Tachycardia dependent early repolarisation pattern in subarachnoid haemorrhage related takotsubo syndrome.

We present a case of a patient who suffered subarachnoid haemorrhage (SAH), complicated by takotsubo syndrome, paroxysmal atrial fibrillation and ECG repolarisation abnormality, compatible with Brugada phenocopy. The early repolarisation morphology showed a paradox association with the cardiac cycle length; a relationship not yet documented in SAH. Our observation also sheds light on the genesis of the "spiked helmet" ECG sign.

Relevance of anaesthesia for dofetilide-induced torsades de pointes in alpha1-adrenoceptor-stimulated rabbits.

BACKGROUND AND PURPOSE: No information is available concerning the effects of anaesthetics in the most frequently used in vivo pro-arrhythmia model. Accordingly, in this study we examined the effect of pentobarbital, propofol or alpha-chloralose anaesthesia on the pro-arrhythmic activity of the class III anti-arrhythmic dofetilide in alpha(1)-adrenoceptor-stimulated rabbits. EXPERIMENTAL APPROACH: Rabbits anaesthetized intravenously with pentobarbital, propofol or alpha-chloralose were infused simultaneously with the alpha(1)-adrenoceptor agonist phenylephrine (15 microg kg(-1) min(-1), i.v.) and dofetilide (0.04 mg kg(-1) min(-1), i.v.). The electrocardiographic QT interval, the T (peak)-T (end) interval and certain QT variability parameters were measured. The heart rate variability and the baroreflex sensitivity were utilized to assess the vagal nerve activity. The spectral power of the systolic arterial pressure was calculated in the frequency range 0.15-0.5 Hz to assess the sympathetic activity. KEY RESULTS: Pentobarbital considerably reduced, whereas propofol did not significantly affect the incidence of dofetilide-induced torsades de pointes (TdP) as compared with the results with alpha-chloralose (40% (P=0.011) and 70% (P=0.211) vs 100%, respectively). In additional experiments, neither doubling of the rate of the dofetilide infusion nor tripling of the rate of phenylephrine infusion elevated the incidence of TdP to the level seen with alpha-chloralose. None of the repolarization-related parameters predicted TdP. The indices of the parasympathetic and sympathetic activity were significantly depressed in the alpha-chloralose and propofol anaesthesia groups. CONCLUSIONS AND IMPLICATIONS: In rabbits, anaesthetics may affect drug-induced TdP genesis differently, which must be considered when results of different studies are compared.

Comparison of hemodynamic responses during dynamic exercise in the upright and supine postures after orthotopic cardiac transplantation.

Abnormal hemodynamic responses during supine exercise have been well documented in orthotopic cardiac transplant recipients. To determine the effect of posture, central hemodynamics were studied in 20 patients during a change from supine to sitting and during graded upright bicycle exercise (group U) and were compared with those of 20 patients matched for age, gender and time from transplantation who were studied after passive leg elevation and during exercise in the supine posture (group S). Passive leg elevation resulted in a 9% increase in stroke index (34 +/- 6 to 37 +/- 6 ml/m2, p less than 0.001) and a 10% increase in cardiac index (3.1 +/- 0.4 to 3.4 +/- 0.5 liters/min per m2, p less than 0.001) in group S patients compared with a 15% reduction in stroke index (34 +/- 7 to 29 +/- 6 ml/m2, p less than 0.001) and a 9% decrease in cardiac index (3.2 +/- 0.6 to 2.9 +/- 0.5 liters/min per m2, p less than 0.001) in group U patients on assuming the sitting posture. Likewise, both the pulmonary capillary wedge pressure and right atrial pressure increased significantly (13 +/- 4 to 17 +/- 8 mm Hg, p less than 0.001 and 5 +/- 3 to 7 +/- 3 mm Hg, p less than 0.001) with passive leg elevation in group S and decreased on sitting (12 +/- 6 to 8 +/- 5 mm Hg, p less than 0.001 and 5 +/- 3 to 3 +/- 2, p less than 0.001) in group U.(ABSTRACT TRUNCATED AT 250 WORDS)

Depressed baroreflex sensitivity in patients with Alzheimer's and Parkinson's disease.

Parkinson's disease (PD) and Alzheimer's dementia (AD) are often associated with an autonomic neuropathy. The extent of autonomic involvement, however is poorly defined and unpredictable. In order to assess the autonomic cardiovascular regulation baroreflex sensitivity (BRS) was determined non-invasively in 23 patients (age: 65 +/- 9.3 years) with PD and 24 patients with AD (age: 72.3 +/- 7.2 years). The results were compared with those on 22 healthy age- and sex-matched volunteers. Patients with PD and AD exhibited marked abnormalities in cardiovascular autonomic reflex regulation showed by markedly depressed BRS. The possible predictive value of centrally based depression of baroreflex sensitivity necessitates further studies.

Normalization of upright exercise hemodynamics and improved exercise capacity one year after orthotopic cardiac transplantation.

The mechanisms of improved functional capacity over the first year after cardiac transplantation are not well studied. To assess the contribution of cardiac changes to this improvement, the serial evolution of upright rest and exercise hemodynamics during graded upright bicycle exercise was studied in 17 patients at 3 and 12 months after heart transplantation. Heart rate responsiveness, reflected by rapid heart rate acceleration on sitting and rapid deceleration after exercise, developed in the first year. Pulmonary capillary wedge pressure was lower at 1 year, both at rest and at peak exercise (10 +/- 3 vs 13 +/- 5 mm Hg at rest supine and 14 +/- 6 vs 18 +/- 8 mm Hg at peak exercise, p less than 0.05). Similarly, right atrial pressures were also significantly lower at 1 year (4 +/- 2 vs 6 +/- 3 mm Hg at rest supine and 6 +/- 5 vs 11 +/- 5 mm Hg at peak exercise, p less than 0.05). Cardiac index at peak exercise was greater at 12 months (6.4 +/- 1.3 vs 5.8 +/- 0.8 liters/min/m2, p less than 0.05), mediated primarily by higher exercise heart rate (135 +/- 16 vs 125 +/- 12 beats/min, p less than 0.05). In the first year after heart transplantation, improved rest and exercise hemodynamics and heart rate responsiveness contribute significantly to the improved functional capacity observed in these patients.

Serial evaluation of lipid profiles and risk factors for development of hyperlipidemia after cardiac transplantation.

To determine the prevalence, time course and factors responsible for hyperlipidemia after heart transplantation, 83 consecutive 1-year survivors were studied. By 1 year, 83% of patients had serum total cholesterol levels greater than 5.2 mmol/liter (200 mg/dl) and 28% of the patients had serum total cholesterol higher than the age- and sex-matched ninety-fifth percentile. At the end of 1-year follow-up, serum total cholesterol correlated with the recipient age (p less than 0.0001), the preoperative cholesterol level (p less than 0.001), the actual dose of maintenance prednisone at 1 year (p less than 0.02) and the cumulative 1-year steroid dose (p less than 0.03). Similarly, the serum triglyceride level at 1 year correlated with the pretransplant level of serum triglycerides (p less than 0.0001), recipient age (p less than 0.03) and cumulative 1-year steroid dose (p less than 0.03). Patients with a pretransplant diagnosis of coronary artery disease had a significantly higher level of serum total cholesterol and triglyceride levels at 1 year (p less than 0.02 and p less than 0.03, respectively). Heart transplant recipients with body mass index greater than or equal to 25 kg/m2 also presented with significantly elevated serum total cholesterol and triglyceride levels at 1 year compared with nonobese patients (p less than 0.01 and p less than 0.002, respectively). Hyperlipidemia occurs frequently and is detected within the first month after heart transplantation. Optimal management of this problem requires further study.

Evolution of heart rate responsiveness after orthotopic cardiac transplantation.

Although anatomic reinnervation of the donor heart is unlikely after transplantation, individual subjects have been noted to show near physiologic heart rate (HR) responses to exercise. To assess development of this phenomenon, we studied HR changes in response to orthostasis and treadmill exercise in 52 orthotopic cardiac transplant recipients grouped according to time after transplantation. In group 1 (2.0 +/- 0.9 months), no significant increase in HR was seen up to 100 cardiac cycles after standing. A maximal acceleration of 4.0 +/- 3.8 beats was seen within 100 cardiac cycles after standing in group 2 (15.8 +/- 5.6 months). Patients in group 3 (42.4 +/- 12.4 months) showed significant cardioacceleration by 5 cardiac cycles after standing to a maximum of 10.7 +/- 5.8 beats/min within the first 100 cardiac cycles. During exercise, HR increased more rapidly during the first minute in group 3 compared with group 1 (p less than 0.01). After exercise, HR continued to increase in group 1 but decreased rapidly in the other groups, most notably group 3 (-26.5 +/- 16.5 by 2 minutes, p less than 0.0001 vs groups 1 and 2). These data indicate development of functional reinnervation after orthotopic heart transplantation. The phenomenon of early acceleration of the HR after orthostasis and rapid deceleration after exercise in transplant recipients implies a local cardiac mechanism rather than response to circulating catecholamines.

Cholesterol-lowering therapy after heart transplantation: a 12-month randomized trial.

BACKGROUND: Hypercholesterolemia, a common problem after heart transplantation, may be important in the genesis and progression of allograft coronary artery disease. The current study was performed to compare the efficacy of gemfibrozil, simvastatin, and cholestyramine for cholesterol lowering in heart transplant recipients. METHODS: In this prospective 1-year study, 48 heart transplant recipients with moderate hypercholesterolemia were randomized to therapy with gemfibrozil 600 mg twice daily (n = 17), simvastatin 10 mg daily (n = 13), and cholestyramine 4 gm twice daily (n = 18). Detailed lipoprotein analysis was performed at baseline and after 3, 6, and 12 months of treatment. RESULTS: Total cholesterol and low-density lipoprotein cholesterol were reduced 19% and 29%, respectively, after 3 months of simvastatin therapy (p < 0.0001) with a sustained reduction in total cholesterol (25%) and low-density lipoprotein cholesterol (39%) at 1 year. Gemfibrozil and cholestyramine treatment did not result in a reduction in cholesterol levels. Apolipoprotein B levels were reduced by 29% at the end of 1 year with simvastatin but not with the other treatments. Serum triglyceride levels were reduced significantly by treatment with gemfibrozil (up to 36%, p < 0.01) but not by the other treatments. High-density lipoprotein cholesterol initially rose in patients treated with simvastatin and gemfibrozil; however, this effect did not persist to 12 months. However, the ratio of low-density lipoprotein/high-density lipoprotein was favorably affected by simvastatin, with a 38% reduction by 12 months (p < 0.0001) but not by the other treatments. Over the course of 1 year, 14 patients dropped out of the study: four from the gemfibrozil arm and ten from the cholestyramine arm. Gastrointestinal intolerance was the most common reason for study termination (8 of 14). All patients in the simvastatin treatment arm completed 12 months of therapy. No biochemical abnormalities resulted from any therapy, and no therapy caused significant alteration in cyclosporine blood levels. CONCLUSIONS: Of the three therapies studied, simvastatin was found to be the most efficacious and well tolerated for cholesterol lowering in patients after heart transplantation.

Immediate cardiovascular responses to orthostasis in the early and late months after cardiac transplantation.

Immediate post-standing (< 30 s) heart rate and blood pressure regulation was studied in patients in the early (2 +/- 2 months, n = 10) and late months (49 +/- 18 months, n = 30) after orthotopic heart or heart and lung transplantation with continuous non-invasive blood pressure (Finapress) and ECG recordings, and was compared to 15 healthy subjects. Heart rate acceleration on standing was standing was absent in the early post-transplantation period. Modest, delayed heart rate acceleration (maximum 12 +/- 8 beats/min) was seen late post-transplantation. Subgroup analysis showed that 15 patients late post-transplantation had limited (maximum 6 +/- 3 beats/min) heart rate acceleration, 11 patients showed maximum heart rate acceleration between 11 and 19 beats/min and 4 patients showed heart rate acceleration comparable in magnitude with that of normal subjects (maximum 28 +/- 5 beats/min). The blood pressure transients were comparable in the 3 groups, with a tendency for greater drop and smaller overshoot in systolic blood pressure in transplant subjects. The findings of normal blood pressure transients in the setting of extensive afferent cardiac denervation questions the role of intracardiac (intraventricular) receptors in reflex blood pressure regulation. The development of heart rate responsiveness is compatible with sympathetic reinnervation in many patients in the late post-transplantation period; however, an intrinsic cardiac mechanism may also be possible.

Vasodepressor syncope in a cardiac transplant recipient: a case of vagal re-innervation?

At the time of hemodynamic assessment three years after cardiac transplantation, a patient developed symptoms and signs of a vasodepressor reaction. In addition to sudden deceleration of heart rate, a 26% fall in mean blood pressure and a 36% fall in cardiac output was observed. Subsequent investigations revealed the presence of respiratory sinus arrhythmia, profound heart rate acceleration on standing and an approximately normal heart rate response during the following exercise. Contrary to current thinking, these observations suggest that certain individuals may develop autonomic re-innervation following orthotopic cardiac transplantation.

Severe cardiovascular autonomic dysfunction in a patient with Guillain-Barre syndrome: a case report.

Autonomic dysfunction is a frequent and severe complication of Guillain-Barre syndrome. It is often responsible for cardiovascular abnormalities, even cardiac arrest. We report a 49-year-old patient, who suffered from Guillain-Barre syndrome necessitating mechanical ventilation. He showed wide fluctuations of blood pressure and heart rate spontaneously or in relation with medical procedures. Though heart rate variability (HRV) and baroreflex sensitivity (BRS) values derived from different methods were extremely low, vigorous stimuli, like eyeball pressure test and carotid sinus massage, produced exaggerated responses, like severe bradycardias, hypotension and cardiac arrest. Despite the plasma exchange and supportive therapies, the patient finally developed adult respiratory distress syndrome (ARDS), sepsis and died due to septic shock.

[Comparison of invasive and non-invasive measuring of blood pressure in patients following open heart surgery]. / Invasiv és nem invasiv úton mért vérnyomás összehasonlítása szívsebészeti betegekben.

Accuracy of blood pressure measurements with a new noninvasive ambulatory blood pressure monitor (Meditech KFT Budapest) was studied in 12 postoperative patients following open heart surgery. We compared 532 systolic and diastolic blood pressure recordings taken simultaneously both invasively and noninvasively. The values obtained noninvasively were subtracted from the corresponding values obtained invasively, and the differences were assessed according the British Hypertension Society recommendations. Values obtained with the two methods demonstrated good correlation (R: 0.85; p < 0.0001). 60 per cent of the differences in diastolic and 76 per cent of the differences in systolic blood pressure recordings fell into the range of +/- 5 mmHg. Thus the accuracy of diastolic blood pressure measurements was classified as "A" (characteristic fo the best equipment) and those of the systolic recordings was classified as "B" (characteristic of good equipment). Based on our findings the new blood pressure monitor provides accurate recordings and its use is highly recommended in the everyday practice.

[Experience with a minute ventilation sensing rate frequency adapted pacemaker]. / Tapasztalataink a percventiláció-változáson alapuló frekvencia adaptált pacemakerrel.

In the last two years 27 patients (mean age: 63.2 +/- 6.9 years) received Telectronics META MV pacemaker generators at the SZOTE. In 6 cases the generators were connected to atrial pacemaker electrodes, and in 21 cases to ventricular electrodes. To assess the characteristics of the rate responsive function exercise stress test was performed by 17 of these subjects. The authors give an account on the rate adaptive functions of these type pacemakers. The generator is an SSIR one. The rate responsive factor--i.e. the numerical characteristics of the pulse rate acceleration suggested by the pacemaker itself--was similar for atrial and ventricular electrodes.

[Carotid sinus syncope: the vasodepressor component]. / Carotis sinus syncope: a vasodepressoros komponens.

Carotis sinus syncope is one of the leading indications for pacemaker implantation in Hungary. Although the role of the vasodepressor component is emphasized in our current guidelines, documentation of the vasodepression in technically difficult and therefore often abandoned. A case of a patient is presented who received a VVI pacemaker in spite of documented mixed carotid sinus syncope. Subsequent to the pacemaker implantation, patient's condition deteriorated, characterized by frequent syncopal episods. Replacing the VVI pacemaker by a DDD device resulted in prompt relief of symptoms. The importance of invasive or noninvasive hemodynamic monitoring in the diagnostic workup of these patients is emphasized.

[The role of autopsy in verifying diagnostic accuracy at the intensive care unit]. / A kórbonctani vizsgálat szerepe a klinikai diagnózis igazolásában intenzív osztályos beteganyagon.

The accuracy of the clinical diagnoses compared to the findings of an autopsy is a more relevant characteristic of the quality of care than the length of stay in the hospital or the daily costs of the stay. The aim of this retrospective study was: a) to compare the clinical and pathological diagnoses, b) to determine the amount of new information supplied by the autopsy and c) to determine wether the knowledge of correct clinical diagnosis would have resulted in a change of therapy. At the medical ICU 163 patients died during 1998, autopsy was performed in 110 cases. Agreement of clinical and pathological diagnoses and causes of death were retrospectively assessed by a board. Acute myocardial infarction accounted for 26% of deaths, pneumonia and respiratory insufficiency for 15%, cardiac failure for 14%, sepsis for 14%, stroke for 13%, pulmonary embolism for 5% and others for 13%. The accuracy of the clinical cause of death was proved in 81% of the cases. The main disease was diagnosed correctly in 86% of the cases. As a tool in quality control, the agreement of clinical and pathological diagnoses and causes of death proved to be good during the examined period of time.

[Electrocardiographic Osborn wave in hypothermia]. / Elektrokardiográfiás Osborn-hullám hypothermiában.

The authors report the first Hungarian case of electrocardiographic Osborn wave with accidental hypothermia (core temperature 32 degrees C). The cellular and ionic mechanisms of the development of J-wave-elevation and the cardiac electrophysiological and ECG changes caused by hypothermia are briefly reviewed. An account is presented of those conditions in which, in a few or in all ECG leads, an Osborn wave or distinct J-point-elevation may be observed.

[Coronary angiography causing coronary embolism and subsequent cardiogenic shock: treatment by intraaortic balloon pumping]. / Coronaria angiographia során kialakuló coronaria embólia és következményes kardiogen shock kezelése intraaortikus ballon pumpával.

A case is presented where coronarography was complicated by coronary embolism. The acute circulatory failure could be controlled only by intraaortic balloon pump therapy. The authors emphasize the importance of the mechanical circulatory support devices in the cardiac catheterization laboratories as well as at the coronary care units.

[Angina pectoris induced by pacemaker syndrome]. / Angina pectorist provokáló pacemaker-szindróma.

Pacemaker syndrome is caused primarily by the lack of atrial kick and by neurocardiogenic reflex mechanisms due to simultaneous atrial and ventricular contractions. The most common clinical symptoms are dyspnoe, hypotension, dizziness and syncopal attacks. A case report of a patient with pacemaker syndrome is presented, in which the main clinical manifestation was a recurrent chest pain. A VVI demand pacemaker was implanted because of sick sinus syndrome ten years ago and shortly afterwards anginal attacks of rest developed. Coronary angiography revealed a non-significant (25%) narrowing of the right coronary artery (RCA). Casual and long-term ambulatory blood pressure (ABPM) measurements elucidated that the patient occasionally has extremely low diastolic blood pressure. This later phenomenon was confirmed and refined by a "beat-to-beat" blood pressure measuring technique. The elimination of the pronounced "beat-to-beat" variability of arterial blood pressure and transient coronary hypoperfusion due to implantation of an AV sequential bifocal pacemaker resulted in a full disappearance of angina pectoris.

[Persistent atrial flutter induced by propafenone (Rytmonorm)]. / Propafenon (Rytmonorm) által kiváltott tartós pitvarlebegés.

The case history of two patients with atrial fibrillation are presented. In order to prevent/terminate fibrillation propafenone (Rytmonorm, 450-600 mg/day) was started, however this therapy resulted in permanent atrial flutter of 230-270/min mainly with 2:1 antrioventricular conduction. Analyzing the cases the authors emphasize that although Class Ic antiarrhythmic drugs (flecainide, encainide, propafenone) are capable to prevent or terminate atrial fibrillation, they may also induce atrial flutter in approximately 3.5-5% of these patients. The mechanism and recognition of this atrial proarrhythmic action are discussed.

[Association of AV reciprocating tachycardia, using a concealed bundle of Kent, and paroxysmal atrial fibrillation in neurocardiogenic syncope]. / Neurocardiogen reflex-syncope, rejtett Kent-köteget felhasználó AV-reciprok tachycardia és paroxysmalis pitvarremegés együttes elöfordulása.

A case of neurocardiogenic syncope is reported in which both AV-reciprocating tachycardia due to a concealed retrogradely conducting posteroseptal bypass tract and paroxysmal atrial fibrillation were observed. In connection with this case, attention is paid to the difficulties of differential diagnosis and to the pathophysiological correlations concerning the occurrence of neurocardiogenic/vasovagal reflex syncope and cardiac arrhythmias. A prolonged period of freedom from syncope and tachycardia was achieved by means of drug treatment, through the combined administration of disopyramide, bisoprolol and theophylline.