The treadmill test has become an invaluable tool for diagnosing the presence and the extent of coronary artery disease. However, its clinical usefulness in our country has not been clarified because there are few reports describing the exact sensitivity and specificity of the test in Japanese patients, and because many of the patients are unable to accomplish submaximal or maximal exercise.
To evaluate the clinical significance and usefulness of the test, 699 cosecutive graded treadmill tests done on out-patients in our center were analyzed. One hundred and seventy-seven hospitalized patients who underwent both treadmill test and coronary arteri-ography were also analyzed. In the latter group, the patients with previous myocardial infarction were excluded from the study. In addition, in order to evaluate the exact value of treadmill test in the diagnosis of ischemic heart disease due to fixed organic coronary artery lesions, we excluded patients with vasospastic angina. The graded treadmill exercise test was carried out to a symptom-limited or submaximal work load of 90% of an age-related predicted maximum heart rate (MHR), using a computer-assisted-system-for-exercise from Marquette Corporation. Diagnostic ST changes were defined as 1mm or greater ST depression at the J point for horizontal or down-sloping ST depression, and 1.5mm or more ST depression at 80 msec from the J point for up-sloping ST depression (1mm to 1.5mm: equivocal result). Of 699 out-patients, positive, negative, and equivocal test results were obtained in 22%, 26%, and 11% of the patients, respectively. Inconclusive test results, in which the patients failed to achieve work load at 85% MHR and showed no evidence of myocardial ischemia, were obtained in 42% of the patients. Major reasons for discontinuation of exercise tests with inconclusive results were leg fatigue (36%), general fatigue (27%), and dyspnea (12%). Of 177 hospitalized-patients, positive, negative, and equivocal test results were obtained in 63%, 15%, and 2% of the patients, respectively. Inconclusive test results were obtained in 21% of the patients. The most frequent end point of the inconclusive tests was leg fatigue(51%). In 177 hospitalized-patients, coronary arteriography revealed significant coronary artery lesions in 69% of the patients (single vessel disease: 28%, double vessel disease: 200, triple vessel disease: 21%). By correlating the results of treadmill test with findings of coronary arteriography, we found 56% true positive, 6% false positive, 11% true negative, and 4% false negative results of the tests. In 37 patients with inconclusive test results, 16 patients revealed significant coronary, artery disease. Accordingly, the sensitivity, the specificity, and the predictability were 93%, 63%, and 90% respectively.

In this study, the sensitivity and the predictability of the treadmill test were significantly high. These findings support the feasibility of the test in patients with angina pectoris. However, about half of the treadmill tests performed by out-patients resulted in inconclusive studies. This inconclusiveness may limit the clinical value of the treadmill test. It is necessary to improve the method or protocol of the treadmill exercise test. These improvements may make the treadmill test more valuable in the diagnosis of coronary artery disease.

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Treadmill stress tests were reviewed retrospectively in 59 patients; 25 without coronary artery disease (normal group) and 34 with coronary artery disease. Changes in the sum of the amplitude of R waves and RS waves in leads CM 5, CC 5 and CL were measured both during the control period and immediately following the exercise period.
Of 25 patients without coronary artery disease, R wave amplitude increased in 23 (92%) and decreased in 2(8%) patients. On the other hand, of 34 patients with coronary artery disease, R wave amplitude decreased in 27(79%) and had either no change or increased in 7 (21%) patients. When there were either no changes or an increase in R wave amplitude after exercise, this was defined as“R wave criteria”.
There were no significant differences between normal group and coronary artery disease group in R wave amplitude changes, and there was also no significant correlation between resting left ventricular performance and“ST-segment criteria”(ST-segment depression>0.05mV) or “R wave criteria” in the latter group.
According to the “ST-segment criteria”, 4(16%) patients without coronary artery disease and 26 (76%) patients with coronary artery disease showed positive, and 8 (24%) patients showed false negative results.
The sensitivity and the specificity of “ST-segment criteria” were 76% and 84%, respectively, whereas those of “R wave criteria” were 21% and 92%, respectively.
Thus, “ST-segment criteria” was much more useful than “R wave criteria” in the diagnosis of coronary artery disease.

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Regional and global cardiac function was evaluated by monitoring the left ventricular (LV) wall motion and the hemodynamic parameters during attack of variant angina. In 12 patients (pts) with variant angina, coronary spasm was evoked with ergonovine maleate and LV wall motion was serially observed with 2-D and M-mode echocardiography during angina. In all pts, LV asynergy was observed and appearance of the asynergy consistently preceded the onset of ST-T changes (106±90sec). Elevation of pulmonary arterial end-diastolic pressure(PAEDP)occurred simultaneously with the appearance of asynergy. During attack, the mean value of stroke index(SI) was unchanged (50.3±6.8ml/beat/m to 49.0±9.3ml/beat/m). However, in 3 pts with large non-contractile segment(NCS), SI decreased. PAEDP remarkably elevated(8.8±2.0mmHg to 17.0±3.4mmHg). Heart rate(67±9 beat/min to 67±11 beat/min) and systolic arterial pressure were unchanged (144±19 mmHg to 145±29mmHg). In 10 pts, mean systolic velocity increased in non-ischemic region (27.7±11.2mm/sec to 33.0±13.0mm/sec), whereas decreased in ischemic region (30.8±6.9mm/sec to 17.2±7.5mm/sec).
Thus, we conclude that the occurrence of abnormal wall motion preceded the electro-cardiographic changes, and the impairment of the regional function during attack in the ischemic region was fully compensated by the hyperkinetic motion of the non-ischemic region and therefore the LV function as a whole was maintained in the cases with small NCS.

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Coronary arteriography is an important tool to evaluate the angina pectoris, but there are certain group of patients with angina pectoris whose arteriographic evidence of coronary stenosis can not be demonstrated. Sixty patients with angina pectoris underwent coronary arteriography, left ventriculography, and/or aortography. In some cases, endomyocardial biopsies were performed. Among them, 21 patients (17 male, 4 female, age range 28 to 68) had angina pectoris without significant coronary stenosis. They were variant angina (4), hypoplasia of coronary artery(2), elongation of coronary artery(5), aortic regurgitation(1), hypertrophic cardiomyopathy(2), aortic aneurysm(1), paroxysmal supraventricular tachy-cardia(1), and normal(5). Since angina pectoris occurs as a result of an imbalance between the myocardial oxgen supply and demand, patients with angina pectoris have not always demonstrable coronary stenosis. It should be considered that some cardiovascular diseases without significant stenosis in coronary artery might produce angina pectoris.

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Since 1979, 66 patients with angina pectoris underwent coronary angiography by Judkins method.
The patients were divided into the following 2 groups: group I. angina pectoris without myocardial infarction, and group II. angina pectoris with myocardial infarction.
The percentages of patients having more than 75% stenosis in any of coronary arteries in each group were 76% and 95% respectively. One case with myocardial infarction was treated by intravenous administration of urokinase immediately after the onset of the disease and no stenotic lesions could be found in any coronary arteries. Ejection fraction decreased significantly in the group II patients. Heavy smoking and low serum HDL-cholesterol levels as risk factors were observed in patients with ischemic heart disease.
It seems reasonable from these data to conclude that so-called risk factors should be overcome to prevent ischemic heart disease in everyday life. Once angina pectoris develops, coronary angiography should be carried out immediately, and then surgical therapy should be considered, if necessary, to prevent the subsequent myocardial infarction. In cases of acute myocardial infarction, thrombolytic therapy should be the first choice to minimize the extent of infarction area.

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Thallium-201 myocardial scintigraphy during exercise test is used for diagnosis of ischemic heart disease. Recently, quantitative analysis by computer is performed instead of visual analysis. For quantitative analysis there are ROI and Circumferential Prolile Method, furthermore, the latter are classified into Count and Density Circumferential Profile Curve. When initial image (immediately after exercise) shows lower perfusion or perfusion defect (less than 50% according to Density Profile), these finding are due to myocardial infarction or transient myocardial ischemia.
The lower perfusion or perfusion defect are filled up at 3-4 hours after exercise. This phenomenon is due to redistribution. The redistribution is observed in cases of transient ischemia, however it is not seen in cases of myocardial infarction. For quantitative determination of filling up in lower perfusion or perfusion defect, washout rate is calculated by Count Profile. Washout rate is as follow: Washout rate=(-Initial Count-Delayed Count)/Initial Count. Washout rate are more than 20%(no redistribution), these segments are located in the area of normal myocardium or myocardial infarction. They are less than 20% (redistribution) in transient ischemia. The distinction between normal myocardium, transient myocardial ischemia and myocardial infarction are possible by using quantitative analysis as Density and Count Prolile. By these methods, the three vessel disease and old myocardial infarction with transient ischemia are diagnosed correctly.

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Twelve patients with ischemic heart disease (IHD) were studied by selective coronary artery angiography (CAG) at Tachikawa National Hospital from September 1981 to April 1982 The subjects included three with acute myocardial infarction, six with effort angina and three with rest angina. Mean value (and standard deviation) of the age at the catheterization was 51.8±10.6 years old. These patients consisted of eight males and four females. The significant stenotic lesions on coronary arteriograms were found in eight cases. Among these, the number of patients with one vessele disease was four, two vessels none, three vessels one and LMT lesion three. Particularly, one patient with three vessels disease was treated by aorto-coronary bypass grafting (ACBG) and has been successful.
In addition to CAG, HDL-ch and arterial sclerosis index (AI) were evaluated. HDL-ch level was 36.8±7.25 mg/dl and AI 4.47±1.53. Both parameters seemed to be useful for the evaluation of the extent of coronary sclerosis. Angiographic findings in three cases were presented.

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In patients with rheumatoid arthritis (RA), cardiac involvement has been recognized as one of the extra-articular manifestations. However, disagreement concerning the cardiac abnormalities has been reported in patients with RA.
By using M-mode echocardiography, multiple indices of left ventricular performance were calculated and compared to laboratory data. Echocardiograms were recorded 26 times in 16 patients with classical or definite RA by the ARA, but with no evidence of hyper-tension or bleeding.
Echocardiograms were recorded by using Toshiba SSL-21A (2.0MHz, 10mm diameter transducer) with simultaneous ECG tracing and permanent records were made on polaroid films.
The mean velocity of circumferential fiber shortening (mVcf) inversely correlated with Hb concentrations (r=-0.7196, p<0.001), RBC counts (r=-0.6950, p<0.001) and Ht values (r=-0.7178, p<0.001), also correlated with ESR (r=0.4343, 0.02<p<0.05), CRP (r=0.4462, 0.02<p<0.05) and serum IgG concentrations (r=0.4727, 0.02<p<0.05), respectively. The ejection fraction(EF)inversely correlated with Hb concentrations(r=-0.5897 0.001<p<0.005), RBC counts(r=-0.4361, 0.02<p<0.05) and Ht values(r=-0.5538, 0.001<p<0.005), and correlated with serum IgM concentrations (r=0.4830, 0.02<p<0.05).
The percent fractional displacement (%FD) inversely correlated with Hb concentrations (r=-0.5423, 0.001<p<0.005), RBC counts (r=-0.4478, 0.02<p<0.05) and Ht values (r=-0.5201, 0.005<p<0.01), and correlated with serum IgG concentrations (r=0.4763, 0.02<p<0.05). Whereas, any indices of left ventricular performance did not correlate signif-
icantly with complement and RAHA.
Indices of left ventricular performance significantly correlated with anemia, erythrocyte sedimentation rate, CRP and immunoglobulines. These results suggested that the activity of the disease might have an effect on left ventricular performances in patients with RA.

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A case of isolated tricupsid valve prolapse with moderate tricupsid regurgitation was reported. A 30-year-old man was referred to our hospital with the chief complaint of left chest oppression. A pansystolic regurgitant murmur was audible at the left lower sternal border.
The electrocardiogram showed slight left axis deviation and complete right bundle blanch block. Prolapse of the anterior tricupsid leaflet was demonstrated by apical four chamber view of two-dimensional echocardiogram, whereas M-mode echocardiogram did not show any evidence of prolapse. No signs of prolapse of mitral valve were found on echocardiogram. The data of the cardiac catheterization was normal, but moderate tricupsid regurgitation was detected by the right ventriculography.
The etiology of the tricupsid valve prolapse in the present case remained unknown.

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A 74-year-old male was admitted with possible angina pectoris, urine and blood cate-cholamine (CA) levels showed extremely high. An abdominal CT scanning was done and tumor shadow of 80×50mm was found in the left adrenal gland. Blood CA by vena cava catheterization indicated extremely high level in the left renal vein, and the diagnosis of pheochromocytoma of the left adrenal gland was made. The patient was operated, and the left adrenal gland with the left kidney was extracted. The left adrenal gland weighed about 160g and a large amount of noradrenalin (NA) secretion granules with high electronic density were recognized the electron microscopic examination. Therefore, a pathologic diagnosis was NA predominant pheochromocytoma. After operation both angina pectoris and hypertension disappeared.

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A case was 56-years-old male. He was pointed out cardiomegaly in 1974. Cardiothorax ratio (CTR) was 59.3%. He developed dyspnea and was hospitalized twice in 1979 and 1981. CTR was 65.6% and PR interval was 0.24 second. Diuretics, CoQio were administered and he was recovered. He was hospitalized again in Hirosaki National Hospital because of exacerbation of dyspnea.
Physical examination revealed the following findings: height, 172.5cm, weight, 103kg, pulse rate, 64/min., regular, blood pressure, 116/90 mmHg, and CTR, 70.0%. Liver and spleen were not palpable under the hypochondrium. There was no heart murmur and breath sound was almost normal. Digitalis and diuretics were administered, and he was discharged. However, he was re-hospitalized in December, 1981 because of dyspnea. In spite of treatment, dyspnea, frequent extrasystoles anorexia, and diarrhea continued and he died in March, 1982.
An autopsy revealed remarkable cardiac enlargement (910g) with marked dilatation of both ventricles. Histologically, cardiac muscle fibers showed hypertrophy, atrophy and degenerative change with irregular arrangement. Diffuse fibrosis was also seen in the interstitial myocardium. From these findings, the patient was diagnosed as idiopathic congestive cardiomyopathy.

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Four young men with acute myocardial infarction from 27 to 33 years old were reported. They had many coronary risk factors, especially all of them had risk factors of cigarette smoking and metabolic abnormalities of lipids. We think that the control of these risk factors is most important to avoid development of myocardial infarction in young adults.
In these patients, coronary arteriographic lesions were less severe and the patients had a better prognosis than the elderly.

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Changes in the oxygen-hemoglobin affinity during acute phase of myocardial infarction were studied using P₅₀ as an index. The patients studied were 11 cases of acute myocardial infarction with no evidence of heart failure or shock. The results showed that the oxygen-hemoglobin affinity decreased immediately following the onset of myocardial infarction, and showed significant decreases by days 3 to 5, but was reverted to normal by the day they were discharged. This finding suggested that during the acute phase of myocardial infarction the supply of oxygen to the periphery of acute necrotic area of the myocardium or the so-called twilight zone was increased as an advantageous compensatory reaction of the living body.
Furthermore, if it is possible to lower artificially the oxygen-hemoglobin affinity during the acute phase of myocardial infarction, we may be able to use it as an effective treatment to prevent extension of the infarction. And we have already started the study of this possibility, the preliminary report is also included in this paper.

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Seven cases of gout following the administration of diuretics in congestive heart failure were reported. It is said that diuretics is uricosuric when given intravenously in large doses, but diuretics cause uric acid retention resulting in hyperuricemia when administered orally over a prolonged period.
In all cases, gouty attack occurred during congestive heart failure, but did not occur after open heart surgery in spite of intravenous administration of large doses.
In addition to these mechanisms of diuretics, we concluded that in congestive heart failure hyperuricemia occurred because of decreased renal uric acid clearance by low cardiac output and increased purine-base catabolism by peripheral circulatory failure.

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Recently the physical training for cardiac patients has been watched with keen interest because of its salutary effects. Thirty cardiac patients underwent exercise program at the gymnasium belonging to our cardiology department. The method was described.
The patients who had been tested their cardiopulmonary capacities were advised to take physical exercise, and the exercise was terminated at the 70-85% level of their maximal heart rate. Walking, two step exercise and bicycle ergometer riding were carried out one after another at regular intervals. Thirty patients, including 14 angina pectoris, 7 myocardial infarction and 9 others (mild hypertension, obesity and neurocirculatory asthenia), took 40-60 minutes including interval time to accomplish these exercises. They have taken exercise training twice a day, 2-5 days a week and for 47 days on the average.
The mean value of the maximal oxygen uptake before training was 22.6ml/kg. min. and this was increased by 19.3% to 26.6ml/kg. min. after training. On the contrary, the heart rate during the sub-maximal exercise level decreased after training.
These results suggested that this training method was effective in these cardiac patients.

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