Neurohumoral activation at the time of hospital discharge in postinfarction patients is an independent sign of poor prognosis. This is particularly true for plasma renin activity and atrial natriuretic peptide. Except for 1-year cardiovascular mortality, captopril does not significantly modify these relations.
The threshold for the admission of patients to a coronary care unit or for the use of invasive diagnostic and therapeutic interventions in the early and late periods after an infarction is higher in Canada than in the United States. This is not associated with any apparent difference in the rate of reinfarction or survival, but is associated with a higher frequency of activity-limiting angina.
Neurohumoral activation occurs in a significant proportion of patients at the time of hospital discharge after infarction. Which neurohormone is activated and which clinical and laboratory variables determine this activation vary from one neurohormone to another.
SUMMARY Rest and exercise radionuclide angiocardiographic measurements of left ventricular function were obtained in 496 patients who underwent cardiac catheterization for chest pain. Two hundred forty-eight of these patients also had an exercise treadmill test. An ejection fraction less than 50% was the abnormality of resting left ventricular function that provided the greatest diagnostic information. In patients with normal resting left ventricular function, exercise abnormalities that were optimal for diagnosis of coronary artery disease were an ejection fraction at least 6% less than predicted, an increase of greater than 20 ml in end-systolic volume and the appearance of an exercise-induced wall motion abnormality. The sensitivity and specificity of the test were lower in patients who were taking propranolol at the time of study and in patients who failed to achieve an adequate exercise end point. In the 387 patients with an optimal study, the test had a sensitivity of 90% and a specificity of 58%. Radionuclide angiocardiography was more sensitive and less specific than the exercise treadmill test. The high degree of sensitivity of the radionuclide test suggests that it is most appropriately applied to patient groups with a high prevalence of disease, including those considered for cardiac catheterization.
MYOCARDIAL
SUMMARY We evaluated the effects of 6 months of exercise training (bicycle ergometry, walking and jogging) on exercise performance and ventricular function in patients with recent myocardial infarction. Fifteen patients were selected on the basis of myocardial infarction at least 6 weeks but not more than 6 months before the study and age younger than 65 years. The patients were evaluated by maximal treadmill exercise testing and radionuclide angiography at rest and exercise before and after training.Before exercise training, maximal treadmill exercise time ranged from 1.5 to 11 minutes, ejection fraction at rest from 18% to 67% and end-diastolic volume from 108 to 208 ml. The mean EF was 48 ± 5% (± SD) at rest and did not change at maximal exercise (48.5 ± 5%). All 11 patients who completed the exercise training program achieved a significant training effect, as defined by a reduction in heart rate at 50% maximal pretraining effort or an increase in maximal treadmill time. The mean ejection fraction and end-diastolic volume and wall motion abnormalities at rest and at comparable pretraining exercise work loads and heart rates were not significantly different after training.Despite a wide range of rest and exercise ventricular function, patients with recent uncomplicated myocardial infarcts significantly increased their exercise performance. Because rest and exercise ventricular function were comparable before and after training, improvement in exercise performance probably resulted from training effects on the peripheral vasculature.PATIENTS with coronary artery disease demonstrate a wide range of impaired cardiovascular adjustments during exercise.' Although exercise performance in certain patients with coronary artery disease may not be different from that in age-matched normal subjects, most patients have lower maximal cardiac output and maximal oxygen consumption,lA a decreased heart rate response to exercise and a decreased stroke volume at submaximal work loads. 1-' During mild supine exercise, left ventricular filling pressures are often elevated$'0 and systolic ejection rate and the rate of rise of pressure at a given ventricular pressure are reduced."1-3 Noninvasive evaluation of ventricular function using radionuclide angiography has shown that the left ventricular ejection fraction frequently decreases and regional wall motion abnormalities appear during exercise in patients with coronary disease.I-'7 These findings indicate that left ventricular dysfunction commonly occurs in patients with coronary artery disease during exercise stress.Exercise training improves exercise tolerance in most patients with coronary disease.2' 5, 18-22 Clausen' summarized the central and peripheral effects of exercise training and pointed out that the effects are qualitatively similar in subjects with and without coronary artery disease. In patients with coronary disease and no chest pain, training may improve maximal exercise
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