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PubMed2005

A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study.

OBJECTIVES: To determine the most cost-effective method of screening for atrial fibrillation (AF) in the population aged 65 years and over, as well as its prevalence and incidence in this age group. Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram (ECG) within a screening programme. DESIGN: Multicentred randomised controlled trial. Purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. SETTING: Fifty primary care centres across the West Midlands, UK. PARTICIPANTS: Patients aged 65 years and over. INTERVENTIONS: GPs and practice nurses in the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening. MAIN OUTCOME MEASURES: AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared with AF detection rate in 5000 patients in the control practices. The screening period was 12 months. RESULTS: Baseline prevalence of AF was 7.2%, with a higher prevalence in males (7.8%) and patients aged 75 years and over (10.3%). The control population demonstrated higher baseline prevalence (7.9%) than either the systematic (6.9%) or opportunistic (6.9%) intervention population. In the control population 47 new cases were detected (incidence 1.04% per year). In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse, with 177 having an ECG, yielding 31 new cases (incidence 0.69% per year). A further 44 cases were detected outside the screening programme (overall incidence 1.64% per year). In the systematic arm 2357 patients had an ECG yielding 52 new cases (incidence 1.1% per year). Of these, 31 were detected by targeted screening and a further 21 by total population screening. A further 22 cases were detected outside the screening programme (overall incidence 1.62% per year). In terms of ECG interpretation, computerised decision support software (CDSS) gave a sensitivity of 87.3%, a specificity of 99.1% and a positive predictive value (PPV) of 89.5% compared with the gold standard (cardiologist reporting). GPs and practice nurses performed less well. The only difference in performance between intervention populations and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead (PPV 38.8% versus 20.8%) and single-lead (PPV 37.7% versus 24.0%) ECGs. The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm, with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm. Opportunistic screening dominated both more intensive screening strategies. Model-based analyses showed small differences in cost and quality-adjusted life-years for different methods and intensities of screening, but annual opportunistic screening resulted in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed. Probabilistic sensitivity results indicated that there was a probability of approximately 60% that screening from the age of 65 years was cost-effective in both men and women. CONCLUSIONS: The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over, the only strategy that improved on routine practice was opportunistic screening, model-based analyses indicated that there was a probability of approximately 60% of annual opportunistic screening being cost effective. It is suggested that the following topics are worthy of further investigation: the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias; the best method for routinely detecting paroxysmal AF; ways of improving healthcare professionals' performance in ECG interpretation; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF, and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF.

Aged↗
PubMed2002

[Effect of HOE642 on ischemic myocardium reperfusion injury]

OBJECTIVE: To investigate whether the specific sodium-hydrogen antiporter HOE642 could modifies myocardial ischemia and reperfusion injury. METHODS: The isolated working rat heart model was used. The rats were divided into four subgroups: Ischemic reperfusion (Control group),HOE642 given before Ischemia (HOE-Pr), HOE642 given during Ischemia (HOE-Is), HOE642 given during reperfusion (HOE-Re). LVDP, LVEDP, arrythmia, coronary flow and myocardial enzymes were measured. RESULTS: HOE642 given 15 minutes before ischemia increased coronary flow and significantly improved cardiac function, reduced the severity of ischemia, reperfusion arrhythmia and myocardial CK-MB, LDH release, but had no effect on heart rate. HOE642 given during ischemia only reduced LVEDP, the ischemia severity, reperfusion arrhythmia and myocardial enzyme release. It had no effect on heart rate or LVDP. There were no effects when the drug was given during reperfusion. CONCLUSION: HOE642 demonstrates significant cardioprotective effects. These protective effects are most significant when the drug is given before ischemia is induced.

Journal Article↗
PubMed2004

[Prevalence of atrial fibrillation and relationed factors in a population in the centre Madrid].

INTRODUCTION: Atrial fibrillation is the most common arrhythmia on clinical practice and an important risk factor for ictus. The aim of this study was to know the prevalence of this arrythmia in a central district of Madrid. MATERIAL AND METHODS: A retrospective study was done analysing medical records of 13,945 patients belonging to a primary care centre of Madrid. Time of study: recruitment of data from September 2000 to May 2001; analysis of data: from September 2001 to May 2002. RESULTS: We obtained a total of 425 atrial fibrillations, 348 non-valvular and 77 valvular. Global prevalence of atrial fibrillation in patients over 40 years in our area was 2.52%. (2.47% male, 2.55% female). Risk factors for atrial fibrillation more frequently found in non-valvular were high blood pressure (HBP), diabetes, ischaemic heart disease and left ventricular dysfunction. Among valvulars we found HBP, left atrial size over 45 mm and left ventricular dysfunction. CONCLUSIONS: Atrial fibrillation shows a prevalence and distribution in the studied area similar to that found in other European countries.

Atrial Fibrillation↗
PubMed1992

Treatment of ventricular arrhythmias after CAST.

OBJECTIVE: The primary objective of this article is to review the management of ventricular arrythmias in the light of the unfavourable results reported in the Cardiac Arrhythmia Suppression Trial (CAST). STUDY SELECTION, DATA EXTRACTION AND SYNTHESIS: CAST tested the hypothesis that suppression of ventricular arrhythmias recorded on a Holter monitor in patients with myocardial infarction would lead to a decrease in subsequent mortality, presumably by preventing sudden death. In the trial, patients with a myocardial infarction which occurred six days to two years previously and with asymptomatic ventricular premature beats which could be suppressed by one of the antiarrhythmic agents flecainide, encainide or moricizine, were randomised to treatment with one of these agents or placebo. Over a mean follow-up period of 10 months, mortality was significantly higher in those patients receiving flecainide or encainide than in those receiving placebo. On the recommendation of the Data and Safety Monitoring Board the trial in these groups was terminated. More recently CAST II in which moricizine was compared to placebo was also terminated, again because of a higher mortality in the patients receiving active treatment. It is likely that much of the excess mortality can be attributed to proarrhythmic effects of the agents. CONCLUSION: Current management of ventricular arrhythmias are considered in the light of these findings. CAST suggests that specific treatment should be dictated by the presence of associated symptoms and as much by associated structural heart disease as the arrhythmia per se. In particular, specific treatment of ventricular premature beats alone should be avoided. In those with potentially lethal ventricular arrhythmias, referral for appropriate investigation and consideration of non-pharmacological measures is necessary.

Anti-Arrhythmia Agents↗
PubMed1995

Clofazimine induced cardiotoxicity--a case report.

A 66-year-old Indian male who had been treated for recurrent erythema nodosum leprosum with 300 mg of clofazimine per day for 11 months presented to hospital with a 4 week history of severe gastrointestinal upset. Soon after admission he developed several short runs of ventricular tachycardia with a morphology suggestive of torsade de pointe. The patient had a slightly low magnesium level which was corrected within 2 days; however, his rhythm disturbance persisted for 5 days despite management with intravenous lidocaine. His gastrointestinal symptoms abated 2 weeks after clofazimine was discontinued. Subsequent investigations showed that the patient had a keratopathy and myelin-type figures in his polymorphonuclear white cells similar to that seen with the cardiotoxic drugs chloroquine and amiodarone. It is postulated that clofazimine alone or in conjunction with electrolyte disturbance was responsible for the patient's cardiac arrythmia.

Aged↗
PubMed1976

[Serological and clinical aspects of mass transfusion].

Massive transfusion of cold blood causes hemodinamic disturbances because of its acidity, surplus of potassium and defiency of calcium. Negative influence also results from stronger viscosity of blood, from the change of the active substances of blood coagulation, change of the patient's coagulation system responding to the transfused blood, subclinical troubles in this system according to the degree of the shock, reduced ability of oxygen transport caused by viscous blood, poor microcirculation etcr. Arrythmia, bradycardia, fibrilation of heart ventricles, may occur. Vasoconstrictions, microembolism and other incidents may appear. The quality of preserved blood changes during the conservation is changed, potassium and ATP are the indicators for its quality. At massive transfusions blood has to be warmed, filtered through special filters, to the patient has to be given just the quality of blood he needs etcr. The transfusiologist can help the therapist with useful advices and informations for the patient's sake.

Adenosine Triphosphate↗
PubMed1999

Functional magnetic stimulation: a new modality for enhancing systemic fibrinolysis.

OBJECTIVE: To investigate whether functional magnetic stimulation (FMS) of the leg muscles could enhance systemic fibrinolysis. DESIGN: A within-subject analysis of systemic fibrinolysis before and after 60 minutes of FMS. SETTING: The Functional Magnetic Stimulation and Special Coagulation Laboratories in the Spinal Cord Injury Service at a Veterans Administration health care facility. PARTICIPANTS: Twenty healthy volunteers were recruited. The exclusion criteria were: (1) personal or family history of venous or arterial thrombosis, (2) personal or family history of cardiac arrythmias, (3) current use of medication, and (4) the presence of a cardiac pacemaker or other metallic implants. MAIN OUTCOME MEASURES: Whole blood clot lysis time (WBCLT) and tissue plasminogen activator (t-PA) antigen determined at baseline and 10 and 60 minutes after FMS. RESULTS: A significant decrease was observed in the mean WBCLT after FMS. The WBCLT decreased from 17+/-1.3 h before FMS to 12+/-1.0 h and 11+/-0.8 h at 10 and 60 minutes post-FMS, respectively. The mean t-PA antigen levels did not show a significant change (p = .6701) from pre-FMS (6.7+/-0.91 ng/mL) to 10 min post-FMS (6.8+/-0.91 ng/mL) and 60 min post-FMS (7.0+/-1.02 ng/mL). Several patterns of fibrinolytic response to FMS were observed. They differed in relation to the degree of enhancement, the period at which maximum enhancement occurred, and the corresponding t-PA antigen levels observed. CONCLUSIONS: The FMS-induced contractions of the leg muscles enhanced systemic fibrinolysis ex vivo. The improvement in fibrinolysis occurred immediately after FMS and was also observed at 60 minutes post-FMS. FMS appears to produce a sustained enhancement of systemic fibrinolysis that may prove useful in deep-vein thrombosis prophylaxis.

Adult↗
PubMed1999

[Evaluation of cranial CT findings of patients with muscular dystrophy: with a reference to cerebral vascular disease and cardiac complications].

We evaluated cranial CT findings of 160 patients with various type of progressive muscular dystrophy (PMD). Significant brain atrophy was observed in 21 out of 63 cases of Duchenne muscular dystrophy (DMD), 7 out of 15 Becker muscular dystrophy (BMD), no case of 2 female dystrophinopathy (F-dyst), 11 out of 21 limb-girdle muscular dystrophy (LG), all cases of 10 Fukuyama type congenital muscular dystrophy (FCMD), 2 out of 5 fascioscapulohumeral muscular dystrophy (FSH), and 32 out of 44 myotonic dystrophy (MyD). Genetical degenerative process and vascular insufficiency seemed to cause brain atrophy in these disease. The intracranial calcification was observed in one DMD, one LG and seven MyD. One LG patient showed focal atrophy in left temporal lobe, and one MyD demonstrated right temporal meningioma. The trace of cerebral vascular accident was disclosed in eleven patients with PMD (1 DMD, 2 BMD, 1 F-dyst, 2 LG, 5 MyD). In these cases, 2 patients had dilated cardiomyopathy, 6 patients with decreased left ventricular ejection fraction, 3 with atrial fibrillation, 1 with cardiac arrest followed by pacemaker instillation, 1 with Adam-Stokes attack, and 3 with 1 degree AV-block. Diffuse low density in the white matter was seen in a patient with F-dyst, a FCMD patient, and 8 MyD patients. Cardiac emobolism, severe arrythmia, cardiogenic shock and hemodynamic disorder were seemed to cause cerebral vascular disease in PMD.

Adult↗
PubMed1999

Paediatric life support instructors courses in Spain. Spanish Paediatric and Neonatal Resuscitation Group.

Between October 1996 and February 1998 we have provided five PLS instructors courses for 127 physicians. The instructor course takes 20-24 h over in 3 days, with 20-36 students per course. Theory classes last 5 h and practical stations between 14 and 18 h. Theory classes include: types and organisation of paediatric courses, resuscitation material, methodology of education, didactic methods, and methods of evaluation. The practical classes include techniques of oral expression, resuscitation material, and methodology, and evaluation of basic life support, airway and ventilation, venous and intraosseous access, diagnosis and treatment of arrythmias, neonatal resuscitation and advanced resuscitation. At the end of the course the students perform an anonymous written evaluation of the course with scores between 1 (very bad), 2, 3, 4 and 5 (very good). Theoretical aspects practical classes, methodology, and organisation of the PLS instructors courses are considered satisfactory by the students. We conclude that PLS instructors courses are important for assuring the uniformity and quality of paediatric life support courses.

Cardiopulmonary Resuscitation↗
PubMed1999

Human forebrain activation by visceral stimuli.

Visceral function is essential for survival. Discreet regions of the human brain controlling visceral function have been postulated from animal studies (Cechetto and Saper [1987] J. Comp. Neurol. 262:27-45) and suspected from lethal cardiac arrythmias (Cechetto [1994] Integr. Physiol. Behv. Sci. 29:362-373). However, these visceral sites remain uncharted in the normal human brain. We used 4-Tesla functional magnetic resonance imaging (fMRI) to identify changes in activity in discrete regions of the human brain previously identified in animal studies to be involved in visceral control. Five male subjects underwent heart rate (HR) and/or blood pressure (BP) altering tests: maximal inspiration (MX), Valsalva's maneuver (VM), and isometric handgrip (HG). Increased neuronal activity was observed during MX, VM, and HG, localized in the insular cortex, in the posterior regions of the thalamus, and in the medial prefrontal cortex. To differentiate special visceral (taste) regions from general visceral (HR, BP) regions in these areas, response to gustatory stimulation was also examined; subjects were administered saline (SAL) and sucrose (SUC) solutions as gustatory stimuli. Gustatory stimulation increased activity in the ventral insular cortex at a more inferior level than the cardiopulmonary stimuli. The observed neural activation is the first demonstration of human brain activity in response to visceral stimulation as measured by fMRI.

Autonomic Nervous System↗
PubMed1999

[Measurement of troponin I levels in suspected myocardial infarction].

Serum cardiac troponin I-values were compared to conventionally obtained diagnosis in 319 consecutive patients suspected of having myocardial infarction, of which 46 patients were given this diagnosis. All patients with troponin I > 20 micrograms/l (n = 40) also had abnormal creatine kinase and abnormal creatine kinase isoenzyme MB activity. All patients with troponin I values in the range 1.0-19.9 micrograms/l (n = 50) had a diagnosis of heart disease (myocardial angina pectoris, myocardial infarction, arrythmia, heart insufficiency). In this patient group, the creatine kinase measurements showed pathological values in only 12 cases. Troponin I seems to be a sensitive indicator of cardiac cell injury, and measurements of troponin I seems to be useful in ruling out cardiac injury.

Biomarkers↗
PubMed1999

Monensin poisoning in Brazilian horses.

Three outbreaks of monensin poisoning caused 12 deaths in 16 horses. The illnesses were associated with the ingestion of the same batch of a commercial ration labeled for feeder calves which contained 180 +/- 20 ppm sodium monensin. The morbidity rate was 100% and lethality was 60%, 75%, and 100%. Clinical signs were tachycardia and cardiac arrythmia, groaning, incoordination, sudoresis, recumbency, and paddling movements with the limbs before death. Two horses had dark discolored urine (myoglobinuria). Serum levels of creatine phosphokinase activity were increased. Main necropsy findings were in the skeletal muscles and myocardium.

Animals↗
PubMed2000

[Laparoscopic and standard cholecystectomy: comparison of immediate results].

The advantages of laparoscopic cholecystectomy (LChE) are undoubtable in comparison with traditional one. However the experience showed, that LChE is not devoid of some shortcomings. It is characterized by the same typical complications as in ChE, besides it may be followed by some specific complications. The literature concerning the rate of complications in LChE are controversial. The comparative analysis has been carried out concerning the rate of complications after ChE (6800 operations) and LchE (900). The mean age of patients with choledocholythiasis--61.4 years. 40% of the patients had severe accompanying diseases coronary artery disease, complicated forms of arrythmia, arterial hypertension, diabetes mellitus, obesity. There were no significant differences between patients who underwent ChE (group 1) and LChE (group 2) by their age and the rate of accompanying diseases. Intraoperative cholangiography was performed in 3.5% of cases of group 1 and in 1.1%--in group 2. The average rate of the operations on extrahepatic bile ducts in group 1 was also lower--choledocholithotomy was carried out in 2.7%, transduodenal papillosphyncterotomy--in 1.7% of cases, drainage of the choledochal duct--in 1.9%. Combined operations were carried out in 10% of patients of group 1 and in 9.1% cases of group 2. The rate of intraoperative bleedings which demanded repeated operations made up in patients of group 1 0.1%, in patients of group 2 0.5%. Intraoperative damage of the choledochal duct in group 1 were detected in 0.14% and in group 2--in 0.11% of cases (the only complication of LChE in a patient was assessed as a endogenous wall clipping).

Cholecystectomy↗
PubMed1976

[Indications for surgery of the coronaries and its results (author's transl)].

In chronic angina pectoris surgery is indicated for all patients with bridgeable central stenoses, suitable distal vessels and patent peripheral coronary circulation, if function of the ventricle is not critically reduced. when more than one vessel is diseased and with isolated stenoses of the anterior interventricular branch of the left coronary a., it does hardly latter whether the angina pectoris can be treated conservatively or not. An absolute indication for revasculariation exists when stenoses of the main branches of the left coronary artery can be shown. Pre-infarct angina (unstable or crescendo-angina, threatened infarction) should, in younger patients, always lead to immediate diagnostic ascertainment. Where severe anatomic coronary changes are present, immediate surgery is indicated, although the real danger of infarction in such patients cannot be reliably predicated as yet. Post-infarct ventricular aneurysmus should be operated on when leftsided insufficiency increases or arrythmias cannot be controlled satisfactorily any more. Surgery can be undertaken with an acceptable risk, if patients are carefully selected. As far as we know from published statistics, the quality of life of such patients can be improved for some time. But their expectation of life after surgery cannot as yet be reliably predicted, because prospective observations of comparable groups of patients treated conservatively or surgically do not yet exist. From a prospective study of McNeer (22) it appears that in 2 randomized groups there was no significant difference in time of survival after 2 years. Neither the size of the material nor the period of follow-up are sufficient for definite evaluation.

Acute Disease↗
PubMed2000

[Transportation of patients with acute myocardial infarction].

The aim of this study was to describe the results and experiences from a local hospital concerning transports with patients with acute myocardial infarction to primary PTCA. Our material includes 27 patients who had primary PTCA. There were no complications during the transports. None of the patients had hypotension or arrythmia requiring treatment during the transports. One patient had ventricular fibrillation before the transport. None of the patients died during the transports. Two patients died in the period following PTCA. The transport delay was 1 hour and 40 minutes on average. Future randomized studies like DANAMI 2 will show if PTCA with delayed treatment, or immediate thrombolysis, give better results for the patient.

Adult↗
PubMed1975

Treatment of tachyarrhythmias by pacing.

The present status of the use of electrical pacing to treat tachyarrythmias is reviewed. The pathogenesis of arrythmia formation, methods of pacing, response of specific tachyarrhythmias to pacing and the clinical application of pacing to terminate and suppress tachyarrhythmias are delineated.

Acute Disease↗
PubMed1975

[Arrhythmia in the course of myocardial infarct. Our year's experience in a coronary unit].

Personal experience with arrythmia in 57 out of 132 cases of myocardial infarct treated over a period of one yr. in a coronary unit. The ECG and biohumoral enzyme pictures gave clear indications of infarct in all 132 cases. The various types of primary stimulus formation or conduction arrhythmia observed in these 57 patients are examined in relation to the site and extent of infarct. The treatment modalities are described. Mortality was less than 10 per cent in the entire series, with 3 per cent deaths due to serious rhythm disturbances. It is concluded that the introduction of coronary units has primarily contributed to the reduction of infarct deaths by their effective treatment of arrhythmia. Earlier admission to such units would lead to further reductions in mortality.

Adult↗
PubMed2000

Adrenalin versus terlipressin: blood loss and cardiovascular side-effects in the vaginal part of laparoscopically-assisted vaginal hysterectomy or vaginal hysterectomy.

The purpose of the study was to compare blood loss and cardiovascular side-effects in the course of the vaginal part of laparoscopically-assisted vaginal hysterectomy (LAVH) or single vaginal hysterectomy (VH) [1]. Blood loss was evaluated in relation to local application of two haemostatic agents, e.g. adrenalin as a gold standard versus terlipressin. The investigation was designed as a prospective randomised study. A prospective group of 40 patients selected for LAVH or VH was randomised into two groups, e.g. 20 patients in each group. In both of these groups, the blindly selected haemostatic agent was applied locally immediately before circular colpotomy, the surgeon not being aware which agent was being used. Because of the claimed delayed effect of terlipressin a third group of another 20 patients was randomly selected. For comparison in this group terlipressin was locally already applied before the laparoscopic part of LAVH, e.g. 20-25 minutes before performing circular colpotomy. Thus, this particular group could not be made blind to the surgeon. The study confirmed a significantly superior haemostatic effect of adrenalin. On the other hand after the adrenalin application a higher frequency of hypertensive reactions and mild arrythmias were observed but without any clinical seguelae.

Adult↗