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Radionuclide evaluation of the effect of oral propranolol on left ventricular function during exercise in patients with coronary artery disease
ABSTRACTS
•DOES EXERCISE INDUCED ST ELEVATION LOCALISE MYOCARDIAL ISCHAEMIA? EXERCISE THALLIUM 201 IMAGING AND CORONARY ANGIOGRAPHIC CORRELATIONS Richard F. Dunn, FRACP" lan K. Bailey, FRACP" Roger Hren, FRACP" David T. Kelly_, FACC" Hallstrom Institute of Cardiology, Sydney Australia.
WEDNESDAY, MARCH 14, 1979 AM EXERCISE STUDIES: PHYSIOLOGIC AND PHARMACOLOGIC INTERVENTIONS 10:30-12:00
THe site of exercise induced ST segment elevation (Ex STY) on 12 lead stress electrocardiography was related to the site of myocardial ischaemia on exercise Thallium 201 myocardial imaging (Ex TI) and the coronary artery anatomy. Of 750 consecutive patients (pts) undergoing routine testing 22 (3%) developed Ex S T ~ ( ~ i m m ) and underwent Ex TI and coronary angiography. Six pts had normal rest ECG (ECG-N). Five of the 6 had Ex S T r a n d also ST depression (Ex S T Y ) in reciprocal leads and the other patient Ex ST~ alone. All 6 pts had Ex TI defects only in the site of Ex ST~ . Sixteen pts had Q waves due to previous myocardial infarction (ECG-Q) and all had Ex ST~ only over Q waves. Nine pts developed both Ex ST~ and Ex ST~ and 7 pts Ex ST~ alone. All 16 pts had Ex TI defects in site of Ex S T ~ . Eight of these in addition had Ex TI defects in another site. Of the 9 pts with ECG-Q with Ex ST~ and Ex ST~ , 7 had Ex TI defects in another site compared to only I of the 7 with ECG-Q and Ex S T ~ a l o n e (p(.025). Four out of 5 pts with ECG-N and Ex ST~ and Ex ST~ had single vessel disease while 9/9 with ECG-Q and Ex ST and Ex ST~ had multivessel disease (p~ .005). In pts with ECG-N the site of Ex S T ~ rather than Ex ST~ indicates the site of myocardial ischaemia. In p~s with ECG-Q Ex ST~ with associated EX ST~ indicates another site of myocardial ischaemia and suggests multivessel disease.
EFFECTS OF VERAPAMIL ON EXERCISE CAPACITY IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY Douglas R. Rosing, MD; Kenneth M. Kent, MD; Barr~ J. Marop_~ MD; Stephen E. Epstein, MD, FACC, NHLBI, Bethesda, Md.
RADIONUCLIDE EVALUATION OF T H E E F F E C T OF ORAL PROPRANOLOL ON LEFT VENTRICULAR FUNCTION DURING EXERCISE IN PATIENTS WITH CORONARY ARTERY DISEASE. Robert Marshall, M.D.; Gera~Wisenberg, M.D.; Heinrich Schelbert, M.D.; Chuck Rue, R.T.; UCLA Departments of Medicine and Radiology; Los Angeles, California Computer assisted gated blood pool imaging was used to evaluate global and regional left ventricular (LV) function. during exercise in 8 patients (pts.) with coronary artery disease (CAD) before and after institution of propranolol (PROP). LV function was evaluated at rest and at each w o r k l o a d d u r i n g graded increases in supine bicycle exercise. The first study was obtained prior to PROP therapy and the/second at least 48 hours after peak PROP dose. Peak PROP dose averaged (± S.D.) 155 + 38 mgs /day. On PROP, peak exercise°heart rate (HR) declined from 128±14 BPM to I00 ± 9.4 BPM (p<.001) and peak exerciseaverage blood pressure (BP) declined from 152±23 to 135-+12 (p<.01). Resting mean left ventricular ejection fraction (LVEF) did not change during PROP therapy (LVEF on PROP, .62±09 vs. LVEF off PROP, .59±.07, pNS). At .peak exercise, mean LVEF was'significantly greater on P~OP (LVEF on PROP, .63±.09 vs. LVEF off PROP, .55-+.14, p<.05). 3 pts. developed areas of asynergy which w e r e improved by PROP in 2 pts. 7 pts. with positive ECG stress tests had a higher peak exercise LVEF on PROP (mean LVEF on PROP, .64-+.13 vs. mean LVEF off PROP, .53± .14, p<.01). 1 pt. with no evidence of exercise induced ischemia showed a decline in peak exercise LVEF on PROP (LVEF on PROP, .60 vs. LVEF off PROP, .71). LVEF was. also determined at equivalent HR x BP products: mean LVEF on PROP was significantly higher (LVEF on PROP .63±.12 vs LVEF off PROP .54±.15, p<.05). PROP at clinically effective doses protects against stress induced LV dysfunction in CAD pts., presumably by decreasing regional ischemia.
398
February 1979
The American Journal of CARDIOLOGY
At the present time, the primary medical treatment of symptoms in pts with hypertrophic cardiomyopathy (HCM) is limited to propranolol. Although operative intervention is available to pts with obstructive HCM, no such alternative exists for pts with non-obstructive disease. Because it has been proposed that abnormal Ca metabolism may contribute to the pathological and physiologic abnormalities in some experimental cardiomyopathies, the Ca antagonist verapamil was administered in the catheterization laboratory to pts with HCM and was found to reduce left ventricular outflow obstruction. In order to assess the clinical significance of this finding, treadmill exercise capacity and symptomatic status was evaluated in 19 pts with HCM during oral verapamil, propranolol and placebo (P) administration. Durgs were given in a randomized, double blinded fashion in 2 dosages. On P, average treadmill time (T) was 6.2~0.8 min with all pts stopped by angina, presyncope or dyspnea. Peak T on verapamil was 7.7±0.7 min (P<.01) and on propranolol was 7.4±0.7 min (P<.05). Eleven pts on verapamil and ll on propranolol improved their T by at least 15% compared to P. No pt on verapamil but 3 on propranolol had a decrease in T greater than 15% relative to P. Nine pts described their symptomatic status as "best" on verapamil, 6 did the same for P and 2 for propranolol. Only 3~pts stated they felt "worst" on verapamil compared to 6 each for P and propranolol. The resuits of exercise and symptomatic evaluation agreed in 13/ 19 pts. These findings indicate that verapamil can improve exercise capacity and symptomatic status in pts with HCM, and thus may provide a much needed new therapeutic agent for the treatment of this disorder.
REDUCTION OF BLOOD PRESSURE AND HEART RATE RESPONSESTO ISOMETRIC EXERCISE BY ISOMETRIC STRENGTHTRAINING Steven Lewis, PhD; Else Nygaard, MS; Henrik Egeblad, MD; Bengt Saltin, MD; August Krogh Institute, University of Copenhagen, Copenhagen, Denmark. From a cardiological viewpoint isometric exercise (IE) has been considered a relatively useless form of physical training. However,-data concerning the effects of isometric training (IST) on the cardiovascular response to IE are lacking. In the present study intra-arterial (brachial) blood pressure (BP) and heart rate (HR) were recorded continuously in 9 healthy men during 2 min knee extension IE tests with each leg before and after the knee extensor muscles of one leg had been strength trained isometr i c a l l y . IST consisted of 120 maximal isometric knee extension contractions (5 sec each) per day, 5 days/wk for 9 wks. Maximum voluntary contraction (MVC) before and after IST was 56±II (mean_+SD) and 68±9kg (p
Volume 43
•DOES EXERCISE INDUCED ST ELEVATION LOCALISE MYOCARDIAL ISCHAEMIA? EXERCISE THALLIUM 201 IMAGING AND CORONARY ANGIOGRAPHIC CORRELATIONS Richard F. Dunn, FRACP" lan K. Bailey, FRACP" Roger Hren, FRACP" David T. Kelly_, FACC" Hallstrom Institute of Cardiology, Sydney Australia.
WEDNESDAY, MARCH 14, 1979 AM EXERCISE STUDIES: PHYSIOLOGIC AND PHARMACOLOGIC INTERVENTIONS 10:30-12:00
THe site of exercise induced ST segment elevation (Ex STY) on 12 lead stress electrocardiography was related to the site of myocardial ischaemia on exercise Thallium 201 myocardial imaging (Ex TI) and the coronary artery anatomy. Of 750 consecutive patients (pts) undergoing routine testing 22 (3%) developed Ex S T ~ ( ~ i m m ) and underwent Ex TI and coronary angiography. Six pts had normal rest ECG (ECG-N). Five of the 6 had Ex S T r a n d also ST depression (Ex S T Y ) in reciprocal leads and the other patient Ex ST~ alone. All 6 pts had Ex TI defects only in the site of Ex ST~ . Sixteen pts had Q waves due to previous myocardial infarction (ECG-Q) and all had Ex ST~ only over Q waves. Nine pts developed both Ex ST~ and Ex ST~ and 7 pts Ex ST~ alone. All 16 pts had Ex TI defects in site of Ex S T ~ . Eight of these in addition had Ex TI defects in another site. Of the 9 pts with ECG-Q with Ex ST~ and Ex ST~ , 7 had Ex TI defects in another site compared to only I of the 7 with ECG-Q and Ex S T ~ a l o n e (p(.025). Four out of 5 pts with ECG-N and Ex ST~ and Ex ST~ had single vessel disease while 9/9 with ECG-Q and Ex ST and Ex ST~ had multivessel disease (p~ .005). In pts with ECG-N the site of Ex S T ~ rather than Ex ST~ indicates the site of myocardial ischaemia. In p~s with ECG-Q Ex ST~ with associated EX ST~ indicates another site of myocardial ischaemia and suggests multivessel disease.
EFFECTS OF VERAPAMIL ON EXERCISE CAPACITY IN PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY Douglas R. Rosing, MD; Kenneth M. Kent, MD; Barr~ J. Marop_~ MD; Stephen E. Epstein, MD, FACC, NHLBI, Bethesda, Md.
RADIONUCLIDE EVALUATION OF T H E E F F E C T OF ORAL PROPRANOLOL ON LEFT VENTRICULAR FUNCTION DURING EXERCISE IN PATIENTS WITH CORONARY ARTERY DISEASE. Robert Marshall, M.D.; Gera~Wisenberg, M.D.; Heinrich Schelbert, M.D.; Chuck Rue, R.T.; UCLA Departments of Medicine and Radiology; Los Angeles, California Computer assisted gated blood pool imaging was used to evaluate global and regional left ventricular (LV) function. during exercise in 8 patients (pts.) with coronary artery disease (CAD) before and after institution of propranolol (PROP). LV function was evaluated at rest and at each w o r k l o a d d u r i n g graded increases in supine bicycle exercise. The first study was obtained prior to PROP therapy and the/second at least 48 hours after peak PROP dose. Peak PROP dose averaged (± S.D.) 155 + 38 mgs /day. On PROP, peak exercise°heart rate (HR) declined from 128±14 BPM to I00 ± 9.4 BPM (p<.001) and peak exerciseaverage blood pressure (BP) declined from 152±23 to 135-+12 (p<.01). Resting mean left ventricular ejection fraction (LVEF) did not change during PROP therapy (LVEF on PROP, .62±09 vs. LVEF off PROP, .59±.07, pNS). At .peak exercise, mean LVEF was'significantly greater on P~OP (LVEF on PROP, .63±.09 vs. LVEF off PROP, .55-+.14, p<.05). 3 pts. developed areas of asynergy which w e r e improved by PROP in 2 pts. 7 pts. with positive ECG stress tests had a higher peak exercise LVEF on PROP (mean LVEF on PROP, .64-+.13 vs. mean LVEF off PROP, .53± .14, p<.01). 1 pt. with no evidence of exercise induced ischemia showed a decline in peak exercise LVEF on PROP (LVEF on PROP, .60 vs. LVEF off PROP, .71). LVEF was. also determined at equivalent HR x BP products: mean LVEF on PROP was significantly higher (LVEF on PROP .63±.12 vs LVEF off PROP .54±.15, p<.05). PROP at clinically effective doses protects against stress induced LV dysfunction in CAD pts., presumably by decreasing regional ischemia.
398
February 1979
The American Journal of CARDIOLOGY
At the present time, the primary medical treatment of symptoms in pts with hypertrophic cardiomyopathy (HCM) is limited to propranolol. Although operative intervention is available to pts with obstructive HCM, no such alternative exists for pts with non-obstructive disease. Because it has been proposed that abnormal Ca metabolism may contribute to the pathological and physiologic abnormalities in some experimental cardiomyopathies, the Ca antagonist verapamil was administered in the catheterization laboratory to pts with HCM and was found to reduce left ventricular outflow obstruction. In order to assess the clinical significance of this finding, treadmill exercise capacity and symptomatic status was evaluated in 19 pts with HCM during oral verapamil, propranolol and placebo (P) administration. Durgs were given in a randomized, double blinded fashion in 2 dosages. On P, average treadmill time (T) was 6.2~0.8 min with all pts stopped by angina, presyncope or dyspnea. Peak T on verapamil was 7.7±0.7 min (P<.01) and on propranolol was 7.4±0.7 min (P<.05). Eleven pts on verapamil and ll on propranolol improved their T by at least 15% compared to P. No pt on verapamil but 3 on propranolol had a decrease in T greater than 15% relative to P. Nine pts described their symptomatic status as "best" on verapamil, 6 did the same for P and 2 for propranolol. Only 3~pts stated they felt "worst" on verapamil compared to 6 each for P and propranolol. The resuits of exercise and symptomatic evaluation agreed in 13/ 19 pts. These findings indicate that verapamil can improve exercise capacity and symptomatic status in pts with HCM, and thus may provide a much needed new therapeutic agent for the treatment of this disorder.
REDUCTION OF BLOOD PRESSURE AND HEART RATE RESPONSESTO ISOMETRIC EXERCISE BY ISOMETRIC STRENGTHTRAINING Steven Lewis, PhD; Else Nygaard, MS; Henrik Egeblad, MD; Bengt Saltin, MD; August Krogh Institute, University of Copenhagen, Copenhagen, Denmark. From a cardiological viewpoint isometric exercise (IE) has been considered a relatively useless form of physical training. However,-data concerning the effects of isometric training (IST) on the cardiovascular response to IE are lacking. In the present study intra-arterial (brachial) blood pressure (BP) and heart rate (HR) were recorded continuously in 9 healthy men during 2 min knee extension IE tests with each leg before and after the knee extensor muscles of one leg had been strength trained isometr i c a l l y . IST consisted of 120 maximal isometric knee extension contractions (5 sec each) per day, 5 days/wk for 9 wks. Maximum voluntary contraction (MVC) before and after IST was 56±II (mean_+SD) and 68±9kg (p
Volume 43