Sudden cardiac death while wearing a Holter monitor

The Holter tapes of 61 patients (46 men, mean age +/- standard deviation 65 +/- 11 years) with sudden cardiac death while being monitored were analyzed. Thirty-eight patients were known to have coronary artery disease, 5 had cardiomyopathy, and 7 had aortic valve disease. Etiology remained unknown in 11 patients. Mean New York Heart Association functional class was 2.5 +/- 0.7. Thirty patients had received antiarrhythmic drugs and 32 had received digitalis. Sudden death occurred at rest in 73%. In the hours before death, repetitive ventricular arrhythmias were found in 50 patients (82%), with atrial fibrillation in 34%. Patients with bradyarrhythmic death (18%) had less complex ventricular …

Influence of digoxin on sinus node function after pharmacologic autonomic blockade.

The effect of iv digoxin on normal sinus node function was studied after pharmacologic autonomic blockade (AB) in ten patients. Sinus cycle length (SCL), sinus node recovery time (SNRT) and sinoatrial conduction time (SACT) were determined before and after AB with propranolol (0.2 mg/kg body weight) and atropine sulfate (0.04 mg/kg body weight) iv, and 15 min, 30 min, and 45 min after 1 mg iv digoxin. AB resulted in a significant decrease (P less than 0.01) in SCL (916 +/- 158 to 716 +/- 120 ms), in SNRT (1,229 +/- 221 to 871 +/- 190 ms), and in SACT (79 +/- 34 to 44 +/- 10 ms). Fifteen minutes after iv digoxin there was no significant change observed in SCL (716 +/- 120 to 708 +/- 92 ms), …

Separation of left atrium from right pulmonary artery: a new echocardiographic sign of pericardial effusion.

We report a new echocardiographic sign of pericardial effusion in patients with pericardial effusion examined by the suprasternal approach. In normal individuals the right pulmonary artery is closely connected with the superior wall of the left atrium. A separation of these structures is only to be noticed during atrial contraction. In 12 of 17 patients with a pericardial effusion observed a separation of the left atrium from the right pulmonary artery ranging from 3 to 20 mm throughout the cardial cycle. We suggest that this echo-free zone represents fluid in the transverse pericardial sinus which is located between the two structures. In five patients with a small pericardial effusion (le…

Intensivtherapie des Myokardinfarktes — Limitierung der Infarktgröße

Der akute Myokardinfarkt gehort mit der instabilen Angina pectoris und dem plotzlichen Herztod zu den drei akuten Koronarsyndromen, die sich nur im Ausmas und der Geschwindigkeit der Thrombusentstehung unterscheiden [16]. Ein solcher Koronarverschlus (Abb. 1) fuhrt zu einem akuten Ausfall der Myokardperfusion und innerhalb weniger Sekunden zum Ausfall der Funktion des nicht mehr perfundierten Myokards. Wird das Gefas innerhalb weniger Minuten wieder geoffnet [34, 37, 38, 48], erholt sich das Myokard vollstandig. Bleibt die Durchblutung langere Zeit blockiert, entwickelt sich ein Infarkt, der von subendokardial nach epikardial sich ausbreitet [24, 46, 47, 52, 53]. t bedeutet eine kurze Ischa…

Elektrokardiographische Infarktlokalisation: Ein Beitrag zur EKG-Nomenklatur

MIC trial: metoprolol in patients with mild to moderate heart failure: effects on ventricular function and cardiopulmonary exercise testing

Beta-blocker therapy results in a functional benefit in patients with heart failure (CHF) due to idiopathic dilated cardiomyopathy (DCM). This study assessed if similar effects were observed in patients with ischemic heart disease (CAD), NYHA II–III after 6 months of therapy with metoprolol. Methods and results: Fifty-two patients with CHF secondary to DCM (26 patients) and CAD (26 patients) and a left ventricular ejection fraction (EF) < 40% were enrolled in the placebo-controlled study. The study medication was titrated over 6 weeks, the mean final dosage was 135 mg/day. Three patients died due to cardiogenic shock, two received placebo and one metoprolol. Eight patients did not complete …

Cardiac output in single-lead VDD pacing versus rate-matched VVIR pacing.

The importance of atrioventricular synchronous pacing compared with single-chamber rate-responsive pacing is still under discussion, especially for low-intensity workload representing daily life activities. We evaluated hemodynamics in single-lead VDD pacing versus VVIR pacing in 11 patients (8 men and 3 women, aged 58.6 +/- 13.8 years) with normal left ventricular function and a previously implanted single-lead VDDR pacemaker. A low-intensity steady-state treadmill test at 1 to 2.5 mph with a gradient of 2% to 4% was performed. Cardiac output was determined using a standard carbon dioxide rebreathing technique. Initially, the VDD mode was programmed, and after 5 minutes of exercise, cardia…

Effect of intravenous flecainide on atrial vulnerability in man.

Sixteen patients were investigated by means of programmed atrial stimulation at 2 different driving rates: 100/min and 120/min. All patients had an increased atrial vulnerability at both driving rates. After the administration of intravenous flecainide (1 mg/kg bodyweight as a bolus, followed by the same amount infused over a period of 20 minutes), the increased vulnerability was abolished in 11 and 9 patients, respectively. In the remaining patients the rate of induced atrial tachyarrhythmia decreased. These findings correlate with a significant prolongation of the effective refractory period of the right atrium and a corresponding significant shortening of its relative refractory period. …

Die Spätpotentialanalyse in der Diagnostik nach akutem Myokardinfarkt:¶Risikomarker für den Arrhythmie-gefährdeten und klinisch symptomatischen Patienten (Late potentials in postinfarction patients: arrhythmogenic risk and clinical characteristics)

Ziel der prospektiven Studie ist die Korrelation ventrikularer Spatpotentiale mit klinischen Parametern bei Patienten nach akutem Myokardinfarkt. Es wurde die prognostische Wertigkeit dieser Methode hinsichtlich der Risikostratifizierung bezuglich des plotzlichen Herztodes in der spaten Postinfarktphase im Vergleich mit herkommlichen diagnostischen Moglichkeiten uberpruft. Zudem wurde untersucht, welche klinischen Symptome die potentiell gefahrdeten Patienten charakterisieren.

Acute Hemodynamic Effects of Nicorandil in Coronary Artery Disease

Nicorandil is a potent vasodilator with antianginal and anti-ischemic properties that acts on both the coronary and the peripheral vascular bed. Because of its dual vasodilatory mechanisms mediated by an increase in cyclic GMP similar to that of nitrates and by a selective increase in the K+ conductance of the smooth muscle cell membrane, nicorandil unloads the right and left ventricles at rest and during exercise. Thus, compared with the classic nitrates, nicorandil is a more balanced vasodilator, i.e., it affects not only the venous capacitance vessels (as predominantly affected by nitrates) but also the arterial resistance vessels. In clinical pharmacologic trials, nicorandil has been ad…

Kurzzeitmessung der Herzfrequenzvariabilität bei Postinfarktpatienten -

Hintergrund: In der Risikostratifizierung fur einen PHT bzw. das Auftreten eines arrhythmogenen Ereignisses nach AMI wurden bisher eine hohe Spezifitat und ein hoher negativ pradiktiver Wert durch Kombination mehrerer Methoden erreicht. Sensitivitat und positive Pradiktion sind jedoch weiterhin nicht ausreichend. Eine dieser Methoden ist die Messung der HRV, die als unabhangiger Pradiktor eines solchen Ereignisses gilt. Sie wird genutzt, um einen schnellen Uberblick uber den Zustand des autonomen Nervensystems zu bekommen, wird jedoch insbesondere in der Kardiologie bisher nur aus dem 24-Stunden-Langzeit-EKG bestimmt.¶   Studienziel: Die Kurzzeitmessung der HRV bei Postinfarktpatienten als …

Current status of phosphodiesterase inhibitors in the treatment of congestive heart failure.

The phosphodiesterase inhibitors have been recognised as potent inotropic and vasodilating drugs. In acute congestive heart failure they increase cardiac output, decrease left pulmonary capillary wedge pressure, and reduce total peripheral resistance with an improvement in loading conditions of the failing heart. Their potency in reversal of symptoms of acute congestive heart failure is quite similar to, or even better than, treatment with intravenous catecholamines and sodium nitroprusside. In chronic congestive heart failure, however, these agents increase mortality and have deleterious effects in the outcome of patients with severe left ventricular dysfunction.

“Three-level shock” in ablation-refractory paroxysmal atrial fibrillation

His-bundle ablation is a very effective method to control drug-refractory supraventricular arrhythmias. We present a 69-year-old woman with paroxysmal atrial fibrillation, in whom several attempts of unipolar and bipolar His-bundle ablation were ineffective. Ultimately a stable 2/1 atrioventricular block was induced when three successive shocks of 400 W were applied. The first shock was given in that position with the largest His-potential deflection. The other two shocks were applied at catheter positions more distal and more proximal from the first one, respectively. We suppose that the initial lack of success was due to an atypical atrioventricular junction anatomy.

Impaired Cardiopulmonary Exercise Capacity in Patients With Hyperthyroidism

Hyperthyroidism (H) has been implicated as a primary cause of decreased exercise tolerance. To our knowledge, analysis of respiratory gas exchange, an efficient noninvasive method in evaluating cardiopulmonary capacity, has not been performed in patients with H.Using cardiopulmonary exercise testing, 12 consecutive women with Graves' H were examined and controlled in euthyroidism (E). Eighteen women with E, in whom cardiac catheterization had ruled out heart disease, served as control subjects (C).The ventilatory anaerobic threshold was determined by means of the V-slope method. Ergometry was performed with patients in a semisupine position using a continuous ramp protocol of 20 W/min. Echo…

Manifestation und Therapie von Reperfusionsarrhythmien bei der Thrombolyse des akuten Myokardinfarktes

Schon seit 1943 ist bekannt, das die Wiederherstellung der Durchlassigkeit eines verschlossenen Kranzgefases zu Rhythmusstorungen fuhren kann (9). Diese Art von Rhythmusstorungen werden Reperfusionsarrhythmien genannt. Seitdem die intrakoronare und intravenose Streptokinaseapplikation bei Patienten mit frischem Herzinfarkt immer haufiger verabreicht werden, ist auch das Interesse fur die Reperfusionsarrhythmien gestiegen.

Effect of intravenous flecainide on atrial vulnerability in man.

Sixteen patients were investigated by means of programmed atrial stimulation at two different driving rates: 100 and 120/min. All patients had an increased atrial vulnerability at both driving rates. After intravenous flecainide application (1 mg/kg body weight as a bolus followed by the same amount given by infusion over a period of 20 min) the increased vulnerability was abolished in 11 and 9 patients respectively. In the remaining patients the rate of induced atrial tachyarrhythmia decreased. These findings correlate with a significant prolongation of the effective refractory period of the right atrium and a significant shortening of the relative refractory period of the right atrium. It…

Prognostic significance of repetitive ventricular response in chronic coronary artery disease.

A prospective study was conducted in 267 patients with angiographically defined coronary artery disease without documented ventricular tachycardia to determine the prognostic significance of repetitive ventricular response (RVR) after programmed electrical stimulation (PES). The patients were classified inducible if RVR with 3 or more echo beats (RVR greater than or equal to 3) could be induced. 89 patients without previous myocardial infarction (MI), 61 survivors of MI occurring between 6 weeks and 3 months before and 117 patients who had survived longer than 3 months after MI were studied. A standardized stimulation protocol with single (S1S2) and double (S1S2S3) extrastimuli during ventr…

Long-Term Enoximone Therapy in Unstable Chronic Heart Failure

Long-term safety and efficacy of oral enoximone were evaluated in 32 patients with unstable chronic heart failure despite digitalis, diuretics, and vasodilator therapy. Oral enoximone, 75-150 mg t.i.d. was given for an average of 32 weeks. At baseline, 21 patients were in NYHA functional class IV, 10 patients in class III, and 1 patient in class II. Within 12 weeks, 14 of 20 patients surviving for more than 26 weeks had improved by at least one functional class. Hemodynamic data showed an 18% increase of cardiac index and a 34% decrease of diastolic pulmonary artery pressure. Echocardiographic recordings revealed an increase of fractional shortening from 13.9 +/- 7 to 15.6 +/- 5% after 12 w…

Respiratory Parameters after Systemic Corticotropin-Releasing Hormone Administration

Neuroanatomical studies on the distribution of corticotropin-releasing hormone (CRH) and its receptors (7) as well as physiological data suggest a regulatory function of endogenous CRH in hypothalamic and extrahypothalamic brain areas [1, 4]. Endogenous CRH acts within the endocrine hypothalamo-pituitary-adrenal axis and affects cardiovascular regulation and respiration through extrahypothalamic pathways. CRH also stimulates gluconeogenesis and release of plasma-catecholamines. Our experiments in humans also demonstrate an influence on respiration and on heart rate activity after systemic application of CRH. Respiratory parameters and heart rate were analyzed during steady-state conditions …

Treatment of Chronic Congestive Heart Failure

Detection of spontaneous echocardiographic contrast within the left atrium by transesophageal echocardiography: spontaneous echocardiographic contrast

Transesophageal echocardiography was performed in 314 patients over a period of 24 months using a 3.5 MHz phased-array system fitted to the distal end of a conventional 12 mm endoscope. In 12 patients (2.6%) transesophageal echocardiography could not be performed because of adverse reaction to the gastroscopic procedure. Side effects were a transient A-V block in one patient and asthmatic attack in another. Mitral valve lesions were found in 99 of 314 patients. In 9 of these 99 patients (11%), including 1 patient with mitral valve stenosis and sinus rhythm, 2 with atrial fibrillation, 3 with disc, and 3 with porcine mitral prosthesis, spontaneous echocardiographic contrast was found within …

Vulnerability of the right ventricle to cathodal, anodal, and bipolar stimulation at double diastolic threshold strength

The repetitive ventricular response (RVR) to three stimulation techniques (bipolar, cathodal and anodal) was investigated in 35 patients. 26 patients suffered from coronary heart disease and 9 patients from dilative cardiomyopathy. The stimulation study was performed at a ventricular driving rate of 120/min with one and two premature ventricular extrastimuli. We used rectangular impulses of 1.8 ms duration at duable diastolic threshold strength. RVR was scored as follows: 0: no RVR, 1: one nonstimulated RVR, 2: two nonstimulated RVR, 3: three nonstimulated RVR, 4: four to ten nonstimulated RVR, 5: more than ten nonstimulated RVR lasting less than 2 minutes, 6: sustained ventricular tachycar…

Ventilation and Heart Rate Response During Exercise in Normals: Relevance for Rate Variable Pacing

The observation of a close relationship of heart rate to oxygen uptake (HR-VO2) and heart rate to minute ventilation (HR-VE) has been shown to be of particular value in rate variable pacing. However, the impact of anaerobic threshold (AT) for the HR-VO2 and HR-VE slope has been studied less. Twenty-three male and 16 female subjects, mean age 52 +/- 7 years, were selected in whom complete heart catherization and extensive noninvasive studies excluded major cardiopulmonary disease. Semisupine bicycle exercise testing with analysis of respiratory gas exchange was performed using a ramping work rate protocol with work increments of 20 watts/min. At the respiratory AT, determined by the V slope …

Platelet-activating factor type activity in plasma from patients with septicemia and other diseases

The purpose of the present study was to determine whether increased levels of platelet-activating factor (PAF) type activity can be detected in plasma from patients with septicemia and other diseases. A level of PAF below 0.5 ng/mL of plasma was considered normal. We found that plasma from a patient with adverse anaphylactoidic reaction to intravenous analgetics contained 2.1 ng PAF/mL. In seven patients with septicemia, including urosepsis, endocarditis and peritonitis, and with positive blood culture, increased plasma PAF levels (1-20 ng PAF/mL) were observed. Other patients with clinical indications of septicemia had negative blood cultures and/or increased levels of C-reactive protein (…

Experience in the long term use of new antiarrhythmic drugs.

Meinertz et a1. (1984) investigated the long term efficacy and tolerability of flecainide in patients with ventricular arrhythmias. 15 patients were studied, 8 women and 7 men, aged 19 to 74 (mean 58.7) years, with more than 30 ventricular premature complexes (VPCs) per hour, and ventricular arrhythmias of Lown grade IVA or IVB. 11 had coronary artery disease and 2 had idiopathic dilated cardiomyopathy. Patients were excluded on the basis of sustained ventricular tachycardia (VT) [defined as ~ 3 consecutive beats at a rate of> 100 beats/min]; myocardial infarction within the last 6 months; unstable angina; severe congestive heart failure; or conduction abnormalities. Previously unsuccessful…

Autonome Blockade: Bedeutung in der elektrophysiologischen Diagnostik des kranken Sinusknotens

Die normale Sinusknotenfunktion ist von einer komplexen und ausgewogenen Interaktion zwischen intrinsischen elektrophysiologischen Eigenschaften des Sinusknotens und der sinuatrialen Leitung einerseits sowie von extrinsischen Faktoren andererseits abhangig [1]. Unter letzteren spielt das autonome Nervensystem die wichtigste Rolle. Vagale Stimulation oder Acetylcholin fuhren zu einer Senkung der Herzfrequenz und zu einer Verlangsamung der sinuatrialen Leitungszeit. Im Gegensatz dazu steigert Sympathikusstimulation oder Katecholamingabe die Herzfrequenz und verkurzt die sinuatriale Leitungszeit [2].