Type 2 Diabetes Mellitus: GLP1 Receptor Agonists and SGLT2 Inhibitors in Patients Referred to Ambulatory Consultant Cardiology Clinics.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) are new antidiabetic drugs that are recommended by current guidelines as a class I novel glucose-lowering treatment that improves cardiovascular outcome in type 2 diabetes mellitus (T2DM), particularly in patients with cardiovascular disease. OBJECTIVES: To evaluate adherence to the current guidelines for treatment with SGLT2i and GLP1-RA drugs in patients referred to ambulatory consultant cardiology clinics with pre-existing T2DM. METHODS: We studied consecutive new patients with a pre-existing diagnosis of T2DM who were referred to the Clalit Health Services ambulatory consultant cardiology clinic over a 6-month period. The recorded information included demographics, co-morbidities, and prescribed drugs at patient admission. RESULTS: During the study period, 1782 patients visited our outpatient cardiology clinic. At screening, T2DM was present in 428 patients (24%); 77 (18%) were being treated with SGLT2i, and 39 (9.1%) with GLP1-RA. Patients receiving SGLT2i and GLP1-RA were younger and had more coronary artery disease, lower mean left ventricular ejection fraction, and higher mean estimated glomerular filtration rates than those who were not receiving these drugs. HbA1C was > 7 in 205 (47.9%) patients and > 7.5 in 136 patients (31.8%). Body mass index was > 30 kg/m2 in 231 (54%) patients. CONCLUSIONS: GLP1-RA and SGLT2i drugs were found to be administered more frequently than previously reported, but they are not yet satisfactorily prescribed.

The impact of anxiety level on decision to seek medical care of non-COVID cardiac patients during the pandemic outbreak-single-center experience in Israel.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has significantly the delivery of healthcare all around the world. In part, an abnormal and unexplained high non-COVID-related cardiovascular mortality rate was reported during the outbreak. We assess the correlation between anxiety level and decision to seek medical care (DSMC) during the COVID-19 pandemic. MATERIALS AND METHODS: We recruited patients with cardiovascular complaints admitted to the emergency department in a single institute in Israel between February and September 2020. Anxiety level was measured using available questionnaires. DSMC was assessed with a newly designed questionnaire (DM-19). RESULTS: Two-hundreds seventy patients were included in the study. The mean age was 52.6 ± 14.9 (females represent 36.2%). 23.6% of the patients had at least moderate cardiovascular risk. High anxiety levels were (HAL) reported in nearly half of the patients (57.1% and 49.8% for General Anxiety Disorder Assessment [GAD-7] and Beck Anxiety Inventory [BAI], respectively). It was more prevalent in old, married, and unemployed patients (significant p-value for all in both questionnaires). Age was an independent factor (χ2 = 6.33, p < 0.001, odds-ratio: 4.8) and had a positive correlation on anxiety level (r = 0.81, p < 0.001 and r = 0.62, p < 0.001, for GAD-7 and BAI, respectively). The DM-19 revealed a strong and positive correlation of seeking medical care with anxiety level (R2 linear = 0.44, r = 0.70, p < 0.001 and R2 linear = 0.30, r = 0.58, p < 0.001 for GAD-7 and BAI, respectively) and results in deferring medical care for several days than patient with low anxiety level (p = 0.02). CONCLUSIONS: We observed an abnormal prevalence of a high level of anxiety among non-COVID patients with cardiovascular complaints, which affected the patient's likelihood to seek medical care and resulted in an unreasonable postponement of medical treatment. Our results may explain cardiovascular mortality trends during the outbreak and should be considered in health crisis management. Future studies will involve multi-institutional efforts to address reproducibility of our findings across geographic regions in the state of the global impact. Additionally, it is imperative to understand the effects of the coronavirus vaccine on patient consideration to seek medical care.

[ACUTE MYOCARDIAL INFARCTION FOLLOWING COVID-19].

INTRODUCTION: A 30 years old woman suffered from Covid-19 that resolved after 4 days. A week later she complained of chest pain and referred to the emergency room. Myocarditis was the first working diagnosis, but in the following few hours acute ST elevation myocardial infarction was diagnosed according to clinical signs, ECG changes, laboratory and coronary angiography findings. She successfully underwent stenting of the left anterior descending (LAD) coronary artery. The patient was discharged a week later in good condition. At 6 months follow-up her clinical condition had improved and an echocardiography showed LVEF=45%. Covid-19 infection may be a trigger for ST elevation myocardial infarction even in young people without a clear presence of cardiovascular risk factors.

Sinus Node Dysfunction due to Occlusion of the Sinus Node Artery during Percutaneous Coronary Intervention.

BACKGROUND: Sinus node artery occlusion (SNO) is a rare complication of percutaneous coronary intervention (PCI). We analyze both the short- and long-term consequences of SNO. METHODS: We retrospectively reviewed 1379 consecutive PCI's involving RCA and Cx arteries performed in our heart institute from 2016 to 2019. Median follow-up was 44 ± 5 months. RESULTS: Among the 4844 PCIs performed during the study period, 284 involved the RCA and the circumflex's proximal segment. Periprocedural SNO was estimated by angiography observed in 15 patients (5.3%), all originated from RCA. The majority of SNO occurred during urgent and primary PCIs following acute coronary syndrome (ACS). Sinus node dysfunction (SND) appeared in 12 (80%) of patients. Four (26.6%) patients had sinus bradycardia, which resolved spontaneously, and 8 (53.3%) patients had sinus arrest with an escaped nodal rhythm, which mostly responded to medical treatment during the first 24 hours. There was no association between PCI technique and outcome. Three patients (20%) required urgent temporary ventricular pacing. One patient had permanent pacemaker implantation. Pacemaker interrogation during follow-up revealed a recovery of the sinus node function after one month. CONCLUSION: SNO is rare and seen mostly during angioplasty to the proximal segment of the RCA during ACS. The risk of developing sinus node dysfunction following SNO is high. SND usually appears during the first 24 h of PCI. The majority of SND patients responded to medical treatment, and only in rare cases were permanent pacemakers required.

Tricuspid regurgitation in ischemic mitral regurgitation patients: prevalence, predictors for outcome and long-term follow-up.

BACKGROUND: Functional tricuspid regurgitation (FTR) is common in left-sided heart pathology involving the mitral valve. The incidence, clinical impact, risk factors, and natural history of FTR in the setting of ischemic mitral regurgitation (IMR) are less known. METHOD: We conducted a cohort study based on data collected from January 2012 to December 2014. Patients diagnosed with IMR were eligible for the study. The median follow-up was 5 years. The primary outcome is defined as FTR developing at any stage. RESULTS: Among the 134 IMR patients eligible for the study, FTR was detected in 29.9% (N = 40, 20.0% mild, 62.5% moderate, and 17.5% severe). In the FTR group, the average age was 60.7 ± 9.2 years (25% females), the mean LV ejection fraction (LVEF) was 37.3 ± 6.45 [%], LA area 46.4 ± 8.06 (mm2), LV internal diastolic diameter (LVIDD) 59.6 ± 3.94 (mm), RV fractional area change 22.3 ± 4.36 (%), systolic pulmonary artery pressure (SPAP) 48.4 ± 9.45 (mmHg). Independent variables associated with FTR development were age ≥ 65y [OR 1.2], failed revascularization, LA area ≥ 42.5 (mm2) [OR 17.1], LVEF ≤ 24% [OR 32.5], MR of moderate and severe grade [OR 419.4], moderate RV dysfunction [OR 91.6] and pulmonary artery pressure of a moderate or severe grade [OR 33.6]. During follow-up, FTR progressed in 39 (97.5%) patients. Covariates independently associated with FTR progression were lower LVEF, RV dysfunction, and PHT of moderate severity. LA area and LVIDD were at the margin of statistical significance (p = 0.06 and p = 0.05, respectively). CONCLUSION: In our cohort study, FTR development and progression due to IMR was a common finding. Elderly patients with ischemic MR following unsuccessful PCI are at higher risk. FTR development and severity are directly proportional to LV ejection fraction, to the extent of mitral regurgitation, and SPAP. FTR tends to deteriorate in the majority of patients over a mean of 5-y follow-up.

Monthly Variation in Emergency Department Admission for Acute Onset Atrial Fibrillation.

BACKGROUND: The cold season seems to be a trigger for atrial fibrillation (AF). Some reports are controversial and demonstrate variability according to the climatic characteristics in different regions. OBJECTIVES: To analyze whether meteorological factors contribute to seasonal variation of exacerbation of AF diagnosed in patients referred to the emergency department (ED) of our hospital. METHODS: We retrospectively reviewed medical data of consecutive patients admitted to the ED with symptomatic acute onset AF from 1 January 2016 to 31 December 2018. We recorded the mean monthly outdoor temperature, barometric pressure, and relative humidity during the study period. RESULTS: During the study period, 1492 episodes of AF were recorded. New onset AF were 639 (42.8%) and paroxysmal atrial fibrillation (PAF) were 853 (57.2%) (P = 0.03). The number of overall admission of AF episodes was not distributed uniformly through the year. Incidence of AF episodes peaked during December and was lowest in June (P = 0.049). Of 696 episodes (46.6 %) the patients were hospitalized and for 796 (53.4%) the patients were discharged (0.01). The number of hospitalizations was not distributed uniformly through the year (P = 0.049). The highest number of hospitalizations happened in December and the lowest in May. Outdoor temperature and barometric pressure (but not relative humidity) may mediate a monthly fluctuation in AF episodes with highest number of ED visits in December and the lowest in June. CONCLUSIONS: Meteorological conditions influence exacerbation of AF episodes and hospitalization. Outdoor temperature and barometric pressure may mediate a monthly fluctuation in AF.

Prognostic Value of J (Osborn) Waves on Surface Electrocardiogram Tracing during Therapeutic Hypothermia in Out-of-Hospital Cardiac Arrest Survivors (JOW trial).

BACKGROUND: Patients admitted to the hospital after successful resuscitation from sudden cardiac death (SCD) are treated with therapeutic hypothermia (TH) to facilitate brain preservation. The prognostic significance of J (Osborn) waves (JOW) in the 12 leads electrocardiogram in this setting has not been elucidated as yet. OBJECTIVES: To ascertain retrospectively the prognostic significance of JOW recorded during TH in SCD survivors. METHODS: The study comprised 55 consecutive patients who underwent TH. All patients achieved a core temperature of 33°C at the time of electrocardiogram analysis. We compared 33 patients with JOW to 22 patients without JOW. The endpoints were in-hospital, long-term all-cause mortality, and irreversible anoxic brain injury (IABI). RESULTS: Patients with JOW compared to patients without JOW were younger (55.1 ± 11.6 vs. 64.5 ± 11.7 years, respectively, P < 0.006), with a lower incidence of hypertension (52% vs. 86%, P < 0.007), diabetes mellitus (15% vs. 50%, P < 0.005), and congestive heart failure (15% vs. 45%, P < 0.013). In-hospital and long-term mortality were significantly higher in patients without JOW (86% vs. 21%, 91% vs. 24%, respectively, P < 0.000001). Among patients without JOW who survived hospitalization, 66.7% presented with IABI versus 7.7% of the patients with JOW (P < 0.0001). In multivariate analysis, the absence of JOW was a significant predictor for poor prognosis. CONCLUSIONS: The absence of J (Osborn) waves on electrocardiograms obtained during TH is associated with poor prognosis among SCD survivors.

Outcomes and safety of concurrent coronary and peripheral catheterization (REVascularization in concomitant PERIpheral artery disease and coronary artery disease REV-PERICAD Study).

BACKGROUND: Atherosclerosis affects various vascular beds, such as the coronary and carotid arteries and peripheral vessels, of the lower limbs. Current recommendations for treating multiple vascular beds include targeted catheterization at different intervals and are mainly intended to avoid kidney injury. We examined the efficacy and safety of simultaneous coronary and lower limb catheterization. METHODS: This retrospective cohort study included 121 patients who underwent catheterization between January 2008 and December 2016. Patients were divided into four groups: 20 (16.5%) simultaneously underwent coronary and peripheral vascular bed catheterization; 32 (26%) underwent separate procedures (time interval between procedures >2 months); 50 (41%) underwent staged procedure (time interval ≤2 months); and 19 (16%) underwent only peripheral catheterization (single procedure). RESULTS: No significant between-group differences were observed regarding demographic variables except for sex and diabetes and congestive heart failure incidences. Almost half of all the patients who underwent a single procedure were symptomatic. The successful peripheral catheterization rate was significantly higher in the single procedure group, with no significant difference among the other groups. There were no significant between-group differences with respect to major cardiovascular events, 30-day mortality, mortality within 1 year, and 24-hr vascular complication rate/acute renal failure incidences. CONCLUSION: Our study demonstrates the efficacy and safety of concurrent catheterization of coronary arteries and lower limb arteries, regardless of the time interval between these two procedures. Simultaneous catheterization of different vascular beds is an effective, timesaving, and safe option. Our findings should be verified in a large-scale prospective study involving additional vascular beds.

Epinephrine soaked tampons induced transient acute dilated cardiomyopathy during FESS procedure.

BACKGROUND: Epinephrine, in all modes of use, may pose a wide range of cardiotoxic events, ranging from sinus tachycardia to heart failure, life threatening arrhythmias, and even death. Because of daily and extensive use of epinephrine, these unusual and rare events tend to be forgotten by physicians. We present a case of dilated cardiomyopathy that developed following routine use of epinephrine-impregnated tampons during function endoscopic sinus (FESS) surgery. CASE PRESENTATION: A healthy, 24-year-old man with no family history of heart disease has undergone elective surgery under general anesthesia to repair the paranasal sinuses using endoscopic approach. During surgery, soon after being treated with 1: 1000 diluted epinephrine-soaked tampons, an hypertensive crisis was noticed followed by pulseless electrical activity. An extensive examination led to the diagnosis of non-ischemic dilated cardiomyopathy. After several days of heart failure medical therapy, complete resolution of all structural and functional changes was achieved. CONCLUSION: In our case, we present an unusual and rare event of acute dilated cardiomyopathy following the use of epinephrine-soaked tampons during elective FESS surgery. A prompt response was observed after several days of heart failure treatment. Awareness of the epinephrine cardiotoxic potential even in the form of soaked tampons is essential for proper diagnosis and prompt treatment.

Role of thrombin generation assays in the diagnosis of acute myocarditis and non-ST myocardial infarction.

Myocarditis and myocardial infarction share a common clinical characteristics despite significant differences in etiology and pathogenesis. Current guidelines recommend using cardiac magnetic resonance imaging (MRI) or endocardial biopsy for a definite diagnosis; however, these guidelines are not fully implemented due to the high cost and low availability. We used a thrombin generation assay and simple blood test to characterize both diseases. We conducted a cross-sectional study from April to December 2018. Patients with initial clinical suspicions of non-ST elevation myocardial infarction (NSTEMI) or myocarditis were eligible. All patients were recruited prior to anticoagulant treatment. Patients in both groups underwent acceptable standard clinical evaluation. Twenty-eight patients were enrolled; 12 patients in the NSTEMI group and 16 in the myocarditis group. Patients in the NSTEMI group were significantly older than those in the myocarditis group (64.25 ± 9.67 vs. 37.94 ± 19.66 years, p < 0.01, respectively) with a higher prevalence of hyperlipidemia, diabetes mellitus, and ischemic heart disease (p < 0.01 for all). There was no difference between the groups regarding INR, PT, aPTT, and serum levels of creatinine, urea, CPK, troponin, and fibrinogen. Endogenous thrombin potential (ETP), which represents the total thrombin concentration in the plasma, was significantly higher in the myocarditis group than in the NSTEMI group (2091.88 ± 336.41 vs. 1860.75 ± 438.02 nM × min, p < 0.03). Myocarditis and myocardial infarction have a different pattern of thrombin generation Thrombogram. The myocarditis group had significantly higher plasma ETP than the NSTEMI group. This finding requires further evaluation to define a numerical threshold, thus avoiding invasive or expensive assessment of myocarditis.

[STRATEGIES FOR IMPLEMENTATIONS OF REMOTE MONITORING FOR PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTRONIC DEVICES (CIED) IN ISRAEL].

INTRODUCTION: Remote monitoring (RM) of patients with cardiovascular implantable electronic devices (CIED) offers clinical benefits by providing early alert for system failure and actionable changes in patient health. Professional societies recommend utilization of RM for CIED patients (Level of recommendation I Level of evidence A). It must be emphasized that RM technology does not provide continuous monitoring but rather "remote snapshot clinics". On the other hand, pacemakers (PCM) and implantable cardiac defibrillators (ICD) are designed to work automatically and continuously without any need for immediate external intervention. Therefore, the guidelines recommend that the clinical response to RM notification will take place during the normal office hours. With appropriate organization, the utilization of RM will save a significant number of unnecessary pacemaker clinic visits and will allow better utilization of healthcare resources on patients in whom early intervention may prevent hospitalization, complication and mortality. The guidelines recommend offering RM to all patients with CIED. In Israel however, RM is offered sporadically only to a few patients. If a patient will suffer from delayed or inadequate treatment due to lack of RM, grave ethical and legal consequences may occur. Follow-up of CIED patients utilizing RM should be performed by a team including a primary physician, primary cardiologist, electrophysiologist, nurses and CIED technologist working in concert utilizing modern information technologies. Data should be shared electronically (with strict data security protocols) utilizing the electronic patient file with secure connection to RM systems. In summary, we believe that RM should be offered to all CIED patients in Israel.

Long-Term Survival of Discharged Patients Admitted to Intensive Coronary Care Unit after Out-of-Hospital Cardiac Arrest.

BACKGROUND: Survival of patients who were discharged from the hospital following out-of-hospital cardiac arrest (OHCA) has not been well defined. OBJECTIVES: To verify predictor variables for prognosis of patients following OHCA who survived hospitalization. METHODS: We retrospectively reviewed clinical, demographic, and outcome data of consecutive patients who were hospitalized from January 1, 2009, through December 31, 2014, into the intensive coronary care unit (ICCU) after aborted OHCA and discharged alive. The patients were followed until December 31, 2015. RESULTS: Of the 180 patients who were admitted into ICCU after OHCA, 64 were discharged alive (59.3%): 55 were male (85.9%), 14 died 16.5 ± 18 months after their discharge. During 1 year follow-up, nine patients (14.1%) died after a median period of 5.5 months and 55 patients (85.9 %) survived. Diabetes mellitus and chronic renal failure (CRF) were more frequent in patients who died within 1 year after their hospital discharge than those who survived. Ventricular fibrillation, such as initial arrhythmia, and opening of occluded infarct related artery were more frequent in survivors. CONCLUSIONS: Most of the patients who were discharged after OHCA were alive at the 1 year follow-up. The risk of death of cardiac arrest survivors is greatest during the first year after discharge. CRF remains a poor long-term prognostic factor beyond the patients' discharge. Ventricular fibrillation, as initial arrhythmia, and opening of occluded infarct related artery have a positive impact on long-term survival.

Permanent pacing in nonagenarians over 20-year period.

INTRODUCTION: Life expectancy increases progressively and nonagenarians are a growing population. We report trends in pacing and long-term outcome in nonagenarians over a 20-year period in a single center compared with those of younger patients. METHODS: We retrospectively reviewed all the patients who underwent their first pacemaker implantation from January 1, 1991 to December 31, 2010 and were followed through December 31, 2013. RESULTS: During the study period, 1,009 patients underwent first pacemaker implantation: 45 patients were older than 90 years (mean age 92.5 ± 2.6) (4.5%); 21 were men. Battery replacement was performed in four patients in whom first implant was made at age ≥ 90 years (8.9%) and in 231 patients aged <90 (24%; P < 0.01). Syncope was the most common symptom leading to pacing, followed by dizziness and fatigue in all age groups; no significant difference of symptoms was found between patient age groups. In patients aged ≥ 90 atrioventricular block and atrial fibrillation with slow ventricular response were more frequent, while sick sinus syndrome and carotid sinus hypersensitivity were less frequent than in younger patients. Ventricular chamber pacemakers were implanted with significant growing frequency, according to the older patients' age. Neither the indication for pacemaker implantation nor pacing mode influenced survival. CONCLUSIONS: Nonagenarians are a growing population. Symptoms leading to pacing in patients aged ≥ 90 were similar to those of younger patients, but different frequency was found in the electrocardiographic indications. Ventricular chamber pacemakers were significantly more implanted than dual-chamber pacemakers but without negative survival influence.

[TRENDS OF PERMANENT PACEMAKER IMPLANTATION IN A SINGLE CENTER OVER A 20-YEAR PERIOD].

AIMS: To review the changes in permanent pacemaker implantation indications, pacing modes and patients' demographics over a 20-year period. METHODS AND RESULTS: We retrospectively retrieved data on patients who underwent first implantation of the pacemaker between 1-1-1991 and 31-12-2010. One thousand and nine (1,009) patients underwent a first pacemaker implantation during that period; 535 were men (53%), their mean age was 74.6±19.5 years; the highest rate of implanted pacemaker was in patients ranging in age from 70-79 years, however there was an increasing number of patients aged over 80 years. The median survival time after initial pacemaker implantation was 8 years. Syncope was the most common symptom (62.5%) and atrioventricular block was the most common electrocardiographic indication (56.4%) leading to pacemaker implantation. There was increased utilization of dual chamber and rate responsive pacemakers over the years. There was no difference regarding mode selection between genders. CONCLUSIONS: Pacemaker implantation rates have increased over a 20-year period. Dual chamber replaced most of the single ventricular chamber pacemaker and rate responsive pacemakers became the norm. The data of a small volume center are similar to those reported in pacemaker surveys of high volume pacemaker implantation centers. They confirm adherence to the published guidelines for pacing.

Permanent lone atrial fibrillation and atrioventricular valve regurgitation: may the former lead to the latter?

BACKGROUND AND AIM OF THE STUDY: Atrioventricular valve regurgitation (AVVR) has been described in patients with long-standing atrial fibrillation (AF) despite normal valve anatomy and leaflet mobility. The study aim was to examine the association between permanent lone AF and AVVR. METHODS: A total of 47 patients with lone AF was studied. Patients provided information regarding the time since onset of arrhythmia, and mitral regurgitation (MR) and tricuspid regurgitation (TR) were graded using color-mapping Doppler echocardiography. AVVR was defined as any degree of valve regurgitation. Annular diameters (in mm) and atrial areas (in cm2) were measured at enddiastole, using digital analysis. RESULTS: Of the 47 patients, 19 (40%) had paroxysmal AF and 28 (60%) had permanent AF. Mild MR was present in nine of 19 patients (47%) with paroxysmal AF and in 15 of 28 (53%) with permanent AF (p = 0.68). Mild TR was identified in nine (47%) patients with paroxysmal AF, and in 16 (58%) of those with permanent AF (p = 0.08). None of the patients with paroxysmal AF had either moderate or severe AVVR. In 28 patients with permanent lone AF, significant MR and TR were detected in six (21%) and five (19%) patients, respectively. Patients with permanent lone AF had a 6.5-fold higher likelihood of having TR (p = 0.0031) and were marginally more likely to have MR (p = 0.053) compared to those with paroxysmal AF. Relative to patients with paroxysmal AF, those with permanent AF had larger atrial areas and annular diameters, while patients with TR had higher atrial areas and mitral annular diameters than those without. The mean follow up of patients with permanent AF and significant AVVR was 54 + 13 months, compared to 13 +/- 7 months for those without significant AVVR (p = 0.002). CONCLUSION: Permanent lone AF is associated with TR and, less strongly, with MR. Atrial size and mitral annular diameter are increased in patients with lone AF who have TR.

[Requests for preoperative cardiology consultation for patients undergoing non cardiac surgery].

AIMS: The number of surgical procedures performed in patients with significant ischemic heart disease is growing. The need for preoperative cardiology consultation in patients undergoing non-cardiac surgery has been the subject of continuous debate. We evaLuated if the requests for preoperative cardiology consultation in patients undergoing non-cardiac surgery were consistent with the 2009 ACC/AHA Guidelines. METHODS AND RESULTS: Patients referred for cardiology consultation before non-cardiac surgery were eligible for the study. Data were collected on age, gender, reasons for consultation, type of surgery, Lee's Cardiac Risk Stratification Class, therapy changes, patients work capacity, and perioperative patients' outcome. Our study population consisted of one hundred and seventy patients; 89 were men (52.3%) and 81 women (47.6%), with a mean age of 74.2±years; 88 patients (51.8%) had a work capacity ≥4 metabolic equivalents [METs). Active cardiac conditions were present in 12 patients (7.1%). The reported clinical risk factors were: 75 patients (44.1%) had diabetes mellitus, 21 patients (12.3%) had prior or compensated heart failure, 79 patients (46.5%) had ischemic heart disease, 29 patients (17.1%) had stroke, and 30 patients (17.7%) had renal insufficiency. Fourteen patients (8.2%) had an implanted pacemaker. There were also 3 perioperative deaths (1.8%). The indication of the requests for preoperative cardiac consultation according to the 2009 ACC/AHA Guidelines was only found in 45 patients (26.5%). CONCLUSIONS: Only in a minority of patients undergoing non-cardiac surgery, the preoperative cardiology consultation requests followed the ACC/AHA Guidelines. Preoperative cardiology consultations in the daily clinical practice are overused.

[Ventricular fibrillation following hyperventilation and apneic underwater swimming].

This is a case study of an 18 years old boy who lost consciousness during apneic underwater swimming. When cardiopulmonary resuscitation was initiated ventricular fibrillation was seen on cardiac monitoring. Bradycardia, atrial and ventricular premature beats are a known response to hyperventilation and apneic underwater diving. This case is the first documentation of ventricular fibritllation as a cause of sudden cardiac death during apneic underwater swimming.

[Sewer gas induced myocardial toxicity].

We report the case of a 19 year-old worker who collapsed after acute exposure to sewer gas. He rapidly developed cardiorespiratory failure with electrocardiographic, echocardiographic and laboratory findings of myocardial involvement. The mainstay of the therapy was mainly supportive treatment with a successful outcome.