Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage.

To determine the frequency and severity of cardiac arrhythmias in intracranial subarachnoid hemorrhage, 120 nonselected patients were prospectively studied by 24-hour Holter monitoring. Arrhythmias were found in 96 of 107 patients (90%) with adequate Holter recording: ventricular premature complexes in 49, nonsustained ventricular tachycardia in 5, supraventricular premature complexes in 29, paroxysmal supraventricular tachycardia or atrial fibrillation in 9, sinoatrial block and arrest in 29, second-degree atrioventricular block in 1, atrioventricular dissociation in 4 and idioventricular rhythm in 2. Life-threatening ventricular arrhythmias (torsades de pointes-type ventricular tachycardia) occurred in 4 patients, degenerating into either ventricular flutter or fibrillation in 2. ST-segment changes suggestive of acute transitory myocardial ischemia were found in 8 patients (1.5 mm or more of ST depression in 7 patients and 1.5 mm or more of ST elevation in 1 patient). The frequency and severity of arrhythmias were significantly higher in patients studied within 48 hours of subarachnoid hemorrhage; serious ventricular arrhythmias were associated with QTc prolongation more than 550 ms and with hypokalemia less than 3.5 mEq/liter. No correlation was found between age, clinical condition, site and extent of subarachnoid hemorrhage and either the occurrence or severity of arrhythmias. The results of our study indicate an extremely high incidence of arrhythmias, sometimes serious, in subarachnoid hemorrhage, especially in the first 48 hours after hemorrhage. Continuous electrocardiographic monitoring is therefore mandatory.

Heart-brain interactions in cerebral ischaemia: a non-invasive cardiologic study protocol.

The cardiologic evaluation of patients with cerebral ischaemia should be aimed at: (1) identifying potential cardiac sources for cerebral emboli, (2) detecting a coexisting ischaemic heart disease, even asymptomatic. The present data concerns a ten-year experience of a systematic cardiologic evaluation of patients admitted to the 1st Division of Neurosurgery, Bellaria Hospital, Bologna, Italy, for cerebral ischaemia. A two-dimensional echocardiography was carried out in 344 consecutive patients (mean age 53 years), cardiac abnormalities were observed in 92 (28%) out of the 328 cases with technically adequate examination, embologenic lesions in 57 (17%). In 18 cases the cardiac lesion was unknown before the cerebral event. An exercise ECG testing was carried out in 322 patients (mean age 56 years), resulting in abnormal in 69 out of the 258 with adequate examination (17%). A subsequent exercise 201Tl myocardial scintigraphy confirmed the presence of ischaemic heart disease in 58 cases. Among patients unable to perform an adequate exercise, a dipyridamole 201Tl myocardial scintigraphy was performed in 38 cases showing perfusional defects in 23 (60%), while a dipyridamole echocardiography was performed in 25 cases showing wall motion abnormalities in 9 (36%). A 24-h Holter monitoring was performed in 65 cases: arrhythmias were detected in 27 patients (41%), but a correlation with the cerebral event was suggested only in 3 cases with atrial fibrillation. According to our experience patients with recent ischaemia should be submitted to the following non-invasive cardiologic screening: (1) exercise ECG testing followed, if abnormal or indeterminant, by 201Tl myocardial scintigraphy in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Torsade de pointes and ventricular flutter-fibrillation following spontaneous cerebral subarachnoid hemorrhage.

Five cases (3.8%) in a series of 132 patients with spontaneous subarachnoid hemorrhage, studied by 24-hour Holter monitoring, presented with ventricular tachycardia of torsade de pointes variety. In all cases, the arrhythmias were observed within 24 hours after the bleeding. The QTc interval was prolonged more than 0.55 sec, and hypokalemia of less than 3.5 mEq/liter was present in all patients. The clinical status was not significant. Torsade de pointes occurred in comatose patients (3 cases) as well as in alert patients (2 cases). The arrhythmia was reversed by therapy in 3 patients, one of whom survived while 2 died due to cerebral damage. Our observations confirm the presence of life-threatening ventricular arrhythmias in the acute phase of subarachnoid hemorrhage. Continuous electrocardiographic monitoring is therefore advisable in view of its potential role in alerting to the need for treatment.

Cardioembolic stroke from atrial septal aneurysm.

Atrial septal aneurysm is an uncommon occult cardiac source of cerebral embolism. It is usually asymptomatic, and clinical cardiologic examination and electrocardiography fail to reveal its presence. We report a case of a 34-year-old woman with sudden right hemiplegia and aphasia from occlusion of the left carotid siphon in whom an atrial septal aneurysm was detected by two-dimensional echocardiography. The absence of atherosclerotic risk factors and vascular lesions proximal to the carotid occlusion strengthened a causal relation between atrial septal aneurysm and cerebral infarction. Consequently, two-dimensional echocardiography may be advisable in every patient with unexplained ischemic stroke to detect possible occult embolic cardiac abnormalities.

Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase.

The frequency and severity of cardiac arrhythmias were studied in 70 patients with spontaneous subarachnoid hemorrhage investigated prospectively with 24-hour Holter monitoring. Patients were less than 70 years old and without clinical and/or ECG signs of previous heart disease; Holter monitoring was initiated within 48 hours of subarachnoid hemorrhage. Arrhythmias were detected in 64 of the 70 patients (91%). Twenty-nine of the 70 patients (41%) showed serious cardiac arrhythmias; malignant ventricular arrhythmias, i.e., torsade de pointe and ventricular flutter or fibrillation, occurred in 3 cases. Serious ventricular arrhythmias were associated with QTc prolongation and hypokalemia. No correlation was found between the frequency and severity of cardiac arrhythmias and the neurologic condition, the site and extent of intracranial blood on computed tomography scan, or the location of ruptured malformation. The extremely high incidence of cardiac arrhythmias, sometimes serious, in the acute period after subarachnoid hemorrhage and the absence of clinical and radiologic predictors make systematic continuous ECG monitoring compulsory to improve the overall results of subarachnoid hemorrhage, irrespective of early or delayed surgical treatment.

[Prognosis of silent myocardial ischemia: follow-up of 100 patients with positive treadmill test and exertion myocardial scintigraphy]. / Prognosi dell'ischemia miocardica silente: follow-up di 100 pazienti con treadmill test e scintigrafia miocardica da sforzo positivi.

Prognosis of asymptomatic myocardial ischemia is largely unknown and the opportunity is still controversial of seeking for patients with silent ischemia. Aim of the present study is to evaluate the prognosis of painless myocardial ischemia documented by exercise test and myocardial scintigraphy. From June 1981 through November 1986, 206 patients without angina, history or ECG signs of old myocardial infarction, presenting a positive (decreases ST greater than or equal to 1.5 mm) exercise treadmill test, underwent exercise Thallium 201 myocardial imaging. Myocardial scintigraphy showed a normal scan in 85 cases and a reversible or fixed perfusion defect in 121. Patients with abnormal scan presenting ischemia at a low to moderate ergometric work-load were treated with betablockers or calcium-antagonist drugs. Out of patients with positive myocardial scintigraphy a sample of the first 100 consecutive subjects was considered. They were 87 men and 13 women aged 28-72 years (mean 54.8) observed during a mean follow up period of 33.1 +/- 1.6 months. Seven patients underwent coronary angiography which showed 3-vessel critical stenosis in 3 cases, 3-vessel lesions plus critical stenosis of the left main coronary-artery in 1 and 2-vessel lesions in 3. Two patients underwent coronary artery bypass surgery. A non fatal myocardial infarction occurred in 1 and 1 became symptomatic for angina, 11 and 20 months respectively after the diagnosis of ischemia. Three patients with ischemia at a low work-load and extensive scintigraphic perfusion defects died of sudden death and one of cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral ischemia and asymptomatic coronary artery disease: a prospective study of 83 patients.

A prospective cardiologic evaluation was performed in 83 consecutive patients with transient cerebral ischemia or mild stroke and without symptoms or electrocardiographic signs of ischemic heart disease. Patients were studied with an electrocardiographic exercise test; a positive test was followed by exercise Thallium-201 myocardial scintigraphy. Results were compared to those obtained in a group of 83 age and sex-matched healthy subjects submitted to the same study protocol. Asymptomatic coronary artery disease was detected in 28% of cerebrovascular patients with adequate electrocardiographic exercise test. A scintigraphic perfusion defect of variable extension was found in 19 of them. In the control group the electrocardiographic exercise test was positive in only 6% (p less than 0.01). Our results support the concept that: asymptomatic ischemic heart disease is often associated with cerebrovascular disease; therefore cerebral ischemic attacks may be a marker of coronary artery disease, an active investigation of the heart should be considered in cerebrovascular patients in order to plan optimal, comprehensive management.

[Early identification of ischemic cardiopathy in patients with cerebrovascular insufficiency.A prospective study with exertion test and perfusion myocardial scintigraphy]. / Identificazione precoce della cardiopatia ischemica in pazienti con insufficienza cerebrovascolare. Studio prospettico con test da sforzo e scintigrafia miocardica perfusionale.

In patients with cerebral transient ischemic attacks or stroke myocardial infarction is the leading long-term cause of death. Despite the importance of coronary artery disease, patients with cerebrovascular insufficiency are seldom evaluated for the detection of ischemic heart disease and usually the cardiological evaluation is limited to the patients with angina or previous myocardial infarction. In order to identify asymptomatic coronary artery disease 74 consecutive patients with cerebral ischemia, and without symptoms or electrocardiographic signs of ischemic heart disease, underwent a maximal exercise treadmill test according to the Bruce protocol. An exercise Thallium myocardial scintigraphy was performed in patients with positive exercise test. A control group of 74 asymptomatic subjects underwent the same study protocol. The study population (Group I) included 57 men and 17 women; the age ranged from 22 to 72 years (mean age 54 years). An adequate exercise test was obtained in 67 patients. Exercise test was positive (ST-segment depression greater than or equal to 1.5 mm) in 19 cases (28%). The end points were exhaustion in 15 patients, ST-segment depression greater than 3 mm in 2 and systolic blood pressure greater than 240 mmHg in 2. The exercise Thallium myocardial scintigraphy was normal in 2 and abnormal in 17: reversible perfusion defects were detected in 12 cases and fixed defects in 5. In the control group (Group II), comparable for age and sex, exercise test was positive in 4 cases (5%; p less than 0.01 percentage of positive exercise tests in Group I vs Group II); the exercise myocardial scintigraphy was normal in 1 and abnormal in 3 subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of silent myocardial ischaemia in patients with cerebral ischaemia.

In order to assess the incidence of silent myocardial ischaemia, 190 consecutive patients with cerebral ischaemia and without symptoms or electrocardiographic signs of ischaemic heart disease, underwent a maximal exercise treadmill test. Patients with a positive exercise test were submitted to exercise thallium myocardial scintigraphy. Results were compared with those obtained in a control group of 113 healthy subjects submitted to the same study protocol. An adequate exercise test was obtained in 140 patients with cerebral ischaemia. The exercise test was positive in 36 cases (26%). The end points were exhaustion in 24 patients, ST segment depression greater than or equal to 3 mm in seven and systolic blood pressure greater than or equal to 240 mmHg in five. The exercise thallium myocardial scintigraphy was normal in three and abnormal in 33: reversible perfusion defects were detected in 26 cases and fixed defects in seven. In the control group, matched for age and sex, the exercise test was positive in only seven cases (6%; P less than 0.01); the exercise myocardial scintigraphy was normal in five and abnormal in two subjects. In conclusion, in a remarkable proportion of middle-aged patients with cerebral ischaemia, silent myocardial ischaemia can be detected by means of noninvasive cardiologic investigations.

Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy.

BACKGROUND AND PURPOSE: Patients with symptomatic carotid stenosis who are candidates for carotid endarterectomy are at high short- and long-term risk of coronary events. To stratify patients at different risk of coronary events we investigated the usefulness of a noninvasive preoperative cardiological workup. METHODS: We studied 172 consecutive patients admitted to the Neurosurgical Department for symptomatic high-grade (70% to 99%) carotid stenosis (age, 42 to 74 years; mean, 57.8 years). Patients without history of coronary artery disease (CAD) and able to exercise were submitted to exercise electrocardiographic testing (EET) and, if abnormal, to exercise thallium myocardial imaging (TMI). Patients were classified into four groups: group 1, patients without CAD: no history of CAD, normal EET, or normal TMI in the presence of indeterminant EET (n = 93, 54%); group 2, patients with silent CAD: no history of CAD and concordant abnormal EET and TMI (n = 28, 16%); group 3, patients unable to exercise: no history of CAD and inability to perform adequate EET because of previous stroke or claudication (n = 29, 17%); and group 4, patients with known CAD: history of angina or myocardial infarction (MI) (n = 22; 13%). RESULTS: The four groups were comparable in regard to age, sex, and computed tomographic scan of the brain. The prevalence of stroke was higher in patients unable to exercise; hypercholesterolemia was more frequent in patients with known CAD. During the perioperative period (< or = 30 days after carotid endarterectomy), coronary events occurred in 3 patients (2%): fatal MI in 2 patients in group 4 and 1 patient in group 3. One hundred percent of patients were followed up for 6.2 years. Coronary events occurred in 23 of the 168 patients discharged from the hospital (13.7%); these were fatal in 11 (6.5%): 3 patients of group 1 (3%; sudden death in 2, fatal MI in 1), 8 patients of group 2 (29%; fatal MI in 5, unstable angina in 3), 8 patients of group 3 (28%; fatal MI in 4, nonfatal MI in 4), and 4 patients of group 4 (18%; fatal MI in 2, sudden death in 1, unstable angina in 1). Kaplan-Meier estimated curves of survival free from fatal and nonfatal coronary events were 97%, 51%, 49%, and 59%, respectively (P < .001, group 1 versus groups 2 and 3; P < .01, group 1 versus group 4). CONCLUSIONS: Among patients undergoing carotid endarterectomy, coronary events occurred twice as often as cerebral recurrences. A preoperative noninvasive cardiac investigation, including EET, can adequately identify groups of patients with diverse short- and long-term prognoses. In addition to patients with known CAD, those with silent CAD or who are unable to exercise represent, without the need of further investigation, groups at high risk of coronary events in long-term follow-up.