Prevalence of anxiety and risk associated with ventricular arrhythmia in patients with an implantable cardioverter defibrillator.

BACKGROUND: Anxiety has been associated with adverse clinical outcomes in patients who have received an implantable cardioverter defibrillator (ICD). However, results are inconclusive likely due to different measures being used to assess anxiety. Hence, the current study aims to examine the prevalence and the association between anxiety, ventricular tachyarrhythmia's (VTa's) and all-cause mortality, respectively. METHODS: Patients who received an ICD for the first time were recruited from 6 Dutch referral hospitals as part of the WEBCARE trial. Patients filled in validated questionnaires (GAD-7, STAI-S, HADS-A, ANX4, ICDC, FSAS) to assess their baseline anxiety symptomatology. Logistic regression analysis and Cox Regression analysis were performed to examine the association between anxiety with 1) VTa's and 2) mortality, respectively. RESULTS: A total of 214 Patients were included in the analysis with mean age 58.9 and 82.7% being male. The prevalence rates of anxiety varied depending on which questionnaire was used 12.4% (GAD-7), 17.5% (HADS-A), and 28.1% (STAI-S). (Cox) Regression analysis revealed that none of the anxiety measures was associated with VTa's or all-cause mortality in the current sample. Stratifying the sample by gender, the analysis showed that GAD-7, STAI-S, and ANX4 scores were associated with increased risk of VTa's but only in male patients. CONCLUSIONS: Prevalence rates of anxiety varied depending on the measurement tool used. No significant association between anxiety and VTa's and all-cause mortality was observed in the total sample. GAD-7, STAI-S, and ANX4 were associated with increased risk for VTa's but only in male patients.

Personality traits, ventricular tachyarrhythmias, and mortality in patients with an implantable cardioverter defibrillator: 6 years follow-up of the WEBCARE cohort.

OBJECTIVE: Risk stratification within the ICD population warrants the examining of the role of protective- and risk factors. Current study examines the association between Type D personality, pessimism, and optimism and risk of ventricular tachyarrhythmias (VTa's) and mortality in patients with a first-time ICD 6 years post implantation. METHODS: A total of 221 first-implant ICD patients completed questionnaires on optimism and pessimism (Life Orientation Test) and Type D personality (Type D scale DS14) 10 to 14 days after implantation. VTa's and all-cause mortality 6 years post implant comprised the study endpoints. RESULTS: Ninety (40.7%) patients had experienced VTa's and 37 (16.7%) patients died, 12 (5.4%) due to a cardiac cause. Adjusted logistic regression analysis showed that pessimism was significantly associated with increased risk of VTa's (OR = 1.09; 95% CI = 1.00-1.19; p = .05). Type D personality (OR = 1.05; 95% CI = 0.47-2.32; p = .91) and optimism (OR = 1.00; 95% CI = 0.90-1.12; p = .98) were not associated with VTa's. None of the personality types were associated with mortality. CONCLUSION: Pessimism was associated with VTa's but not with mortality. No significant association with either of the endpoints was observed for Type D personality and optimism. Future research should focus on the coexistent psychosocial factors that possibly lead to adverse cardiac prognosis in this patient population.

[Atrial fibrillations: daily occurrence possibly leading to embolism in an extremity]. / Boezemfibrilleren: alledaags, maar mogelijk leidend tot embolisatie naar een extremiteit.

A 64-year old woman had been tired and short of breath for the previous few months. During the past few days she had experienced disruptions in the movement and feeling of the right arm and both feet as well as a loss of strength and a heavy feeling in her right leg. Due to atrial fibrillation she had recently started using digoxin and due to possible arterial embolisms in the extremities she had recently started using acenocoumarol. Further investigations revealed one large thrombus in the left atrium, two large thrombi in the left auricle and a serious constriction in the right iliac artery. The thrombi were treated with heparin and oral anticoagulants; the ischaemia which probably occurred as a result of this was successfully treated with embolectomy. After the cardiac thrombi had disappeared, the patient was electrically converted to sinus rhythm. One month later, the patient was still in sinus rhythm and her clinical picture had improved. As she does not feel the atrial fibrillation, she will be permanently maintained on oral anticoagulants. In patients with atrial fibrillations, the possibility of an embolisation towards the extremities deserves serious consideration.

Factors influencing immediate and long-term outcome of electrical cardioversion of persistent atrial fibrillation and flutter.

BACKGROUND: To investigate which factors influence the immediate and long-term outcome of elective electrical cardioversion for persistent (>48h) atrial fibrillation or flutter. METHODS: In 255 patients, 435 electrical cardioversions were performed. Relevant clinical, electrocardiographic and echocardiographic factors were registered at each cardioversion. Each factor was tested separately in relation to immediate success and the outcome at six months and one year after cardioversion. RESULTS: In 70% of the patients, sinus rhythm was restored immediately after electrical cardioversion. After six months only 20% of the patients were still in sinus rhythm, and one year after cardioversion this figure had dropped to 14%. Sotalol used during electrical cardioversion resulted in the highest immediate success. Furthermore, atrial flutter, two or fewer electrical shocks and shocks ≤200 Joules resulted in the highest immediate success rate, whilst hypertensive heart disease resulted in the lowest immediate success rate. However, only shocks ≤200 Joules and a first cardioversion promoted the persistence of sinus rhythm after six months. A normal electrocardiogram, two or more cardioversions in the past and the use of a beta-blocking drug other than sotalol during cardioversion increased the chance of recurrence within six months. The duration of the arrhythmia >one month to 200 Joules and more than two cardioversions in the past were associated with a high number of recurrences one year later. With multivariate analysis we found that atrial flutter, low energy levels, low number of shocks and a long QTc-interval influence the immediate success positively. However, no factor influenced the persistence of sinus rhythm at six months and one year. CONCLUSION: In patients with persistent atrial fibrillation or flutter, only about 15% are in sinus rhythm one year after attempted cardioversion. Atrial fibrillation rather than flutter, high energy shocks and previous cardioversions negatively influenced the immediate success of cardioversion. However, none of the clinical, electrocardiographic or echocardiographic baseline factors studied could be identified as playing a role in the prediction of long-term sinus rhythm.

Furosemide withdrawal in elderly heart failure patients with preserved left ventricular systolic function.

To explore the possibilities of furosemide withdrawal in elderly heart failure (HF) patients with intact left ventricular (LV) systolic function and assess its effects on functional status and orthostatic blood pressure homeostasis, we performed a placebo-controlled pilot trial of furosemide withdrawal with 3 months of follow-up in 32 HF patients (aged 75.1 +/- 0.7 years [mean +/- SEM]) with a LV ejection fraction of 60 +/- 2% and without overt congestion. Investigations included repeated clinical assessment, spirometry, standardized 6-minute walking test, and chest x-rays. Measurements of blood pressure response on active standing and Doppler echocardiography were performed before and 3 months after furosemide withdrawal. Recurrent congestive HF occurred in 2 of 21 patients (10%) who discontinued furosemide use, and in 1 of 11 patients (9%) who continued furosemide (p = NS). Three patients restarted furosemide for ankle edema and 1 for blood pressure levels >180/100 mm Hg. After 3 months, there were no differences regarding HF symptom scores, blood pressure, heart rate, spirometric results, 6-minute walking distance, or quality of life scores between patients who discontinued use and patients who continued the therapy. In patients successfully withdrawn, Doppler E/A ratio increased from 0.68 +/- 0.05 to 0.79 +/- 0.06 after withdrawal (p <0.01), and maximum blood pressure decrease on active standing changed from -8 +/- 5 mm Hg to +5 +/- 3 mm Hg systolic (p <0.05). Thus, in this pilot investigation of furosemide withdrawal in elderly HF patients without overt congestion and with a normal LV systolic function, withdrawal was successful in almost all patients and was associated with improvement of LV diastolic filling and blood pressure homeostasis on active standing.

Furosemide withdrawal improves postprandial hypotension in elderly patients with heart failure and preserved left ventricular systolic function.

OBJECTIVE: To assess the effects of furosemide withdrawal on postprandial blood pressure (BP) in elderly patients with heart failure and preserved left ventricular systolic function. METHODS: Noninvasive measurement of blood pressure (BP) and heart rate, computation of stroke volume and cardiac output (after a 1247-kJ (297-kcal) meal, and Doppler echocardiography before and 3 months after placebo-controlled withdrawal of furosemide therapy. RESULTS: Of 20 patients with heart failure (mean+/-SEM age, 75+/-1 years; left ventricular ejection fraction, 61%+/-3%), 13 were successfully able to discontinue furosemide therapy. At baseline, 11 (55%) of the 20 patients (had maximum postprandial systolic BP declines of 20 mm Hg or more. In the withdrawal group, the maximum systolic BP decline lessened from -25+/-4 to -11+/-2 mm Hg (P<.001) and the maximum diastolic BP from -18+/-3 to -9+/-1 mm Hg (P= .01), compared with no changes in the continuation group. In the withdrawal group, maximum postprandial declines in stroke volume and cardiac output decreased from -9+/-1 to -4+/-2 mL (P =.01) and from -0.6+/-0.2 to -0.2+/-0.1 L/min) (P = .04), respectively. The baseline maximum postprandial systolic BP decrease was correlated with the ratio of early to late flow (n = 20; Spearman rank correlation coefficient, 0.58; P = .007). For patients in the withdrawal group, the changes in postprandial systolic BP response were independently related to changes in peak velocity of early flow (n = 13; r2= 0.61; P = .003). CONCLUSIONS: Postprandial hypotension is common in elderly patients with heart failure and preserved left ventricular systolic function. The withdrawal of furosemide therapy ameliorates postprandial BP homeostasis in these patients, possibly by improving left ventricular diastolic filling.

[Acute rheumatic fever in a 33-year-old man]. / Acuut reuma bij een 33-jarige man.

In a 33-year-old man with an abnormal ECG three weeks after an episode of a sore throat, laboratory investigations revealed signs of a recent streptococcal infection. Mitral valvular and aortic valvular regurgitation were confirmed by echocardiography. The diagnosis of acute rheumatic fever was established according to the Jones criteria.

How long should high-risk patients with acute anterior wall myocardial infarction be monitored?

In 143 patients with an acute anterior wall myocardial infarction, left ventricular ejection fraction was determined within 72 h of admission. Left ventricular ejection fraction was below 40% in 114 patients. In this group late ventricular tachycardia or ventricular fibrillation occurred in 30 patients (26%). A left ventricular ejection fraction below 40% identified all patients who developed any late ventricular tachycardia and a left ventricular ejection fraction below 30% identified all who developed late ventricular fibrillation. After discharge another 2 patients with late ventricular tachycardia were detected. Death between 48 h and 3 weeks only occurred in patients with a left ventricular ejection fraction below 30%. Thus in patients with an acute anterior wall myocardial infarction a left ventricular ejection fraction below 30% within the first 72 h after the acute event identifies a high risk for late ventricular tachycardia or ventricular fibrillation. The occurrence of late ventricular tachycardia showed a gradual increase during 3 weeks of monitoring and no cut-off point could be detected within this time-window.

Angiographic appearance and re-operation in an adult patient with the Bland-Garland-White syndrome.

Reconstructive surgery was performed in a 57-year old woman in whom initially the left coronary artery had originated from the pulmonary trunk, producing progressive symptoms of congestive heart failure. Recurrence of shunting was documented by Doppler echocardiography and contrast angiography, necessitating a second surgical intervention 17 months after the first procedure.

The Activitrax rate responsive pacemaker system.

Bipolar Medtronic Activitrax rate responsive pacemakers were implanted in 31 patients for ventricular (28) or atrial (3) pacing. Mean follow-up was 16 months (range 10 to 26). Twenty pacemakers were implanted after catheter ablation of the His bundle, 7 for sick sinus syndrome. 1 for atrioventricular block and 3 for sick sinus syndrome with atrioventricular block. A rate response value was selected that gave a pacing rate of about 100 pulses/min during walking. Of the 31 patients, all had 24-hour ambulatory electrocardiographic monitoring with diary, 11 walked a 20-minute circuit, including a flight of stairs, and 20 had a treadmill exercise test. In 9 patients the pacing rate could be compared with the underlying sinus rate during exercise and was seen to match it very closely. In 12 patients the pacing rate during car driving was found to be similar to the sinus rate of 5 volunteers under similar conditions (mean minimum and maximum rate was 80 and 99 pulses/min, respectively). No pacing-induced arrhythmias were seen during ambulatory electrocardiographic monitoring. At high pacing rates slightly irregular pacing intervals were sometimes observed, which was due to polarization sensing. Sporadically, 1 pacing interval shortened to the upper rate value, because of a known and now resolved timing anomaly. Neither anomaly was of clinical consequence and the first could be resolved by reprogramming.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful long-term catheter drainage in an immunocompromised patient with purulent pericarditis.

A case of extensive staphylococcal pericarditis following renal transplantation is described. Purulent pericarditis resolved after 18 days of continuous catheter drainage from the pericardium combined with antibiotic therapy. This case illustrates that life-threatening purulent staphylococcal pericarditis after renal transplantation in an immunocompromised patient may respond to medical therapy.

Diagnosis and follow-up of a large inferior caval vein thrombus following right heart catheterization.

A case is described of the development of an inferior caval vein thrombus and subsequent pulmonary embolism after right heart catheterization. The caval thrombus was diagnosed by echography. After six weeks of anticoagulant therapy the thrombus had resolved. The indication for prophylactic heparinization is discussed.