The Query Corner

R EADERS are invited to submit queries on all aspects of cardiovascular diseases. InsO- far as possible these will be answered in this column by competent authorities. The

replies will not necessarily represent the opinions of the American College of Cardiology, the JOURNAL or any medical organization or group, unless stated. Anonymous com- munications and queries on postcards will not be answered. Every letter must contain the writer’s name and address. but these will not be published.

Danger Periods in Coronary Disease

Query: Are there periods of unusual peril to

patients with coronary disease? If so, how are they

identl$ed and what precautionary measures should be

taken during these periods?

Answer : Patients with coronary artery dis- ease may he imperiled by the following compli- cations : (a) occlusion of a coronary vessel ; (b) arrhythmias; (c) heart failure; (d) stress.

Occlusion of a coronary artery may be slow and progressive resulting from narrowing of the lumen or may be sudden due to thrombosis. Slow occlusions may be antedated by progres- sively increasing frequency and duration of angina. Intermittent angina may be the mani- festation of an occluded coronary artery. Acute occlusion (i.e., due to thrombosis) may cause mild to severe retrosternal pain at times accompanied by shock. Anticoagulant therapy should be instituted in either circumstance.

Ventricular or supraventricular arrhythmias of almost any type may occur in coronary disease. Ventricular premature beats should be treated with quinidine, pronestyl, or potassium chloride to prevent the more serious abnormal rhythms. Their identification is simple by electrocardi-

ogram which delineates ventricular from supra- ventricular beats. Atria1 fibrillation is a fre- quently encountered rhythm. Its grossly irregu- lar auscultatory characteristic with a pulse deficit can be confirmed by electrocardiogram and should be treated with quinidine in an attempt to convert to regular sinus rhythm. If unsuccessful, the ventricular rate should be con- trolled with digitalis. If the arrhythmia is due to digitalis intoxication, the drug should be withdrawn.

Congestive heart failure may arise insidiously or rapidly as in nocturnal acute left ventricular failure. Careful interval examination may re-

veal the appearance of rales, tachycardia, in- creasing prominence of the second pulmonic sound associated with dyspnea. Nocturnal left ventricular failure is characterized by sudden onset of orthopnea, cough, varying degrees of cyanosis, tachycardia, prominent P2 and rales in the lungs. Prevention of either type of failure is best obtained by close interval examinations and use of digitalis, low-sodium diet, and diuretics.

Stress may seriously compromise the coronary circulation by reason of its vasodepressor effects (tension, anger, hysteria, or surgery) causing a pooling of blood in the peripheral vascular tree, decreasing venous return to the heart and resulting in decreased diastolic filling and diminished coronary blood flow. To this is added the increased work load of the heart. The effect is the appearance of angina of a de- gree consistent with the quantitative deprivation of coronary blood flow resulting in either coro- nary insufficiency or coronary occlusion. Over- indulgence in food and straining at the stool (Valsalva maneuver) are other factors of stress.

Careful elucidation of these mechanisms by the physician to the patient may avoid serious complications.

Coronary Disease

Query: What is

DAVID NATHAN, M.D.

Miami Beach, Florida

the treatment for “gas” in pa- .

tients with coronary dzsease!

Answer: Patients with angina pectoris fre- quently complain of “gas” or bloating, rather than substernal or chest pain. In such cases, Spirits of Peppermint, 3 to 5 drops in a little water after meals, or Creme de Menthe, 5 cc after meals, may be very helpful, in addition to the usual medication for the relief of angina pectoris.

MARCH, 1958 415