericardiocentesis, after a delay of a few hours. Both are now long term survivors A fourth patient probably had two episodes of rupture which apparently sealed off. He underwent cardiac catheterization, but no epicardial leak was found. Subsequently at operation a sealed myocardial rupture was detected and sutured over. The fifth patient suffered a silent myocardial rupture. A false aneurysm was diagnosed four months later and he withstood successful surgery. In the sixth patient, the course was similar to that of case 1, namely rapid death with a clinical picture suggestive of tamponade. Postmortem examination showed a covert rupture with some evidence of attempts to plug the opening. The purpose of this report is to emphasize the varying course which myocardial rupture can take.
We performed percutaneous transluminal coronary angioplasty as an emergency procedure in 60 patients with unstable angina pectoris that was refractory to treatment with maximally tolerated doses of beta-blockers, calcium antagonists, and intravenous nitroglycerin. The initial success rate for angioplasty was 93 per cent (56 patients). There were no deaths related to the procedure, although total occlusion occurred in four patients. Despite emergency bypass grafting, all four sustained a myocardial infarction. All the patients were followed for at least six months. Late cardiac death occurred in one patient, whereas eight had recurrent angina pectoris. There was no progression to myocardial infarction. The restenosis rate was 28 per cent (13 of 46) in the patients with initially successful coronary angioplasty who had repeat angiography. Improved cardiac functional status after sustained successful coronary angioplasty was demonstrated by an almost normal capacity on bicycle exercise testing and the absence of ischemia during thallium isotope studies in 80 per cent. We conclude that emergency percutaneous transluminal coronary angioplasty may be useful for the treatment of selected patients with unstable angina pectoris who are unresponsive to intensive pharmacologic treatment.
Early post-infarction angina (2-15 days after infarction) occurred in 132 out of 616 consecutive coronary care unit admissions for acute myocardial infarction within 24 h from onset of symptoms. Patients with early post-infarction angina more often had a history of stable pre-infarction angina as well as late post-infarction angina. Coronary artery disease was more extensive in patients with early post-infarction angina compared with those without angina. Forty-five patients with angina were treated before hospital discharge with coronary artery bypass (CABG) (N = 35) or percutaneous transluminal coronary angioplasty (PTCA) (N = 10). Survival and incidence of non-fatal reinfarctions during 1-year follow-up was similar in patients with and without early post-infarction angina (respectively 83% versus 82% and 13% versus 11%). The incidence of angina in the follow-up was higher in the whole group of patients with early post-infarction angina then in patients without angina (53% versus 32%, P less than 0.001), but was lowest (22%) in the subset who underwent CABG or PTCA before discharge. In patients with early post-infarction angina, age, left ventricular dysfunction, extensive coronary artery disease, stable pre-infarction angina and electrocardiographic ischaemic changes distant from the infarct zone during angina were significantly associated with a poor survival.
Molsidomine was compared with propranolol for anti-anginal efficacy in a double-blind, cross-over, fixed-dose clinical trial, involving 39 patients with moderate, stable angina pectoris, and objective evidence of coronary sclerosis. The incidence of anginal attacks under molsidomine did not differ statistically from that under propranolol. However, propranolol was more effective in reducing the nitroglycerin requirement at the doses used. Ergometry showed that both drugs increased exercise tolerance to a comparable extent. However the rate pressure product during exertion indicates that these drugs achieve this result via different paths, molsidomine having a nitrate-like effect. Unwanted effects during the four week treatment periods were minor and generally tolerable. Molsidomine is an effective long-acting anti-anginal agent with nitrate-like effects and should be a useful addition to the drugs already in use.
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