Pre-hospital ambulance care of patients following a suspected seizure: A cross sectional study.

PURPOSE: We aimed to investigate the characteristics of patients presenting to the ambulance service with suspected seizures, the costs of managing these patients and the factors which predicted transport to hospital. METHODS: We employed a cross-sectional design using routine clinical data from a UK regional ambulance service. Logistic regression was used to identify predictors of transport to hospital from ambulance response times, demographics, clinical (physiological) findings and treatments. RESULTS: There were 177,715 emergency incidents recorded in 2011/12 of which 2.9% (5139/177,715) were classified as seizures by ambulance call handlers and 2.7% (4884/177,715) by paramedics on the scene. Suspected seizures were the seventh most common call type. The annual cost of managing these incidents was £890,148. Clinical and physiological variables were normal for most patients. 59.3% (2894/4884) of patients were transported to hospital. 1/4884 (0.02%) patient died. Administration of diazepam, insertion of an airway and pyrexia perfectly predicted transport to hospital, tachycardia had a modest association, but other variables were only weak predictors of transport to hospital. CONCLUSIONS: This study shows that most patients after a suspected seizure are not acutely unwell but nevertheless most patients are transported to hospital. Further research is required to determine which factors are important in decisions to transport to hospital and to create evidence-based tools to help paramedics identify patients who could be safely managed without transport to hospital.

Development and validation of a new Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA) with focus on symptom burden.

BACKGROUND: Arrhythmias can appear with a variety of symptoms, all from vague to pronounced and handicapping symptoms. Therefore, patient-reported outcomes (PROs) concerning symptom burden are important to assess and take into consideration in the care and treatment of patients with arrhythmias. The main purpose was to develop and validate a disease-specific questionnaire evaluating symptom burden in patients with different forms of arrhythmias. METHODS: A literature review was conducted and arrhythmia patients were interviewed. Identified symptoms were evaluated by an expert panel consisting of cardiologists and nurses working daily with arrhythmia patients. SF-36 and Symptoms Checklist (SCL) were used in the validation of the new questionnaire Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA). Homogeneity was evaluated with Spearman's correlations and Cronbach's alpha coefficient (α) was used to evaluate internal consistency. Construct validity was evaluated using item-total correlations and convergent and discriminant validity. For this, Spearman's correlations were calculated between the ASTA symptom scale, SCL and SF-36. Concurrent validity was validated by Spearman's correlations between the ASTA symptom scale and SCL. RESULTS: The correlations between the different items in the ASTA symptom scale showed generally sufficient homogeneity. Cronbach's coefficient was found to be satisfactory (α = 0.80; lower bound 95% CI for α = 0.76). Construct validity was supported by item-total correlations where all items in the symptom scale were sufficiently correlated (≥0.3). Convergent and discriminant validity was supported by the higher correlations to the arrhythmia-specific SCL compared to the generic SF-36. Concurrent validity was evaluated and there were sufficiently, but not extremely strong correlations found between the ASTA symptom scale and SCL. CONCLUSIONS: The nine items of the ASTA symptom scale were found to have good psychometric properties in patients with different forms of arrhythmias. Arrhythmia patients suffer from both frequent and disabling symptoms. The validated ASTA questionnaire can be an important contribution to PROs regarding symptom burden in arrhythmia patients.

Predictive value of presyncope in patients monitored for assessment of syncope.

BACKGROUND: The purpose of this study was to assess the diagnostic value of recording the cardiac rhythm during presyncope in patients undergoing monitoring for undiagnosed syncope. METHODS AND RESULTS: Eighty-five patients (age, 59 +/- 18 years; 44 men, 41 women) with recurrent unexplained syncope underwent prolonged monitoring with an implantable loop recorder. Patients were examined for syncope, which was either recurrent or associated with at least 2 presyncopal episodes. Patients had a mean of 5.1 +/- 5.5 syncopal episodes in the previous 12 months, and 70% of patients had symptoms for >2 years. Sixty-two (73%) patients had recurrent symptoms during a 12-month follow-up period. Of 150 recurrent events captured by the implantable loop recorder, there were 38 (25%) episodes of syncope and 112 (75%) episodes of presyncope. Syncope alone recurred in 12 patients, presyncope in 25, and both in 16. An arrhythmia was present in 64% of syncopal events (bradycardia in 16, tachycardia in 2) versus 25% for presyncopal events (bradycardia in 7, tachycardia in 3, P =.001). An arrhythmia was detected in 9 (56%) of the 16 patients with both syncope and presyncope, which was present in all recorded episodes of syncope compared with 6 of 9 presyncopal episodes. Patient-related failure to freeze the device after symptoms occurred in 21 (36%) of 59 syncopal events compared with 15 (12%) of 127 presyncopal events (P =.0001). CONCLUSIONS: Syncope is more likely to be associated with an arrhythmia than is presyncope in patients undergoing extended monitoring. Presyncope is a nonspecific end point that is frequently associated with sinus rhythm. Patients undergoing extended monitoring for syncope should continue to be monitored after an episode of presyncope unless an arrhythmia is detected.

Assessment of left ventricular function in chronic severe anaemia. An echocardiographic study.

Left ventricle (LV) performance was assessed by echocardiography (2-D and M-mode) in 30 patients with chronic severe anaemia and an equal number of age and sex matched healthy controls. Patients with anaemia were divided into two groups: those with tachycardia (pulse rate more than 100 per min) and those without. LV performance indices computed were LV ejection fraction (LVEF), % fractional shortening (FS), cardiac index (CI) and stroke volume index (SVI). In patients of anaemia with tachycardia, LVEF was 48.6 +/- 8.41 (mean +/- SEM) vs 71.6 +/- 4.96 among controls. Percentage FS was 19.93 +/- 4.21 vs 36.0 +/- 4.5, CI 5.46 +/- 1.2 vs 3.1 +/- 0.78 l/min/m2, and stroke index 48.6 +/- 12.2 vs 41.5 +/- 10.7 ml/beat/m2. In patients without tachycardia, LVEF was 55.1 +/- 8.86, percentage FS 23.6 +/- 5.42, CI 2.87 +/- 0.526 and stroke index 41.34 +/- 12.1. These findings suggest that LV performance was depressed in both groups of patients with anaemia but LV function was better in patients without tachycardia.

Acute and long-term efficacy of propafenone in patients with sustained ventricular tachyarrhythmias: assessment with programmed ventricular stimulation.

To determine the electrophysiological properties of oral propafenone, 50 patients (39 male and 11 female, aged 31 to 80 years) with sustained ventricular tachycardia or ventricular fibrillation underwent serial electrophysiological drug testing, using propafenone (750 to 900 mg daily) as the anti-arrhythmic regimen of first choice. During baseline study, all patients had inducible sustained ventricular tachyarrhythmias. After oral loading of propafenone, 37 patients (74%) remained inducible whereas 13 were rendered non-inducible. Among the still inducible patients, the mean VT rate decreased from 223 +/- 38 b.min-1 (baseline) to 172 +/- 32 b.min +/- 1 (P less than 0.001). Four patients showed an increase of VT rate during propafenone compared to the VT rate at control. Non-inducible patients were discharged on propafenone. During a mean follow-up period of 20 +/- 15 months, there were three non-fatal VT recurrences among the responders, two of them due to non-compliance. Thus, propafenone used as the anti-arrhythmic agent of first choice among patients undergoing serial electrophysiological drug testing for ventricular tachyarrhythmias proved effective in suppressing VT induction in 26%. With regard to arrhythmic events, these patients have a favourable outcome.

Sustained ventricular tachycardia responsive to verapamil in patients with hypertrophic cardiomyopathy. Clinical and electrophysiological assessment of drug efficacy.

Recently, we examined 2 cases of hypertrophic cardiomyopathy (HCM) presenting with sustained ventricular tachycardia (VT). One case was a 62 year old male with midventricular hypertrophy and monomorphic sustained VT. After admission, the efficacies of procainamide, disopyramide, aprindin, flecainide, mexiletine and verapamil were evaluated by means of continuous electrocardiographic monitoring. Verapamil prevented the recurrence of sustained VT and markedly reduced the frequency and number of runs of nonsustained VT. In the electrophysiologic study, rapid VT was induced by double extrastimuli at the right ventricular apex. Intravenous verapamil at a dose of 10 mg prevented the induction of VT. The patient was discharged on verapamil and remains asymptomatic after 3 months of follow up. The other case was a 34 year old female who was a survivor of cardiac arrest. Monomorphic VT was observed on emergency admission and was converted to sinus rhythm by direct current cardioversion after resuscitation. In the electrophysiologic study, rapid VT was induced by double extrastimuli at the right ventricular outflow tract. Verapamil at a dose of 10 mg prevented the induction of VT. These 2 cases of HCM are rare in that they presented with sustained VT. It is also of interest that verapamil, which has been used conventionally in HCM, prevented VT.

A new protocol of programmed stimulation for assessment of predisposition to spontaneous ventricular arrhythmias.

We have devised a simple method for identifying predisposition to spontaneous sustained ventricular fibrillation (VF) and tachycardia (VT). A standardized protocol of programmed stimulation was applied to 111 control subjects without ventricular disease and with no history of VF or VT (Group I) and to 27 patients with previous myocardial infarction and documented spontaneous (in the absence of evidence of further acute myocardial ischaemia) VF or VT (Group II). The stimulation protocol consisted of single and paired ventricular extra stimuli introduced during ventricular drive at the right ventricular apex and outflow tract, at twice diastolic threshold current intensity and at 20 mA. None of the Group I subjects exhibited VF or sustained (more than 10 s) VT. In contrast sustained arrhythmias were induced in 24 (89%) of Group II patients. We conclude: In our study population, initiation of a sustained ventricular tachyarrhythmia at programmed stimulation was both a sensitive (89%) and specific (100%) indicator for predisposition to spontaneous VF and VT.

Assessment of the mid systolic click late systolic murmur syndrome by noninvasive methods.

In patients with the mid systolic click/late systolic murmur syndrome (MSC/LSM Sy) a ballooning, billowing or aneurysmal protrusion of one or both mitral leaflets has previously been described in angiographic studies. It is accepted that besides angiography noninvasive methods such as dynamic electrocardiography, phonocardiography, apexcardiography and echocardiography can provide valuable information in the diagnosis of this syndrome. Little is known however about diagnostic value and sensitivity of these methods. The dynamic Ecg, recorded during an average of 10 hours, showed in 8/20 patients (40%) one or several significant arrhythmias such as frequent ventricular premature contractions (VPCs) (greater than 12/min), multifocal VPCs, VPCs in a row or ventricular tachycardia, or 2 degrees SA-block. 12/20 patients (60%) showed in the phonocardiogram a movement of the click toward the first heart sound when the patients' position was changed from supine to sitting. In 40% of the patients a double or triple click was recorded. A late systolic bulge in the apexcardiogram was seen in 13/20 patients (65%). In one patient the recording was not successful. Echocardiographic signs of abnormal posterior movement (prolapse) of one or both mitral leaflets were recorded in 15/20 patients (75%). Five echocardiograms did not show any abnormality, but all these cases demonstrated in their apexcardiogram a late systolic bulge. We believe that in patients with the MSC/LSM Sy a mitral valve abnormality can be documented adequately by noninvasive methods.

The course of acute myocardial infarction. Feasibility of early discharge of the uncomplicated patient.

This report represents our experience with 522 consecutive patients with acute myocardial infarction admitted directly to the Duke Coronary Care Unit. Fifty items of information were used to characterize the patients, their hospital course and follow-up. Serious complications included death, ventricular tachycardia or fibrillation, second- or third-degree heart block, pulmonary edema, cardiogenic shock, persistent sinus tachycardia or hypotension, atrial flutter or fibrillation, and extension of infarction. Forty-nine percent of the patients (252 of 522) experienced a serious complication. All patients who experienced any serious complications had at least one of the above during the first four days of hospitalization. Patients who survived through day 4 were subgrouped on the basis of the occurrence (complicated) or lack of occurrence (uncomplicated) of the above on day 5. Complicated patients had a subsequent hospital mortality of 14% and an incidence of late serious complications of 51%. Patients who were uncomplicated through day 4 had a subsequent hospital mortality of zero and an incidence of late serious complications of zero. These data suggest that it would be feasible and ethically justified to conduct a prospective clinical trial of early discharge (7th day) in patients who meet the above criteria for uncomplicated. The potential economic savings through earlier discharge in uncomplicated patients are of major significance.

Adams-Stokes seizures due to ventricular tachydysrhythmias in patients with heart block: prevalence and problems of management.

One hundred and twelve patients with heart block and chronic tendency to syncope were ECG-monitored during syncope. Ventricular tachycardia and/or fibrillation (VT-VF) was observed as the cause of syncope in 11 patients: in 6 of 20 patients with chronic third degree A-V block, in 3 of 65 with paroxysmal A-V block and in 2 of 27 with S-A block. The R-R interval preceding the escape beat which initiated VT-VF varied between 1.2 and 2.2 seconds. The cerebral attacks were amenable to long-term pacemaker treatment. However, relapses of VT-VF were observed during pacing with a low rate of 55 per minute and during short interruptions in pacing, as produced by intermittent pacemaker failure or threshold determination. In one patient, supplementary treatment with a beta-blocking agent had to be given to suppress exercise-induced attacks of VT-VF after pacemaker implantation.