Summary:To assess the etiology and prognosis of a large pericardial effusion, we reviewed 25 consecutive patients who presented with a large pericardial effusion and underwent a drainage procedure. Large pericardial effusion was defined as: (1) an echo-free space 2 10 mm anteriorly and posteriorly by M-mode echocardiography and (2) removal of 1 350 ml of fluid at pencardial drainage. The etiologies of large pericardial effusion were: neoplastic (36%), idiopathic (32 %), uremic (20%), postmyocardial infarction (8%), and acute rheumatic fever (4%). Of our patients, 44% presented with cardiac tamponade, while 25% of patients with idiopathic pericarditis had hemorrhagic effusion and cardiac tamponade. At follow-up, 37 f 17 months after pericardial drainage, 68% had died from complications of their underlying disease. There were no deaths attributed to pericardial disease. While 88 % of patients with idiopathic large pericardial effusion were alive at follow-up, none of the neoplastic large pericardial effusion patients survived longer than 5 months after initial pericardial drainage (p < 0.001). Additionally, the survival of patients with uremic large pericardial effusion was better than patients with neoplastic large pericardial effusion (p < 0.05). We conclude: (1) neoplastic, idiopathic, and uremic pericarditis are the most common causes of large pericardial effusion in men, (2) idiopathic pericarditis can be hemorrhagic and cause cardiac tamponade, and (3) the prognosis of large pericardial effusion is related to patients' underlying disease.

Effects on anginal symptoms of sudden withdrawal of large doses of propranolol or placebo were evaluated in 20 patients in a double-blind crossover efficacy trial requiring sudden cessation of the agent. With propranolol, 160 to 320 mg per day for six and 12 weeks, no patients had increased angina or nitroglycerin use, and there were no hospitalizations or deaths. However, within two weeks of discontinuance of propranolol, untoward ischemic events developed in 10 patients. Six had serious withdrawal complications: intermediate coronary syndrome in three, and ventricular tachycardia, fatal myocardial infarction, and sudden death in one each. In four patients discontinuance of placebo increased anginal symptoms; in the remaining 10, ischemic symptoms were not provoked. The rebound phenomenon was related to degree of pre-propranolol angina and relief of pain by the agent. Thus, chronically administered propranolol should be gradually reduced, and activity restricted during its withdrawal.

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To determine the prognostic value of exercise testing in patients with unstable angina pectoris, 125 hospitalized patients were prospectively evaluated soon after stabilization of their pain. Exercise testing was performed after exclusion of acute myocardial infarction and a pain-free period of at least 3 days (mean +/- SD 3.9 +/- 1.4). No complications were noted during or immediately after exercise testing. A positive test (angina or greater than or equal to 1 mm ST segment depression, or both) was noted in 60 patients (48%). During a 1 year follow-up period, 52 (87%) of these 60 patients had an unfavorable outcome (American Heart Association class III or IV angina, recurrent unstable angina, coronary artery bypass surgery, acute myocardial infarction or cardiac death) compared with 19 (29%) of the 65 patients with a negative test (p less than 0.001). The sensitivity and specificity of exercise testing in predicting outcome were 73 and 85%, respectively. The predictive value of a positive test was 87% and that of a negative test was 71%. Angina by itself during the exercise test was a reliable predictor of severe angina (class III or IV angina) at follow-up (sensitivity 92%, specificity 89%, positive predictive value 83% and negative predictive value 95%; p less than 0.001). The findings were not significantly affected by beta-adrenergic blocking agents or digitalis in the study sample. Thus, in patients with unstable angina which has been stabilized, the results of early submaximal exercise testing may be useful in predicting outcome in the first year after hospital discharge. Patients with a positive test result should be considered for further diagnostic studies.

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