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PubMed1998

Etiology and complications of atrial fibrillation: insights from pathology studies.

Atrial fibrillation (AF) is an arrhythmia associated with a wide variety of cardiac conditions, and it carries a risk of thromboembolism which varies with the underlying disease. The prevalence of AF increases markedly with age, and a review of histopathologic studies reveals that normal aging produces histologic changes in atrial conduction that may lead to the development of atrial arrhythmias. The diverse pathologic causes of AF also result in histologic abnormalities, and an examination of the relation of the etiology of the arrhythmia to pathologic changes suggests a possible reason for the varying risk of thrombus formation. The interaction between the histologic abnormalities and the presence of triggers of AF may also play an important role in the onset and maintenance of this common condition.

Aged↗
PubMed1999

Intravenous antiarrhythmic therapy in the acute control of in-hospital destabilizing ventricular tachycardia and fibrillation.

Ventricular tachycardia, which causes hemodynamic instability, and ventricular fibrillation do not occur frequently in any hospital. However, they usually occur in patients who have severe underlying cardiovascular disease such as myocardial ischemia/infarction or congestive heart failure, and they are associated with high mortality. Most of those deaths are due to an intractable arrhythmia, not suppressible with even the most potent antiarrhythmic drugs. Fortunately, during the last few years, our ability to suppress highly lethal ventricular arrhythmia has been enhanced by the approval of intravenous amiodarone. When used in appropriate patient populations, intravenous amiodarone has been successful in suppressing the most malignant arrhythmia, thus permitting aggressive and successful treatment of severe underlying cardiac conditions. This article reviews data on the use of parenteral antiarrhythmic drugs for the control of ventricular arrhythmia in patients in hospital, and will attempt to provide some guidance as to how these antiarrhythmic drugs may be used in specific patient populations to maximize their efficacy and safety. We will also make recommendations on the sequence of therapy for specific arrhythmias to optimize the chances of patient survival.

Amiodarone↗
PubMed1995

Noninvasive estimation of pulmonary arterial wedge pressure with Doppler transmitral flow velocity pattern in patients with known heart disease.

Pulmonary arterial wedge pressure (PAWP) is an important marker of cardiac function. Regrettably, it requires catheterization, which can occasionally result in serious complications. A noninvasive method of estimating PAWP would thus be helpful. Recent studies have indicated that the Doppler transmitral flow velocity pattern was strongly dependent on preload and could provide an estimate of PAWP. This study was therefore designed to evaluate the relation between doppler transmitral flow velocity indexes and measured PAWP in 91 patients (learning group: 73 men, mean age 57 +/- 13 years) with ischemic heart disease (n = 41), dilated (n = 29) or hypertrophic cardiomyopathy (n = 4), or aortic stenosis (n = 17). Multiple regression analysis was used to derive an equation for estimation of PAWP, which was subsequently tested in a separate group of 33 patients (testing group: 28 men, mean age 58 +/- 12 years) with similar cardiac conditions. PAWP ranged from 4 to 48 mm Hg in the learning group and from 7 to 40 mm Hg in the testing group. In the learning group, PAWP correlated with the E/A ratio (r = 0.95), atrial filling fraction (r = -0.80), peak E velocity (r = 0.79), isovolumic relaxation period (r = -0.75), and deceleration time (r = -0.61). In the learning group, PAWP was best predicted as PAWP = 18.4 + [17.1.In(E/A ratio)]. This equation allowed prediction of PAWP within 3 mm Hg of the measured value in 24 of 33 patients (73%) in the testing group. In 8 additional patients, the equation also accurately predicted the changes in PAWP induced by volume loading or intravenous nitrates (r = 0.98).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1998

Etiology and diagnosis of bilateral leg edema in primary care.

PURPOSE: To identify the causes of bilateral leg edema in a primary care setting, and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. PATIENTS AND METHODS: Fifty-eight ambulatory adult patients with bilateral leg edema were enrolled at an inner city family practice during a 3-year period. Historical information, physical examination findings, and clinical impressions of primary care providers were compared with the results of laboratory evaluations consisting of echocardiograms, venous duplex ultrasound leg scans, serum albumin levels, and when appropriate, 24-hour urinalyses. RESULTS: Forty-five patients (78%) completed the study. The initial clinical impression was venous insufficiency in 32 (71%) patients and congestive heart failure in 8 (18%) patients. In actuality, 15 (33%) patients had a cardiac condition as a cause of their leg edema, and 19 (42%) had pulmonary hypertension. All of the patients with heart disease, and almost all of those with pulmonary hypertension, were age 45 years or older. Only 10 (22%) of the subjects had venous insufficiency. Renal conditions, medication use, and hypoalbuminemia were less common. CONCLUSIONS: Utilizing clinical information only, many patients with cardiopulmonary pathology were incorrectly diagnosed as having more benign conditions, most commonly venous insufficiency. Echocardiographic evaluation, including an estimation of pulmonary artery pressure, may be advisable in many patients with bilateral leg edema, especially if they are at least 45 years old.

Clinical Competence↗
PubMed1984

Should valve replacement and related procedures be performed in elderly patients?

The cases of 135 consecutive elderly patients 70 years old or older who had valve replacement and related surgical procedures from October, 1977, through April, 1982, were reviewed. There were 75 men and 60 women. The mean left ventricular ejection fraction was 50.16 +/- 5%. The overall operative mortality was 8% (11 patients). The early operative deaths were related mainly to cardiac failure, low cardiac output, sepsis, and renal and multiorgan failure. To assess the operative risk, these 135 patients were compared with 312 younger patients (less than 70 years old) who had undergone similar procedures during the same period. The operative mortality in this group was 5.2% (16). In-hospital complications included arrhythmia (13%), psychosis (7.4%), respiratory failure (6.7%), renal failure (6.7%), cerebrovascular accident (5.2%), myocardial infarction (4.4%), and reoperation for bleeding (2.2%). Wound dehiscence occurred in 1.5% of the patients, and pulmonary emboli and sepsis developed in 0.7%. Of these complications, only the incidence of cerebrovascular accident appeared to be more common in the elderly group (5.2% versus 2.8%), but it had no statistical significance (p = 0.18). A follow-up of 3,892 patient-months was completed in 98.4% of the survivors. There were 8 late deaths (6.4%). Six were related to the valve or to ongoing cardiovascular disease. Thirty-four patients subsequently required medical attention: 4 had bleeding because of the anticoagulant; 3 required a blood transfusion; and 27 were hospitalized. Six were admitted for related cardiac conditions and 7, for observation of other conditions; 14 underwent surgical procedures not related to the cardiovascular system.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed2000

Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement.

Combined aortic and mitral valve operations are still considered major cardiac surgical procedures. The duration of aortic cross-clamping and cardiopulmonary bypass is longer, which increases morbidity and mortality for these combined, complicated operations. Aortic valve exposure is generally satisfactory, but mitral valve exposure may be difficult and add to the length of the aortic cross-clamping time. We have exposed the mitral valve by transecting the ascending aorta, and retracting both ends apart, to give direct access through the dome of the left atrium in 7 patients. This approach gave good exposure and did not increase the risk of complications. Exposure of the mitral valve through the left atrium using a superior approach, by transecting the ascending aorta, is a good option for patients with multiple cardiac conditions who are undergoing combined aortic and mitral valve operations.

Aorta↗
PubMed1981

Computed tomography and histological correlation of the thymic remnant.

Pre-operative computed tomography (CT) of the anterior mediastinum was performed in eight patients undergoing surgery for cardiac conditions. At operation the anterior mediastinum was generously biopsied. Histology of the material allowed evaluation of the proportion of normal residual thymic tissue. Wide variation in CT appearances and in the degree of thymic involution was found, but there was good correlation between CT findings and thymic histology. This normal variation is of importance when considering the CT diagnosis of anterior mediastinal soft tissue density tumours.

Adolescent↗
PubMed1993

Intestinal rotation and fixation abnormalities in heterotaxia: early detection and management.

Intestinal rotation and fixation abnormalities (IRFA) are known to coexist with heterotaxia (defined as an abnormal arrangement of body organs that is different from complete situs solitus or complete situs inversus), but little is known about the incidence of this association or its clinical management. We have reviewed the records of 34 patients diagnosed with heterotaxia during a 12-year period at Yale-New Haven Hospital in order to develop a plan for the early diagnosis of IRFA and to assess the value of preventive treatment in this complicated group of patients. Of the 34 patients with heterotaxia, all except one presented with complex congenital heart disease. The 34 patients were divided into two groups on the basis of their gastrointestinal workup for suspected IRFA. The 28 patients in group A had no upper gastrointestinal (GI) contrast study performed prior to symptoms suggestive of IRFA. Four of these 28 patients (14%) eventually developed complications of IRFA requiring emergency surgery. Group B consisted of six patients seen during the past 5 years with heterotaxia who had upper GI contrast studies while asymptomatic. All six (100%) were shown to have IRFA and subsequently underwent an uncomplicated elective Ladd procedure once their cardiac condition stabilized. This study confirms the high incidence of IRFA in patients with heterotaxia. We propose that evaluating patients with heterotaxia syndrome for IRFA while asymptomatic may prevent the need for emergency abdominal surgery in patients that have major cardiovascular anomalies.

Abnormalities, Multiple↗
PubMed1998

Panic disorder in coronary artery disease patients with noncardiac chest pain.

In this study we address the following questions: (1) What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)? (2) How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress? Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales. Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample. A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD. Thirty-four percent (25 of 74) of CAD patients met criteria for PD. Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD. However, they did not differ from non-CAD patients with PD. PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.

Chest Pain↗
PubMed1997

St. Jude Medical valve prosthesis: an analysis of long-term outcome and prognostic factors.

Between 1979 and 1984, 321 patients received 354 St. Jude Medical prostheses (194 aortic, 94 mitral, 1 tricuspid, and 32 multiple valve replacements). Follow-up was 96% complete (2967 patient-years; mean 9.5 years per patient). Actuarial event-free rates at 10 years and linearized rates (in parentheses) of late complications were as follows: embolism, 85.0% +/- 2.3% (2.3% per patient-year); anticoagulant-related hemorrhage, 74.8% +/- 2.7% (3.3% per patient-year); cerebrovascular accident, 81.8% +/- 2.5% (2.6% per patient-year); prosthesis thrombosis, 98.5% +/- 0.7% (0.1% per patient-year); endocarditis, 97.2% +/- 1.1% (0.4% per patient-year); prosthesis dysfunction, 97.1% +/- 1.0% (0.4% per patient-year); hemolytic anemia, 98.5% +/- 0.7% (0.1% per patient-year); reoperation, 97.4% +/- 1.0% (0.4% per patient-year); overall mortality, 63.3% +/- 2.7% (4.2% per patient-year); and valve-related death (including sudden death), 84.7% +/- 2.2% (1.4% per patient-year). Independent preoperative risk factors were as follows: (1) for embolism, cardiac failure as indication for operation and history of prior systemic embolism; (2) for cerebrovascular accidents, the same two factors and age; (3) for endocarditis, diabetes, chronic alcoholism, and aortic valve replacement; (4) for overall mortality, age, ejection fraction (or cardiac index or cardiothoracic index), chronic alcoholism, and history of systemic embolism; and (5) for valve-related death, chronic alcoholism, degenerative cause of valve disease, and prosthetic diameter 23 mm or smaller. Ninety percent of survivors were in New York Heart Association functional class I or II at the end of follow-up. In conclusion, this study confirms the excellent durability of the St. Jude Medical valve and the remarkable functional benefit for the majority of the patients. However, prosthesis-related complications are still common, particularly for small-diameter prostheses. Outcome is strongly related to the patient's preoperative cardiac condition and to the adequacy of anticoagulation control.

Aged↗
PubMed1984

Tetralogy of Fallot after surgery: autopsy review of 14 cases.

The possible determinants of a fatal outcome following surgical repair of the tetralogy of Fallot were analyzed by postmortem examination in 14 cases. Only one patient died late in the postoperative period, due to patch detachment; the others died shortly after undergoing surgery. Death could not be explained in three cases. In three patients with perimembranous ventricular septal defects, complete atrioventricular block occurred as a consequence of traumatic disruption of the branching bundle. In four cases residual stenosis of the pulmonary outflow tract was shown; in one of these cases adequate relief of obstruction had been prevented by a large conal coronary artery. A residual mitral cleft was found in one patient. Death was not related to the cardiac conditions in two cases; one of these patients died of brain apoplexy and the other of tracheal hemorrhage. These findings stress the need for accurate preoperative diagnosis and precise knowledge of the surgical anatomy of this malformation.

Adult↗
PubMed2001

Exercise testing in special populations: athletes, women, and the elderly.

Exercise testing in special populations such as athletes, women, and the elderly requires additional considerations from the clinician. Different protocols, as well as special accommodations, may be necessary for performing the test. Symptomatic athletes may have a number of cardiac conditions that lead to ischemic changes on the exercise test. Asymptomatic athletes often use serial exercise testing to evaluate the efficacy of training programs. For women and the elderly, assessment of risk factors and evaluation of symptoms are important considerations before performing the exercise test. Negative exercise test findings suggest a low risk for future cardiovascular events. Positive exercise test findings must be interpreted in light of the individual's pre-test probability. Assessment of the needs of these patients allows the clinician to tailor the exercise test to produce useful information.

Adult↗
PubMed2003

Peptides from the N-terminal domain of chromogranin A (vasostatins) exert negative inotropic effects in the isolated frog heart.

The negative inotropic effects of synthetic peptides derived from the N-terminus of chromogranin A (CgA) were studied in an avascular model of the vertebrate myocardium, the isolated working frog heart (Rana esculenta). The peptides were frog and bovine CgA(4-16) and CgA(47-66), and bovine CgA(1-40) with (CgA(1-40SS)) and without an intact disulfide bridge (CgA(1-40SH)). Under basal cardiac conditions, four of the peptides caused a concentration-dependent negative inotropism that was comparable to the negative inotropy reported for human recombinant vasostatin I (CgA(1-78)) and bovine CgA(7-57). By comparison of the structural characteristics of the bovine and frog sequences with their minimally effective concentrations ranging from 68 to 125 nM of peptide, the results were consistent with the natural structure (CgA(17-38SS)) being essential for the negative inotropism. In addition, the partial sequences of the frog and bovine vasostatin I were effective in counteracting the characteristic positive inotropism exerted by isoproterenol (1 nM) at minimally effective concentrations ranging from 45 to 272 nM. Taken together, these results extend the first evidence for a cardiosuppressive role of the N-terminal domain of chromogranin A known for its co-storage with catecholamines in the sympathoadrenal system of vertebrates.

Adrenergic beta-Agonists↗
PubMedDate not supplied

Bacterial endocarditis of oral etiology in an elderly population.

The aim of this study was to analyze the prevalence and characteristics of bacterial endocarditis (BE) of oral origin in a group of elderly people. A retrospective study of 115 BE clinical records was performed, focusing on the demographic and predisposing features, as well as on the analytical and clinical variables. Twenty-two of the 115 cases were excluded as they were detected in intravenous drug users. Of the remaining 93 cases, 54.8% were diagnosed in patients older than 60 years of age (group A) and 45.2% in patients younger than 60 years (group B). There were 16 cases (17.2%) of oral origin; 4 BE cases mainly associated with tooth extractions were found in group A and 12 BE (most of them related with odontogenic abscesses) in group B. Within group A, 1 patient (25%) had not an underlying cardiac condition versus 5 cases (41.6%) in group B. Even though the prevalence of BE of oral origin in patients older than 60 is low, the high frequency of cardiopathies, poor oral health and high number of dental procedures shown by the old population makes them a risk group for BE of oral origin.

Aged↗
PubMed1982

Emergency medical service utilization by the elderly.

The growing number of aged in the United States will continue to increase the demand for medical services, including emergency care. In a medium-sized city, 22% of 14,400 emergency medical service responses were to patients over 65 years of age. Of the elderly, those over 75 years were more likely to call EMS than were those between 65 and 74 years old. Men used the service more often than did women. Men were more likely to suffer a cardiac condition; women, an injury. Elderly patients were 1.7 times more likely to require paramedic-accompanied transportation to hospital.

Age Factors↗
PubMed2000

[The bidirectional cavopulmonary (Glenn) shunt without cardiopulmonary bypass: a safe and advisable technique].

The bidirectional cavopulmonary (Glenn) shunt is almost a routine first step procedure for total cavopulmonary connection in children with single-ventricle cardiac anomalies. It is usually performed with cardiopulmonary bypass, of which adverse effects can be especially deleterious in these cardiac conditions. To avoid these adverse effects, we performed the cavopulmonary shunt in 5 children through sternotomy without cardiopulmonary bypass. There was no mortality nor morbidity. We think that this technique is safe, reproducible, and even advisable in children with single-ventricle anomalies.

Child↗
PubMed2002

The epidemiology of cardiac arrests in a Sydney hospital.

AIM: To examine the epidemiology of cardiac arrest (CA) in New South Wales (NSW), Australia, and a large teaching hospital in Sydney and to identify predictors of survival. METHODS: Data from the 1996/97 NSW inpatient statistics collection were analysed. Logistic regression was used to determine predictors of mortality from CA. RESULTS: In 1996/97 in public hospitals, Eastern Sydney Area Health Service (AHS) (47.5), and in private hospitals of Macleay-Hastings District Health Services (DHSs), recorded the highest crude CA rates in NSW with figures of 47.5 and 21.3 per 10,000 hospital separations. Standardised CA rates were highest in Western Sydney, Illawara, Macleay-Hasting, Mid North Coast and Orana DHSs. Most CAs in hospital 'X' occurred after admission and 55.7% occurred in patients admitted with a non-cardiac principal diagnosis, mainly pneumonia. Acute myocardial infarction was the leading diagnosis (28.9%) in patients who suffered CA after admission. Only 32% of CA patients survived to discharge. Age above 65 (odds ratio (OR)=2.284, P=0.006) had the highest effect on cardiac mortality. The longer the patients were in the intensive care unit (OR=0.997, P=0.037), the more likely they were to survive. CONCLUSION: We describe considerable variation in CA rates in NSW. The majority of hospital CAs occur at or soon after admission, and are associated with underlying non-cardiac conditions. Survival following hospital CA is low, but there may be preventable elements. Knowledge of risk factors and epidemiology of hospital CAs may help identify patients at risk of CA.

Adult↗
PubMed1997

Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) compared with standard CPR in a manikin model--decompression force, compression rate, depth and duration.

During active compression-decompression cardiopulmonary resuscitation (ACD-CPR), the rescuer applies traction to the chest between compressions. Under experimental conditions, cardiac output increases, possibly through accentuated intrathoracal pressure fluctuations. ACD-CPR requires specific training and may be more complex to perform than standard CPR. The aim of this study was to characterize ACD-CPR performance compared with standard CPR by emergency care providers; in terms of decompression force, compression rate, depth and duration. Thirty-three ambulance paramedics were studied while performing standard CPR and ACD-CPR with the Ambu Cardiopump on a specially designed transducer-equipped manikin 9 months following initial training. The order of CPR performance was determined randomly by cross-over design. Performance data were recorded by a computer. The 2-min average active decompression force was 9.3 kg (interquartile range 2.5-15.3 kg) and six subjects (18%) met the manufacturers recommendation of 10-15 kg. External chest compression (ECC) rate decreased from 85 (70-101) to 76 (63-88) min-1 (P < 0.001), ECC depth decreased from 54 (50-58) to 45 (39-48) mm (P < 0.001) and compression duration from 40 (35-45) to 31% (28-33%) (P < 0.001) upon change from standard CPR to ACD-CPR. We conclude that the recommended level of decompression force was achieved by less than one fifth of study subjects. ACD-CPR when compared with standard CPR causes a consistent and significant reduction of compression rate, depth and duration. These are all factors of possible clinical significance. Training in ACD-CPR should address this issue, with special emphasis on optimal decompression force and ECC rate.

Adult↗