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SUMMARY Ten consecutive hospitalized patients with uncontrolled variant angina were studied to evaluate the efficacy of nifedipine and perhexiline maleate treatment and to determine if the results of incremental ergonovine testing during treatment predicted the short-term clinical response. During a mean control period of 5.2 days without treatment other than nitroglycerin, 3.9 ± 4.7 (mean ± SD) episodes of variant angina occurred per day. During the subsequent treatment period with nifedipine 20 mg every 6 hours, only 0.09 ± 0.15 episodes/day occurred (p < 0.02 vs control) and seven patients had no angina. During perhexiline treatment (400 mg twice daily), 2.3 ± 3.2 attacks/day were recorded; this was not significantly different than during the control period.Without treatment all 10 patients had positive ergonovine tests at doses ranging from 0.025-0.3 mg. During nifedipine treatment nine of the 10 tests became negative at doses as large as 0.4 mg (p < 0.0001). The results of ergonovine testing during perhexiline treatment did not differ significantly from the control period. Overall, 11 of the 12 ergonovine tests positive at 0.1 mg or less occurred during observation periods with more than one episode/day of variant angina, and all 16 negative tests, or tests positive only at 0.2 mg or more, occurred during periods with less than one episode/day of variant angina.We conclude that the results of ergonovine testing during treatment correlate with the short-term clinical response to therapy. Although the effect of chronic treatment with calcium antagonists on the natural evolution of this syndrome is unknown, nifedipine rapidly and effectively controls the acute clinical manifestation of variant angina.

SummaryBackground: For many years, cardiac auscultation has been the only available method for distinguishing between functional and organic murmurs; however, a more reliable differential diagnosis can now be achieved with Doppler echocardiography. The question remains as to whether a Doppler echocardiogram needs to be routinely recorded in the presence of a heart murmur or whether the auscultatory diagnosis of a functional murmur is sufficient.Hypothesis: This prospective study attempts to answer this important question at a time when medical costs have to be curbed.Methods: The three cardiologists involved in this study saw 516 new patients in their private practice over a 10-month period; of these, 321 (63.6%) underwent Doppler echocardiography. All patients underwent careful auscultation prior to echocardiography. At the end of their examinations, the cardiologists noted whether they considered the murmur to be of functional or organic origin. Minimal mitral or aortic regurgitations of short duration and low velocity occurring on nonthickened valves were considered functional.Results: The results for cardiac auscultation and Doppler echocardiography were considered to be concordant, that is, both techniques diagnosed either a functional or organic murmur in 250 of 32 1 patients (77.9%). The results for cardiac auscultation and Doppler echocardiography showed a major

Variant angina was diagnosed after coronary artery bypass surgery in six patients over a 22-month period. Although all six patients had at least occasional angina at rest preoperatively, all but one had predominantly exertional angina. After surgery, rest angina with transient ST-segment elevation appeared in all six after an asymptomatic interval of 1 week to 4 years. In two patients the involved artery had not been bypassed, in two patients it was perfused by a patent graft and in two patients the graft to the involved vessel was occluded. Treatment with calcium antagonist drugs (four cases) or isosorbide dinitrate (one case) eliminated symptoms; one patient spontaneously became asymptomatic. The diagnosis of variant angina should be considered when rest angina occurs after bypass surgery, particularly if exertional angina is absent and grafts are patent.