Angiology

Systemic lupus erythematosus (SLE) is a well-known acute and/or chronic multisystem disease of complex autoimmune nature, having predilection for cardiovascular system. While its cardiac manifestations have been adequately studied, there is paucity of information on its vascular manifestations. Accord ingly, we studied the incidence of vascular manifestations in 50 consecutive SLE patients seen at our institutions and in private practice during the past 12 years.

Systemic hypertension (44%) was the most common vascular manifestation followed by vasculitis (30%), Raynaud's phenomenon (26%), telangiectasis (20%), premature coronary atherosclerosis (6%), digital ulceration (6%), thrombophlebitis (6%), pulmonary hypertension (4%) and portal hypertension (4%). Diffuse systemic vasculitis similar to polyarteritis nodosa was rare (2%). Often more than one lesion was found in the same patient. The clinical diagnosis of these vascular manifestations in the context of the primary disease (SLE) usually does not pose any difficulty except when they antedate it.

We also studied the pathology and pathogenesis of some of these vascular lesions in both autopsy and biopsy specimens by both light microscopy and immunofluorescent techniques. Our results as well as those of others who also studied these lesions indicate that immune complex deposition and subsequent complement activation play an important role in the pathogenesis of vasculitis, coronary arteritis and premature coronary atherosclerosis.

Corticosteroids and vasodilators remain the drugs of choice for the manage ment of the majority of the symptoms arising from the vascular lesions of SLE.

The authors have developed a vascular reactivity test to cold using the digital plethysmograph technique with a mercury strain gauge. Three types of arterial reactivity were determined: local reactivity after immersion of the hand in 11°C water, general reactivity after thorax ventilation, and cumulative reactivity as sociating both of these cooling modes. The method is based on measurement of the digital plethysmographic signal expressed as a ratio of a reference warm amplitude obtained after immersion of the hand in 45°C water for 3 min. The method was tested and perfected in 66 control subjects before being applied to 65 patients with Raynaud's disease. Significant differences were noted between these 2 groups, especially in cumulative reactivity (p < 10^-9), which led to nu merical expression of results in 5 types of increasingly important reactivity. It would appear that the test has diagnostic and prognostic value in the explora tion of vascular acrosyndromes and their therapeutic follow-up.

Pulmonary edema of non-cardiac origin is usually an urgent clinical prob lem, which has recently increased in frequency throughout the world in the past few years. This is partly due to sociological factors and to pre-eminent advances in industrial technology. Recent severe massive toxic gas explosions have had national and worldwide implications. Therefore, urgent and appropriate ther apy is of utmost importance in most of these patients. The use of high flow oxygen with Constant Positive Pressure Breathing are the main inhalational therapeutic approaches. Newer modalities of treatment include: (1) earlier Fi beropticbronchoscopy in those individuals afflicted with aspiration problems and (2) certain specific chemical blocking agents for the management of phos gene intoxication and hydrogen sulfide toxicity. Preventive environmental mea sures are also important.

Twenty patients completed a double-blind cross-over study to determine the influence of a transdermal preparation of Nitroglycerin on exercise perform ance in stable angina. Angiographically proven two or three vessel coronary disease was present in all. After a base-line exercise test the active device was titrated to efficacy or side effects and the number of patches thereafter re mained constant (2-6 patches per day; mean 3.5). Patients were randomly allo cated to active treatment or placebo, and further exercise tests were performed at 2 hours and 26 hours after application of the device. Patients were then crossed over after one days rest to the opposite treatment group, and exercise studies repeated. Two hours after application of transdermal nitroglycerin total exercise duration increased (mean 14.0 minutes) compared to placebo (12.5 minutes) and control (12.0 minutes) (p < 0.05). This effect was maintained at 26 hours. Exercise time to anginal threshold (angina + 1.5 mm ST segment depression) was increased at 2 hours and 26 hours with active drug by 11 % compared to placebo and by 22% in comparison to control. Double product of heart rate and blood pressure was not significantly different in treated and placebo groups. Oral nitroglycerin consumption assessed during the titration phase was reduced by 71%. It is concluded that transdermal nitroglycerin sig nificantly increases exercise capacity in patients with stable angina, with an effect that is maintained over a 24-hour period using a single dose application.

The management of newly diagnosed left main obstruction varies through out institutions. At some Centers, very aggressive measures including intra- aortic balloon counterpulsation and emergent revascularization are routine protocol. Twenty consecutive patients with greater than 50% luminal narrowing of the left main coronary artery were treated over a 1 year period. Routine post catheterization protocol for 19 patients included intensive care observation, continuation of nonparenteral anti-anginal agents, and coronary revasculariza tion within 24 hours of diagnosis. One patient experienced severe hemodynamic embarrassment at the time of catheterization and underwent emergency coro nary bypass. All patients were discharged uneventfully following successful sur gery. Based on this experience, it is felt that with surgical support, patients with significant left main stenosis can be treated with standard anti-anginal therapy, and undergo elective revascularization without complications.

Although it is universally accepted that the grade of reduction of district blood flow in PVD is directly correlated to alteration of the haemorheological pattern, there is still no uniformity of opinion regarding the existence of a spe cific rheological alteration in PVD. The scope of our study was to discover the existence of possible PVD-specific markers; we thus carried out a comparative evaluation of the rheological characteristics in blood of controls and patients affected with PVD. Eighty-nine males between the ages of 50 and 65 years (me dian 58 ± 1 SE) were studied, all with a stage II vascular pathology with clinical onset of less than three months. Exclusion criteria were: diabetes mellitus, hy perlipaemia, stable hypertension, presence of vascular disease in other districts, cardio-circulatory problems and serious medical or surgical pathologies, pre vious vascular surgery, a history of acute thrombo-embolic episodes, and chronic alcoholism. Each patient, after a drug wash-out of 20 days, was moni tored for haemorheological parameters. At the same time, the above parame ters were measured in a group of 50 male controls of the same age range. All 139 subjects were smokers (10-15 cigarettes average per day). Our results indicate that modification in the bio-humoral (fibrinogen and plasma globulins) parame ters, a reduced red blood cell filterability and a relative increase in the number of activated polymorphonucleate cells are probably specific haemorheological markers of the clinical onset of PVD.

A case of severe, delayed rectal bleeding following an episiotomy was treated with selective pelvic arteriography and embolization after surgery failed to con trol the hemorrhage.

Cutaneous necrosis secondary to anticoagulation (heparin and warfarin) and cholesterol (atheromatous) emboli can be similar clinically and histologically. A unique case is reported of cholesterol emboli clinically mimicking heparin ne crosis. The patient was a 57 year old white male who underwent coronary angio plasty and was treated with intravenous heparin. Shortly after he developed large ecchymotic areas at the level of the umbilicus and distally which pro gressed to eschar. Renal failure ensued and he died secondary to stress ulcers. Cholesterol emboli were demonstrated in small muscular arteries of the dermis and panniculus along with a full thickness infarct. Because of the increasing popularity of angioplasty utilizing a retrograde femoral approach plus heparin anticoagulation, it is important to recognize the difficulty in making a clinical diagnosis when cutaneous necrosis supervenes. An incisional biopsy of the skin is recommended.

A 49-year-old man with rheumatoid arthritis presented with acute conges tive heart failure. Acute viral myocarditis was suspected clinically as a Gallium- 67 myocardial scan was positive. Percutaneous catheter-directed biopsy of the right ventricular endomyocardium, however, revealed heavy endothelial de posits of I _gM in the small blood vessels of the myocardium. Prednisone therapy resulted in normalization of both the myocardial Gallium-67 scan and left ven tricular ejection fraction with resolution of the symptoms of congestive heart failure. This is the first report documenting rheumatoid arteritis antemortem by myocardial biopsy.