Forty-five patients presenting with unstable angina having 70 p. 100 stenosis of the left anterior descending artery judged acceptable for coronary bypass surgery were randomly allocated, using a table of random numbers, for medical (21 patients) or surgical treatment (24 patients). There were no significant differences between the two groups with regards to age (53 +/- 10 years for the medical group; 55 +/- 9 years for the surgical group), the length of follow-up (55 +/- 26 vs 61 +/- 28 months), left ventricular end diastolic volumes (87 +/- 27 vs 84 +/- 18 ml/m2) or ejection fraction (62 +/- 8 vs 59 +/- 11 p. 100). There were no deaths in the medical group; two patients developed uncomplicated myocardial infarction 19 days and 7 months after coronary angiography, respectively. 5 patients had recurrent angina and were referred for surgery. This operation of second intention did not pose any special problems. 6 of the 14 patients with stenosis of the LAD before the origin of the first septal artery had complications (infarction in 1 case, recurrent angina in 5 cases). In the surgical group, 1 patient died in the immediate postoperative period, of resistant cardiac arrhythmia; 2 patients developed uncomplicated peroperative myocardial infarction; 21 patients had no complications at all. The surgical patients were heparinised in the immediate postoperative period and anticoagulant therapy was continued with oral vitamin K antagonists for 6 months to 1 year, followed in some cases, by platelet antiaggregant therapy. 20 patients in this group underwent maximal exercise stress testing which was negative in 19 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

A 46-year-old chronic alcoholic patient with typical and severe congestive cardiomyopathy was studied hemodynamically on two separate occasions. The second study followed after a 1 1/2-year period of virtually complete abstention from alcohol and revealed that the left ventricular dysfunction had disappeared. Depsite persisting atrial fibrillation, the response to moderate exercise and to plasma volume expansion was within the normal range. When last seen, 29 months after initial hospitalization, the patient was symptom-free and was not given any treatment.

Intravenous trinitroglycerine (IV TNT) was used in 17 patients with myocardial pre-infarction syndrome defined by the presence of prolonged spontaneous attacks of attacks of angina, with electrocardiographic changes, persisting despite medical treatment with beta-blockers and oral nitrite derivatives. Seven patients had chronic angina, 7 had angina of recent onset and 3 patients had early post-infarction angina. IV TNT was used for 3 to 11 days at a mean dose of 40 micrograms/mn in 11 patients and 8 micrograms/mn in 6 patients. In the latter, cardiac output and pulmonary pressures were measured. IV TNT made it possible to decrease or stop angina attacks in all the patients except one. There was no significant variation in heart rate and mean blood pressure fell by 8 mmHg (p < 0.001). Cardiac index was maintained despite a fall in capillary pressure of 4.1 mmHg (p < 0.01). Coronary arteriography was performed in 16 cases, with circulatory assistance in 4 patients. Thirteen patients were treated by surgical revascularisation, with two operative deaths. IV TNT appeared to be effective and well tolerated treatment in these particularly severe forms of unstable angina.

Infarct size (IS) was estimated from serial total creatine phosphokinase (CK) changes in 82 patients with acute myocardial infarction (MI). Anteroseptal and inferior MI involved a relatively small mass of myocardium (16.0 +/- 6.4 and 24.7 +/- 10.0 CK-g-eq respectively); anteroapical and inferoposterior MI had an average IS of 35.9 +/- 15.9 and 32.8 +/- 13.8 CK-g-eq respectively (NS); extensive anterior and inferoposterolateral MI had an average IS of 57.8 +/- 20.1 and 51.1 +/- 11.5 CK-g-eq respectively (NS). Left ventricular failure (LVF) correlated with estimated IS and not with location of the infarct. In patients with an IS ranging from 30 to 50 CK-g-eq, the incidence of LVF was 33%. In patients with an IS greater than 50 CK-g-eq, the incidence of LVF was 65%. Out of the 6 patients who died, 3 had an IS greater than 60 CK-g-eq. 3 groups of patients could be identified from the duration of the CK release time: in group I (mean = 20 +/l h; n = 61), infarct size was highly correlated with peak CK activity (r = 0.93); in group II (mean = 39 +/- 7 h; n = 17) the correlation between IS and peak CK activity was poor (r = 0.59) and might indicate a gradual necrosis; in group III (n = 4) patients with reinfarction showed a second peak on the descending limb of the CK activity curve. Follow-up information was available in 96% of the 76 survivors. At the end of the follow-up (18.1 +/- 10.8 mth) IS was not significantly different in patients with LVF (42.7 +/- 17.5 CK-g-eq) and in those without LVF (34.7 +/- 19.7 CK-g-eq).

80 patients with a primary myocardial infarction (32 anterior and 48 posterior) underwent cardiac catheterisation and angiography (coronary arteriography and selective left ventricular cineangiography) within 12 months of infarction. Analysis of the results of catheterisation and angiography showed: -- Diffuse coronary artery narrowing to be more frequent in patients with posterior infarction. Significant stenosis of the left anterior descending artery was observed in half these cases; -- No correlation between the results of cardiac catheterisation and the distribution of the coronary artery lesions. Changes of ventricular contraction are essentially related to the infarct size and much less to the quality of the healthy myocardium as far as can be appreciated by the usual haemodynamic methods in both anterior and posterior myocardial infarction.

The hemodynamic effects of an oral sustained-release nitroglycerin preparation were determined in 20 patients with or without congestive heart failure. Twenty additional patients given a placebo served as a control group. In 10 patients with congestive heart failure, 1 hour after administration of 5 mg of sustained-release nitroglycerin, the left ventricular filling pressure decreased from 31.2 ± 10.2 to 21.5 ± 10.8 mm Hg ( P In 20 patients with uncomplicated acute myocardial infarction, heart rate, blood pressure and central venous pressure were monitored for 12 hours. After administration of either placebo or sustained-release nitroglycerin, heart rate and blood pressure remained unchanged. In contrast, 30 minutes after sustained-release nitroglycerin, central venous pressure decreased significantly by 40 percent and remained lower than the baseline value for 8 hours. These data demonstrate that sustained-release nitroglycerin has prolonged physiologic activity and may be suitable for the therapy of congestive heart failure and angina pectoris.

In nine patients with medically refractory left ventricular failure and/or ventricular arrhythmias, secondary to acute formation of a ventricular aneurysm, intra-aortic balloon pumping (IABP) was instituted 24 to 36 hours before diagnostic angiographic studies. Ventricular irritability was reduced and heart failure was controlled in all patients. Eight patients underwent operation, four within 3 weeks of an acute myocardial infarction and four within 3 months. All had resection of the recent infarction and two had myocardial revascularization as well. Two of the eight patients died in the early postoperative period from intractable ventricular fibrillation. All six patients who survived the operation (mean follow-up 12 months) had excellent clinical results. Ventricular irritability was suppressed and only one patient had residual heart failure. However, there was one late death 7 months after operation. The results suggest that surgical therapy may be effective in the management of medically unresponsive arrhythmias and/or congestive heart failure in the acute or intermediate postinfarction phase. IABP assistance was helpful in supporting the circulation and reducing ventricular irritability during the preoperative and postoperative periods.