Improvement of systolic and diastolic heart function after physical training in sedentary women.

The present study examined the cardiac effects of football training and running for inactive pre-menopausal women by standard echocardiography and tissue Doppler imaging. Thirty-seven subjects were randomized to two training groups (football: FG; n=19; running; RG; n=18) training 1 h with equal average heart rates twice a week for 16 weeks and compared with a matched inactive control group (CG; n=10). During the training period, left ventricular end-diastolic volume increased by 13% in FG and 11% in RG (P<0.05). Left ventricular posterior wall thickness increased in FG from 8.5+/-1.4 to 9.0+/-1.3 mm (P<0.05). Right ventricle diameter increased by 12% in FG and 10% in RG (P<0.05). Tissue Doppler imaging demonstrated increased left ventricular systolic and diastolic performances in both training groups. Peak systolic velocity increased by 26% in FG and 17% in RG (P<0.05) and left ventricular longitudinal displacement increased in both groups by 13% (P<0.05). Isovolumetric relaxation time decreased significantly more in FG than in RG (26% vs 14%, respectively P<0.05). In conclusion, 16 weeks of football and running exercise training induced significant changes of cardiac dimensions and had favorable effects on both left ventricular systolic and diastolic function. These training-induced cardiac adaptations appeared to be more consistent after football training compared with running.

Initiation and persistence with clopidogrel treatment after acute myocardial infarction: a nationwide study.

AIMS: To identify possible underuse by analysing initiation and persistence with clopidogrel treatment in an unselected population of patients admitted with myocardial infarction (MI) with or without subsequent percutaneous coronary intervention (PCI). METHODS: Patients admitted with first-time MI from 2000 to 2005 and subsequent prescription claims of clopidogrel were identified by individual-level linkage of nationwide administrative registries in Denmark. Independent factors affecting initiation and persistence with treatment were analysed by multivariable logistic regression models and Cox proportional hazard models. RESULTS: A total of 46,190 MI patients were included in the study, of whom 14,939 were treated with PCI. From 2000 to 2005 initiation of clopidogrel increased from 80.4 to 93.7% among MI patients with PCI and from 2.8 to 39.3% among MI patients without PCI. MI patients with concomitant heart failure received less treatment [odds ratio (OR) 0.49, confidence interval (CI) 0.43, 0.56 among patients with PCI and OR 0.90, CI 0.81, 0.99 among patients without PCI in 2002-2003, and OR 0.89, CI 0.80, 1.00 in 2004-2005, respectively]. Of MI patients with PCI, 77.5% completed 9 months' clopidogrel treatment in 2004-2005, the corresponding figures for MI patients without PCI being 53.9%. CONCLUSIONS: Initiation and persistence with clopidogrel treatment is high in MI patients with PCI. However, we found substantial underuse among MI patients without PCI and in MI patients with heart failure.

Effect of intravenous streptokinase on the relation between initial ST-predicted size and final QRS-estimated size of acute myocardial infarcts.

Thrombolytic therapy has been documented to reduce acute myocardial infarct size. The previously established relation between initial ST segment elevation and final electrocardiographic (ECG) myocardial infarct size in patients without coronary reperfusion might therefore be altered by thrombolytic therapy. The effect of intravenous streptokinase on this relation was therefore studied in 73 patients with initial acute myocardial infarction who had participated in the Second International Study of Infarct Survival (ISIS-2). Patients who received streptokinase were considered as one group and patients who did not receive streptokinase as a control group. Final myocardial infarct size, which was estimated from the QRS score, was predicted from the admission standard ECG by previously developed formulas based on ST segment elevation. In the 40 control patients there was no change from ST-predicted to final QRS-estimated infarct size (median 17.7% versus 18.3%; p = NS). In the 33 patients in the streptokinase group, there was a highly significant decrease from predicted to final myocardial infarct size (median 21.9% versus 16.2%; p less than 0.0002). This decrease was found for both anterior (median 23.7% versus 19.5%; p less than 0.03) and inferior (median 21.9% versus 12.0%; p = 0.001) infarct locations. Multiple regression analysis adjusting for differences in predicted infarct size confirmed the significance of streptokinase on the difference in infarct size (p = 0.006). Based on the variability of the percent change from predicted to final infarct size in the control group, a threshold decrease greater than or equal to 20% is required for identification of salvage.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelial injury of arteries following catheterisation with polyethylene tubes: experimental studies on rabbit aorta using the Seldinger technique.

The effect of catheterisation on the rabbit aortic wall is investigated employing a technique identical to that used for continuous monitoring of blood pressure in humans. The catheters were introduced into the aorta through the right femoral artery of the rabbit using the Seldinger technique, except that the catheters were introduced directly into the femoral artery and not percutaneously. It was found that catheterisation for 24 h was followed by intimal and medial injuries. 3 to 60% (mean 20.4%) de-endothelialisation of the aortic surfaces was observed. The present experiments appear to explain some of the complications observed after continuous registration of blood pressure in humans. Case histories are referred to in which the brachial artery was catheterised.

Developments in the invasive diagnostic-therapeutic cascade of women and men with acute coronary syndromes from 2005 to 2011: a nationwide cohort study.

OBJECTIVES: To investigate for trends in sex-related differences in the invasive diagnostic-therapeutic cascade in a population of patients with acute coronary syndromes (ACS). DESIGN: A nationwide cohort study. SETTING: Administrative and clinical registries covering all hospitalisations, invasive cardiac procedures and deaths in the Danish population of 5.6 million inhabitants. PARTICIPANTS: We included 52,565 patients aged 30-90 years who were hospitalised with a first ACS from January 2005 to November 2011. Follow-up was 60 days from the day of index admission. MAIN OUTCOME MEASURES: Diagnostic coronary angiography, percutaneous coronary intervention or coronary artery bypass within 60 days of index admission. RESULTS: Women constituted 36%, were older, had more comorbidity and were less likely to be admitted to a hospital with cardiac catheterisation facilities than men. Mortality rates were similar for both sexes. Diagnostic coronary angiography was performed less frequently on women compared with men, both within 1 day (31% vs 42%; p<0.001) and within 60 days (67% vs 80%; p<0.001), yielding adjusted female-male HRs of 0.83 (0.79-0.87) and 0.86 (0.84-0.89), respectively.Among the 39,677 patients undergoing coronary angiography, non-obstructive coronary artery disease was more frequent among women than men (22% vs 9%; p<0.001). Women were less likely to undergo percutaneous coronary intervention (58% vs 72%; p<0.001) and coronary artery bypass (6% vs 11%, p<0.001) within 60 days than men, yielding adjusted HRs of 0.96 (0.92-0.99) and 0.81 (0.74-0.89), respectively. The sex-related differences were not attenuated over time for any of the invasive cardiac procedures (p values for trend >0.05). CONCLUSIONS: In this nationwide study, men were more likely to undergo an invasive approach than women when hospitalised with a first ACS--a difference persisting from 2005 to 2011. Future studies should focus on the potential mechanisms behind this differential treatment.

Risk factors and prognosis after discharge for patients admitted because of suspected acute myocardial infarction with and without confirmed diagnosis.

The prognosis regarding cardiac events--acute myocardial infarction (AMI) or cardiac death after discharge--was evaluated in 257 patients admitted because of suspected AMI due to chest pain, but in whom AMI was not confirmed (non-AMI patients). The findings and patient prognoses were compared with those of 275 patients with confirmed AMI. All patients were younger than 76 years and free of severe chronic diseases, and no cause of chest pain other than possible ischemic heart disease was found. The patients were followed for cardiac events for 11 to 24 months (median 14). The prognoses for the non-AMI patients were significantly better than those for the AMI patients (p = 0.05). The proportion without a cardiac event after 1 year was estimated at 91% and 86%, respectively. In the non-AMI patients, angina pectoris, previous AMI and electrocardiographic changes on admission (intraventricular block and permanent or transient ST-T changes) were significant predictors of cardiac events by univariate and multivariate analysis. In the AMI patients, female gender, heart failure, previous AMI and angina pectoris were significant predictors of cardiac events by univariate analysis. With use of multivariate analysis, female gender, heart failure and angina pectoris were independent predictors of cardiac events. Thus, non-AMI patients admitted with chest pain have a high risk of cardiac events after discharge. The risk is highest when there is evidence of coronary artery disease (electrocardiographic changes on admission and angina pectoris or previous AMI.

Continuous monitoring of global left ventricular ejection fraction during percutaneous transluminal coronary angioplasty.

Continuous monitoring of left ventricular (LV) function during percutaneous transluminal coronary angioplasty (PTCA) was performed in 40 patients (53 +/- 2 years) with a miniature, nuclear detector system after labeling the patients' red blood cells with technetium-99m. Balloon dilation (113 seconds, range 60 to 240) induced on average a 0.12 ejection fraction (EF) unit (19%) decrease in the LVEF, which was explained by a 34% increase in end-systolic counts. Balloon dilation of the left anterior descending artery (n = 23) produced a decrease in the LVEF of 0.17 +/- 0.13 EF units compared with the decrease of 0.06 +/- 0.07 EF units in patients undergoing dilation of the left circumflex artery (n = 9) and 0.05 +/- 0.04 EF units in patients treated for a stenosis of the right coronary artery (n = 8), (p = 0.02). Balloon deflation was associated with an immediate return to pre-PTCA levels. In 10 patients with 2 identical balloon occlusions, the second occlusion led to a significantly less decrease in the LVEF (0.41 +/- 0.14 vs 0.44 +/- 0.15) and electrocardiographic ST-segment deviation (88 +/- 54 microV vs 65 +/- 42 microV) than the first. We conclude that PTCA is associated with an abrupt transient decrease in the LVEF. The effect of balloon occlusion of the left anterior descending artery is more pronounced than balloon occlusion of the left circumflex and the right coronary arteries. Neither single nor multiple balloon occlusions were associated with post-PTCA global LV dysfunction, whereas the lesser degree of LV dysfunction and electrocardiographic signs of myocardial ischemia during the second of 2 identical balloon occlusions suggests that preconditioning can be induced during PTCA.

Metoprolol abolishes exercise-induced left ventricular dysfunction in patients with silent ischemia.

Left ventricular systolic function is reduced during episodes of silent ischemia in patients with coronary artery disease (CAD). Left ventricular ejection fraction (LVEF) is increased at least 5 absolute percent during exercise in most normal subjects; however, in patients with CAD, LVEF often remains unchanged or decreases. The anti-ischemic effect of beta-adrenergic receptor blockade is well documented, including a reduction of exercise-induced electrocardiographic ST depressions; however, the effect of these drugs on left ventricular volume changes during exercise in patients with silent ischemia is unknown. The aim of this study was to evaluate the effect of a cardio-selective beta-blocking agent, metoprolol, on rest and exercise LVEF in patients with silent ischemia, using radionuclide cardiography. Fifteen patients with silent ischemia completed a double-blind, placebo-controlled crossover study at rest and during submaximal exercise. LVEF remained unchanged during exercise in the placebo phase (56% to 58%; p = NS), but even though LVEF tended to decrease 56% during rest after metoprolol versus 52% after placebo (p = NS), the LVEF increase from rest to exercise resembled a normal LVEF response, 52% to 58% (p = 0.005). Exercise-induced electrocardiographic ST depressions were also reduced during metoprolol treatment. In patients with silent ischemia, the exercise-induced change in LVEF rises significantly during metoprolol treatment. The mechanism may be a reduction in myocardial ischemia as indicated by a reduction in ischemic electrocardiographic findings.

Verapamil and angiotensin-converting enzyme inhibitors in patients with coronary artery disease and reduced left ventricular ejection fraction.

Verapamil is effective as antianginal medication but contraindicated in patients with congestive heart failure. Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure but have limited effect on patients with angina pectoris. No studies have been published on the combined treatment with verapamil and ACE inhibitors in patients with stable angina pectoris and left ventricular dysfunction. We performed an open study in 14 patients with angina pectoris and ejection fraction < 40%. The patients received verapamil 180 mg and trandolapril 2 mg twice daily for 3 months. We found a significant increase in ejection fraction from 28 +/- 6 to 35 +/- 11 (p < 0.03), wall motion index from 1.0 +/- 0.3 to 1.2 +/- 0.3 (p < 0.03), exercise duration from 6.9 +/- 2.5 to 7.7 +/- 2.9 minutes (p < 0.01), and ratio of exercise to rest rate-pressure product from 2.2 +/- 0.4 to 2.5 +/- 0.6 (p < 0.02). Use of nitroglycerin and number of angina pectoris attacks were both significantly reduced after 3 months of treatment. These findings support the hypothesis that the combination of verapamil and trandolapril is useful in patients with attenuated left ventricular function and angina pectoris.

Effects of revascularization after first acute myocardial infarction on the evolution of QRS complex changes (the DANAMI trial). DANish Trial in Acute Myocardial Infarction.

The changes in QRS complex morphology associated with acute myocardial infarction (AMI) can resolve spontaneously over time. Whether complete revascularization of the infarct-related myocardial territory after AMI affects this QRS resolution has not been studied adequately. The present study compares the evolution of the changes in the QRS complex associated with AMI during 1-year follow-up in patients treated with or without revascularization after their first thrombolyzed AMI. The study is a substudy of the DANish Trial in Acute Myocardial Infarction (DANAMI) (n = 1,008) that randomized patients with inducible ischemia after their first AMI, treated with intravenous thrombolytic therapy, to conservative treatment or coronary angiography followed by the appropriate revascularization strategy. A total of 817 patients had complete sets of evaluable electrocardiograms. Electrocardiograms were obtained at randomization, and at 3, 6, and 12 months of follow-up and subjected to blinded core-laboratory evaluation according to the Selvester QRS scoring method. This score considers Q-, R-, and S-wave duration and ratios to provide a semiquantitative estimate of AMI size. The median electrocardiographic estimated infarct size in the entire population was 15% of the left ventricle at randomization. At the end of the follow-up period this estimate had decreased to 12% (p < 0.00001). There was no difference in the rate of QRS resolution whether the patients were subgrouped according to randomization or subgrouped according to actual treatment with or without revascularization. The present study confirms the findings from previous studies conducted in the prethrombolytic era, that considerable normalization of the QRS complex also occurs after AMI treated with thrombolytic therapy. This QRS normalization seems unaffected by an aggressive treatment strategy with revascularization via balloon angioplasty or bypass surgery.

Amlodipine reduces myocardial ischaemia during exercise without compromising left ventricular function in patients with silent ischaemia: a randomised, double-blind, placebo-controlled study.

BACKGROUND: Left ventricular systolic function is reduced during episodes of silent ischaemia in patients with coronary artery disease (CAD). In most normal subjects left ventricular ejection fraction (LVEF) increases at least 5% during exercise whereas LVEF often remains unchanged or decreases in patients with CAD. The anti-ischaemic effect of calcium antagonists is well documented including a capability to reduce exercise-induced electrocardiographic ST-depressions, whereas the effect of these drugs on LV volume changes during exercise in patients with silent ischaemia is unknown. AIM: The aim of this study was to evaluate the effect of amlodipine on rest and exercise LVEF in patients with silent ischaemia. METHODS: Twenty-one patients completed a double-blind placebo-controlled cross-over study. Conventional exercise test and radionuclide cardiographies during exercise were used for determining haemodynamic parameters. RESULTS: Exercise-induced electrocardiographic ST-depressions were reduced in 83% of the patients having ST-deviations during placebo even though 10 patients were already treated with a beta-blocker. Amlodipine did not affect left ventricular systolic function compared to placebo, neither at rest nor during exercise. CONCLUSION: The results indicated that amlodipine is a safe anti-ischaemic drug in patients with silent ischaemia concerning cardiac function.

Improvement in renal function by felodipine during cyclosporine treatment in acute and short-term studies.

The purpose was to study whether the calcium entry blocker, felodipine, could reduce the nephrotoxic and hypertensive effect of cyclosporine. The effect of felodipine on glomerular filtration rate (GFR), renal plasma flow (RPF), fractional excretion of sodium, lithium clearance and blood pressure was measured in three randomized, placebo-controlled studies of cyclosporine treated patients. In study one, 10 renal transplant recipients were examined within the first six months after transplantation in a cross-over design. Renal hemodynamics were determined after the acute ingestion of felodipine or placebo, with an interval of less than one week between the two examinations. In study two, 79 renal transplant recipients were randomized to a treatment with felodipine or placebo just before transplantation, and renal hemodynamics were determined after twelve weeks. In study three, 18 patients, who were treated with cyclosporine due to dermatological diseases, were examined in a cross-over design to determine their renal hemodynamics after four weeks of treatment with felodipine or placebo. Felodipine increased renal hemodynamics in study one (GFR 16%, RPF 33%, P < 0.01 for both), in study two (GFR 23%, RPF 28%, P < 0.05 for both), and in study three (GFR 13%, RPF 26%, P < 0.01 for both). FE(Na) was significantly increased by felodipine in studies one and three, but not in study two. Lithium clearance was significantly increased and blood pressure significantly reduced by felodipine in all three studies. It can be concluded that felodipine counteracts both the cyclosporine induced impairment in renal hemodynamics and the increase in blood pressure in acute and short-term studies.

The long-term predictive value of an exercise thallium-201 scintigraphy for patients with acute chest pain but without myocardial infarction.

BACKGROUND: Patients who are hospitalized because of chest pain and suspected acute myocardial infarction, but in whom the diagnosis is ruled out, are at high risk for subsequent cardiac events (cardiac death or nonfatal acute myocardial infarction). Risk stratification was done for 158 such patients who underwent exercise thallium-201 scintigraphy at the time of discharge. METHODS: Thirty-eight patients (24%) were women, and all patients were followed for 7 years. The diagnostic sensitivity, specificity, and predictive value of thallium scintigraphy for the identification of patients having subsequent cardiac events during follow-up was calculated. RESULTS: A cardiac event occurred in 41 patients during the follow-up period. Presence of both transient and permanent defects and abnormal ST-segment responses during thallium scintigraphy were significantly associated with an impaired prognosis (P < 0.0001). The highest sensitivity (85%) was achieved by the combination of transient defect with or without persistent defect and with or without abnormal ST-segment response. The highest specificity was provided by a transient defect (90%), and the predictive value of a positive test result was 60%. Seventeen of 29 patients with a transient defect had a cardiac event during follow-up. Patients with normal test results had excellent prognoses; 93% of 82 patients were free of cardiac events during follow-up. CONCLUSIONS: Exercise thallium-201 scintigraphy is suitable for long-term risk stratification in patients with chest pain and suspected but unconfirmed myocardial infarction, because high- and very low-risk subsets can be identified at the time of discharge.

Significance and management of early graft failure after coronary artery bypass grafting: feasibility and results of acute angiography and re-re-vascularization.

UNLABELLED: Perioperative ischaemia and infarction after CABG are associated with increased morbidity and mortality. OBJECTIVE: To study causes of perioperative ischaemia and infarction by acute re-angiography and to treat incomplete re-vascularization caused by graft failure or any other cause. METHODS: Between 1990 and 1995, 2003 patients underwent an isolated CABG operation. Myocardial ischaemia was suspected if one or more of the following criteria were present: New changes in the ST-segment in the ECG; a CKMB value greater than 80 U/L; new Q-waves in the ECG; recurrent episodes of, or sustained ventricular tachyarrhythmia; ventricular fibrillation; haemodynamic deterioration and left ventricular failure. Acute coronary angiography was performed in stable patients, while haemodynamically severely compromised patients were rushed to the operating room. RESULTS: A total of 71 (3.5%) patients of all CABGs with suspected graft failure were identified and included in the study. Patients were grouped according to whether they had an acute re-angiography (n = 59; group 1) or an immediate re-operation (n = 12; group 2) performed. In group 1, the acute re-angiography demonstrated graft failure/incomplete re-vascularization in 43 patients (73%). The angiographic findings were: Occluded vein graft(s) in 19 (32%); poor distal run-off to the grafted coronary artery in ten (17%); internal mammary artery stenosis in four (7%); internal mammary artery occlusion in three (5%); vein graft stenoses in three (5%); left mammary artery subclavian artery steal in two (3%); and the wrong coronary artery grafted in one (2%). Based on the angiography findings, 27 patients were re-operated and re-grafted. At the time of re-operation, 18 patients (67%) had evolving infarction documented by ECG or CKMB. Two patients (3%) experienced stroke in immediate relation to the re-angiography. The 30-day mortality was three (7%). In group 2, graft occlusions were found in 11 patients (92%). The 30-day mortality was six (50%). CONCLUSION: An acute re-angiography demonstrated graft failure or incomplete re-vascularization in the majority of patients with myocardial ischaemia early after CABG. Re-operation for re-re-vascularization was performed with low risk. Few patients with circulatory collapse could be saved by an immediate re-operation without preceding angiography.

Elevated pain threshold in patients with effort-induced angina pectoris and asymptomatic myocardial ischemia during exercise test.

The purpose of the present study was to analyze the prevalence of asymptomatic (silent) myocardial ischemia during exercise testing among patients with effort-induced angina pectoris, and further, to compare the pain threshold of patients with symptomatic and asymptomatic myocardial ischemia. A group of 26 patients comprised the study. In half of the patients myocardial ischemia during the exercise testing was silent and in one half it was symptomatic. Asymptomatic myocardial ischemia was defined as an asymptomatic ST-segment depression greater than or equal to 0.1 mV, lasting longer than 60 s during an exercise test. In patients with asymptomatic ischemia the pain thresholds both on toe and finger were significantly higher than in patients with symptomatic ischemia: mean values were 10.1 versus 4.9 mA on the toes, p less than 0.025, and 8.4 versus 2.5 mA on the fingers, p less than 0.01. We conclude that asymptomatic myocardial ischemia during exercise test is seen often in patients with angina pectoris and that this may be due to an increased pain threshold.

Ventricular premature beats on Holter monitoring in patients admitted with chest pain, in whom acute myocardial infarction is not confirmed. The prognostic value and relationship to scars or ischemia on thallium-201 scintigraphy.

Ambulatory 24-h Holter monitoring was carried out in 198 patients who had been admitted because of suspected acute myocardial infarction (AMI) due to chest pain, but in whom AMI was not confirmed. During a follow-up period of 12-24 months (median 14 months) 16 cardiac events (i.e., nonfatal AMI or cardiac death) occurred. Ventricular premature beats (VPBs) were found in 65.2% of the patients, complex VPBs in 28.8%. Pairs of VPBs which were seen in 10.0% of the patients were the only important type of VPBs significantly related to an impaired prognosis. Thallium-201 scintigraphy was performed in 144 of the patients. VPBs were significantly related to scar formation (i.e., to permanent defects, but not to ischemia, specifically, to transient defects). It is concluded that ventricular arrhythmias in this patient category indicate presence of chronic ischemic heart disease, and that pairs of VPBs seem to identify patients at risk for cardiac events.

The left ventricular end-systolic pressure and pressure-volume index. Comparison between invasive and auscultatory arm pressure measurements.

The slope of the left ventricular (LV) end-systolic pressure-volume relation (ESPVR) has been established as a valuable clinical method to assess LV contractile function independent of LV loading factors. The purpose of the present study was to evaluate whether the ESPVR could be reliably determined from auscultatory blood pressure (BP) measurements and from LV volume measurement by contrast ventriculography (CVG). Twenty-four patients with suspected or known ischemic heart disease were studied by cardiac catheterization with simultaneous, blinded, intravascular and auscultatory pressure measurements. LV volume was determined by CVG. The auscultatory mean arterial blood pressure (MAP) derived from: [formula: see text] was found to be a useful measure of the LV end-systolic pressure in this connection. The correlation between invasively measured LV end-systolic pressure (ESP) and MAP was highly significant (r = 0.82; SEE = 6.9 mmHg; p = 0.001). The correlation between invasively and semi-invasively measured ESPVR fell close to the line of identity (r = 0.99; SEE = 0.23 mmHg.mL-1; p < 0.001). The replacement of ESP by MAP induced only a minimal error in the assessment of the ESPVR. A complete noninvasive determination of the ESPVR and LV contractility therefore seems possible by using the MAP and by measuring the end-systolic volume by radionuclide ventriculography or by echocardiography.

Propafenone versus quinidine slow-release for the treatment of chronic ventricular arrhythmias.

The efficacy and side-effects of oral propafenone 300 mg b.i.d. were compared to those of quinidine slow-release 800 mg b.i.d. in a randomized double-blind placebo controlled cross-over study in 12 patients with symptomatic premature ventricular complexes (PVCs). Furthermore during steady-state the plasma levels of propafenone and quinidine were measured repeatedly over an 8-hour period and correlated to the numbers of PVCs. In 6 patients both drugs reduced PVCs by 80%. In 2 patients this effect was obtained by propafenone and not by quinidine, while the reverse was found in another 2 patients. In 2 patients neither of the drugs was able to reduce PVCs by 80%. During treatment with quinidine 4 patients experienced diarrhoea and 1 patient suffered headaches taking propafenone. The plasma levels showed great variation. No correlation between the plasma levels expressed as area under the concentration-time curve and the reduction of PVCs was found.

Ten year mortality in patients with suspected acute myocardial infarction.

OBJECTIVE: To describe the 10 year mortality in patients with suspected acute myocardial infarction. DESIGN: Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81. SUBJECTS: Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction. MAIN OUTCOME MEASURES: Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population). RESULTS: The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox's analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively. CONCLUSIONS: The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.

[The value of exercise test in acute coronary syndrome]. / Vaerdien af arbejdstest ved akut koronart syndrom.

In general, exercise testing in acute coronary syndrome (ACS) has been used in the assessment of physical capacity and to obtain prognostic information. Within recent years, however, a number of randomized studies have addressed the role of exercise testing in identifying patients, who may benefit from an invasive versus a conservative treatment strategy. According to the literature, a normal exercise test result after ACS is associated with an excellent clinical outcome. Patients who for clinical reasons are unable to perform an exercise test comprise a high risk group for future cardiac events. An invasive strategy is warranted in patients who continue to have angina and exhibit significant ST-segment depression in the exercise-ecg or reversible defects on perfusion scintigraphy. Based on the results of a recent, large scale randomized study, patients with unstable angina or acute non-Q-wave infarction appear to benefit from an early invasive treatment strategy--regardless of the results of a preceding exercise test.