A double-blind cross-over study was performed on 12 men sith stable angina pectoris in order to determine the effect of antilipolytic treatment on exercise tolerance and exercise-induced electrocardiographic changes. The men were exercised to the onset of anginal pain using a reproducible and standardized ergometric load. A nicotinic acid analogue was used to reduce plasma free fatty acids and free glycerol before and during exercise testing and to eliminate their post-exercise rise. This was associated with significant reduction of exercise-induced ST segment depression (p less than 0-005), though there was no significant difference in the duration of exercise before the oneset of pain. A change in the prportions of lipid and carbohydrate for oxidation by the ischaemic myocardium, making relatively more glucose available, is a likely explanation.

(Rakita et al., 1954;Maroko et al., 1971;Kjekshus et al., 1972). Though absolute infarct size may not be accurately predicted by this technique (Norris et al., 1976), it is likely that changes in praecordial ST segment elevation, at least in the early hours after infarction, do reflect acute changes in underlying myocardial ischaemic injury. A close correlation has been shown in the dog between the magnitude of praecordial and of epicardial ST segment changes (Muller et al., 1975), and further between epicardial ST segment elevation and changes in local myocardial oxygen tension (Sayen et al., 1961) and blood flow (Kjekshus et al., 1972 The method of praecordial ST segment mapping in common use (Reid et al., 1971;Maroko et al., 1972)

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SUMMARY The case is presented of a 25 year old footballer with multiple systemic emboli from a left ventricular apical thrombus which occurred as a delayed complication of non-penetrating cardiac trauma. The presentation was with intermittent claudication, and this case demonstrates the need to suspect multiple embolism in younger patients with occlusive peripheral vascular disease and to exclude a cardiac source. There was no significant past medical history or family history of cardiac disease, and the patient was a non-smoker. There was no history of chest pain. Clinical examination disclosed absent pulses in both feet with normal femoral pulses and no other abnormalities in the cardiovascular system. An electrocardiogram disclosed an old inferior infarction, with pathological Q waves and T wave inversion in the inferior leads. Chest x-ray film was normal. All biochemical and haematological variables tested were within the normal range; in particular, specific testing for the presence ofa hypercoagulable state was normal. Fasting serum lipids were also normal. An echocardiogram was requested to exclude left atrial myxoma, and both M-mode and two dimensional scans were reported as normal.Femoral angiography was performed and showed occlusion of the left anterior and posterior tibial arteries just beyond their origins with collateral flow through the peroneal arteries, with poor peripheral reconstitution. In the right leg, extensive thrombus was noted in the anterior tibial artery, with a small thrombus also present in the profunda femoris vessel.Despite a normal echocardiogram, it was decided to perform coronary angiography and left ventriculography. The left coronary system was completely normal but there was an extensive filling defect throughout the right coronary artery, consistent with recanalising thrombus (Fig. 1). The left ventriculogram showed mild inferior hypokinesis with normal anteroapical contraction, and a small, pedunculated, and mobile filling defect was noted at the apex of the left ventricle (Fig. 2). A provisional diagnosis of left ventricular tumour was made and surgical excision advised.At operation, a 1 cm red "tumour" was found at the apex (Fig. 3), attached to the endocardium by several cord-like structures. The lesion was removed together with its endocardial base through a left ventriculotomy. Histology of the excised specimen showed organising thrombus around strands of normal myocardium, with no evidence of tumour tissue. The appearances were consistent with thrombosis secondary to ruptured trabeculae. When questioned, the patient remembered a blow to the left chest while playing football which had resulted in fractured ribs, some months before the onset of the claudication. No other history of chest trauma was obtained. The patient's postoperative recovery was excellent but a few weeks later he presented again with an acute left brachial artery occlusion requiring embolectomy. This was considered to be secondary to a thrombus at the site of the left ventriculotomy, and his subsequ...

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