Effect ofacute administration of propranolol on ventricular function in hypertrophic obstructive cardiomyopathy measured by non-invasive techniques'. C. Saenz ...
British Heart Journal, 1976, 38, 798-803.
Effect of acute administration of propranolol on ventricular function in hypertrophic obstructive cardiomyopathy measured by non-invasive techniques' C. Saenz de la Calzada,2 G. M. Ziady, T. Hardarson, R. Curiel, and J. F. Goodwin From the Division of Cardiovascular Diseases (Clinical Cardiology), Department of Medicine, Royal Postgraduate Medical School, and Hammersmith Hospital, London
Seventeen patients with hypertrophic obstructive cardiomyopathy, were studied using non-invasive techniques before and after the intravenous injection of 5 mg propranolol. The following were analysed: left ventricular ejection time index, derivedfrom the carotid pulse and heart rate; the isovolumic relaxation time, derived from the apex cardiogram and phonocardiogram; the diastolic closure rate of the mitral valve; and left ventricular diameters, systolic and diastolic, both measured by echocardiography. Propranolol produced shortening of the isovolumic relaxation time, increase in both the diastolic closure rate of the mitral valve and left ventricular systolic and left ventricular diastolic diameters. These results show that propranolol increases the rate of filling and the volume of the left ventricle, indicating that an improvement in distensibility is produced by beta-adrenergic blockade. Since the first description of hypertrophic obstructive cardiomyopathy (HOCM) or idiopathic hypertrophic subaortic stenosis (Brock, 1957; Braunwald et al., 1960; Goodwin et al, 1960), advances have been made in the treatment of this disease, both medically and surgically (Flamm, Harrison, and Harcock, 1968; Bentall et al., 1965; Cooley et al., 1967). The acute effects of beta-adrenergic blockade with propranolol in HOCM suggest that it produces an improvement in distensibility and filling of the left ventricle (Webb-Peploe et al., 1971). Propranolol has been thought to be the treatment of choice (Hubner et al., 1973). Because most drug studies involve using invasive techniques, they are not applicable for the repeated assessment of patients, and therefore the beneficial effects of propranolol in HOCM must be judged mainly by symptomatic assessment of the patient (Cohen and Braunwald, 1967; Hubner et al., 1973). The purpose of the present paper is to study the acute effect of propranolol (5 mg intravenously) in Received 19 December 1975. 'This paper was presented at the VII World Congress of Cardiology, 1-7 September 1974, Buenos Aires, Argentina. 2Present address: Division of Cardiology, C. S. '1° de Octubre', Madrid, Spain.
HOCM, using simple bedside non-invasive techniques, and see if these methods are sensitive enough to detect the haemodynamic benefit of beta-blockade.
Subjects and methods The present series consists of 17 adult patients with
he
HOCM. Eleven were women and sien. six men. The diagnosis was proven by previous catheterization and angiocardiography. All patients stopped propranolol therapy 4 to 7 days before the investigation, which was carried out in the early afternoon with the patient lying Eleven
were
wo
ad
th
supine. Non-invasive studies These were recorded using a 6-channel Cambridge Machine (model 72112, Cambridge Scientific Instruments, England), at a paper speed of 100 mm per second. The sensitivity settings of the control study were used in the post-propranolol state. The following studies were made. (1) Electrocardiogram A bipolar lead showing
clearly the beginning of the QRS complex was recorded simultaneously with the rest of the tracing. (2) Phonocardiogram A clear aortic component
Effect of acute administration of propranolol 799
6A
s
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of the second heart sound was obtained. Phonocardiograms were recorded at the third and fourth intercostal spaces along the left sternal border using suction microphones with high (band with 450 and 1 000 Hz) frequency filters. (3) Carotid pulse A clear upstroke and dicrotic w was obtained. >notch (4) Apex cardiogram A well-inscribed 'O' point was obtained. Recordings were made with the patient in the left anterior oblique position.
and I! ICarotid I II|! obtained with j :< X l A%
:A 14
apex cardiogram tracings were
a hand-held polythene funnel connected to a piezoelectric transducer with a pulse amplifier of time constant s, band with 0 1 to
1P6
(5) Echocardiography (12 patients only). Echocardiograms were made using an Ekolone 20
diagnostic ultrasound (frequency 2-25 MHz, repetition frequency 1000/s), with polaroid photography.
The following measurements were analysed: (A) Left ventricular ejection time index (LVETI),
taken as the time (in ms), fromthe carotid upstroke to the dicrotic notch (LVET). The values were l l l || | r | f ]l H| 4n[ I1 I IIIII I I I I I I!I I IN
ECG
FIG. 1 Simultaneous tracing of the electrocardio-
II (ECG), phonocardiogram (PCG), and carotid I
