646
Letters
to
the Editor
DIAGNOSIS OF CHEST PAIN
SiR,—:Your editorial (Jan. 15, p. 129) complicates
a
simple
Where disability or suffering is caused by angina pectoris and the painless syndromes of ischaemic heart-disease it is unusual to find a healthy left ventricle supplied by coronary arteries of normal appearance. In most cases the left ventricle cannot respond to the physical and emotional challenges of life with its old freedom because morbid anatomical and neurohumoral changes have caused disorders of function. These disorders reduce the ability of the left ventricle to fill rapidly in early diastole and cause the left atrial beat (the "a" wave) to1 enlarge to such a degree that it becomes palpable and audible. This presystolic left atrial "kick" is found over the apex of the left ventricle when the patient is lying in the left lateral position.2 Records of the beat can be taken with an apex-cardiograph/phonocardiograph transducer attached to a commercial case.
electrocardiograph (figure). 1. 2.
Bethell, H. J. N., Nixon, P. G. F. Br. Heart J. 1973, 35, 229. Bethell, H. J. N., Nixon, P. G. F. ibid. p. 902.
In the natural history of ischaemic heart-disease this palpable and audible left atrial beat commonly appears many months before the QRS complexes of the E.C.G. become deranged, although it is often accompanied by "mitralisation of the p wave".3 Turner and Hunter4 found the disturbance of function characterised by the atrial sound in each of fifty patients with angina pectoris, and considered "its absence makes the presence of ischmmic heart disease unlikely". In patients with functional abnormalities of the E.C.G. associated with anxiety or hyperventilation but not "organic" disease it is reassuring to find a normal apex cardiogram and
phonocardiogram (figure). The non-invasive method for recording an apex cardiogram and phonocardiogram is a relatively inexpensive way of con. firming the physical signs in the consulting-room and at the bedside. Echocardiography costs more, demands a much higher level of technical skill, and detects only about a half of the abnormal cases that can be picked up by apex cardiography and phonocardiography, presumably because it looks at the left ventricle transversely instead of longitudinally.’ There has been much argument about the significance of the fourth heart sound (which can be recorded with sensitive apparatus and heard sometimes in health) but I am not aware of any disagreement with the proposition that a palpable and audible left atrial beat is an important sign of left-ventricular dysfunction.6The Eighth Bethesda Conference of the American College of Cardiology, on Cardiovascular Problems Associated with Aviation Safety, has said that the detection of a palpable and audible apical "a" wave in a pilot should cause him to be disqualified from flying until his case has been spe-
cially investigated.8 It would have been more helpful if you had invited the clinician to put his patient into the left lateral position and examine him for the palpable and audible sign of left-ventricular dysfunction over the apex of the left ventricle when he suspected cardiac pain. If Charcelay (1838), Bouillard, and Potain (1875)1 could recognise the sign I do not see why we should fail to use it today, particularly since a simple technique for recording the motion of the apex beat was introduced into general practice 75 years ago.’ Cardiac Department, Charing Cross Hospital (Fulham), London W6 8RF
P. G. F. NIXON
POST-VAGOTOMY DIARRHŒA
SIR,-Allan et at.’" have shown that the faecal excretion of hile acids may be increased in patients with post-vagotomy diarrhoea. They suggested that the diarrhoea results from the cathartic effect of malabsorbed bile acids on the colonic I mucosa as happens after ileal resection." The 14C-glycocholic acid (l4C-G.C.A.) test, including measurement of fsecat 14C, may be used to indicate bile-acid malabsorption!Using this test we have found evidence of bileacid malabsorption in five patients with post-vagotomy diarrhoea. In each case treatment with cholestyramine was successful. The five patients had had persistent watery diarrhoea for at least two years which had failed to respond to conventional antidiarrhreal therapy. All had undergone truncal vagotomy with drainage. E.C.G.s, phonocardiograms, and apex cardiograms. Upper tracing: healthy young adult. Flattening of E.C.G. lead II associated with anxiety. The phonocardiogram records physiological third sounds.’ The apex cardiogram shows a dominant early diastolic rapid filling wave (0-3) and a diminutive "a" wave (a). Lower tracing: middle-aged male with symptoms of impending myocardial infarction and a normal E.c.G. The phonocardiogram and apex cardiogram illustrate the loss of the dominant early diastolic rapid filling wave and show the enlarged atrial beat (a) and fourth sound.4
3. Bethell, H. J. N., Nixon, P. G. F. ibid. 1974, 36, 507. 4. Turner, P. P., Hunter, J. ibid. 1973, 35, 657. 5. Dighton, D. H., Nixon, P. G. F. Unpublished. 6. Tavel, M. E. Circulation, 1974, 49, 4. 7. Spodick, D. H. ibid. p. 1263. 8. Cardiovascular Problems Associated with Aviation
Safety Am. J. Cardiol. 1975, 36, 604. 9. Mackenzie, J. The Study of the Pulse. Edinburgh, 1902. 10. Allan, J. G., Gerskowitch, P., Russell, R. I. Br. J. Surg. 1974, 61, 516. 11. Hofmann, A. F. Gastroenterology, 1967, 52, 752. 12. Fromm, H., Hofmann, A. F. Lancet, 1971, ii, 621.
Letters
to
the Editor
DIAGNOSIS OF CHEST PAIN
SiR,—:Your editorial (Jan. 15, p. 129) complicates
a
simple
Where disability or suffering is caused by angina pectoris and the painless syndromes of ischaemic heart-disease it is unusual to find a healthy left ventricle supplied by coronary arteries of normal appearance. In most cases the left ventricle cannot respond to the physical and emotional challenges of life with its old freedom because morbid anatomical and neurohumoral changes have caused disorders of function. These disorders reduce the ability of the left ventricle to fill rapidly in early diastole and cause the left atrial beat (the "a" wave) to1 enlarge to such a degree that it becomes palpable and audible. This presystolic left atrial "kick" is found over the apex of the left ventricle when the patient is lying in the left lateral position.2 Records of the beat can be taken with an apex-cardiograph/phonocardiograph transducer attached to a commercial case.
electrocardiograph (figure). 1. 2.
Bethell, H. J. N., Nixon, P. G. F. Br. Heart J. 1973, 35, 229. Bethell, H. J. N., Nixon, P. G. F. ibid. p. 902.
In the natural history of ischaemic heart-disease this palpable and audible left atrial beat commonly appears many months before the QRS complexes of the E.C.G. become deranged, although it is often accompanied by "mitralisation of the p wave".3 Turner and Hunter4 found the disturbance of function characterised by the atrial sound in each of fifty patients with angina pectoris, and considered "its absence makes the presence of ischmmic heart disease unlikely". In patients with functional abnormalities of the E.C.G. associated with anxiety or hyperventilation but not "organic" disease it is reassuring to find a normal apex cardiogram and
phonocardiogram (figure). The non-invasive method for recording an apex cardiogram and phonocardiogram is a relatively inexpensive way of con. firming the physical signs in the consulting-room and at the bedside. Echocardiography costs more, demands a much higher level of technical skill, and detects only about a half of the abnormal cases that can be picked up by apex cardiography and phonocardiography, presumably because it looks at the left ventricle transversely instead of longitudinally.’ There has been much argument about the significance of the fourth heart sound (which can be recorded with sensitive apparatus and heard sometimes in health) but I am not aware of any disagreement with the proposition that a palpable and audible left atrial beat is an important sign of left-ventricular dysfunction.6The Eighth Bethesda Conference of the American College of Cardiology, on Cardiovascular Problems Associated with Aviation Safety, has said that the detection of a palpable and audible apical "a" wave in a pilot should cause him to be disqualified from flying until his case has been spe-
cially investigated.8 It would have been more helpful if you had invited the clinician to put his patient into the left lateral position and examine him for the palpable and audible sign of left-ventricular dysfunction over the apex of the left ventricle when he suspected cardiac pain. If Charcelay (1838), Bouillard, and Potain (1875)1 could recognise the sign I do not see why we should fail to use it today, particularly since a simple technique for recording the motion of the apex beat was introduced into general practice 75 years ago.’ Cardiac Department, Charing Cross Hospital (Fulham), London W6 8RF
P. G. F. NIXON
POST-VAGOTOMY DIARRHŒA
SIR,-Allan et at.’" have shown that the faecal excretion of hile acids may be increased in patients with post-vagotomy diarrhoea. They suggested that the diarrhoea results from the cathartic effect of malabsorbed bile acids on the colonic I mucosa as happens after ileal resection." The 14C-glycocholic acid (l4C-G.C.A.) test, including measurement of fsecat 14C, may be used to indicate bile-acid malabsorption!Using this test we have found evidence of bileacid malabsorption in five patients with post-vagotomy diarrhoea. In each case treatment with cholestyramine was successful. The five patients had had persistent watery diarrhoea for at least two years which had failed to respond to conventional antidiarrhreal therapy. All had undergone truncal vagotomy with drainage. E.C.G.s, phonocardiograms, and apex cardiograms. Upper tracing: healthy young adult. Flattening of E.C.G. lead II associated with anxiety. The phonocardiogram records physiological third sounds.’ The apex cardiogram shows a dominant early diastolic rapid filling wave (0-3) and a diminutive "a" wave (a). Lower tracing: middle-aged male with symptoms of impending myocardial infarction and a normal E.c.G. The phonocardiogram and apex cardiogram illustrate the loss of the dominant early diastolic rapid filling wave and show the enlarged atrial beat (a) and fourth sound.4
3. Bethell, H. J. N., Nixon, P. G. F. ibid. 1974, 36, 507. 4. Turner, P. P., Hunter, J. ibid. 1973, 35, 657. 5. Dighton, D. H., Nixon, P. G. F. Unpublished. 6. Tavel, M. E. Circulation, 1974, 49, 4. 7. Spodick, D. H. ibid. p. 1263. 8. Cardiovascular Problems Associated with Aviation
Safety Am. J. Cardiol. 1975, 36, 604. 9. Mackenzie, J. The Study of the Pulse. Edinburgh, 1902. 10. Allan, J. G., Gerskowitch, P., Russell, R. I. Br. J. Surg. 1974, 61, 516. 11. Hofmann, A. F. Gastroenterology, 1967, 52, 752. 12. Fromm, H., Hofmann, A. F. Lancet, 1971, ii, 621.
