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The clinical value of cardiac fluoroscopy
Annotations what extent similarities consistent with differences
females combined) for the period 1968 to 1972 was found to be (I) double that of non-Jewish Whites, and (2) four times that for the population of Israel.’ Differences in values between the sexes was slight. The rate for total Johannesburg Jews was 25 per 100,000, the same as that for the population of Scotland for the same period-whose rate was the highest of values reported for na.tional populations.” Remarkably, no such disparities prevailed for rectal cancer. Furthermore, a recent survey has indicated that the prevalence of ulcerative colitis (a risk factor for colon cancer) in Johannesburg Jews is more than double that prevailing for the non-Jewish White moiety. A report from Baltimore indicated the corresponding differential to be even g;reater.” Our preliminary dietary studies by one of us (C. H.) on groups of Jews in Tel Aviv and in Johannesburg have indicated no outstanding differences in average intakes of gross dietary components: although in the Johannesburg group greater proportions of the fat and protein moieties are derived from animal sources. However, undoubtedly, there were greater disparities in dietary patterns 10 to 20 years ago. Finally, there is evidence that for Jews in the USA, expectation of life at 65 years is decreasing,Y in contrast to that of most other populations. We certainly would not wish to unduly press the accuracy of our data; nevertheless, the very excessive proneness of Johannesburg Jews to the diseases mentioned is judged to be beyond dispute. We very much doubt whether the phenomena are explicable wholly on the basis of differences in environmental factors, particularly diet. We consider that not only individuals but ethnic groups such as Jews may be programmed with the weaknesses described, which becomes more prominent with rise in sophistication of diet and manner of life. It may be recalled that Burch”’ entertained the possibility that Negroes in the USA ma:y be “programmed” for an expectation of life shorter than that of the White inhabitants. It would seem very important that in cities or regions where major differentials in morbidity and mortality from particular diseases prevail between Jewish and non-Jewish Whites, there should be intensive characterizations of diet and biological variables. It should then be possible to learn, inter alia, to
The clinical
South
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9. 10.
Abu-Zeid, H. A. H., Maini, K. K., and Choi, N. W.: Ethnic differences in mortality from ischemic heart disease: A study of migrant and native populations, J. Chronic Dis. 31: 137, 1978. Annual Global Data on Mortality 1970-1972. Ischemic Heart Disease (B.28), World Health Statistical Report 27:82, 1974. Epstein, F. H., Boas, E. P., and Simpson, R.: The epidemiology of atherosclerosis among a random sample of clothing workers of different origin in New York City, J. Chronic Dis. 5:300, 1957. Walker, A. R. P.: Extremes of coronary heart disease mortality in ethnic groups in Johannesburg, South Africa, AM. HEART J. 66:293,1963. Statistical Year Book No. 15. Tel-Aviv-Yafo Municipality: Department of Research and Statistics, 1975, p. 323. Logan, W. P. D.: Cancer of oesophagus, stomach, intestine and rectum. International mortality patterns and trends, World Health Statistical Report 28:473, 1975. Israel Cancer Registry: Cancer in Israel-Facts and Figures for 1967-1971, Jerusalem: Ministry of Health, September, 1977, p. 32-35. Mendeloff, A. I., Monk, M., Siegel, C. I., and Lilienfeld, A.: Illness experience and life stresses in patients with ulcerative colitis, N. Engl. J. Med. 282:14, 1970. Fauman, S. J., and Mayer, A. J.: Jewish mortality in the U.S., Hum. Biol. 41:416, 1969. Burch, G. E.: People are not living longer any more, AM.
HEART J. 83:285, 1972.
value of cardiac fluoroscopy
In 1962 Erich Zdansky wrote in his famous classical work, “Roentgendiagnostik des Herzens und der grosaen Gefasse” (Roentgen diagnosis of the heart and great vessels): “Even today thorough fluoroscopy is an integral part of the roentgenologic examination of the heart and great vessels.“’ For a long time fluoroscopy was a powerful tool in the hands of the cardiovascular radiologists and cardiologists for the evaluation of the cardiac chambers and great vessels. In the last 20 years reliable electrocardiographic criteria for hypertrophy and dilatation of the heart chambers were developed; more recently ultrasonography was introduced as a valuable diagnostic tool in the diagnosis of various abnormal
0002-8703/80/010131
in these variables evoke or are in pathology. A. R. P. Walker, DSc. African Institute for Medical Research Johannesburg I. Segal, M.B., B.Ch., M.R.C.P. Baragwanath Hospital Johannesburg, South Africa T. Gilat, M.D. C. Horowitz, Ph.D. Zchilov Hospital Tel Aviv, Israel
+ 02$00.20/O
0 1980 The
C. V. Mosby
Co.
heart conditions; cinefluorography has become another new modality in the diagnosis of heart diseases. Considering these new developments, it appears appropriate to review the role of conventional fluoroscopy in differential diagnosis of the heart diseases. In our experience the standard four views of the chest with barium swallow, obtained preferably with high kV technique, have replaced fluoroscopy in the evaluation of cardiac chamber enlargement. On good films the heart is seen without magnification and its configuration can be studied at leisure. Correlation between pulmonary vasculature and heart size and shape can be readily made. The evaluation of pulsations
American Heart Journal
131
Annotations
of the pulmonary artery by fluoroscopy is highly subjective and the so-called typical hilar dance is rarely observed. The patient’s radiation exposure is 50 to 100 times greater for one minute of fluoroscopy than for a single PA chest radiogram.’ Thus fluoroscopy represents a significantly higher radiation hazard which is particularly important in the pediatric age group. However, there remain some indications for cardiac fluoroscopy, which should no longer be performed on a routine basis. If valvar calcifications are to be demonstrated, fluoroscopy or preferably cinefluorography is the procedure of choice. But nowadays the same diagnosis can be made without ionizing radiation, namely by ultrasonography. However, small coronary artery calcifications are detectable only during fluoroscopy. In both groups of patients fluoroscopy does not have to be performed as a separate procedure. Most of these patients came to cardiac catheterization or coronary arteriography and thus calcifications can be seen on the angiographic studies. The function of the artificial prosthetic valves can be well studied by fluoroscopy or preferably by cineradiography. For the visualization of the movement of artificial discs and valve leaflets a C-arm is very helpful because a true end-on view has to be obtained for the detection of these extremely thin structures. Admittedly, similar information can be obtained nowadays by two-dimensional ultrasonography. Fluoroscopic evaluation of ventricular aneurysms is not indicated. Paradoxical pulsations are virtually never seen.
Of T waves and chronic failure
congestive
Akinetic areas are usually not appreciated. Aneurysms or contraction abnormalities can only be excluded with certainty by tine left ventriculography. Transmitted pulsations cannot be distinguished from true pulsation. This is the reason why fluoroscopy does not allow differentiation of mediastinal masses from aortic aneurysms. The diagnosis of pericardial effusion used to be a good indication for fluoroscopy. In recent years however, it was replaced by ultrasonography which is much more sensitive. In summary, few indications remain. Cardiac fluoroscopy has been largely replaced by better and more diagnostic, less hazardous tests. In carefully selected patients, it remains a useful diagnostic t,ool, but its indiscriminate and routine use is no longer justified. Agustin Formanek, M.D. Associate Professor of Radiology Vuriet.y Club Heart Hospital Dept. of Radiology University of Minnesota Hospitals Minneapolis, Minn. .554.55 REFERENCES 1.
2.
Zdansky, Erich: Roentgendiagnostik der Grossen Gefasse, 3rd edition, Verlag. Johns, H. E., and Cunningham, Radiology, 3rd edition, Springfield, C Thomas, Publisher.
des Vienna,
Herzens und 1962, Springer-
J. R.: The Physics of Illinois, 1974, Charles
heart
Chronic congestive heart failure (CHF) is always associated with T wave abnormalities in the electrocardiogram. Abnormal T waves are a reliable diagnostic confirmation of chronic CHF. Beware of a diagnosis of chronic CHF in the absence of abnormal T waves in the ECG. George E. Burch, M.D. Tulane University School of Medicine and Charity Hospital of Louisiana New Orleans, La.
132
January,
1980,
Vol.
99, No.
1
0002-8703/80/010132
+ 01$00.10/0
0 1980 The
C. V. Mosby
Co
females combined) for the period 1968 to 1972 was found to be (I) double that of non-Jewish Whites, and (2) four times that for the population of Israel.’ Differences in values between the sexes was slight. The rate for total Johannesburg Jews was 25 per 100,000, the same as that for the population of Scotland for the same period-whose rate was the highest of values reported for na.tional populations.” Remarkably, no such disparities prevailed for rectal cancer. Furthermore, a recent survey has indicated that the prevalence of ulcerative colitis (a risk factor for colon cancer) in Johannesburg Jews is more than double that prevailing for the non-Jewish White moiety. A report from Baltimore indicated the corresponding differential to be even g;reater.” Our preliminary dietary studies by one of us (C. H.) on groups of Jews in Tel Aviv and in Johannesburg have indicated no outstanding differences in average intakes of gross dietary components: although in the Johannesburg group greater proportions of the fat and protein moieties are derived from animal sources. However, undoubtedly, there were greater disparities in dietary patterns 10 to 20 years ago. Finally, there is evidence that for Jews in the USA, expectation of life at 65 years is decreasing,Y in contrast to that of most other populations. We certainly would not wish to unduly press the accuracy of our data; nevertheless, the very excessive proneness of Johannesburg Jews to the diseases mentioned is judged to be beyond dispute. We very much doubt whether the phenomena are explicable wholly on the basis of differences in environmental factors, particularly diet. We consider that not only individuals but ethnic groups such as Jews may be programmed with the weaknesses described, which becomes more prominent with rise in sophistication of diet and manner of life. It may be recalled that Burch”’ entertained the possibility that Negroes in the USA ma:y be “programmed” for an expectation of life shorter than that of the White inhabitants. It would seem very important that in cities or regions where major differentials in morbidity and mortality from particular diseases prevail between Jewish and non-Jewish Whites, there should be intensive characterizations of diet and biological variables. It should then be possible to learn, inter alia, to
The clinical
South
REFERENCES 1.
2.
3.
4.
5.
6.
7.
8.
9. 10.
Abu-Zeid, H. A. H., Maini, K. K., and Choi, N. W.: Ethnic differences in mortality from ischemic heart disease: A study of migrant and native populations, J. Chronic Dis. 31: 137, 1978. Annual Global Data on Mortality 1970-1972. Ischemic Heart Disease (B.28), World Health Statistical Report 27:82, 1974. Epstein, F. H., Boas, E. P., and Simpson, R.: The epidemiology of atherosclerosis among a random sample of clothing workers of different origin in New York City, J. Chronic Dis. 5:300, 1957. Walker, A. R. P.: Extremes of coronary heart disease mortality in ethnic groups in Johannesburg, South Africa, AM. HEART J. 66:293,1963. Statistical Year Book No. 15. Tel-Aviv-Yafo Municipality: Department of Research and Statistics, 1975, p. 323. Logan, W. P. D.: Cancer of oesophagus, stomach, intestine and rectum. International mortality patterns and trends, World Health Statistical Report 28:473, 1975. Israel Cancer Registry: Cancer in Israel-Facts and Figures for 1967-1971, Jerusalem: Ministry of Health, September, 1977, p. 32-35. Mendeloff, A. I., Monk, M., Siegel, C. I., and Lilienfeld, A.: Illness experience and life stresses in patients with ulcerative colitis, N. Engl. J. Med. 282:14, 1970. Fauman, S. J., and Mayer, A. J.: Jewish mortality in the U.S., Hum. Biol. 41:416, 1969. Burch, G. E.: People are not living longer any more, AM.
HEART J. 83:285, 1972.
value of cardiac fluoroscopy
In 1962 Erich Zdansky wrote in his famous classical work, “Roentgendiagnostik des Herzens und der grosaen Gefasse” (Roentgen diagnosis of the heart and great vessels): “Even today thorough fluoroscopy is an integral part of the roentgenologic examination of the heart and great vessels.“’ For a long time fluoroscopy was a powerful tool in the hands of the cardiovascular radiologists and cardiologists for the evaluation of the cardiac chambers and great vessels. In the last 20 years reliable electrocardiographic criteria for hypertrophy and dilatation of the heart chambers were developed; more recently ultrasonography was introduced as a valuable diagnostic tool in the diagnosis of various abnormal
0002-8703/80/010131
in these variables evoke or are in pathology. A. R. P. Walker, DSc. African Institute for Medical Research Johannesburg I. Segal, M.B., B.Ch., M.R.C.P. Baragwanath Hospital Johannesburg, South Africa T. Gilat, M.D. C. Horowitz, Ph.D. Zchilov Hospital Tel Aviv, Israel
+ 02$00.20/O
0 1980 The
C. V. Mosby
Co.
heart conditions; cinefluorography has become another new modality in the diagnosis of heart diseases. Considering these new developments, it appears appropriate to review the role of conventional fluoroscopy in differential diagnosis of the heart diseases. In our experience the standard four views of the chest with barium swallow, obtained preferably with high kV technique, have replaced fluoroscopy in the evaluation of cardiac chamber enlargement. On good films the heart is seen without magnification and its configuration can be studied at leisure. Correlation between pulmonary vasculature and heart size and shape can be readily made. The evaluation of pulsations
American Heart Journal
131
Annotations
of the pulmonary artery by fluoroscopy is highly subjective and the so-called typical hilar dance is rarely observed. The patient’s radiation exposure is 50 to 100 times greater for one minute of fluoroscopy than for a single PA chest radiogram.’ Thus fluoroscopy represents a significantly higher radiation hazard which is particularly important in the pediatric age group. However, there remain some indications for cardiac fluoroscopy, which should no longer be performed on a routine basis. If valvar calcifications are to be demonstrated, fluoroscopy or preferably cinefluorography is the procedure of choice. But nowadays the same diagnosis can be made without ionizing radiation, namely by ultrasonography. However, small coronary artery calcifications are detectable only during fluoroscopy. In both groups of patients fluoroscopy does not have to be performed as a separate procedure. Most of these patients came to cardiac catheterization or coronary arteriography and thus calcifications can be seen on the angiographic studies. The function of the artificial prosthetic valves can be well studied by fluoroscopy or preferably by cineradiography. For the visualization of the movement of artificial discs and valve leaflets a C-arm is very helpful because a true end-on view has to be obtained for the detection of these extremely thin structures. Admittedly, similar information can be obtained nowadays by two-dimensional ultrasonography. Fluoroscopic evaluation of ventricular aneurysms is not indicated. Paradoxical pulsations are virtually never seen.
Of T waves and chronic failure
congestive
Akinetic areas are usually not appreciated. Aneurysms or contraction abnormalities can only be excluded with certainty by tine left ventriculography. Transmitted pulsations cannot be distinguished from true pulsation. This is the reason why fluoroscopy does not allow differentiation of mediastinal masses from aortic aneurysms. The diagnosis of pericardial effusion used to be a good indication for fluoroscopy. In recent years however, it was replaced by ultrasonography which is much more sensitive. In summary, few indications remain. Cardiac fluoroscopy has been largely replaced by better and more diagnostic, less hazardous tests. In carefully selected patients, it remains a useful diagnostic t,ool, but its indiscriminate and routine use is no longer justified. Agustin Formanek, M.D. Associate Professor of Radiology Vuriet.y Club Heart Hospital Dept. of Radiology University of Minnesota Hospitals Minneapolis, Minn. .554.55 REFERENCES 1.
2.
Zdansky, Erich: Roentgendiagnostik der Grossen Gefasse, 3rd edition, Verlag. Johns, H. E., and Cunningham, Radiology, 3rd edition, Springfield, C Thomas, Publisher.
des Vienna,
Herzens und 1962, Springer-
J. R.: The Physics of Illinois, 1974, Charles
heart
Chronic congestive heart failure (CHF) is always associated with T wave abnormalities in the electrocardiogram. Abnormal T waves are a reliable diagnostic confirmation of chronic CHF. Beware of a diagnosis of chronic CHF in the absence of abnormal T waves in the ECG. George E. Burch, M.D. Tulane University School of Medicine and Charity Hospital of Louisiana New Orleans, La.
132
January,
1980,
Vol.
99, No.
1
0002-8703/80/010132
+ 01$00.10/0
0 1980 The
C. V. Mosby
Co