Joint outpatient clinics for the adult with congenital heart disease at the district general hospital: an alternative model of care.

Congenital heart disease (CHD) affects approximately 250,000 adults in the UK. Most of these patients would benefit from specialized follow-up. However, there is at present a significant shortfall of specialized tertiary care expertise and facilities for this growing cardiovascular field in the UK and around the world. We aimed to report our experience with a joint adult CHD clinic run in a district general hospital with regular input from the local cardiology team and a visiting adult CHD specialist. In total, 148 patients aged 33.6+/-14.1 years were seen once or more in 12 clinics over the study period (September 1999 to January 2003). Diagnostic case mix consisted of 2.9% complex, 67.9% moderate and 29.2% minor cases of CHD. Twenty percent of patients visited the counterpart tertiary center for additional investigations (mostly MRI) and 8% for intervention (with no operative mortality). There was one death during the study period giving an overall mortality of 0.2%/year. Patients were referred to the clinic from tertiary centres, the local cardiology and paediatric clinics and with time from obstetric and community sources. Nonattendance rates were relatively low, comparing favourably with tertiary care. This model of joint care for the adult CHD patient at a general district hospital with regular onsite specialized input appears to be effective and highlights the need for additional resource allocation to provide optimal care for these patients. Our data may be useful in future planning for CHD services.

Heart rate and QT interval in subjects adapted to beta-blockade: bradycardia and hypotension as uncorrelated adaptations.

Subjects in whom it was found that after a month's treatment with beta-blockers there was a fall of not less than 10 mmHg in systolic blood pressure persisting 54 h after cessation of treatment were considered to have "adapted". Significant falls of blood pressure and heart rate were observed, and were still present after two further weeks of treatment with placebo, but these adaptations were not correlated with each other. Fourteen hypertensive patients and five normotensive subjects received oral propranolol 80 mg, or metoprolol 100 mg, twice daily for 5 days. They were studied before treatment, and 54 h after the last dose. Drug administration was continued for a further 26 days, and the subjects were again examined 54 h after cessation of treatment. Blood was withdrawn at the times of study and contained negligible amounts of drug in the plasma. Records were made of blood pressure and ECG at rest and after exercise, the post-exercise QT being measured at a heart rate of exactly 100 beats per minute, obviating the need for any correction of QT. QT intervals were significantly prolonged, both at rest and on exercise. Responses to intravenous propranolol 10 mg or metoprolol 20 mg were also measured during the study periods, and no hypersensitivity to the drugs was found at rest or after exercise.

Small animal ventilation using a co-axial circuit.

A method is presented for the ventilation of small animals using standard adult anaesthetic equipment.

Should beta-blockers be stopped if myocardial ischaemia occurs?

56 patients who were taking a long-term beta-blocker, and in whom myocardial ischaemia occurred, were randomised to stop or to continue the drug. Assessed in terms of deaths, heart failure, cardiogenic shock, further myocardial ischaemia and arrhythmias (except atrial fibrillation), the outcome did not differ significantly in the two groups. We found no evidence in this small series that either maintaining or stopping beta-blockers after an episode of myocardial ischaemia significantly alters the short-term prognosis of chronically beta-blocked patients.

Contrast media for left ventricular angiography. A comparison between Cardio-Conray and iopamidol.

Forty consecutive patients with coronary artery disease undergoing left ventricular angiography took part in a randomised double blind trial comparing a conventional contrast medium sodium meglumine iothalamate (Cardio-Conray) with the low osmolar agent iopamidol. Iopamidol produced a smaller rise in heart rate and a smaller fall in left ventricular systolic pressure, but the changes in left ventricular and diastolic pressure and maximum rate of change of pressure (dP/dt max) were not different. The numbers of extrasystoles per minute for five minutes after ventriculography were similar in both groups except for the first 15 seconds, when the number of extrasystoles was increased in the iopamidol group. The frequency and magnitude of symptoms (heat, angina, headache, nausea) were significantly different in two groups. Iopamidol caused less haemodynamic disturbance than Cardio-Conray, although the improvement is small and offers no advantage in reducing symptoms or extrasystoles.

Massive acute arsenic poisoning.

A 28-year-old male ingested 75 g of arsenic trioxide in a successful suicide attempt. The presentation, management and postmortem findings are presented and discussed.

The Bain system: gas flows in small subjects.

Rabbits weighing 2-4 kg were ventilated using a Bain type co-axial circuit. Acceptable blood-gas tensions were achieved with a tidal volume of 10 ml kg-1, a frequency of 40 b.p.m., and a fresh gas flow of 3 litre min-1. This technique may be applicable to neonatal anaesthesia.

Intravenous isosorbide dinitrate in acute left ventricular failure--a dose--response study.

The haemodynamic effects of intravenous isosorbide dinitrate (Cedocard) in patients with severe acute left ventricular failure have been assessed using incremental infusion rates from 50 to 800 micrograms min-1. For most patients most of the fall in pulmonary arterial diastolic pressure occurred by 200 micrograms min-1, with little further fall at higher doses. At 200 micrograms min-1 pulmonary arterial diastolic pressure fell from 29 to 23 mgHg (P less than 0.001), there was no significant change in cardiac index (1.9 to 2.0 L min-1 m-2) or heart rate (108 to 108 beats min-1). Despite high doses, no side effects were observed. Intravenous isosorbide dinitrate is effective and safe in the management of acute severe left ventricular failure. In most patients an infusion rate of about 200 micrograms min-1 produces optimal haemodynamic effects.

Use of low-dose insulin infusions in diabetics after myocardial infarction.

Myocardial infarction in diabetics is often accompanied by poor diabetic control. An assessment of a low-dose insulin infusion regimen in 26 diabetic patients after myocardial infarction found this system to be simple, effective, and safe.

Myocardial infarct size and mortality in diabetic patients.

The mortality rate from myocardial infarction is disproportionately high in diabetic patients. One explanation for this may be that diabetic patients incur more extensive myocardial necrosis. This possibility was examined in a three part study. Firstly, peak serum aspartate aminotransferase concentrations of all diabetic and non-diabetic patients admitted with myocardial infarction over a 16 year period were compared retrospectively. Secondly, peak aspartate aminotransferase concentrations in a series of diabetic patients and controls matched by age and sex were examined retrospectively. Thirdly, creatine kinase MB release and electrocardiographic measures of infarct size were investigated prospectively in a case/control study. Although cardiac failure and death were more common in the diabetic groups, there were no significant differences in estimates of infarct size between diabetic and non-diabetic patients in any of the studies. Therefore, the high case fatality rate amongst diabetic patients is not caused by increased myocardial damage. Presumably survival is prejudiced by factors operating before the infarction.

Effect of intravenous insulin infusion on mortality among diabetic patients after myocardial infarction.

A review of the records of 353 diabetic patients after a myocardial infarction confirmed the high mortality associated with the condition. The influence of improved diabetic control achieved by intravenous insulin was assessed in 64 patients and compared with earlier experience in a diabetic control group. The frequency of the major complications of myocardial infarction was unchanged and the death rate in both groups was identical (33%); even the patients with blood glucose concentrations greater than 20 mmol/l on admission failed to benefit. Thus careful control of blood glucose concentrations after myocardial infarction in diabetic patients fails to improve the outcome of this high risk group.