Objective-To evaluate a clinic set up specifically to assess patients with recent onset chest pain, particularly those presenting with a normal resting electrocardiogram.Design-Retrospective review of case notes.Setting-Cardiac department of a tertiary referral cardiothoracic centre.Patients-250 consecutive patients with recent onset chest pain seen within 24 hours of general practitioner referral.Outcome measures-Clinical diagnosis and management.Results-40% of patients were seen within seven days of the onset of symptoms. Twenty seven per cent had non-cardiac symptoms and could be discharged while 60% were considered to have cardiac pain. Sixty six patients (26%) were admitted directly from the clinic and 48 of these underwent coronary angiography within three weeks. Seventy patients (28%) have so far undergone intervention (angioplasty or coronary artery surgery), 22 within one month of presentation. One hundred and nine patients (44%) presented with a normal resting electrocardiogram, 21 of whom were considered to have unstable angina. Forty one of these patients were investigated of whom 37 were found to have significant coronary disease and 26 have undergone intervention.Conclusions-This experience highlights the inadequacy of a routine electrocardiogram reporting service in patients with recent onset of chest pain. An alternative facility offering immediate and complete cardiac assessment produced patient benefit with early diagnosis and intervention. Investigation of these patients, however, accounted for 5% of cardiac catheterisation laboratory throughput; this was a significant additional and unscheduled workload.
Blunt trauma to the chest is associated with significant morbidity and mortality. The latter is usually due to an aortic transection, whereas the former is related to myocardial contusion, cardiac valve injury, coronary artery disruption and intracardiac shunts due to the formation of septal defects. The main mechanisms causing these injuries are due to the sudden deceleration force and compression within the chest cavity. Moreover, there is also the sudden increase in intravascular pressure due to a mechanical compression effect and a hormonal adrenergic surge during the event. We report a case of a tricuspid valve injury caused by the deployment of the airbag during a high-speed impact car accident and the subsequent damage to the tricuspid valve chordal mechanism. The patient's management and the pathophysiological mechanisms involved in the injury are reviewed.
Accelerated coronary artery disease following cardiac transplantation remains an important obstacle to long-term survival and the correct management strategy remains unclear. This observational, prospective study was designed to examine the feasibility of using percutaneous transluminal coronary angioplasty (PTCA) in the treatment of post-transplant coronary disease. Thirteen consecutive patients were selected from the total population of 276 transplant recipients who underwent routine coronary angiography between 1987 and 1990. Selection of patients was on angiographic criteria alone and PTCA was performed to all accessible stenoses with more than 80% luminal narrowing. PTCA was performed using standard angioplasty equipment and procedure as considered appropriate for the individual lesion. A successful PTCA was defined as more than 30% reduction in luminal narrowing and a residual narrowing of less than 50%. Restenosis was defined as a loss of 50% or more of the gain achieved at the time of successful PTCA or more than a 30% increase in narrowing at the site of stenosis. A total of 31 lesions were dilated in this group and a successful result was achieved in 29 of these (93%) and in 12 of the 13 patients. The one patient with failed PTCA underwent later successful coronary artery bypass grafting to complete revascularization. Four of the 13 patients have had two angioplasty procedures, two for restenosis and two for disease progression in other sites. One patient died 15 months after the initial PTCA and the remaining 12 were asymptomatic with good exercise tolerance and ventricular function at a mean of 19 months (range 1-39 months) following first PTCA.(ABSTRACT TRUNCATED AT 250 WORDS)
The QT responses to exercise during ventricular pacing were evaluated in 12 patients in whom permanent pacemakers were implanted for complete heart block. The initial response of the QT to exercise was a paradoxical lengthening during the first minute of exercise (mean 4.8 ms P < 0.01). Thereafter, the QT was found to shorten in a linear fashion in response to increasing exercise, both in terms of exercise duration (r = 0.787; P < 0.001) and atrial rate (r = 0.712; P < 0.001). The total QT shortening with exercise was small (20 ms for a mean increase in atrial rate of 60 beats.min-1) and displayed substantial inter-individual variability (9-31 ms). These results explain some of the limitations of the QT pacemaker, and provide insights in to the dynamics of the QT response, which may help tailor the programming of these systems to the individual patient.
Digital subtraction angiography has recently been applied to left ventricular imaging to detect abnormalities of wall motion.'"As in nuclear cardiology, exercise has been used to induce such abnormalities in regions rendered ischaemic by coronary stenoses, and results similar to those of nuclear gated blood pool scanning have been achieved.34When digital subtraction angiography is performed after exercise, however, the problems of motion subtraction artefact become more important, and the image quality can be considerably impaired. This has less effect on nuclear ventriculography, where the combination of the low resolution and lack of image degradation by bone and soft tissue structures enables satisfactory imaging despite considerable cardiac motion.We showed that satisfactory digital images of the left ventricle after exercise can be achieved by the application of an analysis technique that is not dependent on image subtraction, namely phase and amplitude analysis.' This has been widely used in nuclear cardiology67 and may be applied to any imaging technique that acquires data in a digital format. Therefore, we decided to evaluate this techRequests for reprints to Dr J Lyons, East Surrey Hospital, Three Arch Road, Redhill, Surrey RHI 5RH.Accepted for publication 7 March 1989 nique in the assessment of patients with coronary artery disease. Patients and methods PATIENTSWe studied 48 patients who were investigated by coronary angiography for chest pain and suspected coronary artery disease. Eight of these patients were found to have normal coronary arteries or minor coronary disease (no coronary stenosis > 70%) and were used as a "control" group. Of these none had had a myocardial infarction and five were taking antianginal medication (,B blockers in two
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