Adverse psychological effects and costs associated with waiting for radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is undertaken as a potentially curative treatment for a variety of heart rhythm disturbances. Previous studies have demonstrated improved quality of life and reduced symptoms after ablation. In many health care environments waiting lists exist for scheduling of procedures. However, the psychological effects of waiting for radiofrequency ablation have not previously been assessed. We hypothesized that waiting for this intervention may be associated with increased psychological morbidity and health care costs. METHODS: Ninety-two patients scheduled for elective RFA completed repeated questionnaires comprising the Medical Outcomes Short Form 36, Hospital Anxiety and Depression Scale, and an in-house questionnaire designed to assess the burden of symptoms related to arrhythmia (arrhythmia-related burden score). Mean scores were generated and compared at time points while waiting, before and after the procedure. Regression analyses were carried out to identify predictors of increased psychological morbidity while waiting and immediately prior to the procedure. Health care costs during the waiting period as a consequence of arrhythmia were quantified. RESULTS: Mean scores for parameters of psychological morbidity worsened during the period of waiting and improved after the procedure. Predictors of adverse effects within the cohort varied according to the time point assessed for each of the measures of psychological morbidity. A conservative estimate of the health care cost incurred while waiting exceeds £ 181 per patient. CONCLUSIONS: Waiting for radiofrequency ablation appears to be associated with adverse psychological effects and health care costs. These results may support strategies to reduce waiting times and prioritize resource allocation.

Lack of effect of nitrogen dioxide exposure on heart rate variability in patients with stable coronary heart disease and impaired left ventricular systolic function.

OBJECTIVES: Epidemiological studies of air pollution on cardiovascular health show associations of cardiac mortality and admissions with exposure to nitrogen dioxide (NO(2)) at low concentrations. These associations could be causal or NO(2) could be acting as a surrogate measure for another air pollutant, most likely ultrafine particles. No studies of cardiac susceptibility to acute exposure to NO(2) have been undertaken. METHODS: Randomised controlled exposures to NO(2) (400 ppb for 1 h) and air in subjects with coronary heart disease and impaired left ventricular systolic function not taking ß adrenoceptor blocking drugs. RESULTS: There were no significant changes in heart rate, blood pressure, leucocyte coping capacity or any heart rate variability measure following NO(2) exposure compared with air. CONCLUSION: These findings suggest that NO(2) does not affect heart rate variability at these concentrations (which are high for urban background levels) and in the absence of other pollutants. While a synergistic effect has not been ruled out, these data lend support to the idea that the epidemiological data associating cardiac outcomes with NO(2) are more likely due to an associated pollutant rather than NO(2) itself.

Noninvasive assessment of left ventricular filling pressure after acute myocardial infarction: a prospective study of the relative prognostic utility of clinical assessment, echocardiography, and B-type natriuretic peptide.

BACKGROUND: Elevated left ventricular filling pressure after acute myocardial infarction (AMI) may be identified using clinical assessment, echocardiography, and B-type natriuretic peptide (BNP) levels. All of these predict outcome in this setting. There are, however, no data assessing their relative prognostic value. The current study addresses this. METHODS: Four hundred patients underwent detailed echocardiography and measurement of BNP levels after AMI (median 1 day). The study end points were (1) a composite of death, recurrent AMI, and/or admission to hospital with heart failure within 1 year and (2) all-cause mortality during medium-term follow-up (median 2.9 years). RESULTS: Both an elevated ratio of early transmitral flow to early mitral annulus velocity (E/e') and higher BNP levels were associated with an increased risk of an adverse event within the first year (odds ratio 6.14 for E/e' >15, P < .001; odds ratio 1.19 per 50-pg/mL increase in BNP, P < .001) and medium-term mortality (hazard ratio 4.67 for E/e' >15, P < .001; hazard ratio 1.10 per 50-pg/mL increase in BNP, P < .001). Among patients with BNP levels higher than the median or in the upper quartile, an E/e' ratio >15 identified a subgroup at greatest risk of mortality (P < .001 for both). CONCLUSIONS: The E/e' ratio and BNP levels play important and complementary roles in the risk stratification of patients after AMI.

The relationship between transmural extent of infarction on contrast enhanced magnetic resonance imaging and recovery of contractile function in patients with first myocardial infarction treated with thrombolysis.

BACKGROUND: The aim of the current study was to assess the utility of transmurality of delayed enhancement on cardiac magnetic resonance imaging (MRI) in predicting functional recovery in patients with first ST-elevation myocardial infarction (MI) who had received thrombolysis. METHODS: Nineteen patients underwent cine and contrast-enhanced MRI 3 days and 8 weeks after MI. The transmural extent of infarction (TEI) was determined from the late enhancement component of the first scan. Segmental wall thickening was scored from the cine components of both the initial and follow-up scans. RESULTS: The TEI was inversely related to the likelihood of improvement in wall thickening; chi(2) test for trend = 53.9, p < 0.0001. Delayed enhancement with >50% transmurality predicted a lack of recovery with 82% sensitivity and 54% specificity. The equivalent values for >75% transmurality were 57 and 77%, respectively. The proportion of the left ventricular segments exhibiting functional recovery was related to the percentage of the left ventricle that was severely dysfunctional but had

Relation of left atrial volume to B-type natriuretic peptide levels in patients with stable chronic heart failure.

This study assessed the relation between B-type natriuretic peptide (BNP) and echocardiographic indexes of left ventricular (LV) filling pressure in 53 patients with stable heart failure and without significant valvular dysfunction. Left atrial volume indexed to body surface area (LAVi), an indicator of chronic LV filling pressure, was correlated with BNP (r = 0.692, p <0.001) and was the strongest independent predictor of elevated levels in this cohort. LAVi was also the best predictor of BNP >or=100 pg/ml, with an area under the receiver-operating characteristic curve of 0.85 (95% confidence interval 0.74 to 0.96, p <0.001). Using the optimal cutoff of >31 ml/m(2), LAVi had a sensitivity of 92% and a specificity of 65% for BNP >or=100 pg/ml. Patients with LAVi >31 ml/m(2) had a median BNP of 122 pg/ml, compared with 21 pg/ml in patients with LAVi

Air pollution and the heart : cardiovascular effects and mechanisms.

There has been increasing awareness in recent years of the adverse cardiovascular effects of ambient air pollution. The recent publication of a statement from the Expert Panel on Population and Prevention Science of the American Heart Association has highlighted this issue. It has been appreciated for several decades that major pollution episodes, such as that associated with the London Fog of 1952, are responsible for increased numbers of deaths and most of these are due to cardiorespiratory causes. Realisation of this prompted government and environmental health initiatives to reduce emissions through establishing air quality standards. Previously, the major sources of air pollution were related to domestic coal burning and industry. However, the pattern of emissions in modern developed countries has changed, resulting in a pollution mixture of different composition to that on which early air quality standards were based. Even current 'lower' levels of air pollution have been shown consistently to be associated with adverse health effects. Over the past two decades, a wealth of epidemiological studies have considered both long- and short-term health effects of air pollution. Although the relative risk of respiratory disease in relation to air pollution exposure seems to be higher than that of cardiovascular disease, the latter are of greater absolute significance in population terms. A number of hypotheses have been proposed in order to explain the observed associations, and recent research efforts have focused on examining the mechanisms underlying the effects. It is suggested that certain subgroups of the population such as the elderly or those with pre-existing cardiorespiratory disease may be more susceptible to the effects of air pollution, and analysis of survival data from cohort studies supports this observation.

Entanglement of passive fix ventricular lead in tricuspid valve.

Modern pacing leads are designed to minimize the risk of trauma to intracardiac structures. This case illustrates an unusual complication of permanent pacing using a passive fixation ventricular lead.