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The acute effects of nitroprusside on plasma norepinephrine, renin activity, and arginine vasopressin in patients with congestive heart failure
ABSTRACTS
TUESDAY, APRIL 27, 1982 AM TREATMENT OF VALVULAR, MYOCARDIAL AND PERICARDIAL DISEASE 8:30- lo:oo THE ACUTE EFFECTS OF NITROPRUSSIDE ON PLASMA NORBPINEPHRINE, RENIN ACTIVITY, AND ARGININE VASOPRBSSIN IN PATIENTS WITH CONGESTIVE HEART FAILURE Gary S. Francis, MD, FACC; Steven R. Goldsmith, MD; Gordon Pierpont, MD, Ph.D.; Jay N. Cohn, MD, FACC; University of MN and VA Medical Center, Minneapolis, MN Activation of the sympathetic nervous system, manifested by an increase in heart rate (HR) and circulating plasma norepinephrine (NE), can occur in normal subjects when given vasodilators. This activation could account for the hemodynamic "rebound" sometimes observed following abrupt withdrawal of nitroprusside (NP) in patients (pts) with congestive heart failure (CHF). We studied the effects of NP on plasma NE, renin activity (PRA), and arginine vasopressin (AVP) in 12 pts with CHF to determine if acute vasodilator therapy activates these vasoconstrictor systems during or following such treatment. Baseline supine plasma NE (689+118 pg/ml, SEX), PRA (1824 ng/ml/hr) and AVP (10.3tO.l pg/ml) were increased in the control state. NP (94?25 ug/min) was infused for 30 min. after achieving an optimal hemodyna;ic response: CI increased (2.19+0.1 to 2.7420.2 L/min/m , p
RIGHT AND LEFT VENTRICULAR FUNCTION AND VOLUMES BEFORE AND AFTER PERICARIIOCENTESIS IN PATIENTS WITH MODERATE TO LARGE PERICARDIAL EFFUSION. Dante E. Manyari, Paul Purves, William J. Kostuk, University Hospital, London, Ontario. There is limited information concerning ventricular performance following pericardiocentesis in the clinical setting. Accordingly, ECG-gated radionuclide angiography was used to assess left (LV) and right (RV) ventricular ejection fraction (EF) and volumes, immediately before and after 15 elective pericardiocentesis in 11 patients, 7 men and 4 women, mean age 46 years. Two had diagnostic and 13 had therapeutic pericardiocentesis because of mild to moderate symptoms. Paradoxical pulse was present in 5 subjects. After removal of 50-1,100 ml, mean 495 ml ? 320, (ZSD) there was a subjective and objective clinical improvement in 11 instances. Left ventricular function was normal (EF > 55%) in 8 and abnormal (EF <55X) in 7 instances. After pericardiocentesis, the LV EF increased from 63 to 64%, the RV EF decreased from 47 to 46% (p > .05). However, end-diastolic volume (EDV) and endsystolic volume (ESV) increased significantly (p< .05). In the LV, EDV increased by 26% and ESV by 32%. In the RV, EDV increased by 32% and ESV by 35%. Changes in EF were similar (p>.O5) in subgroups of patients with or without paradoxical pulse and in patients with normal or abnormal LV function. However, right and left ventricular EDV and ESV increased more markedly (p< .05) in patients with paradoxical pulse than in those without paradoxical pulse, and in patients with normal LV function than in those with abnormal LV function. Thus, hemodynamic and clinical improvement following pericardiocentesis may be related only to an increase in stroke volume. Right and left ventricular EF, a measure of myocardial contractility did not change significantly.
OCCULT PERICARDIAL EFFUSION DURING PREGNANCY: A NEW ENTITY Robert Haiat, MD, FACC ; Christine Halphen, MD, Centre Hospitalier, Saint Germain en Laye, France. In order to investigate the hemcdynamic changes which occur during pregnancy 123 healthy women (mean age 28yrs) were studied at varicxls stages of their gestation by Tm and two dimensional echocardiography (E). Of 123, 46 were in their late pregnancy (32nd to 38th week). The hemodynamic data will be discussed elsewhere. We just wanted to stress here that surprisingly E showed definite signs of pericardial effusion in 19 of the 46 (41.3 %) women who were in late pregnancy : in these cases a separation between posterior left ventricular epicardium and pericardium continued thrcugh the cardiac cycle ; according to Horowitz's criteria, the effusion was large in 2, moderate in 4 and small in 13 cases. Pericardial effusion was clinically silent as neither precordial pain nor pericardial friction rub was present. Clinical examination was normal in all cases but blood pressure was slightly elevated in 3. None of the pregnant women presented with eclsmpsia, recent viral illness or evidence of congestive heart failure. The ECG was normal or showed non specific ST-T changes. Pericardial effusion appeared in the late pregnancy and did not occur before the 32nd week ; it was always transient and could not any longer be seen within the two months following delivery. It was likely to result from water and salt inflation : at the same stage of gestation the mean weight gain was significantly (p ( 0.03) higher in women who showed signs of pericardial effusion than in others (13.60 ? 4.28 vs 10.96 ? 3.7 Kg). In conclusion : pericardial effusion has not been reported so far during normal pregnancy. As it cannot be detected either by clinical examination or ECG, E affords a safe and reliable approach of its diagnostic.
BACTEREMlA AND THE HEART: SERIAL ECHO FINDINGS IN 80 PATIENTS WITH DOCUMENTED OR SUSPECTED BACTEREMIA. JR Stratton MD; JA Werner MD, FACC; AS Pearlman MD, FACC; CL Janko; S Kliman MD; MC Jackson MD. VA Medical Center and Univ. of Washington, Seattle, WA. Cardiac complications of bacteremia can include purulent pericarditis with pericardial effusion (EFF), left ventricular dysfunction (LVD), and bacterial endocarditis (BE) with vegetations (VEG). To define the incidence and course of echo defined abnormalities, and the role of routine echo, in bacteremic (BAC) pts, we performed serial M-mode and 2D ethos at l-2 wk intervals on 57 BAC pts and 23 controls with suspected bacteremia but negative cultures. Risk factors for BE including valvular heart disease and IV drug abuse were noted. No clinical feature distinguished BAC pts from controls at entry. A total of I86 ethos (2.4/pt) were blindly interpreted. Nine of 57 BAC pts had a total of IO VEG while no controls had VEC (p < 0.05). Of the 9 pts with VEG, 4 had clinically unsuspected BE prior to echo, while 5 had clinically diagnosed BE. On serial study, 4 VEG were unchanged, 3 increased, and 3 decreased in size. Risk factors predisposing to BE were present in 67% (6/9) BAC pts with VEG vs. 8% (3/48) without VEG (p < 0.001). EFF occurred in 33% BAC pts vs. 17% controls (p = NS) but never led to tamponade or purulent pericarditis and were thus never clinically important. Global LVD occurred in 19% (II/571 BAC pts vs. 13% (3/23) controls (p = NS). LVD improved in 6/1l BAC pts but in no controls. Other lesions including prolapse and nonspecific valve thickening were equally present in both groups. Echo can detect clinically unsuspected VEG in BAC pts. However, routine echo to rule out VEG or EFF or LVD is not justified. We recommend echo in BAC pts who have I) suspected BE or risk factors for BE, 2) a possible intravascular source, or 3) no clearly defined source of bacteremia. Had these guidelines been used, only 28% (16/57) of BAC pts would have hnd echo, including all 9 pts with VEG.
March 1982
The American Journal ol CARDIOLOGY
Volume 49
937
TUESDAY, APRIL 27, 1982 AM TREATMENT OF VALVULAR, MYOCARDIAL AND PERICARDIAL DISEASE 8:30- lo:oo THE ACUTE EFFECTS OF NITROPRUSSIDE ON PLASMA NORBPINEPHRINE, RENIN ACTIVITY, AND ARGININE VASOPRBSSIN IN PATIENTS WITH CONGESTIVE HEART FAILURE Gary S. Francis, MD, FACC; Steven R. Goldsmith, MD; Gordon Pierpont, MD, Ph.D.; Jay N. Cohn, MD, FACC; University of MN and VA Medical Center, Minneapolis, MN Activation of the sympathetic nervous system, manifested by an increase in heart rate (HR) and circulating plasma norepinephrine (NE), can occur in normal subjects when given vasodilators. This activation could account for the hemodynamic "rebound" sometimes observed following abrupt withdrawal of nitroprusside (NP) in patients (pts) with congestive heart failure (CHF). We studied the effects of NP on plasma NE, renin activity (PRA), and arginine vasopressin (AVP) in 12 pts with CHF to determine if acute vasodilator therapy activates these vasoconstrictor systems during or following such treatment. Baseline supine plasma NE (689+118 pg/ml, SEX), PRA (1824 ng/ml/hr) and AVP (10.3tO.l pg/ml) were increased in the control state. NP (94?25 ug/min) was infused for 30 min. after achieving an optimal hemodyna;ic response: CI increased (2.19+0.1 to 2.7420.2 L/min/m , p
RIGHT AND LEFT VENTRICULAR FUNCTION AND VOLUMES BEFORE AND AFTER PERICARIIOCENTESIS IN PATIENTS WITH MODERATE TO LARGE PERICARDIAL EFFUSION. Dante E. Manyari, Paul Purves, William J. Kostuk, University Hospital, London, Ontario. There is limited information concerning ventricular performance following pericardiocentesis in the clinical setting. Accordingly, ECG-gated radionuclide angiography was used to assess left (LV) and right (RV) ventricular ejection fraction (EF) and volumes, immediately before and after 15 elective pericardiocentesis in 11 patients, 7 men and 4 women, mean age 46 years. Two had diagnostic and 13 had therapeutic pericardiocentesis because of mild to moderate symptoms. Paradoxical pulse was present in 5 subjects. After removal of 50-1,100 ml, mean 495 ml ? 320, (ZSD) there was a subjective and objective clinical improvement in 11 instances. Left ventricular function was normal (EF > 55%) in 8 and abnormal (EF <55X) in 7 instances. After pericardiocentesis, the LV EF increased from 63 to 64%, the RV EF decreased from 47 to 46% (p > .05). However, end-diastolic volume (EDV) and endsystolic volume (ESV) increased significantly (p< .05). In the LV, EDV increased by 26% and ESV by 32%. In the RV, EDV increased by 32% and ESV by 35%. Changes in EF were similar (p>.O5) in subgroups of patients with or without paradoxical pulse and in patients with normal or abnormal LV function. However, right and left ventricular EDV and ESV increased more markedly (p< .05) in patients with paradoxical pulse than in those without paradoxical pulse, and in patients with normal LV function than in those with abnormal LV function. Thus, hemodynamic and clinical improvement following pericardiocentesis may be related only to an increase in stroke volume. Right and left ventricular EF, a measure of myocardial contractility did not change significantly.
OCCULT PERICARDIAL EFFUSION DURING PREGNANCY: A NEW ENTITY Robert Haiat, MD, FACC ; Christine Halphen, MD, Centre Hospitalier, Saint Germain en Laye, France. In order to investigate the hemcdynamic changes which occur during pregnancy 123 healthy women (mean age 28yrs) were studied at varicxls stages of their gestation by Tm and two dimensional echocardiography (E). Of 123, 46 were in their late pregnancy (32nd to 38th week). The hemodynamic data will be discussed elsewhere. We just wanted to stress here that surprisingly E showed definite signs of pericardial effusion in 19 of the 46 (41.3 %) women who were in late pregnancy : in these cases a separation between posterior left ventricular epicardium and pericardium continued thrcugh the cardiac cycle ; according to Horowitz's criteria, the effusion was large in 2, moderate in 4 and small in 13 cases. Pericardial effusion was clinically silent as neither precordial pain nor pericardial friction rub was present. Clinical examination was normal in all cases but blood pressure was slightly elevated in 3. None of the pregnant women presented with eclsmpsia, recent viral illness or evidence of congestive heart failure. The ECG was normal or showed non specific ST-T changes. Pericardial effusion appeared in the late pregnancy and did not occur before the 32nd week ; it was always transient and could not any longer be seen within the two months following delivery. It was likely to result from water and salt inflation : at the same stage of gestation the mean weight gain was significantly (p ( 0.03) higher in women who showed signs of pericardial effusion than in others (13.60 ? 4.28 vs 10.96 ? 3.7 Kg). In conclusion : pericardial effusion has not been reported so far during normal pregnancy. As it cannot be detected either by clinical examination or ECG, E affords a safe and reliable approach of its diagnostic.
BACTEREMlA AND THE HEART: SERIAL ECHO FINDINGS IN 80 PATIENTS WITH DOCUMENTED OR SUSPECTED BACTEREMIA. JR Stratton MD; JA Werner MD, FACC; AS Pearlman MD, FACC; CL Janko; S Kliman MD; MC Jackson MD. VA Medical Center and Univ. of Washington, Seattle, WA. Cardiac complications of bacteremia can include purulent pericarditis with pericardial effusion (EFF), left ventricular dysfunction (LVD), and bacterial endocarditis (BE) with vegetations (VEG). To define the incidence and course of echo defined abnormalities, and the role of routine echo, in bacteremic (BAC) pts, we performed serial M-mode and 2D ethos at l-2 wk intervals on 57 BAC pts and 23 controls with suspected bacteremia but negative cultures. Risk factors for BE including valvular heart disease and IV drug abuse were noted. No clinical feature distinguished BAC pts from controls at entry. A total of I86 ethos (2.4/pt) were blindly interpreted. Nine of 57 BAC pts had a total of IO VEG while no controls had VEC (p < 0.05). Of the 9 pts with VEG, 4 had clinically unsuspected BE prior to echo, while 5 had clinically diagnosed BE. On serial study, 4 VEG were unchanged, 3 increased, and 3 decreased in size. Risk factors predisposing to BE were present in 67% (6/9) BAC pts with VEG vs. 8% (3/48) without VEG (p < 0.001). EFF occurred in 33% BAC pts vs. 17% controls (p = NS) but never led to tamponade or purulent pericarditis and were thus never clinically important. Global LVD occurred in 19% (II/571 BAC pts vs. 13% (3/23) controls (p = NS). LVD improved in 6/1l BAC pts but in no controls. Other lesions including prolapse and nonspecific valve thickening were equally present in both groups. Echo can detect clinically unsuspected VEG in BAC pts. However, routine echo to rule out VEG or EFF or LVD is not justified. We recommend echo in BAC pts who have I) suspected BE or risk factors for BE, 2) a possible intravascular source, or 3) no clearly defined source of bacteremia. Had these guidelines been used, only 28% (16/57) of BAC pts would have hnd echo, including all 9 pts with VEG.
March 1982
The American Journal ol CARDIOLOGY
Volume 49
937