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van Duijvenboden S, Ramírez J, Orini M, Aung N, Petersen SE, Doherty A, Tinker A, Munroe PB, Lambiase PD. Prognostic Significance of Different Ventricular Ectopic Burdens During Submaximal Exercise in Asymptomatic UK Biobank Subjects. Circulation 2023; 148:1932-1944. [PMID: 37855144 PMCID: PMC10712993 DOI: 10.1161/circulationaha.123.064633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/22/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The consequences of exercise-induced premature ventricular contractions (PVCs) in asymptomatic individuals remain unclear. This study aimed to assess the association between PVC burdens during submaximal exercise and major adverse cardiovascular events (MI/HF/LTVA: myocardial infarction [MI], heart failure [HF], and life-threatening ventricular arrhythmia [LTVA]), and all-cause mortality. Additional end points were MI, LTVA, HF, and cardiovascular mortality. METHODS A neural network was developed to count PVCs from ECGs recorded during exercise (6 minutes) and recovery (1 minute) in 48 315 asymptomatic participants from UK Biobank. Associations were estimated using multivariable Cox proportional hazard models. Explorative studies were conducted in subgroups with cardiovascular magnetic resonance imaging data (n=6290) and NT-proBNP (N-terminal Pro-B-type natriuretic peptide) levels (n=4607) to examine whether PVC burden was associated with subclinical cardiomyopathy. RESULTS Mean age was 56.8±8.2 years; 51.1% of the participants were female; and median follow-up was 12.6 years. Low PVC counts during exercise and recovery were both associated with MI/HF/LTVA risk, independently of clinical factors: adjusted hazard ratio (HR), 1.2 (1-5 exercise PVCs, P<0.001) and HR, 1.3 (1-5 recovery PVCs, P<0.001). Risks were higher with increasing PVC count: HR, 1.8 (>20 exercise PVCs, P<0.001) and HR, 1.6 (>5 recovery PVCs, P<0.001). A similar trend was observed for all-cause mortality, although associations were only significant for high PVC burdens: HRs, 1.6 (>20 exercise PVCs, P<0.001) and 1.5 (>5 recovery PVCs, P<0.001). Complex PVC rhythms were associated with higher risk compared with PVC count alone. PVCs were also associated with incident HF, LTVA, and cardiovascular mortality, but not MI. In the explorative studies, high PVC burden was associated with larger left ventricular volumes, lower ejection fraction, and higher levels of NT-proBNP compared with participants without PVCs. CONCLUSIONS In this cohort of middle-aged and older adults, PVC count during submaximal exercise and recovery were both associated with MI/HF/LTVA, all-cause mortality, HF, LTVAs, and cardiovascular mortality, independent of clinical and exercise test factors, indicating an incremental increase in risk as PVC count rises. Complex PVC rhythms were associated with higher risk compared with PVC count alone. Underlying mechanisms may include the presence of subclinical cardiomyopathy.
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Affiliation(s)
- Stefan van Duijvenboden
- Institute of Cardiovascular Science, University College London, United Kingdom (S.v.D., M.O., P.D.L.)
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- Nuffield Department of Population Health, University of Oxford, United Kingdom (S.v.D., A.D.)
| | - Julia Ramírez
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- Aragon Institute of Engineering Research, University of Zaragoza, Spain and Centro de Investigación Biomédica en Red – Bioingeniería, Biomateriales y Nanomedicina, Spain (J.R.)
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, United Kingdom (S.v.D., M.O., P.D.L.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (M.O., N.A., S.E.P. P.D.L.)
| | - Nay Aung
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (M.O., N.A., S.E.P. P.D.L.)
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (N.A., S.E.P., A.T., P.B.M.)
| | - Steffen E. Petersen
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (M.O., N.A., S.E.P. P.D.L.)
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (N.A., S.E.P., A.T., P.B.M.)
| | - Aiden Doherty
- Nuffield Department of Population Health, University of Oxford, United Kingdom (S.v.D., A.D.)
| | - Andrew Tinker
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (N.A., S.E.P., A.T., P.B.M.)
| | - Patricia B. Munroe
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (S.v.D., J.R., N.A., S.E.P., A.T., P.B.M.)
- NIHR Barts Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (N.A., S.E.P., A.T., P.B.M.)
| | - Pier D. Lambiase
- Institute of Cardiovascular Science, University College London, United Kingdom (S.v.D., M.O., P.D.L.)
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (M.O., N.A., S.E.P. P.D.L.)
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Gupta K, Zahedi S, Kakar TS, Khuttan A, Kalra R, Zweig BM. Independent prognostic value of high-risk ventricular premature complexes during exercise or recovery in asymptomatic patients: A meta-analysis of observational studies. Indian Heart J 2023; 75:423-428. [PMID: 37858721 PMCID: PMC10774578 DOI: 10.1016/j.ihj.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/16/2023] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION Ventricular premature contractions (VPCs) are a common finding during cardiac stress tests. The independent prognostic value of these findings in patients in asymptomatic patients is unclear. METHODS We conducted a systematic review and meta-analysis of observational studies exploring the independent prognostic value of VPCs to predict all-cause mortality. The secondary outcome was cardiovascular (CV) mortality. We excluded studies that did not report outcomes after adjusting for ≥1 confounder. Random effect meta-analyses were used to predict cumulative hazard ratios. We stratified results based on VPC during exercise or recovery. RESULTS We found 7 studies with 24,518 patients that met our inclusion criteria. Two studies reported all-cause mortality only, 1 study reported CV mortality only, rest 4 reported both. There was significant heterogeneity in the baseline population, definition of high-risk VPCs, and variables used in adjusted models. Using multivariable summary estimates from individual studies, only VPCs during exercise were associated with a higher risk of all-cause mortality (HR 1.27, 95 % CI 1.07, 1.48). Both VPCs during exercise and recovery were associated with a higher risk CV mortality (HR 1.69, 95 % CI 1.19, 2.20, I2 = 17.6 % and 1.62, 95 % CI 1.25, 2.00, p < 0.001 for both). CONCLUSION High-risk VPCs during exercise is associated with increased risk of all-cause and CV mortality, while those during recovery are associated with an increased risk of CV mortality only.
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Affiliation(s)
- Kartik Gupta
- Heart and Vascular Institute, Division of Cardiovascular Diseases, Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Sulmaz Zahedi
- Division of General Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Tanya Singh Kakar
- Division of Hospital Medicine, Department of Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | | - Rajat Kalra
- Division of Cardiology, University of Minnesota, Minnesota, USA
| | - Bryan M Zweig
- Heart and Vascular Institute, Division of Cardiovascular Diseases, Department of Medicine, Henry Ford Hospital, Detroit, MI, USA.
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Refaat MM, Gharios C, Moorthy MV, Abdulhai F, Blumenthal RS, Jaffa MA, Mora S. Exercise-Induced Ventricular Ectopy and Cardiovascular Mortality in Asymptomatic Individuals. J Am Coll Cardiol 2021; 78:2267-2277. [PMID: 34857087 DOI: 10.1016/j.jacc.2021.09.1366] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The prognosis of exercise-induced premature ventricular contractions (PVCs) in asymptomatic individuals is unclear. OBJECTIVES This study sought to investigate whether high-grade PVCs during stress testing predict mortality in asymptomatic individuals. METHODS A cohort of 5,486 asymptomatic individuals who took part in the Lipid Research Clinics prospective cohort had baseline interview, physical examination, blood tests, and underwent Bruce protocol treadmill testing. Adjusted Cox survival models evaluated the association of exercise-induced high-grade PVCs (defined as either frequent (>10 per minute), multifocal, R-on-T type, or ≥2 PVCs in a row) with all-cause and cardiovascular mortality. RESULTS Mean baseline age was 45.4 ± 10.8 years; 42% were women. During a mean follow-up of 20.2 ± 3.9 years, 840 deaths occurred, including 311 cardiovascular deaths. High-grade PVCs occurred during exercise in 1.8% of individuals, during recovery in 2.4%, and during both in 0.8%. After adjusting for age, sex, diabetes, hypertension, lipids, smoking, body mass index, and family history of premature coronary disease, high-grade PVCs during recovery were associated with cardiovascular mortality (hazard ratio [HR]: 1.82; 95% CI: 1.19-2.79; P = 0.006), which remained significant after further adjusting for exercise duration, heart rate recovery, achieving target heart rate, and ST-segment depression (HR: 1.68; 95% CI: 1.09-2.60; P = 0.020). Results were similar by clinical subgroups. High-grade PVCs occurring during the exercise phase were not associated with increased risk. Recovery PVCs did not improve 20-year cardiovascular mortality risk discrimination beyond clinical variables. CONCLUSIONS High-grade PVCs occurring during recovery were associated with long-term risk of cardiovascular mortality in asymptomatic individuals, whereas PVCs occurring only during exercise were not associated with increased risk.
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Affiliation(s)
- Marwan M Refaat
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon; Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine, Beirut, Lebanon
| | - Charbel Gharios
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon; Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - M Vinayaga Moorthy
- Center for Lipid Metabolomics, Divisions of Preventive and Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Farah Abdulhai
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roger S Blumenthal
- The Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland, USA
| | - Miran A Jaffa
- Epidemiology and Population Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
| | - Samia Mora
- Center for Lipid Metabolomics, Divisions of Preventive and Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Electrophysiologic and imaging evidence for an occult myopathic substrate in patients with idiopathic ventricular arrhythmias. Int J Cardiol 2021; 336:60-66. [PMID: 34048856 DOI: 10.1016/j.ijcard.2021.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 05/02/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Idiopathic VA are traditionally considered benign, although occasional patients develop an ectopy-mediated cardiomyopathy (EMC). It is unclear whether patients with idiopathic VA in the absence of left ventricular (LV) dysfunction harbor a subclinical cardiomyopathy. We aim to assess for cardiomyopathic substrate in patients with idiopathic ventricular arrhythmias (VA) using imaging and electrophysiologic markers of early fibrosis. METHODS Cardiac magnetic resonance (CMR) imaging and ventricular electroanatomic mapping was performed in 3 groups: patients undergoing ablation for idiopathic VA without (Group 1, n = 17) and with LV dysfunction (Group 2 [presumed EMC], n = 12) plus a control group undergoing ablation of supraventricular tachycardia (Group 3, n = 16). Global LV strain, T1 mapping and extended electrogram (EGM) characteristics were compared. RESULTS Global strain was impaired in patients with presumed EMC (Group 2, p < 0.001). Native T1 times did not differ between groups, however patients in both idiopathic VA groups (Groups 1 and 2) had shorter post-contrast T1 times at 8 min compared to SVT controls (Group 3, p = 0.04). Similarly, the duration of the bipolar EGM was subtly prolonged in both Group 1 and 2 compared to Group 3 (p = 0.002). There were no between group differences in unipolar or bipolar voltage, the no. of bipolar EGM deflections or the maximal unipolar EGM dV/dt. CONCLUSION Patients with idiopathic VAs and apparently structurally normal hearts may have subtle CMR and electrophysiologic changes similar in magnitude to that seen in frank presumed EMC, possibly suggestive of an occult cardiomyopathic process.
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Lee A, Walters TE, Gerstenfeld EP, Haqqani HM. Frequent Ventricular Ectopy: Implications and Outcomes. Heart Lung Circ 2019; 28:178-190. [DOI: 10.1016/j.hlc.2018.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 11/29/2022]
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Chevalier L, Kervio G, Doutreleau S, Mathieu JP, Guy JM, Mignot A, Corneloup L, Passard F, Laporte T, Girard-Girod A, Hennebert O, Bernadet P, Vincent-Chevalier MP, Gencel L, Carré F. The medical value and cost-effectiveness of an exercise test for sport preparticipation evaluation in asymptomatic middle-aged white male and female athletes. Arch Cardiovasc Dis 2017; 110:149-156. [DOI: 10.1016/j.acvd.2016.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/19/2016] [Accepted: 06/01/2016] [Indexed: 01/02/2023]
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Lee V, Perera D, Lambiase P. Prognostic significance of exercise-induced premature ventricular complexes: a systematic review and meta-analysis of observational studies. HEART ASIA 2017; 9:14-24. [PMID: 28123456 DOI: 10.1136/heartasia-2016-010854] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 11/03/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Exercise-induced premature ventricular complexes (EI-PVCs) are common during exercise stress tests. Their optimal management and prognostic significance remain uncertain. AIM To perform meta-analysis of observational studies on the prognostic significance of EI-PVCs. METHODS A search was conducted on Medline and Embase. Inclusion criteria were observational studies comparing the prognosis of patients with and without EI-PVCs whilst exclusion criteria were studies without confounder adjustment and studies with zero endpoints. Composite endpoints included all-cause mortality, cardiac mortality and cardiovascular events. Relative risk of endpoints were analysed with random effects model. Meta-regression and sensitivity analysis were performed. RESULTS Ten studies were included. In asymptomatic patients who had no clinical evidence of heart disease, EI-PVCs were associated with a pooled risk ratio of 1.82 (95% CI 1.44 to 2.30) of developing adverse cardiovascular events over 16 years. The corresponding pooled RR for patients with symptomatic heart disease was 1.36 (95% CI 1.18 to 1.57) over 5.4 years. Sensitivity analysis: only EI-PVCs on the recovery phase of an exercise test, not during exercise, had adverse prognostic significance. CONCLUSIONS EI-PVCs are correlated with a higher risk of all cause death or cardiovascular events in the long term. This risk is elevated in asymptomatic patients without clinical heart disease and in patients with symptomatic heart disease. The fact that only EI-PVCs during recovery, and not during exercise, have poor prognostic value suggests that autonomic dysfunction may play a role in this association. Further studies are needed to see if autonomic manipulation by drugs or catheter-based methods can improve the poor prognosis associated with EI-PVCs.
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Affiliation(s)
- Victor Lee
- Princess Margaret Hospital , Kowloon , Hong Kong
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Kim J, Kwon M, Chang J, Harris D, Gerson MC, Hwang SS, Oh SW. Meta-Analysis of Prognostic Implications of Exercise-Induced Ventricular Premature Complexes in the General Population. Am J Cardiol 2016; 118:725-32. [PMID: 27394411 DOI: 10.1016/j.amjcard.2016.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/03/2016] [Accepted: 06/03/2016] [Indexed: 11/18/2022]
Abstract
Ventricular premature complexes (VPCs) during stress testing in the general population are commonly seen in clinical practice, but their prognostic value is not well understood. A comprehensive literature search of MEDLINE, Embase, and the Cochrane Library from January 1970 to May 2015 was conducted. Observational cohort studies on general populations evaluating the association between exercise-induced VPCs and all-cause or cardiovascular mortality were included in the analysis. Nine studies comprising 62,488 participants comparing clinical outcomes of patients with and without exercise-induced VPCs were included. The overall combined relative risks (RRs) for all-cause mortality and cardiovascular mortality in patients with exercise-induced VPCs were 1.41 (95% CI 1.23 to 1.61) and 1.86 (95% CI 1.51 to 2.30), respectively. In subgroup analysis, both frequent VPCs (RR 1.35, 95% CI 1.14 to 1.60) and infrequent VPCs (RR 1.57, 95% CI 1.13 to 2.18) were associated with an adverse outcome. VPCs during recovery were associated with an increased risk of death (RR 1.55, 95% CI 1.22 to 1.96). VPCs during exercise did not achieve statistical significance (RR 1.14, 95% CI 0.96 to 1.34), but only a few studies were included in the analysis. In conclusion, our meta-analysis suggests that exercise-induced VPCs in the general population significantly increase the risk of total mortality and cardiovascular mortality. Our study calls for further studies to assess the prognostic significance of exercise-induced VPCs and the utility of efforts to reduce the VPC burden to improve the clinical outcome.
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Affiliation(s)
- Joonseok Kim
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Minkyung Kwon
- Department of Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Jinsoo Chang
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - David Harris
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Myron C Gerson
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Seung-Sik Hwang
- Department of Social and Preventive Medicine, Inha University School of Medicine, Incheon, Korea
| | - Seung-Won Oh
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea.
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Turan OE, Ozturk M, Kocaoglu I, Turan SG. Blood pressure response is impaired in patients with exercise-induced ventricular ectopy. ACTA ACUST UNITED AC 2016; 10:447-56. [PMID: 27085207 DOI: 10.1016/j.jash.2016.03.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/09/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
Abstract
Exercise-induced ventricular ectopy (EIVE) has clinical and prognostic significance. But the mechanism underlying EIVE-related mortality still remains unclear. This study aims to assess blood pressure alteration in patients with EIVE and to identify the potential causes of increased mortality in this patient group. A total number of 3611 patients were screened within a 1-year period, and patients with a structural heart disease, coronary artery disease, hypertension, diabetes mellitus, thyroid dysfunction, and chronic renal disease were excluded from the study. A total number of 98 patients with no chronic disease, who were retrospectively diagnosed with EIVE, were included in the study as patient group and 116 patients without EIVE were included as control group. The median age, gender distribution, laboratory test results, and echocardiographic findings were similar between the two groups. Systolic blood pressure (SBP) alterations during exercise stress testing were found to be significantly different (P < .001). Moreover, EIVE group had significantly higher peak SBP (P < .001). A significant positive relation was found between peak SBP level and ventricular ectopy count (r:0.27, P = .006). Our study showed that EIVE patients without a structural heart disease or a chronic disease had higher peak SBP levels. Higher SBP alteration can be related to ventricular ectopy occurrence during exercise stress testing, which can be a possible reason underlying the increased rate of mortality among EIVE patients.
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Affiliation(s)
| | - Mustafa Ozturk
- Department of Cardiology, Erzurum Medical Training School, Erzurum, Turkey
| | | | - Selen Gursoy Turan
- Department of Public Health, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
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Nakou ES, Parthenakis FI, Kallergis EM, Marketou ME, Nakos KS, Vardas PE. Healthy aging and myocardium: A complicated process with various effects in cardiac structure and physiology. Int J Cardiol 2016; 209:167-75. [PMID: 26896615 DOI: 10.1016/j.ijcard.2016.02.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/25/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
It is known that there is an ongoing increase in life expectancy worldwide, especially in the population older than 65years of age. Cardiac aging is characterized by a series of complex pathophysiological changes affecting myocardium at structural, cellular, molecular and functional levels. These changes make the aged myocardium more susceptible to stress, leading to a high prevalence of cardiovascular diseases (heart failure, atrial fibrillation, left ventricular hypertrophy, coronary artery disease) in the elderly population. The aging process is genetically programmed but modified by environmental influences, so that the rate of aging can vary widely among people. We summarized the entire data concerning all the multifactorial changes in aged myocardium and highlighting the recent evidence for the pathophysiological basis of cardiac aging. Keeping an eye on the clinical side, this review will explore the potential implications of the age-related changes in the clinical management and on novel therapeutic strategies potentially deriving from the scientific knowledge currently acquired on cardiac aging process.
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Affiliation(s)
- E S Nakou
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece.
| | - F I Parthenakis
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece
| | - E M Kallergis
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece
| | - M E Marketou
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece
| | - K S Nakos
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece
| | - P E Vardas
- Department of Cardiology, Heraklion University Hospital, 7100, Voutes, Heraklion-Crete, Greece
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Cintra FD, Makdisse MRP, Oliveira WAAD, Rizzi CF, Luiz FODO, Tufik S, Paola AAVD, Poyares D. Exercise-induced ventricular arrhythmias: analysis of predictive factors in a population with sleep disorders. EINSTEIN-SAO PAULO 2016; 8:62-7. [PMID: 26761754 DOI: 10.1590/s1679-45082010ao1469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Accepted: 12/18/2009] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the prevalence of ventricular arrhythmias induced by exercise in a population with sleep disorders and to analyze the triggering factors. METHODS Patients were consecutively selected from the database of the Sleep Clinic of Universidade Federal de São Paulo. All subjects were submitted to basal polysomnography, blood sample collection, physical examination, 12-lead ECG, spirometry, cardiorespiratory exercise study on a treadmill, and echocardiogram. The Control Group was matched for age and gender. RESULTS A total of 312 patients were analyzed. Exercise-induced ventricular arrhythmia was observed in 7%. The aortic diameter was larger (3.44 ± 0.30, 3.16 ± 0.36, p = 0.04) and the minimal saturation was lower (92.75 ± 3.05, 95.50 ± 1.73, p=0.01) in the ventricular arrhythmia group when compared to controls, respectively. After correction of the aortic root to body surface, there was only a trend to a larger diameter being associated with the emergence of arrhythmia. CONCLUSIONS Exercise-induced ventricular arrhythmia was observed in 7% of sample and it was associated with lower oxygen saturation during exercise.
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Affiliation(s)
- Fatima Dumas Cintra
- Cardiac Arrhythmia Center, Hospital Israelita Albert Einstein - HIAE, São Paulo, SP, Brazil
| | | | | | | | | | - Sergio Tufik
- Department of Psychobiology, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil
| | | | - Dalva Poyares
- Department of Psychobiology, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil
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Jeserich M, Merkely B, Olschewski M, Kimmel S, Pavlik G, Bode C. Patients with exercise-associated ventricular ectopy present evidence of myocarditis. J Cardiovasc Magn Reson 2015; 17:100. [PMID: 26590904 PMCID: PMC4655086 DOI: 10.1186/s12968-015-0204-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 11/09/2015] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The origin and clinical relevance of exercise-induced premature ventricular beats (PVBs) in patients without coronary heart disease or cardiomyopathies is unknown. Cardiovascular magnetic resonance enables us to non-invasively assess myocardial scarring and oedema. The purpose of our study was to discover any evidence of myocardial anomalies in patients with exercise-induced ventricular premature beats. METHODS We examined 162 consecutive patients presenting palpitations and documented exercise-induced premature ventricular beats (PVBs) but no history or evidence of structural heart disease. Results were compared with 70 controls matched for gender and age. ECG-triggered, T2-weighted, fast spin echo triple inversion recovery sequences and late gadolinium enhancement were obtained as well as LV function and dimensions. RESULTS Structural anomalies in the myocardium and/or pericardium were present in 85 % of patients with exercise-induced PVBs. We observed a significant difference between patients with PVBs and controls in late gadolinium enhancement, that is 68 % presented subepicardial or midmyocardial lesions upon enhancement, whereas only 9 % of the controls did so (p < 0.0001). More patients presented pericardial enhancement (35 %) or pericardial thickening (27 %) compared to controls (21 % and 13 %, p < 0.0001). Myocardial oedema was present in 37 % of the patients and in only one control, p < 0.0001. Left ventricular ejection fraction did not differ between patients and controls (63.1 ± 7.9 vs. 64.7 ± 7.0, p = 0.13). CONCLUSIONS The majority of patients with exercise-associated premature ventricular beats present evidence of myocardial disease consistent with acute or previous myocarditis or myopericarditis.
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Affiliation(s)
- Michael Jeserich
- Department for Cardiology and Angiology, Heart Center University of Freiburg, Albert-Ludwigs University Freiburg, Freiburg, Germany.
- , Koenigstr. 39, 90402, Nuernberg, Germany.
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor str, 68, 1122, Budapest, Hungary.
| | - Manfred Olschewski
- Department of Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany.
| | - Simone Kimmel
- Medical Practice, Cardiology and Angiology, Koenigstr. 39, 90402, Nuernberg, Germany.
| | - Gabor Pavlik
- Department of Health Sciences and Sports Medicine, Universitiy of Physical Education, H-1123 Alkotás str. 44, Budapest, Hungary.
| | - Christoph Bode
- Department for Cardiology and Angiology, Heart Center University of Freiburg, Albert-Ludwigs University Freiburg, Freiburg, Germany.
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Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873-934. [PMID: 23877260 DOI: 10.1161/cir.0b013e31829b5b44] [Citation(s) in RCA: 1222] [Impact Index Per Article: 111.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Marine JE, Shetty V, Chow GV, Wright JG, Gerstenblith G, Najjar SS, Lakatta EG, Fleg JL. Prevalence and prognostic significance of exercise-induced nonsustained ventricular tachycardia in asymptomatic volunteers: BLSA (Baltimore Longitudinal Study of Aging). J Am Coll Cardiol 2013; 62:595-600. [PMID: 23747767 DOI: 10.1016/j.jacc.2013.05.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/26/2013] [Accepted: 05/06/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This study sought to determine the clinical predictors and prognostic significance of exercise-induced nonsustained ventricular tachycardia (NSVT) in a large population of asymptomatic volunteers. BACKGROUND Prior studies have reported variable risk associated with exercise-induced ventricular arrhythmia. METHODS Subjects in the BLSA (Baltimore Longitudinal Study of Aging) free of known cardiovascular disease who completed at least 1 symptom-limited exercise treadmill test between 1977 and 2001 were included. NSVT episodes were characterized by QRS morphology, duration, and rate. Subjects underwent follow-up clinical evaluation every 2 years. RESULTS The 2,099 subjects (mean age: 52 years; 52.2% male) underwent a mean of 2.7 exercise tests, in which 79 (3.7%) developed NSVT with exercise on at least 1 test. The median duration of NSVT was 3 beats (≤5 beats in 84%), and the median rate was 175 beats/min. Subjects with (vs. without) NSVT were older (67 ± 12 years vs. 51 ± 17 years, p < 0.0001) and more likely to be male (80% vs. 51%, p < 0.0001) and to have baseline electrocardiographic abnormalities (50% vs. 17%, p < 0.0001) or ischemic ST-segment changes with exercise (20% vs. 10%, p = 0.004). Over a mean follow-up of 13.5 ± 7.7 years, 518 deaths (24.6%) occurred. After multivariable adjustment for age, sex, and coronary risk factors, exercise-induced NSVT was not significantly associated with total mortality (hazard ratio: 1.30; 95% confidence interval: 0.89 to 1.90; p = 0.17). CONCLUSIONS Exercise-induced NSVT occurred in nearly 4% of this asymptomatic adult cohort. This finding increased with age and was more common in men. After adjustment for clinical variables, exercise-induced NSVT did not independently increase the risk of total mortality.
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Affiliation(s)
- Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 20892, USA
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15
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Chow GV, Marine JE, Fleg JL. Epidemiology of arrhythmias and conduction disorders in older adults. Clin Geriatr Med 2013; 28:539-53. [PMID: 23101570 DOI: 10.1016/j.cger.2012.07.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Normal aging is associated with a multitude of changes in the cardiovascular system, including decreased compliance of blood vessels, mild concentric left ventricular hypertrophy, an increased contribution of atrial contraction to left ventricular filling, and a higher incidence of many cardiac arrhythmias, both bradyarrhythmias and tachyarrhythmias. Conduction disorders also become more common with age, and may either be asymptomatic, or cause hemodynamic changes requiring treatment. The epidemiology of common arrhythmias and conduction disorders in the elderly is reviewed.
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Affiliation(s)
- Grant V Chow
- Division of Cardiology, Johns Hopkins Medical Institutions, Johns Hopkins University School of Medicine, Carnegie 568, 600 N. Wolfe Street, Baltimore, MD 21287, USA
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16
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17
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Abstract
Underlying causes of ventricular tachycardia (VT) or complex ventricular arrhythmias (VA) should be treated if possible. Antiarrhythmic drugs should not be administered to treat asymptomatic individuals with complex VA and no heart disease. Beta-blockers are the only antiarrhythmic drugs that have been documented to reduce mortality in patients with VT or complex VA. Radiofrequency catheter ablation of VT has been beneficial in treating selected patients with arrhythmogenic foci of monomorphic VT. The automatic implantable cardioverter-defibrillator (AICD) is the most effective treatment for patients with life-threatening VT or ventricular fibrillation. Patients with AICDs should be treated with biventricular pacing, not with dual-chamber rate-responsive pacing at a rate of 70/min. Patients with AICDs should also be treated with beta-blockers, statins, and angiotensin-converting enzyme inhibitors or angiotensin blockers.
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18
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Beta-blockade as first-line therapy in the elderly heart failure patient--the proper approach or asking for trouble? Cardiovasc Drugs Ther 2008; 22:347-50. [PMID: 18679783 DOI: 10.1007/s10557-008-6126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 06/30/2008] [Indexed: 10/21/2022]
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Abstract
We have begun to study the genetic basis of deterioration of cardiac function in the fruit fly Drosophila melanogaster as an age-related cardiac disease model. For this purpose we have developed heart function assays in Drosophila and found that the fly's cardiac performance, as that of the human heart, deteriorates with age: aging fruit flies exhibit a progressive increase in electrical pacing-induced heart failure as well as in arrhythmias. The insulin receptor and associated pathways have a dramatic and heart-autonomous influence on age-related cardiac performance in flies, suggestive of potentially similar mechanisms in regulating cardiac aging in vertebrates. Compromised KCNQ and K(ATP) ion channel functions also seem to contribute to the decline in heart performance in aging flies, suggesting that the corresponding vertebrate gene functions may similarly decline with age, in addition to their conserved role in protecting against arrhythmias and hypoxia/ischemia, respectively. The fly heart is thus emerging as a promising genetic model for studying the age-dependent decline in organ function.
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Affiliation(s)
- Karen Ocorr
- The Burnham Institute for Medical Research, Center for Neuroscience and Aging, 10901 North Torrey Pines Road, La Jolla, CA 92130, USA
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20
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Beckerman J, Mathur A, Stahr S, Myers J, Chun S, Froelicher V. Exercise-induced ventricular arrhythmias and cardiovascular death. Ann Noninvasive Electrocardiol 2005; 10:47-52. [PMID: 15649237 PMCID: PMC6932206 DOI: 10.1111/j.1542-474x.2005.00599.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Exercise-induced ventricular arrhythmias (EIVA) are frequently observed during exercise testing. However, the clinical guidelines do not specify their significance and so we examined this issue in our population. METHODS A retrospective analysis of prospectively collected data was performed on 5754 consecutive male veterans referred for exercise testing at two university-affiliated Veterans Affairs Medical Centers. Exercise test responses were recorded and cardiovascular mortality was assessed after a mean follow-up of 6 +/- 4 years. EIVA were defined as frequent premature ventricular complexes (PVCs) constituting more than 10% of all ventricular depolarizations during any 30-second ECG recording, or a run of three or more consecutive PVCs during the exercise test or recovery. RESULTS EIVA occurred in 426 patients (7.4%). There were 550 (10.6%) cardiovascular deaths during follow-up. Seventy two (17%) patients with EIVA died of cardiovascular causes, whereas 478 (9.0%) of patients without EIVA died of cardiovascular causes (P < 0.001). Patients with EIVA had a higher prevalence of cardiovascular disease, resting PVCs, resting ST depression, and ischemia during exercise than patients without EIVA. In a Cox hazards model adjusted for age, cardiovascular disease, exercise-induced ischemia, ECG abnormalities, exercise capacity and risk factors, EIVA was significantly associated with time to cardiovascular death. The combination of both resting PVCs and EIVA was associated with the highest hazard ratio. CONCLUSIONS EIVA are independent predictors of cardiovascular mortality after adjusting for other clinical and exercise test variables; combination with resting PVCs carries the highest risk.
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Affiliation(s)
- James Beckerman
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Anima Mathur
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Stephen Stahr
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Jonathan Myers
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Sung Chun
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Victor Froelicher
- Division of Cardiovascular Medicine, Stanford University Medical Center and the Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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21
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Iwamoto M, Niimura I, Shibata T, Yasui K, Takigiku K, Nishizawa T, Akaike T, Yokota S. Long-Term Course and Clinical Characteristics of Ventricular Tachycardia Detected in Children by School-Based Heart Disease Screening. Circ J 2005; 69:273-6. [PMID: 15731530 DOI: 10.1253/circj.69.273] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prognosis of ventricular tachycardia (VT) in children with overt heart disease is generally good, so the aim of this study was to review the prognosis and necessity of treatment of VT that detected by school-based heart disease screening. METHODS AND RESULTS Of the 48 cases of pediatric VT that have been followed for 2-30 years, 17% were diagnosed at the first school-based screening test (12-lead ECG at rest) and the remainder who had premature ventricular contractions (PVC) on the resting 12-lead ECG required Holter ECG test and exercise stress ECG test to detect VT. In 90% of cases, VT in healthy children is idiopathic non-sustained VT and more than half of the present cases showed natural disappearance of the VT during follow up. In particular, cases of monomorphic PVC or maximum PVC runs less than 5 had a good prognosis. The cases of polymorphic VT and VT with heart disease continued for the long term. CONCLUSION Treatment is unnecessary for monomorphic VT with the maximum number of salvos less than 5. The necessity for treatment depends on the symptoms and profile of the VT. The prognosis for polymorphic VT and underlying heart disease is not good and may require implantable cardioverter defibrillator.
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Affiliation(s)
- Mari Iwamoto
- Cardiovascular Center, Yokohama City University Medical Center, Japan.
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22
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Richardson JD, Cocanour CS, Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg 2004; 199:133-46. [PMID: 15217641 DOI: 10.1016/j.jamcollsurg.2004.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 02/20/2004] [Accepted: 02/24/2004] [Indexed: 12/20/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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23
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Affiliation(s)
- Kimberly A Selzman
- Division of Cardiology, University of North Carolina at Chapel Hill, 27599-7075, USA
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Morshedi-Meibodi A, Evans JC, Levy D, Larson MG, Vasan RS. Clinical Correlates and Prognostic Significance of Exercise-Induced Ventricular Premature Beats in the Community. Circulation 2004; 109:2417-22. [PMID: 15148273 DOI: 10.1161/01.cir.0000129762.41889.41] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Recent investigations suggest that ventricular premature beats during exercise (EVPBs) are associated with increased cardiovascular mortality in asymptomatic individuals, but mechanisms underlying the association are unclear.
Method and Results—
We evaluated 2885 Framingham Offspring Study participants (1397 men; mean age, 43 years) who were free of cardiovascular disease and who underwent a routine exercise stress test; 792 participants (27%) had development of EVPBs (median, 0.22/min of exercise). Logistic regression was used to evaluate predictors of EVPBs. Cox models were used to examine the relations of infrequent (less than or equal to median) and frequent (greater than median) versus no EVPBs to incidence of hard coronary heart disease (CHD) event (recognized myocardial infarction, coronary insufficiency, or CHD death) and all-cause mortality, adjusting for vascular risk factors and exercise variables. Age and male sex were key correlates of EVPBs. During follow-up (mean, 15 years), 142 (113 men) had a first hard CHD event and 171 participants (109 men) died. EVPBs were not associated with hard CHD events but were associated with increased all-cause mortality rates (multivariable-adjusted hazards ratio, 1.86, 95% CI, 1.24 to 2.79 for infrequent, and 1.71, 95% CI, 1.18 to 2.49 for frequent EVPBs versus none). The relations of EVPBs to mortality risk were not influenced by VPB grade, presence of recovery VPBs, left ventricular dysfunction, or an ischemic ST-segment response.
Conclusions—
In our large, community-based sample of asymptomatic individuals, EVPBs were associated with increased risk of death at a much lower threshold than previously reported. Additional studies are needed to confirm these findings and to clarify the underlying mechanisms.
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Affiliation(s)
- Ali Morshedi-Meibodi
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Mass 01702-5827, USA
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25
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Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part II: the aging heart in health: links to heart disease. Circulation 2003; 107:346-54. [PMID: 12538439 DOI: 10.1161/01.cir.0000048893.62841.f7] [Citation(s) in RCA: 797] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edward G Lakatta
- Gerontology Research Center, Intramural Research Program, National Institute on Aging, National Institutes of Health, Baltimore, Md 21224-6825, USA.
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26
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Krittayaphong R, Bhuripanyo K, Punlee K, Kangkagate C, Chaithiraphan S. Effect of atenolol on symptomatic ventricular arrhythmia without structural heart disease: a randomized placebo-controlled study. Am Heart J 2002; 144:e10. [PMID: 12486439 DOI: 10.1067/mhj.2002.125516] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ventricular arrhythmia (VA) from the right ventricular outflow tract (RVOT) is a common problem. Symptomatic patients are usually treated with beta-blockers. There is little data on the systematic evaluation of the efficacy of beta-blocker. We determine the efficacy of atenolol in the treatment of symtomatic VA from RVOT compared with placebo. METHODS AND RESULTS This was a randomized, double-blinded, placebo-controlled study. We prospectively studied 52 consecutive patients with symptomatic VA. Severity of symptoms, 24-hour ambulatory monitoring (AECG) and quality of life (QOL) were assessed at baseline and 1 month after atenolol. Exercise testing was performed at baseline. Average premature ventricular complex (PVC) count at baseline was 21,407 +/- 1740 beats per 24 hours, and 19% had ventricular tachycardia as measured by AECG. Results of this study showed that atenolol significantly decreased symptom frequency (P =.03), PVC count (P =.001) and average heart rate (P <.001) measured by AECG, whereas placebo significantly decreased symptom frequency (P =.002) but had no effect on PVC count (P =.78) or average heart rate (P =.44). Neither atenolol nor placebo had an effect on QOL. CONCLUSIONS Atenolol improves symptoms and decreases PVC count from ambulatory monitoring. Placebo improved symptoms to the same extent as atenolol but had no effect on severity of VA. This might be the so-called placebo effect, which is a concern when treating patients or doing research on the effects of a drug.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Elhendy A, Chandrasekaran K, Gersh BJ, Mahoney D, Burger KN, Pellikka PA. Functional and prognostic significance of exercise-induced ventricular arrhythmias in patients with suspected coronary artery disease. Am J Cardiol 2002; 90:95-100. [PMID: 12106835 DOI: 10.1016/s0002-9149(02)02428-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Our aims were to assess (1) the relation between exercise-induced ventricular arrhythmia (VA) and myocardial wall motion abnormalities during exercise echocardiography in patients with suspected coronary artery disease (CAD), and (2) the effect of this relation on outcome. We studied the clinical and prognostic significance of exercise-induced VA in 1,460 patients (mean age 64 +/- 10 years; 867 men) with intermediate pretest probability of CAD and no history of previous myocardial infarction or revascularization who underwent exercise echocardiography. Exercise-induced VA occurred in 146 patients (10%). Compared with patients without VA, those with VA had a greater prevalence of abnormal exercise echocardiographic findings (48% vs 29%, p = 0.001) and ischemia on exercise echocardiography (39% vs 22%, p = 0.001), greater increase in wall motion score index with exercise (0.14 +/- 0.28 vs 0.06 +/- 0.18, p <0.0001), and a greater percentage of abnormal segments with exercise (21 +/- 30% vs 9 +/- 19%, p <0.0001). During follow-up (median 2.7 years), cardiac death and nonfatal myocardial infarction occurred in 36 patients. In multivariate analysis of combined clinical and exercise stress test variables, independent predictors of cardiac events were exercise-induced VA (chi-square 4.7, p = 0.03) and exercise heart rate (chi-square 18, p = 0.0001). The percentage of abnormal myocardial segments with exercise echocardiography was the most powerful predictor of VA (chi-square 31, p = 0.0001) and cardiac events (chi-square 15, p = 0.0001). In patients with suspected CAD, exercise-induced VA is associated with a greater risk of cardiac death and nonfatal myocardial infarction. This risk is attributed to the relation between VA and the extent and severity of left ventricular functional abnormalities with exercise.
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Affiliation(s)
- Abdou Elhendy
- Division of Cardiovascular Diseases and Internal Medicine and the Section of Biostatistics, Mayo Clinic, Rochester, Minnesota 55905, USA
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28
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Aronow WS, Ahn C, Mercando AD, Epstein S, Kronzon I. Prevalence and association of ventricular tachycardia and complex ventricular arrhythmias with new coronary events in older men and women with and without cardiovascular disease. J Gerontol A Biol Sci Med Sci 2002; 57:M178-80. [PMID: 11867655 DOI: 10.1093/gerona/57.3.m178] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We report the prevalence of ventricular tachycardia (VT) and of complex ventricular arrhythmias (VA) and their association with new coronary events in older men and women. METHODS The prevalence of VT and of complex VA detected by 24-hour ambulatory electrocardiograms and the incidence of new coronary events in older persons with coronary artery disease (CAD), with hypertension, valvular disease, or cardiomyopathy without CAD, and with no cardiovascular disease was investigated in 915 men (mean age 80 +/- 8 years) and in 1,874 women (mean age 81 +/- 8 years) in a long-term health care facility. Follow-up was 45 +/- 30 months in men and 47 +/- 30 months in women. RESULTS The prevalence of VT was 16% in men and 15% in women with CAD, 9% in men and 8% in women with hypertension, valvular disease, or cardiomyopathy without CAD, and 3% in men and 2% in women with no cardiovascular disease. The prevalence of complex VA was 69% in men and 68% in women with CAD, 54% in men and 55% in women with hypertension, valvular disease, or cardiomyopathy without CAD, and 31% in men and 30% in women with no cardiovascular disease. In men and in women with CAD or with hypertension, valvular disease, or cardiomyopathy, VT and complex VA increased the incidence of new coronary events (p <.0001). Within each of the groups of patients, the incidences of new coronary events in men and in women with and without VT or complex VA were similar. CONCLUSIONS The prevalence of VT and of complex VA were similar in older men and women. VT and complex VA were associated with a higher incidence of new coronary events in men and women with CAD or with hypertension, valvular disease, or cardiomyopathy without CAD, but not in men and women with no cardiovascular disease.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York 10804, USA.
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Abstract
The ever-increasing number of older patients requiring diagnostic and prognostic assessment for coronary artery disease has necessitated accurate, noninvasive techniques applicable to this age group. Exercise testing, either alone or with radionuclide or echocardiographic imaging, remains a useful tool in elderly patients capable of performing vigorous treadmill or cycle exercise. Fortunately, for the large elderly subset incapable of such exercise, pharmacologic stress testing with dipyridamole, adenosine, or dobutamine offers an excellent alternative. Choosing the most appropriate stress testing modality for a given patient from among the many choices available remains the clinician's challenge.
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Affiliation(s)
- J L Fleg
- Laboratory of Cardiovascular Science, Gerontology Research Center, National Institute on Aging, National Institutes of Health, Baltimore, MD 21224, USA.
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30
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Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Piña IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694-740. [PMID: 11581152 DOI: 10.1161/hc3901.095960] [Citation(s) in RCA: 1121] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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31
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Affiliation(s)
- M E Tavel
- Indiana Heart Institute, Care Group, Inc, Indianapolis, IN, USA.
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32
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Evans CH, Froelicher V. Some common abnormal responses to exercise testing: what to do when you see them. Prim Care 2001; 28:219-32 ,ix. [PMID: 11346507 DOI: 10.1016/s0095-4543(05)70016-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article reviews the role of exercise testing in the assessment of patients with suspected coronary disease. To accomplish this, four major topics are considered: the general concept of risk stratification; the estimation of outcomes using data from the initial evaluation of the patient; diagnostic assessment with the exercise test; and prognostic assessment with the exercise test. This review focuses on the standard treadmill exercise test.
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Affiliation(s)
- C H Evans
- The Family Practice Residency Program, Bayfront Medical Center, 700 Sixth Street South, St. Petersburg, FL 33701, USA
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Maron BJ, Araújo CG, Thompson PD, Fletcher GF, de Luna AB, Fleg JL, Pelliccia A, Balady GJ, Furlanello F, Van Camp SP, Elosua R, Chaitman BR, Bazzarre TL. Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: an advisory for healthcare professionals from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2001; 103:327-34. [PMID: 11208698 DOI: 10.1161/01.cir.103.2.327] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Life-threatening ventricular arrhythmias in the athlete nearly always occur in the presence of structural heart disease. In the last few years, 2 new causes of life-threatening arrhythmias have been described in patients with normal hearts-that of the Brugada syndrome and that of commotio cordis. Non-life-threatening premature ventricular beats and even nonsustained ventricular tachycardia are not rare, and although usually benign, can be secondary to cardiomyopathies. Athletes with symptoms of syncope, especially if exertional, warrant a complete evaluation. The treatment of athletes and other individuals with life-threatening ventricular arrhythmias has been revolutionized by the implantable cardioverter defibrillator, a device that affords excellent protection from sudden death. Defining those athletes who would benefit from the implantable defibrillator is not always clear. Furthermore, participation in competitive athletics for athletes with life-threatening arrhythmias or structural heart disease known to put the athlete at risk for life-threatening arrhythmias is usually prohibited.
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Affiliation(s)
- M S Link
- The Cardiac Arrhythmia Service, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
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35
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Elhendy A, Sozzi FB, van Domburg RT, Bax JJ, Geleijnse ML, Roelandt JR. Relation among exercise-induced ventricular arrhythmias, myocardial ischemia, and viability late after acute myocardial infarction. Am J Cardiol 2000; 86:723-9. [PMID: 11018190 DOI: 10.1016/s0002-9149(00)01070-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This study assesses the relation between exercise-induced ventricular arrhythmia (VA) and scintigraphic markers of myocardial ischemia and viability in patients referred for exercise stress testing late after acute myocardial infarction. We studied 171 patients (144 men, age 57 +/- 10 years) with resting wall motion abnormalities by exercise stress testing in conjunction with methoxyisobutyl isonitrile (MIBI) single-photon emission computed tomography at a mean of 4.1 years after myocardial infarction. Ischemia was defined as reversible perfusion abnormalities. Myocardial viability was considered in myocardial segments with resting wall motion abnormalities in the presence of normal perfusion, a reversible defect or a fixed defect with regional MIBI uptake > or = 50% of maximal uptake. Exercise-induced VA occurred in 46 patients (27%). Patients with VA had a higher prevalence of infarct-related artery stenosis (43 [93%] vs 93 [74%], p < 0.01), peri-infarction ischemia (32 [70%] vs 54 [43%], p < 0.005), and ischemia in > or = 2 vascular regions (20 [43%] vs 27 [22%], p < 0.01) than patients without VA. Reversible defects were detected in 39 of 97 dyssynergic segments (40%) in patients with versus 40 of 248 dyssynergic segments (16%) in patients without VA (p < 0.0001). In dyssynergic segments without reversible perfusion abnormalities, the percent resting MIBI uptake was > or = 50% in 39 of 58 segments (67%) in patients with versus 63% in 131 of 208 segments in patients without VA (p = NS). The percentage of viable segments was 80% and 69% in patients with and without VA, respectively (p < 0.05). It is concluded that patients with exercise-induced VA late after myocardial infarction have a higher prevalence of ischemia in the peri-infarction zone and in multivessel distribution. Myocardial ischemia in the dyssynergic myocardium appears to be a major mechanism underlying the occurrence of VA in these patients.
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Affiliation(s)
- A Elhendy
- Thoraxcenter, University Hospital-Dijkzigt, Rotterdam, The Netherlands.
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36
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Kallinen M, Era P, Heikkinen E. Cardiac adverse effects and acute exercise in elderly subjects. AGING (MILAN, ITALY) 2000; 12:287-94. [PMID: 11073348 DOI: 10.1007/bf03339849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiac arrhythmias, ST segment depressions and other cardiac adverse effects are occasionally seen in relation to physical exercise in elderly people. However, the magnitude, quality, and time-dependence of these events need to be clarified. During voluntary maximal cycle ergometer exercise (CEE), immediate cardiac disturbances as a reason for exercise termination were registered in a sample of 75-year-old men and women (N=203) (population group, PG). Any referrals to hospital following cardiac incidents within 24 hours post-CEE were obtained from patient records. Ambulatory ECG was recorded 24 hours before and after CEE in 23 elderly subjects (12 men, 11 women) capable of maximal effort (Holter group, HG). In the PG, 23.4% of the men and 6.4% of the women had to terminate CEE because of cardiac disturbances. One subject was referred to hospital because of exercise-induced atrial fibrillation. In the HG, no long-lasting effect of exercise on the occurrence of cardiac disturbances was found in elderly subjects capable of maximal effort.
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Affiliation(s)
- M Kallinen
- Peurunka-Medical Rehabilitation and Physical Exercise Center, Laukaa, Finland.
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Abstract
OBJECTIVE To review the prognosis and management of ventricular arrhythmias (VA) in persons with and without heart disease, with emphasis on older adults. DATA SOURCES A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. STUDY SELECTION Studies on the prognosis and management of VA in persons with and without heart disease were screened for review. Studies in older persons and recent studies were emphasized. DATA EXTRACTION Pertinent data were extracted from the reviewed articles. Emphasis was placed on studies involving older persons. Relevant articles were reviewed in depth. DATA SYNTHESIS Available data on the prognosis and management of VA in persons with and without heart disease, with emphasis on studies in older persons, were summarized. CONCLUSIONS Ventricular arrhythmias in older persons without heart disease should not be treated with antiarrhythmic drugs, nor should Class I antiarrhythmic drugs be used to treat VA in older persons with heart disease. Beta-blockers should be used to treat complex VA in older persons with ischemic or nonischemic heart disease without contraindications to beta-blockers. Amiodarone should be reserved for life-threatening ventricular tachyarrhythmias in older persons who cannot tolerate or who do not respond to beta-blockers. Angiotensin-converting enzyme inhibitors should be used to treat older persons with heart failure, an anterior myocardial infarction, or a left ventricular ejection fraction < or = 40%. If older persons have life-threatening recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) resistant to antiarrhythmic drugs, invasive intervention should be performed. The automatic implantable cardioverter-defibrillator is recommended in older persons who have medically refractory sustained VT or VF.
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Affiliation(s)
- W S Aronow
- Hebrew Hospital Home, Bronx, New York 10475, USA
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Schweikert RA, Pashkow FJ, Snader CE, Marwick TH, Lauer MS. Association of exercise-induced ventricular ectopic activity with thallium myocardial perfusion and angiographic coronary artery disease in stable, low-risk populations. Am J Cardiol 1999; 83:530-4. [PMID: 10073856 DOI: 10.1016/s0002-9149(98)00908-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study sought to determine the association of exercise-induced ventricular ectopic activity with thallium perfusion defects and severity of angiographic coronary artery disease (CAD). Two cohorts consisting of adults without heart failure or known severe ventricular ectopic activity at rest were studied. The first cohort consisted of adults (n = 2,743) who underwent maximum exercise thallium stress testing. The second cohort consisted of adults (n = 423) who underwent coronary angiography within 90 days of treadmill testing. Significant exercise-induced ventricular ectopic activity was defined as frequent ventricular premature complexes or nonsustained ventricular tachycardia. Severe CAD was defined as left main CAD (> or = 50% stenosis), 3-vessel CAD (> or = 70% stenosis), or 2-vessel CAD with > or = 70% stenosis of the proximal left anterior descending artery. In the thallium cohort, exercise-induced ventricular ectopic activity was associated with a greater frequency of thallium defects (35.2% vs 18.7%, odds ratio [OR] 2.35, 95% confidence intervals [CI] 1.62 to 3.42, p <0.001); after adjusting for possible confounders, this association persisted (for any defect adjusted OR 1.66, 95% CI 1.09 to 2.53, p = 0.02; for septal defect adjusted OR 2.77, 95% CI 1.51 to 5.07, p <0.001). There was no association between exercise-induced ventricular ectopic activity and mortality during 2 years of follow-up. In the angiographic cohort, there was no association of exercise-induced ventricular ectopy with severe CAD (19% vs 20%, OR 0.93, 95% CI 0.41 to 2.09, p = NS). Exercise-induced ventricular ectopic activity was associated with a greater likelihood of thallium perfusion defects, but was not associated with angiographic severity of coronary disease or with short-term mortality.
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Affiliation(s)
- R A Schweikert
- George M. and Linda H. Kauffman Center for Heart Failure, Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Sudden cardiac death (SCD) remains a significant medical problem in the United States. The incidence of SCD increases with advancing age because cardiovascular disease is more prevalent in the elderly. Management of ventricular arrhythmias in the elderly patient is especially challenging because of increased risk of interventional and pharmacologic therapies, altered pharmacokinetics of drugs, and sometimes unclear long-term benefits.
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Affiliation(s)
- D D Tresch
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, USA
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40
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Abstract
OBJECTIVE To review the prognosis and management of ventricular arrhythmias (VA) in persons with and without heart disease with emphasis on older adults. DATA SOURCES A computer-assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles. STUDY SELECTION Studies on the prognosis and management of VA in persons with and without heart disease were screened for review. Studies in older people and recent studies were emphasized. DATA EXTRACTION Pertinent data were extracted from the reviewed articles. Emphasis was on studies involving the older persons. Relevant articles were reviewed in depth. DATA SYNTHESIS Available data about the prognosis and management of VA in persons with and without heart disease, with emphasis on studies involving older people, were summarized. CONCLUSIONS VA in older persons without heart disease should not be treated with antiarrhythmic drugs. Class I antiarrhythmic drugs should not be used to treat VA in older persons with heart disease. Beta blockers should be used to treat complex VA in older persons with ischemic or nonischemic heart disease if there are no contraindications to beta blocker therapy. The use of amiodarone in treating complex VA should be reserved for life-threatening ventricular tachyarrhythmias in older persons who cannot tolerate or who do not respond to beta blockers. VA associated with congestive heart failure should be treated with angiotensin converting enzyme inhibitors. If older patients have life-threatening recurrent ventricular tachycardia or ventricular fibrillation resistant to antiarrhythmic drugs, invasive intervention should be performed. The automatic implantable cardioverter-defibrillator is recommended in older patients who have medically refractory sustained ventricular tachycardia or ventricular fibrillation.
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Affiliation(s)
- W S Aronow
- Hebrew Hospital Home, Bronx, NY 10475, USA
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42
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Affiliation(s)
- L Goldman
- Department of Medicine, School of Medicine, University of California, San Francisco 94143
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Räihä IJ, Piha SJ, Seppänen A, Puukka P, Sourander LB. Predictive value of continuous ambulatory electrocardiographic monitoring in elderly people. BMJ (CLINICAL RESEARCH ED.) 1994; 309:1263-7. [PMID: 7888847 PMCID: PMC2541781 DOI: 10.1136/bmj.309.6964.1263] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To determine the predictive value of findings on continuous ambulatory electrocardiographic monitoring in elderly subjects. DESIGN Retrospective cohort study. Ten year follow up of randomly selected elderly subjects who participated in ambulatory electrocardiography study in 1982. Mortality data derived from official registers. SETTING Turku, Finland. SUBJECTS 480 people aged 65 or older in 1982 who were living in the community, of whom 72% agreed to participate. MAIN OUTCOME MEASURES Mortality from cardiac and non-cardiac causes during 10 year follow up. RESULTS In the univariate analysis adjusted for age, risk of death from cardiac causes was increased among those with ventricular ectopy of more than 100 beats during the day (odds ratio 2.6; 99% confidence interval 1.4 to 6.1) or at night (3.3; 1.1 to 9.8) and in those with multifocal ventricular ectopic beats during the day (2.3; 1.0 to 5.0) or night (3.0; 1.3 to 7.1) compared with those with no ventricular ectopy. Sinoatrial pauses exceeding 1.5 seconds during the day (4.5; 1.8 to 11.1) were also associated with excess mortality from cardiac causes. None of the findings on ambulatory electrocardiography predicted death from non-cardiac causes. A further study of explanatory variables in the stepwise logistic regression analysis showed that sinoatrial pauses exceeding 1.5 seconds (4.0; 95% confidence interval 1.8 to 8.9) and night time multifocal ventricular ectopy (2.7; 1.2 to 5.9) predicted excess mortality from cardiac causes independently of age or clinically evident heart disease. CONCLUSION Daytime sinoatrial pauses exceeding 1.5 seconds and night time multifocal ventricular ectopy in the ambulatory electrocardiogram predict increased mortality from cardiac causes independently of clinically evident cardiac diseases in unselected elderly subjects.
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Affiliation(s)
- I J Räihä
- Department of Geriatrics, University of Turku, Finland
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Lakatta EG. Cardiovascular reserve capacity in healthy older humans. AGING (MILAN, ITALY) 1994; 6:213-23. [PMID: 7880870 DOI: 10.1007/bf03324244] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In healthy normotensive individuals who have been rigorously screened to exclude coronary disease, the cardiovascular reserve capacity decreases with aging. A reduction in the maximum aerobic capacity is accompanied by a reduction in the maximum heart rate. Stroke volume during vigorous exercise in the upright position does not decline with aging in healthy individuals, because the left ventricular end-diastolic volume dilates more in older than in younger individuals; however, the reduction in left ventricular end-systolic volume that occurs during exercise is blunted in older individuals, resulting in a lesser increase in the left ventricular ejection fraction. This pattern of altered cardiac reserve resembles that caused by beta-adrenergic blockade, and substantial evidence indicates that the efficacy of the beta-adrenergic post synaptic response of cardiovascular tissues declines with aging. Changes in cardiac structure, e.g., enlargement of cardiac myocytes leading to a moderate heart wall thickening, and changes in vascular properties, e.g., aortic wall thickening and increased stiffness, also likely have a role in the reduction in left ventricular reserve in older individuals. Chronic exercise conditioning in older individuals increases aerobic capacity, decreases arterial stiffness and left ventricular function. The exercise heart rate deficit that occurs with aging, however, is not affected by physical conditioning.
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Affiliation(s)
- E G Lakatta
- Laboratory of Cardiovascular Science, Gerontology Research Center, National Institute on Aging, Baltimore, MD 21224
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46
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Abstract
This study assesses the persistence of arrhythmia at rest or during exercise tests, or both, after a mean follow-up period of 6.7 years in 76 young men (mean age 21.5 years) without evidence of organic heart disease. The exercise test was performed using a near-maximal protocol based on progressively increasing intermittent work loads, each of 5 minutes' duration. The initial work load was 50 W. The electrocardiogram was continuously registered throughout all stages of the examination. Arrhythmia was defined as the occurrence of greater than or equal to 1 supraventricular or 1 ventricular premature beat at any stage of the examination. At the follow-up examination, the rate of persistence of arrhythmia did not differ significantly among the subgroups, irrespective of follow-up interval, type of arrhythmia, or arrhythmia patterns of response to exercise. Two-dimensional echocardiography did not show any structural abnormalities and Doppler examination did not demonstrate significant abnormal flow patterns. Our data show that almost all patients continued to present arrhythmia after the follow-up period, without any evidence of development of organic heart disease. Moreover, the arrhythmia pattern of response to exercise remained constant throughout the years. At this time, arrhythmia without underlying heart disease seems to be of a benign natural course in these young men.
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Affiliation(s)
- Y Drory
- Cardiac Rehabilitation Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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47
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Aronow WS, Mercando AD, Epstein S, Kronzon I. Effect of quinidine or procainamide versus no antiarrhythmic drug on sudden cardiac death, total cardiac death, and total death in elderly patients with heart disease and complex ventricular arrhythmias. Am J Cardiol 1990; 66:423-8. [PMID: 2386118 DOI: 10.1016/0002-9149(90)90697-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A prospective study correlated the effect of quinidine or procainamide versus no antiarrhythmic drug on sudden cardiac death, total cardiac death and total death in 406 elderly patients with heart disease and asymptomatic complex ventricular arrhythmias detected by 24-hour ambulatory electrocardiograms. Of 397 patients treated with quinidine, 184 (46%) developed adverse effects during the first 2 weeks of therapy and were given no further antiarrhythmic therapy. Of 9 patients treated with procainamide, 2 (22%) developed adverse effects during the first 2 weeks of therapy and were given no further antiarrhythmic therapy. Adverse effects developed during long-term therapy in 6 patients (2%) receiving quinidine and in 3 patients (33%) receiving procainamide. Mean follow-up was 24 +/- 15 months in both groups. Sudden cardiac death, total cardiac death and total death occurred in 21, 43 and 65% of patients receiving quinidine or procainamide, respectively, and in 23, 44 and 63% of patients receiving no antiarrhythmic drug, respectively (difference not significant). Survival by Kaplan-Meier analysis showed no significant difference between the 2 groups for sudden cardiac death, total cardiac death or total death through 4 years. Patients with abnormal left ventricular ejection fraction had a 3.4 times higher incidence of sudden cardiac death, a 2.4 times higher incidence of total cardiac death and a 1.4 times higher incidence of total death than patients with normal left ventricular ejection fraction. These data showed no significant difference in sudden cardiac death, total cardiac death or total death between patients treated with quinidine or procainamide or with no antiarrhythmic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W S Aronow
- Hebrew Hospital for Chronic Sick, Bronx, New York 10475
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48
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Marieb MA, Beller GA, Gibson RS, Lerman BB, Kaul S. Clinical relevance of exercise-induced ventricular arrhythmias in suspected coronary artery disease. Am J Cardiol 1990; 66:172-8. [PMID: 2371947 DOI: 10.1016/0002-9149(90)90583-m] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Because there is controversy regarding the clinical relevance of exercise-induced ventricular arrhythmias, we analyzed their significance in 383 patients who had undergone both exercise thallium-201 stress-testing and cardiac catheterization. Two-hundred twenty-one patients (58%) had no exercise-induced ventricular arrhythmias while 162 (42%) did. There was no difference between patients with and without exercise-induced ventricular arrhythmias in terms of previous myocardial infarction (p = 0.61), incidence of fixed thallium-201 defects (0.06), number of diseased vessels (p = 0.09) and resting left ventricular ejection fraction (p = 0.06). In contrast, evidence of provocable ischemia (redistribution on thallium-201 and ST-segment depression on the electrocardiogram) were more likely (p less than 0.02) to be seen in patients with exercise-induced ventricular arrhythmias. Discriminant function analysis revealed that these 2 variables best separated patients with and without exercise-induced ventricular arrhythmias. In a 4- to 8-year follow-up, 89 patients had adverse cardiac events. Of these 89, there were 41 deaths, 9 nonfatal myocardial infarctions and 39 coronary revascularization procedures performed later than 3 months after catheterization. Patients with exercise-induced ventricular arrhythmias were more likely (p = 0.01) to have these events than those without these arrhythmias. Moreover, these arrhythmias provided independent prognostic information beyond that provided by the thallium-201 stress test and coronary angiography. We conclude that exercise-induced ventricular arrhythmias are associated with exercise-induced ischemia and provide prognostic information which adds marginally to that provided by other noninvasive and invasive parameters in ambulatory patients being evaluated for chest pain.
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Affiliation(s)
- M A Marieb
- Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville 22908
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