Secondary medical prevention among Danish patients hospitalised with either peripheral arterial disease or myocardial infarction.

OBJECTIVE: We compared the use of secondary prevention among patients with a first-time hospitalisation for peripheral arterial disease (PAD) of the lower limb with that among patients with a first-time hospitalisation for myocardial infarction (MI). DESIGN AND MATERIALS: Population-based follow-up study between 1997 and 2003 using registry data from the counties of Northern Jutland, Aarhus and Viborg, Denmark. RESULTS: Between 1997 and 2003, within 180 days after hospital discharge, 26% of patients with lower limb PAD (n=3,424) used antiplatelet drugs, 10% statins, 22% ACE-inhibitors/AT-II receptor antagonists and 13% betablockers compared with 55%, 46%, 42% and 78% respectively among patients with MI (n=11,927). Patients with PAD were substantially less likely than patients with MI to use antiplatelet drugs [adjusted relative risk (RR)=0.39 (95% confidence interval (CI): 0.36-0.41)], statins [adjusted RR=0.21 (95% CI: 0.19-0.23)], ACE-inhibitors/AT-II receptor antagonists [adjusted RR=0.43 (95% CI: 0.40-0.47)] and beta-blockers [adjusted RR=0.10 (95% CI: 0.09-0.11). Between 1997 and 2003 secondary prevention increased considerably in both patient groups, but the disparity in treatment persisted. CONCLUSIONS: Efforts to further increase secondary prevention among patients with PAD are needed urgently.

Plasma catecholamines and carbohydrate metabolism in patients with acute myocardial infarction.

Blood glucose, glucose tolerance, serum insulin, free fatty acids in serum, plasma noradrenaline, and plasma adrenaline were measured in 10 patients with acute myocardial infarction (AMI) as well as in healthy subjects. Both noradrenaline and adrenaline in plasma were elevated in patients with AMI, the level being fairly constant in the individual patients and dependent on their degree of illness. In the fasting state, blood glucose, serum insulin, and free fatty acids were elevated in patients with AMI. Plasma noradrenaline showed a highly significant correlation with the fasting blood glucose concentration, but not with serum insulin or free fatty acids. The concentration of free fatty acids in serum could be predicted only if both plasma noradrenaline and the basal insulin concentration were known. Intravenous glucose tolerance was reduced in patients with AMI, especially in patients with high plasma noradrenaline and a low initial rise in insulin. There was a significant negative correlation between the initial rise in insulin expressed in percentage of the basal insulin concentration and the plasma noradrenaline level. The statistical effects of serum insulin and plasma noradrenaline on the glucose tolerance could not be separated from each other. The decline in free fatty acids after intravenous injection of glucose showed a negative correlation with plasma noradrenaline and a positive correlation with the initial rise in insulin. Plasma adrenaline did not correlate with any of the metabolic parameters mentioned above. The plasma noradrenaline concentration was elevated to such a degree in patients with AMI that the observed changes in metabolism might have been caused directly by the circulating noradrenaline. During the glucose tolerance tests, the effects of noradrenaline was probably carried out indirectly via a suppression of insulin secretion. It is conceivable that any effect of plasma noradrenaline on the basal insulin secretion was neutralized by the fasting hyperglycemia.

Fractal analysis and time- and frequency-domain measures of heart rate variability as predictors of mortality in patients with heart failure.

Time-domain measures of heart rate (HR) variability provide prognostic information among patients with congestive heart failure (CHF). The prognostic power of spectral and fractal analytic methods of HR variability has not been studied in the patients with chronic CHF. The aim of this study was to assess whether traditional and fractal analytic methods of HR variability predict mortality among a population of patients with CHF. The standard deviation of RR intervals, HR variability index, frequency-domain indexes, and the short-term fractal scaling exponent of RR intervals were studied from 24-hour Holter recordings in 499 patients with CHF and left ventricular ejection fraction < or =35%. During a mean follow-up of 665 +/- 374 days, 210 deaths (42%) occurred in this population. Conventional and fractal HR variability indexes predicted mortality by univariate analysis. For example, a short-term fractal scaling exponent <0.90 had a risk ratio (RR) of 1.9 (95% confidence interval [CI] 1.4 to 2.5) and the SD of all RR intervals <80 ms had an RR of 1.7 (95% CI 1.2 to 2.1). After adjusting for age, functional class, medication, and left ventricular ejection fraction in the multivariate proportional-hazards analysis, the reduced short-term fractal exponent remained the independent predictor of mortality, RR 1.4 (95% CI 1.0 to 1.9; p <0.05). All HR variability indexes were more significant univariate predictors of mortality in functional class II than in class III or IV. Among patients with moderate heart failure, HR variability measurements provide prognostic information, but all HR variability indexes fail to provide independent prognostic information in patients with the most severe functional impairment.

n-3 polyunsaturated fatty acids and cardiovascular diseases.

An expert round table discussion on the relationship between intake of n-3 polyunsaturated fatty acids (PUFA) mainly of marine sources and coronary heart disease at the 34th Annual Scientific Meeting of European Society for Clinical Investigation came to the following conclusions: 1. Consumption of 1-2 fish meals/wk is associated with reduced coronary heart disease (CHD) mortality. 2. Patients who have experienced myocardial infarction have decreased risk of total, cardiovascular, coronary, and sudden death by drug treatment with 1 g/d of ethylesters of n-3 PUFA, mainly as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The effect is present irrespective of high or low traditional fish intake or simultaneous intake of other drugs for secondary CHD prevention. n-3 PUFA may also be given as fatty fish or triglyceride concentrates. 3. Patients who have experienced coronary artery bypass surgery with venous grafts may reduce graft occlusion rates by administration of 4 g/d of n-3 PUFA. 4. Patients with moderate hypertension may reduce blood pressure by administration of 4 g/d of n-3 PUFA. 5. After heart transplantation, 4 g/d of n-3 PUFA may protect against development of hypertension. 6. Patients with dyslipidemia and or postprandial hyperlipemia may reduce their coronary risk profile by administration of 1-4 g/d of marine n-3 PUFA. The combination with statins seems to be a potent alternative in these patients. 7. There is growing evidence that daily intake of up to 1 energy% of nutrients from plant n-3 PUFA (alpha-linolenic acid) may decrease the risk for myocardial infarction and death in patients with CHD. This paper summarizes the conclusions of an expert panel on the relationship between n-3 PUFA and CHD. The objectives for the experts were to formulate scientifically sound conclusions on the effects of fish in the diet and the administration of marine n-3 PUFA, mainly eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA, 22:6n-3), and eventually of plant n-3 PUFA, alpha-linolenic acid (ALA, 18:3n-3), on primary and secondary prevention of CHD. Fish in the diet should be considered as part of a healthy diet low in saturated fats for everybody, whereas additional administration of n-3 PUFA concentrates could be given to specific groups of patients. This workshop was organized on the basis of questions sent to the participants beforehand, on brief introductions by the participants, and finally on discussion and analysis by a group of approximately 40 international scientists in the fields of nutrition, cardiology, epidemiology, lipidology, and thrombosis.

[Noisy pneumothorax. Clicking pneumothorax mimicking pericarditis]. / Noisy pneumothorax. Kappepneumothorax forkloedt som pericarditis.

A clicking, crackling, or crunching sound over the cardiac apex, sometimes followed or accompanied by left-sided chest pain, is usually thought to be caused by pericarditis. It is frequently ignored that these symptoms can be due to a small left-sided pneumothorax, called noisy pneumothorax. The pneumothorax can be visualized on X-ray taken in full expiration. Noisy pneumothorax can be followed by various electrocardiographic changes, thus simulating myocardial infarction and other serious heart diseases. Therefore, it is important to have this differential diagnosis in mind as a possibility when healthy, young people are admitted to the hospital with heart symptoms. Two cases of noisy pneumothorax simulating pericarditis are described.

[Serious arrhythmias in Borrelia infections]. / Alvorlige arytmier ved Borrelia-infektioner.

Carditis is seen in about 4-10% of cases of Lyme's disease. It is usually dominated by varying degrees of atrioventricular block, and implantation of a temporary pacemaker may be necessary. Ventricular and supraventricular tachycardias seem to be less frequent than block, and as far as we know ventricular tachycardia provoked by bradycardia has not been reported previously. Third degree AV-block after oral penicillin treatment of erythema migrans is unusual in Europe. When an atrioventricular block of unknown origin is diagnosed, Lyme carditis must be considered, especially among young patients.

[The pacemaker syndrome]. / Pacemakersyndrom.

The pacemaker syndrome is a complex of symptoms consisting of heart failure, near fainting, sensations of pulsation in the neck or abdomen or cough which develop or are aggravated after cardiac pacing. Objectively, a fall in systolic blood pressure is observed in the majority of cases and also canon waves in the neck veins, signs of heart failure, retrograde arterial activation and possibly canon-a-awaves in the central venous pressure. The syndrome occurs in approximately 15% of the patients with ventricular pacing. The condition is most probably caused by lack of atrioventricular synchrony with resultant distension of the atria which results in a reflex mediated decrease or defective increase in the total peripheral resistance and, thus, a fall in systolic blood pressure. Treatment consists of establishing normal atrioventricular synchrony either by implantation of an atrial or AV-sequential pacemaker or by re-programming so that the patient has, primarily, his own rhythm. Ensuring normal atrioventricular synchrony has also other advantages as several investigations have shown that 60-80% of the patients prefer this form of pacing rather than ventricular pacing. The working capacity improves and the patients feel subjectively better and the risk for development of chronic atrial fibrillation and heart failure decreases.

[The pacemaker syndrome: an overlooked complication?]. / Pacemakersyndrom: en overset komplikation?

The pacemaker syndrome is a frequently occurring and frequently overlooked syndrome which can, as a rule, be treated. The diagnosis is often overlooked on account of the diffuse symptoms together with the frequency of symptoms in elderly patients. The temporal connection with VVI pacing is often, but not always, helpful in establishing the diagnosis. Three case histories with various manifestations of the syndrome are reviewed.

[Influence of various therapeutic models on survival after prehospital cardiac arrest]. / Forskellige behandlingsmodellers indflydelse på overlevelse efter praehospitalt hjertestop.

We analyzed the outcome after prehospital cardiac arrest in a part of greater Copenhagen. Four different emergency medical systems were acting: a system providing basic life support only (group 1), a system providing basic life support and early defibrillation (group 2), a system providing basic life support followed by advanced cardiac life support (group 3), and a system providing basic life support and early defibrillation followed by advanced cardiac life support (group 4). Over a 2-year period 624 cases of cardiac arrest were reported, 34 were discharged from hospital. The survival to discharge from hospital and the one-year survival were significantly better in group 4. Our data reconfirm that early advanced cardiac life support improves survival rates for prehospital cardiac arrest.

[Models for calculating risks as a tool in screening for cardiovascular diseases]. / Risikoberegningsmodeller som redskab i screeningsundersøgelser for kardiovaskulaere sygdomme.

In connection with screening for risk factors for ischaemic heart disease in Bispebjerg Hospital, we have assessed three different models for calculation of the risk, employed on our own material. A total of 462 persons participated in the screening and 275 of these were under the age of 65 years. Out of these 275, 92 had plasma cholesterol values over or equal to 7.0 mmol/l and or smoked over 20 gram tobacco daily. On comparison between three models for calculation of the risk: one American, one British and one Swedish, moderate agreement was observed: the correlation coefficients varied between 0.75 and 0.89. The reason for this may be that the models for calculation of the risk are constructed on the basis of statistics already described from epidemiological investigations in which coincidence is demonstrated between selected observable factors and ischaemic heart disease. It is thus possible that the factors which we measure and possibly attempt to influence are not pathogenetic. We consider, therefore, that risk scoring should be employed with caution. As causal connection between ischaemic heart disease and cholesterol and smoking, respectively, have been demonstrated with reasonable certainty, we consider that it is reasonable to screen and intervene for these factors alone.

[The significance of trandelapril for mortality after AMI in patients with reduced left ventricular function. TRACE Study Group]. / Trandolaprils betydning for overlevelse efter AMI hos patienter med nedsat funktion af venstre ventrikel. TRACE Study Group.

Angiotensin converting-enzyme (ACE) inhibition reduces mortality among patients surviving an acute myocardial infarction, but whether to give ACE-inhibitors to all patients or target their use to selected patients is unclear. Seven thousand and one consecutive enzyme-confirmed myocardial infarctions were screened. One thousand seven hundred and forty-nine patients with echocardiographic signs of left ventricular dysfunction were randomized to oral trandolapril (876 patients) or placebo (873 patients) starting from days three to seven following the infarction. Average follow-up was 27 months. There were 304 deaths (34.7 percent) among patients on trandolapril vs. 369 deaths (42.3 percent) among patients on placebo (p = 0.0013). Relative risk (RR) of death in the trandolapril group was 0.78 (95% confidence interval (CD 0.67-0.91). Trandolapril reduced cardiovascular death (RR 0.75, CI 0.63-0.89) and sudden death (RR 0.76, CI 0.59-0.98). Progression to severe/resistant heart failure was reduced (RR 0.71, CI 0.56-0.90). Recurrent myocardial infarction (fatal or non-fatal) was not significantly reduced (RR 0.86, CI 0.66-1.13). It is concluded that long-term treatment with trandolapril in patients with reduced left ventricular function shortly after myocardial infarction significantly reduced total mortality. The substantial mortality risk reduction was obtained in 25% of consecutive patients screened for entry encouraging a selective use of ACE inhibition following myocardial infarction.

[Dofetilide to patients with heart failure and left ventricular dysfunction]. / Dofetilid til patienter med hjerteinsufficiens og dårligt fungerende venstre ventrikel.

INTRODUCTION: Dofetilide, a new class III antiarrhythmic drug, was tested for its ability to reduce mortality and morbidity in patients with congestive heart failure and left ventricular dysfunction. METHODS: In 34 Danish centers, 1518 patients with NYHA class III or IV heart failure and wall motion index of the left ventricle < or = 1.2 (ejection fraction < or = 35%) were randomized to receive dofetilide or placebo in a double blind study. The dose of dofetilide was adjusted to renal function and the QT interval. Patients were monitored continuously with ekg during the first three days in the study. Minimum follow up was one year. RESULTS: Dofetilide did not affect mortality. Hospitalizations for worsening of heart failure were reduced significantly, hazard ratio 0.75 (0.63-0.89) Dofetilide effectively converted atrial fibrillation to sinus rhythm. After one year, 61% of patients with atrial fibrillation had converted on dofetilide and 33% on placebo (p < 0.001). DISCUSSION: Dofetilide can be used to convert atrial fibrillation to sinus rhythm and to maintain sinus rhythm in patients with congestive heart failure and left ventricular dysfunction. Dofetilide does not affect mortality.

Survival trends among Danish patients undergoing coronary angiography for known or suspected ischaemic heart disease: a population based follow up study, 1992-2000.

OBJECTIVE: To determine, from population based clinical data, changes in the survival of Danish patients examined by coronary angiography for known or suspected ischaemic heart disease (IHD) during the 1990s. DESIGN: Follow up study. SETTING: The departments of cardiology at Rigshospitalet, Copenhagen University Hospital, and Skejby Hospital, Aarhus University Hospital, Denmark. PATIENTS: Patients with IHD (n = 7021) who underwent first time coronary angiography in 1992, 1996, or 2000. MAIN OUTCOMES MEASURES: Three year survival was compared between cohorts and with that of the general population. Cox proportional hazards regression was used to estimate mortality ratios adjusted for differences in patient characteristics. RESULTS: Survival improved substantially--for example, adjusted mortality ratio was 0.69 (95% confidence interval (CI) 0.55 to 0.87) when comparing patients from 2000 with patients from 1992. The absolute standardised survival rates after three years of follow up were 87.1% (95% CI 85.4% to 88.8%), 89.9% (95% CI 88.5% to 91.3%), and 91.2% (95% CI 90.3% to 92.1%) among patients examined in 1992, 1996, and 2000, respectively. The improvement was not explained by the improvement in overall survival in the general population during the study period. CONCLUSIONS: The survival of Danish patients with known or suspected IHD appears to have improved substantially during the 1990s.

Changes in myocardial performance induced by pancuronium and gallamine in hypercapnic and hypocapnic dogs.

Changes in myocardial performance after administration of gallamine 1.5 mg kg-1 and pancuronium 0.1 mg kg-1 were investigated in hypercapnic (PaCO2 = 7.08 kPa) and hypocapnic (PaCO2 = 2.74 kPa) dogs anaesthetized with thiopentone, nitrous oxide and halothane. Administration of pancuronium during hypocapnia caused a decrease of 25% in dP/dt max (corrected for changes in preload, afterload and heart rate). This change was not seen during hypercapnia, probably because of the associated sympathetic stimulation. By contrast, gallamine was without effect on dP/dt max in both groups. The increase in heart rate and cardiac output caused by the atropine-like action of both groups. The increase in heart rate and cardiac output caused by the atropine-like action of these relaxant drugs differed in the hypercapnic and hypocapnic group of dogs, with the more pronounced response in the latter group. The duration of the chronotropic changes was the same in both groups.