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PubMed1978

The echocardiographic diagnosis of rupture of a papillary muscle.

The echocardiographic diagnosis of acute rupture of a papillary muscle is described. The pertinent findings included (1) decreased systolic motion of the posterior wall, (2) exaggerated septal motion, (3) left ventricular enlargement and pattern suggesting left ventricular diastolic overload, and (4) bizarre fluttering of posterior leaflet of the mitral valve in diastole, suggesting an unhinging of the mitral valvular apparatus. The echocardiogram is a useful noninvasive tool in the diagnosis of this often fatal complication of myocardial infarction.

Aged↗
PubMedDate not supplied

Diltiazem. A review of its pharmacology and therapeutic use in older patients.

Diltiazem is a benzothiazepine derivative calcium antagonist available in several formulations, some of which enable once daily administration. The drug as monotherapy has demonstrated similar efficacy to diuretics in older patients with hypertension. Data comparing diltiazem with beta-blockers and angiotensin converting enzyme inhibitors are more limited, but available studies suggest at least comparable antihypertensive efficacy. Diltiazem as monotherapy or in combination with a beta-adrenoceptor-antagonist, isosorbide dinitrate, or another calcium antagonist, has demonstrated efficacy in patients with effort angina. The drug has also been used intravenously to terminate supraventricular tachycardias and to control the ventricular response to atrial fibrillation or flutter; it also appears to reduce the rate of early reinfarction in patients with non-Q-wave myocardial infarction. The most common adverse events during diltiazem therapy include headache, flushing, peripheral oedema and hypotension. Atrioventricular block although rare, is the most frequent serious adverse event related to diltiazem therapy and may be exacerbated by coadministration of beta-adrenoceptor antagonists, especially in the elderly. Thus, diltiazem appears to be an effective and well tolerated treatment for hypertension and angina in older patients and has shown promise as therapy for supraventricular tachycardias and as prophylaxis against early reinfarction in patients with non-Q-wave myocardial infarction.

Adult↗
PubMed1992

[The interruption of atrioventricular conduction by cardiac fulguration in patients with supraventricular tachycardias. The mid- and long-term results].

Catheter ablation of the atrioventricular node is a therapeutic technique for the treatment of patients with drug-refractory supraventricular tachyarrhythmias. In our Arrhythmia Unit 25 patients (8 women, 17 men) aged (mean +/- DE) 56 +/- 10 years have undergone fulguration of the atrioventricular junction since 1986. The more frequent treated rhythm disturbance was atrial flutter or fibrillation, with uncontrolled rapid ventricular response. Absence of organic heart disease was diagnosed in 9 patients; the remainder had valvular heart disease (2), cor pulmonale (2), cardiomyopathy (7), hypertensive heart disease (2) and Wolff-Parkinson-White syndrome (3). Under general anesthesia 1.8 +/- 0.8 shocks/patients were delivered along 1.2 +/- 0.7 sessions/patient. In 23 of 25 patients (92%) complete atrioventricular block was achieved, and a pacemaker was implanted. There were no complications. The other 2 patients were referred to surgery for cryoablation of the atrioventricular junction. Patients were followed for an average of 21 +/- 12 months. Four patients have died: two due to congestive heart failure, which was present prior to the ablation procedure, the third because of a metastatic carcinoma, and the fourth had a sudden death 14 months after the procedure (he had dilated cardiomyopathy and Wolff-Parkinson-White syndrome). The remainder in chronic stable complete atrioventricular block are asymptomatic for arrhythmias and without antiarrhythmic medication.

Adult↗
PubMed2005

[Fetal supraventricular tachyarrhythmias refractory to initial therapy].

Fetal arrhythmia is an unusual cause of admission in critical care unit. We report three cases of pregnant patients with gestational age of 27 to 32 weeks, with diagnosis of fetal sustained supraventricular tachyarrhymias; which were resistant to digoxin as first line therapy. Two fetuses had supraventricular tachycardia and were converted with flecainide in association with digoxin. A remaining hydropic fetus suffering atrial flutter with 2:1 auriculo-ventricular conduction, failed to restore sinus rhythm with digoxin alone or in association with flecainide nor amiodarone, and required premature c-section at 30a week of gestation. Due to amiodarone administration the neonate suffered transient neonatal hypothyroidism.

Adult↗
PubMed1986

Cardiovascular pharmacology. III: Atropine, calcium, calcium blockers, and beta-blockers.

Atropine, calcium, calcium-channel blockers, beta-adrenergic-receptor blockers, oxygen, morphine, vasodilators, and potent diuretics are frequently used in advanced cardiac life support (ACLS). Since the last AHA conference on ACLS standards, little controversy has arisen regarding the use of oxygen, morphine, vasodilators, or potent diuretics. In 1979, a full vagolytic dose of atropine was recommended for use early in the course of asystolic or bradycardiac arrest. Since then reports suggest that this higher dose of atropine may be of some limited value in treating this highly resistant form of arrest. The routine use of calcium for asystole, bradycardiac arrest, and electromechanical dissociation has come under intense scrutiny. Studies have failed to demonstrate improved survival and have found potentially deleterious levels of serum calcium when calcium was administered according to AHA standards. It is also possible that postanoxic cerebral injury is exacerbated by the use of calcium. No controversy exists, however, concerning the use of calcium for the moribund patient with possible hypocalcemia or with an excess of calcium-channel blockers. The use of calcium-channel blockers has been advocated to prevent or retard the intracellular accumulation of calcium, which may cause irreversible postanoxic tissue damage. Calcium-channel blockers may also be useful in preventing or decreasing cerebral and coronary arteriospasm. These drugs have antianginal properties that may decrease ischemia. The antiarrhythmic effect of verapamil is particularly useful in the treatment of uncomplicated paroxysmal supraventricular tachycardia. Verapamil and diltiazem slow conduction through the atrioventricular node and may be used to slow the ventricular response in atrial fibrillation and flutter.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMed1981

Arrhythmia control by cardiac stimulation.

Cardiac programmed stimulation in the control of tachyarrhythmias offers encouraging prospectives. We describe two devices which utilize radiofrequency as a means of synchronization and stimulation and can be triggered by the patient himself when tachycardia occurs. In addition we introduce a third anti-tachycardia device, completely automatic, which can be used in cardiologic departments. The first device described permits critical stimulation and can be programmed to deliver a single or double synchronized impulse. The second device, which utilizes the same implanted unit and electrode as used for critical stimulation, when activated searches the tachycardia interruption zone by scanning. The third device, based on the same principles, has a rate discriminator that activates the scanning stimulation. We treated 12 patients: 8 suffering from paroxysmal supraventricular tachycardia (4 with Wolff--Parkinson--White syndrome, 2 with intranodal reentry, 2 with brady--tachy syndrome); 2 patients with ventricular recurrent tachycardia; 1 with atrial flutter; and another with iterative junctional tachycardia. The follow-up varied for every patient from 6 yr to 3 mth.

Arrhythmias, Cardiac↗
PubMedDate not supplied

Treatment of supraventricular tachyarrhythmias with intravenous calcium channel blockers: are subtle differences worth the cost?

Verapamil and diltiazem are effective in terminating paroxysmal supraventricular tachycardias and slowing ventricular response during atrial fibrillation or flutter. Results from clinical trials for each individual drug demonstrate comparative efficacy rates, and both drugs share the same contraindications and relative precautions. Well-designed comparative clinical trials are needed to establish if either drug has any clinical advantages in a particular patient population.

Calcium Channel Blockers↗
PubMed1988

Treatment of atrial tachyarrhythmias and preexcitation syndrome with flecainide acetate.

Sixteen consecutive patients who had ventricular preexcitation complicated by atrial fibrillation or flutter were treated with intravenous flecainide acetate after treatment with as many as 5 unsuccessful trial regimens with other drugs. In 15 patients who had atrial fibrillation, the shortest RR interval during spontaneous episodes was 210 +/- 39 ms (mean +/- standard deviation), and the average ventricular rate was 208 +/- 37 beats/min. Intravenous flecainide prevented induction of atrial fibrillation in 4 of 9 patients and eliminated anterograde accessory pathway conduction in 9 of the 16 patients. In 5 patients whose atrial fibrillation remained inducible and who continued to have preexcitation, the shortest preexcited RR interval increased from 185 +/- 29 to 281 +/- 46 ms (p less than 0.01). Fourteen patients who had favorable responses to intravenous flecainide were given an oral regimen of the drug. Oral treatment was discontinued early because of proarrhythmic effects in 2 patients, and after 2 1/2 months because of headaches in 1 patient. Eleven patients, 5 receiving concomitant beta-blockade therapy, have continued to receive a regimen of flecainide for a mean of 21 months (range 3 to 48). Seven patients have had no clinical recurrence of arrhythmias. Recurrences in 4 patients have been rare and brief with no changes in therapy required.

Adult↗
PubMed1981

Frequency and outcome of disorders of cardiac rhythm and conduction in a population of newborn infants.

Of 3,383 apparently healthy newborn infants studied in one region of England, 33 showed cardiac arrhythmias or preexcitation on a standard ECG. Twenty-six infants had multiple atrial or ventricular premature beats. One infant had atrial flutter, two had multifocal atrial tachycardia, and two had supraventricular tachycardia. Two infants showed the ECG pattern of the Wolff-Parkinson-White syndrome, but did not demonstrate cardiac arrhythmias. Performance of 24-hour ECG recordings of 15 of the 26 subjects with premature beats showed additional supraventricular or ventricular tachycardia in five cases. In one of two infants with multifocal atrial tachycardia, 24-hour recordings also demonstrated long episodes of rapid supraventricular tachycardia. Follow-up recordings (standard and 24-hour ECG) showed that in the majority of infants arrhythmias or preexcitation could not be demonstrated after 12 weeks of age. One infant with atrial premature beats, one infant with ventricular premature beats and ventricular tachycardia, and one infant with multifocal atrial tachycardia showed persisting arrhythmias. Four infants received antiarrhythmic therapy which probably influenced the natural history of their arrhythmias. Disorders of cardiac rhythm and conduction occur in apparently healthy infants. This study provides a basis for further prospective research into their natural history.

Arrhythmias, Cardiac↗
PubMed2004

[Risk assessment in acute myocardial infarction].

Despite the appearance in clinical practice of modern treatment modes as thrombolysis and percutaneous coronary intervention, in-hospital mortality from acute myocardial infarction remains an important problem. In this paper we review recently published data concerning risk stratification in the acute phase of myocardial infarction, different factors affecting the prognosis, their dynamics in the course of the disease, and inter-factor relations. We emphasize the prognostic value of three factors: heart rate variability, left ventricular dysfunction and arrhythmias. Changes in heart rate variability are discussed in association to location of myocardial infarction, patency of infarct-related artery, the chosen treatment mode and its timing. Left ventricular diastolic function and right ventricular function are shown to be predictors of morbidity and mortality after myocardial infarction besides left ventricular systolic function. We also present the latest data concerning the prognostic implication of arrhythmias, their relation to left ventricular function and autonomic nervous system balance. Atrial fibrillation and atrial flutter appear to be important factors in predicting mortality after myocardial infarction, especially in the elderly, as well as ventricular arrhythmias - sustained ventricular tachycardia and ventricular fibrillation.

Aged↗
PubMed1997

Emergency management of atrial fibrillation and flutter: intravenous diltiazem versus intravenous digoxin.

STUDY OBJECTIVE: To compare the effects of i.v. diltiazem and i.v. digoxin on ventricular rate control in the emergency treatment of acute atrial fibrillation and flutter (AFF). METHODS: This prospective, randomized, open-label trial involved 30 consecutive patients who presented with acute AFF to the emergency department of an urban, 420-bed community teaching hospital from April 1993 through March 1994. Exclusion criteria included systolic blood pressure lower than 100 mm Hg, treatment with calcium-channel blockers other than diltiazem, lack of informed consent, and objection of the private physician. Patients were randomly assigned to receive either i.v. diltiazem alone, i.v. digoxin alone, or both. Heart rate control was defined as a ventricular rate of less than 100 beats/minute. I.v. digoxin, 25 mg, was given as a bolus at time 0 and at time 30 minutes. An initial dose of .25 mg/kg diltiazem was given intravenously over the first 2 minutes, followed by a dose of .35 mg/kg at time 15 minutes and then a titratable i.v. infusion at a rate of 10 to 20 mg/hour to maintain heart rate control. The dosing regimens were the same whether the drugs were given alone or in combination. Heart rhythm, heart rate, and blood pressure were measured at time 0, 5, 10, 15, 30, 60, 120, and 180 minutes. Statistical significance was assessed with the use of Student's t test and ANOVA methodology. RESULTS: At time 0, the heart rate (mean +/- SD) was 150 +/- 19 beats/minute in the diltiazem group and 144 +/- 12 in the digoxin group (difference not significant, P = .432). The decrease in heart rate from time 0 reached statistical significance at time 5 minutes in the diltiazem group (P = .0006); the mean rates at time 5 minutes were 111 +/- 26 beats/minute for diltiazem and 144 +/- 13 for digoxin. The decrease in heart rate achieved with digoxin did not reach statistical significance until time 180 minutes (P = .0099), at which time the rates were 90 +/- 13 for diltiazem and 117 +/- 22 for digoxin. CONCLUSION: Treatment of acute AFF with i.v. diltiazem decreases ventricular heart rate significantly within 5 minutes, compared with 3 hours for treatment with i.v. digoxin. No advantage was noted within 3 hours for i.v. treatment with a combination of diltiazem and digoxin. I.v. diltiazem is superior to i.v. digoxin in the emergency control of ventricular rate in acute AFF and should be considered as a drug of choice for this condition. This study was not large enough to adequately assess adverse effects, and further studies may be warranted for clinical validation.

Acute Disease↗
PubMed1996

Use of intravenous dofetilide in atrial flutter with hemodynamic instability.

Paroxysmal atrial flutter is a drug-resistant supraventricular tachyarrhythmia that is often accompanied by hemodynamic instability due to an excessive ventricular response. We report here a case of atrial flutter with 1:1 atrioventricular conduction, in which we were able to rescue the patient from a state of cardiogenic shock by using intravenous dofetilide, a new class III antiarrhythmic agent. Dofetilide was suitable for the treatment because it immediately increased atrioventricular nodal refractoriness without any negative inotropic action.

Adult↗
PubMedDate not supplied

[Electric cardioversion in the emergency service. Experience in 1000 cases].

We describe our experience with 1000 electric cardioversions performed at the emergency ward in the Hospital of Cardiology y Neumology, National Medical Center I.M.S.S. The objectives are: 1. Report our experience. 2. Investigate if digitalis treatment should be discontinued before the procedure. 3. Determine if all patients should be on anticoagulant therapy for elective cardioversion. 4. Indicate the optimal anesthetic drug with minimal side effects. A therapeutic procedure was performed in 73% of our cases and an elective one in the remaining 27%. Patients were grouped as ischemic heart disease 26%, rheumatic heart disease 24%, chronic obstructive pulmonary disease 14%, systemic hypertensive heart disease 13%, without clinical heart disease 6%, preexcitation syndrome 6%, adult congenital heart disease 4%, with implanted pacemaker 2%, pregnancy 2% and diverse myocardial diseases 2%. As a cardiac arrhythmias atrial fibrillation was the main cause 45%. Atrial flutter represented 25%, atrial paroxysmal tachycardia was 21% and ventricular tachycardia 9%. A cardioversion was performed in 43% of patients under digitalis treatment at therapeutic levels, without complications. Atrial flutter reverted to sinus rhythm in 98% of the procedures, and atrial fibrillation in 97%. Elective cardioversion in patients with atrial fibrillation was achieved with energies of 200 joules in 82% of the procedures (P less than 0.001) and in atrial flutter with 100 joules in 89% of the cases (P less than 0.001). The most frequent complications were atrial and junctional premature beats in 41% of the cases. We consider this procedure a safe one, effective at the energy levels described, with no need for discontinuation of digitalis therapy, with no mandatory previous anticoagulant therapy, and with no contraindications on pregnancy or implanted pacemakers.

Adolescent↗
PubMed2004

Temporal and spatial phase analyses of the electrocardiogram stratify intra-atrial and intra-ventricular organization.

We hypothesized that electrocardiogram (ECG) spatial phase analysis would define a spectrum of intracardiac organization from atrial fibrillation (AF), nonisthmus-dependent and isthmus-dependent atrial flutter (AFL) to supraventricular tachycardias (SVT), and similarly for ventricular arrhythmias. We analyzed arrhythmia ECGs of 33 patients with isthmus (n = 9) and nonisthmus (n = 5) dependent AFL and SVT: atrial (n = 3), atrioventricular nodal (n = 3), and orthodromic reciprocating (n = 3) tachycardias, as well as AF (n = 5), ventricular tachycardia (monomorphic, VT-MM; n = 7), and fibrillation (VF; n = 3). ECG spatial phase was considered coherent when the correlation coefficient of an atrial (or ventricular) template to its ECG over time maintained a constant relationship in XY, XZ, and YZ planes. Regularity was quantified spectrally from ECG and correlation series. Spatial coherence occurred in 9/9 cases of isthmus--but only 1/5 of cases of nonisthmus-dependent AFL (p < 0.01; chi2). All showed one dominant spectral peak (temporal coherence). In AF, spatial phase was inconsistent in all planes and spectra were broad band. Temporal and spatial coherence occurred in other SVT. VT-MM maintained spatial phase and a single spectral peak, while VF displayed neither. Our conclusions are that temporal and spatial phase analysis from the ECG stratifies intra-atrial and intra-ventricular organization and reveals subtle variability lost on visual inspection.

Adult↗
PubMedDate not supplied

[Trans-surgical ablation of atrial flutter in patients treated with closure of atrial septal defect. Pilot project].

Atrial flutter is one of the most common arrhythmias in patients with atrial septal defect, after surgery 14% of patients can develop it and may be associated with high morbidity. In this study we performed prophylactic and therapeutic ablation of atrial flutter during atrial septal closure surgery drawing 4 lines; line 1, isthmus cavo-tricuspid, the area between the inferior vena cava and the tricuspid ring; line 2, the area between coronary sinus ostium and inferior vena cava; line 3, the area between tricuspid valve annulus and coronary sinus ostium; and line 4, the area between lateral atriotomy and atrial septal defect. Twenty-one patients were included, 6 (28.5%) patients had atrial flutter before surgery and 15 (71.4%) were in sinus rhythm. There were no new cases of atrial flutter, but at six months follow up 2 (33.3%) patients recidivated with atrial flutter. One patient developed high degree atrio-ventricular block and a pacemaker had to be implanted. Older age at the time of surgery and high systolic pulmonary pressure were significantly higher in those patients with atrial flutter before surgery and in patients with arrhythmias recurrence. Ablation of atrial flutter during atrial septal closure surgery can be a good option for the treatment and prevention of atrial arrhythmias, but more studies are still needed.

Adolescent↗