A complicated chinese herbal medicine nephrotoxicity.

Chinese herbal medicine is widely used globally. In many instances, it is associated with severe adverse outcomes. We report case of a Chinese herbal nephropathy occurring in a 43-year-old woman showing renal impairment, metabolic acidosis, Stokes - Adams syndrome, hypernatremia, and hypokalemia, characteristics not usually encountered in published cases.

Cardiac pacemaker treatment of heart block in Enugu a 5-year review.

BACKGROUND: Symptomatic heart block is a treatable cardiac cause of death which occurs globally. In Nigeria it is increasingly diagnosed and treated with permanent artificial cardiac pacemaker insertion and pulse generator implantation, sometimes after a period of misdiagnosis and inappropriate treatment. METHODS: Twenty-three patients who were diagnosed with symptomatic heart block and surgically treated with permanent artificial cardiac pacemaker in National Cardiothoracic Centre, Enugu, between April 2001 and March 2006 had their case notes retrospectively reviewed and information entered into a proforma. This was analyzed. Patients diagnosed with symptomatic heart block but not treated with artificial cardiac pacemaker insertion were excluded from the study. There were eight such patients who could not afford the cost of surgical treatment during the period under review. RESULTS: The mean age of the patients was 70 years and the commonest presentation was shortness of breath (100%). Hypertensive heart disease was present in 65% of the patients and a history of chronic chloroquine usage was positive in 73% of the patients. Predominant pretreatment pulse rate was in the range of 30-40 per minute (43%) while 21% of the patients had pulse rate below 30 per minute. These categories of patients commonly had Stoke-Adams syndrome. Sixty-seven per cent of the patients had predominantly systolic hypertension on admission and 16% had hypotension. Third degree heart block was present in 65% of the patients and 89% of all patients needed pre-pacing haemodynamic stabilization with positive inotropic/chronotropic drug(s). Treatment consisted of permanent endocardial pacing in 65% and epicardial pacing in 35% of the patients with equally good response in symptoms, haemodynamic parameters and electrocardiographic features. CONCLUSION: Permanent artificial cardiac pacing is, the reliable treatment of symptomatic heart block and should be included in the National Health Insurance Scheme list.

'Cardiogenic vertigo'--true vertigo as the presenting manifestation of primary cardiac disease.

BACKGROUND: A 90-year-old woman presented to a hospital emergency department with a brief loss of consciousness that was heralded by spinning vertigo lasting approximately 2 min. She had a long history of intermittent brief episodes of rotatory vertigo, presyncope, and non-vertiginous dizziness, occurring either with or without loss of consciousness. Although initially attributed to symptomatic carotid artery stenosis, these episodes persisted, despite surgical restoration of carotid artery blood flow 1 year after her first syncope. Her medical history was otherwise notable for hypertension, mild depression and a gradual decline in gait and balance function attributed to left hip arthritis and older age. INVESTIGATIONS: Bedside history and examination, non-contrast head CT scan, electrocardiogram, transthoracic echocardiogram, and bedside cardiac telemetry. DIAGNOSIS: Sick sinus syndrome or severe reflex bradycardia with asystole causing recurrent, episodic vertigo, presyncope, non-vertiginous dizziness and syncope (Stokes-Adams attacks). MANAGEMENT: Placement of a temporary pacing wire, followed by surgical implantation of a single-chamber ventricular (VVI) pacemaker.

Monophasic action potential duration at the crista terminalis in patients with sinus node disease.

BACKGROUND: The repolarization properties of the crista terminalis (CT) cells have not been elucidated in patients with sinus node disease (SND). In the present study a new technique of recording the monophasic action potential (MAP) at the CT was used to examine the repolarization of the right atrium (RA) in SND patients. METHODS AND RESULTS: Symptomatic SND (n=13) patients and age-, sex-matched control patients (n=13) were tested. The MAP duration (MAPD) at a basic cycle length of 600 ms was recorded at the CT in the superior vena cava - RA junction and at the middle - anterior RA with the effective refractory period (ERP) at the high RA. In 6 controls and 4 SND patients, the effect of adenosine triphosphate on the MAPD was examined. The MAPD at the CT exceeded that at the middle - anterior RA in both groups. The MAPD at the CT in the SND group was significantly prolonged compared with the control group (CT: 358+/-39 ms vs 289+/-43 ms). Between the SND and control groups, the MAPD at the middle - anterior RA (278+/-36 ms vs 265+/-39 ms) and ERP (294+/-42 ms vs 266+/-41 ms) did not differ. Both the corrected-sinus node recovery time and sinoatrial conduction time were better correlated with the MAPD at the CT than the MAPD at the middle - anterior RA and ERP. Adenosine triphosphate shortened the MAPD, which was augmented at the CT in the SND patients. CONCLUSION: A novel method of estimating the MAP at the CT revealed the characteristics of atrial repolarization in SND patients.

[Atrial standstill: a paralysis of cardiological relevance]. / "Atrial standstill": una paralisi di competenza cardiologica.

Atrial standstill is a rare arrhythmogenic condition characterized by the absence of electrical and mechanical activity in the atria, transient or persistent, and complete or partial. It can be "idiopathic", sporadic or familial, or secondary to Ebstein's anomaly, Emery-Dreifuss muscular dystrophy (X-linked), Kugelberg-Welander syndrome (autosomal recessive), and amyloidosis. Idiopathic familial atrial standstill is inherited as autosomal dominant trait with variable penetrance. To date, a few cases of familial forms of primary atrial standstill have been described. In each family, the number of affected members was small and limited to relatives of one generation. The genetic basis for familial atrial standstill is unknown. Recently a mutation in the cardiac sodium channel gene SCN5A associated with relatively rare genotypes for two connexin 40 polymorphisms has been reported. The diagnosis relies on the ECG demonstration of bradycardia, absence of P waves, and junctional narrow complex escape rhythm. Nearly 50% of patients suffer from Adams-Stokes attacks. In the primary persistent form, the atrial paralysis is paralleled by atrial dilation, mitral valve incompetence, and thrombotic complications, with high risk of thromboembolic complications. The treatment is addressed to the thromboembolic risk (anticoagulation), mitral incompetence (diuretics and vasodilators) and syncope (pacemaker implantation).

Simultaneous EEG and ECG recording during a Stokes-Adams attack.

Simultaneous electroencephalographic and electrocardiographic recordings were obtained from a 77-year-old patient during a Stokes-Adams attack. The recordings showed a clear temporal relationship between symptoms, electroencephalographic and electrocardiographic changes during the Stokes-Adams attack. This case shows the usefulness of simultaneous EEG and ECG recordings in the investigation of patients with unexplained episodes of disturbed consciousness.

[Adams-Stokes syncope disclosing a crisis of rheumatic fever. Apropos of a case]. / Syncope d'Adams Stokes révélant une crise de rhumatisme articulaire aigu. A propos d'un cas.

A high degree atrioventricular block (AVB) is an exceptional finding during an acute episode of rheumatic fever (RF). The authors report a case of complete syncopal AVB requiring a temporary pacemaker, representing the first episode of RF.

Convulsiones y paro cardíaco: forma inhabitual de presentación de miocarditis asociada a virus de Epstein Barr / Convulsions and heart arrest: atypical presentation of myocarditis associated with Epstein Barr virus

La incidencia de compromiso cardíaco en la mononucleosis infecciosa es baja. El espectro de manifestaciones incluye cambios electrocardiográficos en 6% y síntomas cardíacos en 0,7% de los casos. Se describe el caso de un paciente de 9 años que ingresó al hospital por convulsiones tónicas generalizadas, que se repitieron a pesar del empleo de fenobarbital y diazepam. Fue admitido a tratamiento intensivo, en coma, grado 3 de Glasgow, con bradicardia irregular y apneas, bloqueo auriculoventricular completo, frecuencia auricular 150/min y ventricular 53/min. Poco después de ingresar sufrió cinco paros cardíacos, requiriendo reanimación cardiopulmonar, ventilación mecánica, infusión de isoproterenol, dopamina y prednisona. Su evolución fue crítica con hipotensión y persistencia del bloqueo atrio ventricular. A las 24 horas de su ingreso se repitió la asistolía, por lo que se le instaló marcapaso externo. Los exámenes mostraron cardiomegalia en la radiografía de tórax; dilatación de la aurícula y ventrículo derecho, edema de pared y disminución de la contractilidad ventricular izquierda en la ultrasonografía cardíaca, concentraciones séricas de creatina fosfokinasa de 196 U/I con fracción MB de 53 U/I. La serología y los cultivos para virus Echo y Coxsackie fueron negativos. La IgM anticápside de virus de Epstein Barr al ingreso y 10 días después fue positiva en título máximo de dilución (1/40), proteína C reactiva 6 mg/l, velocidad de sedimentación de los eritrocitos 10 mm/h, factor reumatoídeo negativo. El bloqueo cedió progresivamente, el isoproterenol pudo ser suspendido al tercer día, la dopamina al noveno y el marcapaso al décimo séptimo día, siendo dado de alta 18 días después de ingresar con ritmo sinusal, extrasístoles ventriculares aislados, buena contractilidad ventricular y tasas normales de enzimas séricas

Physiology of rate-responsive pacing.

The search for a pacemaker that accurately and easily mimics normal physiology is a continuing effort. There have been many achievements in the past, including sensing of the pacing chamber and programming of the pacing rate, sensitivity, and output. Present pacing developments include atrioventricular synchrony and rate adaptiveness. Results of studies on activation sequence and circadian variations will impact future pacing. The usefulness, cost effectiveness, and clinical value of some of the new pacing features remain unclear. Further clinical trials are necessary to clarify the value of new pacing techniques.

Stokes-Adams attacks in congenital complete heart block.

Stokes-Adams attacks are a well-known complication of congenital complete heart block. Although they are generally felt to be precipitated by either bradycardia or tachycardia, this is poorly documented. A case is presented in which a 23 month old with congenital complete heart block and an intermittently prolonged QT interval had a Stokes-Adams attack during a spontaneous episode of ventricular tachycardia. The combination of congenital complete heart block and a prolonged QT interval carries a significant risk of ventricular tachycardia.

Successful treatment of ventricular tachycardia by physiological pacing.

The case is presented of a young patient with atrioventricular (AV) block but no evidence of other disease; in this patient exercise or stress-related syncope continued after implantation of a ventricular inhibited (VVI) pacemaker. Investigation revealed exercise-induced limited rapid multiform ventricular tachycardia (VT) which was associated with faintness or syncope. Temporary atrial triggered ventricular inhibited ventricular (VDD) pacing resulted in enhanced exercise tolerance with no significant arrhythmia. A permanent full function dual chamber (DDD) pacemaker was implanted and prevented the VT. There have been no further exercise-related symptoms during two years of follow up.

A new pacemaker for monitoring asystole and prevention of Adams-Stokes syndrome and sudden cardiac death.

Patients with suspected Adams-Stokes syndrome are examined by Holter monitoring. During the monitoring, there is the danger of syncopes occurring and there are even reports of sudden cardiac death. We therefore developed a pacemaker for cardiac arrest monitoring and the prevention of Adams-Stokes syndrome and sudden cardiac death, which has the following functions: (1) the longest escape interval of the pacemaker not exceeding the value at which syncope is induced is determined by the decline of the mean heart rate including the asystole to a certain threshold rate; (2) once the pacemaker escapes from the interval it continues pacing for a while at a physiological rate to allow recover from ischemias in organs or tissues; and (3) to prevent overdrive suppression to the heart, the pacing rate gradually declines and stops pacing until the next asystole. This pacemaker is useful not only in the diagnosis of Adams-Stokes syndrome but also in pharmacological and pathophysiological studies and in determining when pacing should cease.