Relationship between subjective symptoms and trans-telephonic ECG findings in patients with symptomatic paroxysmal atrial fibrillation and flutter

Borg's exertion scale did not coincide with ventilatory anaerobic threshold in atrial fibrillation patients with restored sinus rhythm after ablation

The determination of precise exercise intensity is essential for effective exercise rehabilitation. The Borg rating of perceived exertion category ratio (CR) scale is utilized to prescribe an appropriate level of exertion intensity. A Borg CR of approximately 13 coincides with the ventilatory aerobic threshold (VAT). Patients with atrial fibrillation (AF) exhibit various symptoms. We hypothesized that the workload at Borg CR13 (Borg CR13-Watt) differs from the workload at the VAT level (VAT-Watt) in AF patients with restored sinus rhythm (SR) following ablation. Accordingly, the relationship between Borg CR13-Watt and VAT-Watt was studied in patients with restored SR. Cardiopulmonary exercise testing (CPET) was performed at 101±88 days after ablation in 150 patients using a bicycle ergometer. No adverse events were observed during CPET. Borg CR13-Watt was significantly higher than VAT-Watt (67.2±27.8 Watt vs. 54.7±17.6 Watt, P<0.0001). Borg CR13-Watt showed significant linear regression with VAT-Watt (regression coefficient, 0.49, P<0.01; correlation coefficient, 0.80, P<0.01). Higher Borg CR13-Watt was associated with greater differences between Borg CR13-Watt and VAT-Watt (ΔWatt). The Bland-Altman plot showed nonconcordance between the two. Male sex, use of antiarrhythmic drugs, and smoking had contributed to the increased ΔWatt. Duration from ablation to time of CPET did not correlate with ΔWatt. Therefore, Borg CR13-Watt did not coincide with VAT-Watt in patients with restored SR. Higher Borg CR13-Watt was associated with greater ΔWatt. Prescribing exertion intensity as determined solely by perceived exertion is inadequate. CPET is required to determine the precise exercise intensity in AF patients with restored SR after ablation.

The Amplification of Symptoms in the Medically Ill

The mechanism of symptom amplification, developed in the study of somatization, may be helpful in caring for patients with symptoms that, while they have a demonstrable medical basis, are nonetheless disproportionately severe and distressing. Amplified medical symptoms are marked by disproportionate physical suffering, unduly negative thoughts and concerns about them, and elevated levels of health-related anxiety. They are accompanied by extensive and sustained illness behaviors, disproportionate difficulty compartmentalizing them and circumscribing their impact, and consequent problems and dissatisfaction with their medical care. A distinction has long been made between "medically explained" and "medically unexplained" symptoms. However, a more comprehensive view of symptom phenomenology undermines this distinction and places all symptoms along a smooth continuum regardless of cause: Recent findings in cognitive neuroscience suggest that all symptoms-regardless of origin-are processed through convergent pathways. The complete conscious experience of both medically "explained" and "unexplained" symptoms is an amalgam of a viscerosomatic sensation fused with its ascribed salience and the patient's ideas, expectations, and concerns about the sensation. This emerging empirical evidence furnishes a basis for viewing persistent, disproportionately distressing symptoms of demonstrable disease along a continuum with medically unexplained symptoms. Thus, therapeutic modalities developed for somatization and medically unexplained symptoms can be helpful in the care of seriously ill medical patients with amplified symptoms. These interventions include educational groups for coping with chronic illness, cognitive therapies for dysfunctional thoughts, behavioral strategies for maladaptive illness behaviors, psychotherapy for associated emotional distress, and consultation with mental health professionals to assist the primary care physician with difficulties in medical management.

Association of spontaneous echo contrast with Systemic Immune Inflammation Index in patients with mitral stenosis

OBJECTIVE

Spontaneous echo contrast (SEC) is the appearance of swirling, smoke-like echoes in the left atrium (LA) and is accepted as an independent predictor of thromboembolic risk. There is an established relationship between the inflammatory state and the prothrombotic state. Therefore, we investigated the relationship between the Systemic Immune Inflammation Index (SII), a new inflammation parameter introduced recently, and SEC in patients with mitral stenosis (MS).

MATERIAL AND METHODS

A total of 262 patients who underwent percutaneous mitral valvuloplasty (PMBV) for MS were included in this study. The patients were divided into two groups: patients with MS complicated by SEC and patients with MS without SEC, based on whether SEC occurred in the LA.

RESULTS

There were 79 patients (mean age 47.1 ± 6.6, 30.3% male gender) in the SEC (+) group, while there were 183 patients (mean age 46.4 ± 8.6, 29.5% male gender) in the SEC (-) group. In multivariate analysis, high levels of SII were an independent risk factor for SEC in patients with MS (OR: 1.001, 95% confidence interval (CI): 1.000-1.001, p<0.001) together with high levels of C-reactive protein (OR: 1.145, 95% CI: 1.027-1.277, p=0.014). The receiver operating characteristics (ROC) curve analysis showed that at a cutoff value of 547.6 for SII to predict SEC with 74.6% sensitivity and 77.6% specificity (area under ROC curve=0.736 (95% CI: 0.668-0.805), p<0.001).

CONCLUSION

Our study showed that the SII levels were independently associated with SEC in patients with MS.

Advantages of using a portable cardiac monitor in outpatients with paroxysmal atrial fibrillation

Aim. To study the advantages of using a portable electrocardiographic (ECG) monitor in outpatients with paroxysmal atrial fibrillation (AF).

Material and methods. We examined 88 patients (26 men, 62 women, mean age, 63 [57;68] years) with paroxysmal AF with an average frequency of arrhythmia episodes of 1,0 [0.3;3.75] per month. Forty three (49%) patients were included in the remote monitoring (RM) group using the ECG Dongle monitor, and 45 (51%) patients were included in the conventional monitoring (CM) group. Patients underwent scheduled examinations 2, 6 and 12 months after the start of therapy. Unscheduled consultations were carried out in case of AF recurrence. Patients from the RM group, using portable cardiac monitor, additionally self-registered ECG 1 time per week and in case of symptoms suggestive of AF. ECG strips were sent to the clinical investigator for analysis.

Results. With the help of portable cardiac monitor, 2477 ECG strips were collected and analyzed: 2159 (87,2%) — sinus rhythm, 318 (12,8%) — AF and atypical atrial flutter. Forty four episodes of AF in 3 patients were asymptomatic. In addition, 211 (8,5%) sinus rhythm ECG strips were recorded by 13 patients with symptoms suggestive of AF. In the RM group, 7 (16%) patients were hospitalized due to recurrent AF, while in the CM group, 20 (44%) patients (p=0,004). The total number of emergency hospitalizations was 8 and 29 in the RM and CM groups, respectively. The number of patients who called an ambulance was significantly lower in the RM group: in the CM group, 37 calls for an ambulance were made by 22 patients, while in the RM group — 12 patients made 15 calls (p=0,044). The proportion of calls followed by hospitalization (40 vs 70%, p=0,043) was significantly lower in the RM group.

Conclusion. Remote ECG monitoring using the ECG Dongle system is a useful way to monitor patients with paroxysmal AF, which make it possible to register asymptomatic AF episodes, differentiate the causes of palpitations, and significantly reduce the frequency of emergency calls and hospitalizations.

Symptoms and the body: Taking the inferential leap

The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of "medically unexplained" or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account.

Subjectively reported symptoms in patients with persistent atrial fibrillation and emotional distress

Background: Patients with atrial fibrillation (AF) are characterized by emotional distress and poor quality of life. Little is known about the relation between emotional distress and subjectively reported AF symptoms. Our aims were to compare emotional distress levels in AF patients with distress levels in the general population and to examine the cross-sectional and prospective relationship between subjective AF symptom reports and emotional distress around electrical cardioversion (ECV).

Methods: At baseline, this study included 118 patients with persistent AF planned for ECV (aged 68 ± 10 years, 60% men) in which depression (BDI), anxiety (STAI), Type D personality (DS14), perceived stress (PSS-10), and AF symptoms (ATSSS) were assessed. The prospective substudy included 52 patients. Objective AF status was determined by ECG.

Results: AF patients experienced significantly higher levels of anxiety (p < 0.001) and depression (p < 0.001) than age and gender matched persons from the general population. Linear regression analyses showed that AF patients with higher depression levels reported significantly more AF symptoms (β = 0.44; p < 0.0005) and reported symptoms to occur with a higher frequency (β = 0.51; p < 0.0005) during the AF episode, independent of age, sex, cardiac disease, BMI, and physical activity. At 4 weeks follow-up, 56% of all patients had maintained sinus rhythm. Repeated Measures Linear mixed modeling showed that these patients reported fewer AF symptoms and a lower frequency of AF symptoms pre and post-ECV (p = 0.04). Also, the course of the number and frequency of reported symptoms was significantly associated with the change in depression over that same time period (p < 0.0005).

Conclusion: Patients with persistent AF are characterized by emotional distress. Distressed AF patients, particularly the depressed, report more AF symptoms before and after ECV. These findings call for increased attention of clinicians to emotional distress in this patient population.

Relationship between platelet indices and spontaneous echo contrast in patients with mitral stenosis

AIMS

To determine the association of platelet indices with spontaneous echo contrast (SEC) in patients with mitral stenosis.

METHODS AND RESULTS

A total of 232 consecutive patients with mitral stenosis who undergoing mitral balloon valvuloplasty were enrolled to the study. Patients were divided into two groups according to the formation of SEC in the left atrium. Group 1: mitral stenosis complicated with SEC; Group 2: mitral stenosis without SEC. Transthoracic echocardiography and transoesophageal echocardiography were performed for each patient. Complete blood counting parameters were measured and all routine biochemical tests were performed. There were 133 patients (mean age 42 ± 11 and 74% female) in the SEC(-) group and 99 patients (mean age 45 ± 10 and 64% female) in the SEC(+) group. Plateletcrit (0.25 ± 0.06 vs. 0.27 ± 0.07, P = 0.043) and mean platelet volume (MPV) levels (9.4 ± 1.1 vs. 10.4 ± 1.2, P < 0.001) were significantly higher in the SEC(+) group. When we divided the SEC(+) patients into four subgroups according to previously reported criteria, MPV levels increased to correlate with the degree of SEC (P < 0.001). At multivariate analysis, MPV levels [odds ratio (OR) 2.365, 95% confidence interval (CI) 1.720-3.251; P < 0.001] and PCT levels (OR 2.699, 95% CI 1.584-4.598; P= 0.033) are independent risk factors of SEC in patients with mitral stenosis.

CONCLUSION

In patients with mitral stenosis, cheaply and easily measurable platelet indices including MPV and PCT levels are associated with the presence of SEC and are independent risk factors of SEC.

A unique iatrogenic organized left atrial tachycardia with a gap conduction in previously ablated lesions

This case concerns a 57-year-old woman with an organized left atrial tachycardia (AT) after pulmonary vein (PV) isolation. The left inferior PV (LIPV) exhibited a figure of eight tachycardia around the LIPV ostium with one loop at the anterior aspect and another at the posterior aspect, which corresponded to regular surface P waves. Although a gap ablation of fractionated electrograms changed the LIPV sequence, the atrial potentials were organized with a shortened cycle length accompanied by the same surface P-wave morphology. The elimination of the anterior loop and modification of the posterior loop after the gap ablation might have yielded that specific sequence change of the AT.

Quantitative assessment of cibenzoline administration for vagally mediated paroxysmal atrial fibrillation using frequency-domain heart rate variability analysis

BACKGROUND

Cibenzoline (CBZ), a class I antiarrhythmic drug, has been widely used to maintain sinus rhythm in patients with paroxysmal atrial fibrillation (P-AF). This agent has an anticholinergic action and will become the drug of first choice for vagally mediated P-AF. We assessed its efficacy quantitatively by analyzing the frequency-domain heart rate variability (FD-HRV) of the Holter electrocardiogram (ECG) in patients with vagal P-AF.

METHODS

We enrolled 65 consecutive patients with vagal P-AF, but 31 patients were excluded because of the occurrence of significant arrhythmias during the 24-h Holter recordings. Accordingly, CBZ was administered to the remaining 34 patients. After administration, a Holter ECG recording was made again. High frequency (HF) components, i.e., vagal tone index, on the FD-HRV analysis from 00:00 h to 06:00 h were used for assessment. In 14 patients, the treatment was changed to disopyramide (DSP) and the same analyses were performed.

RESULTS

In two patients, the FD-HRV analysis was not utilized after administration. Finally, 32 patients were available for evaluation. CBZ was considered effective for vagal P-AF in 24 patients (75%). After administration, the HF component levels decreased (1589+/-795 ms(2) vs. 850+/-524 ms(2), p<0.0001). Comparison of the pre-administration HF component levels between the CBZ-responsive group and the CBZ-non-responsive group showed higher levels in the CBZ-responsive group (1766+/-758 ms(2) vs. 1058+/-690 ms(2), p=0.026). Although no significant difference in the reduction of the HF component levels was found between CBZ and DSP, DSP had anticholinergic side effects in two patients (14%).

CONCLUSIONS

In vagal P-AF patients, larger HF components on the FD-HRV analysis could be a hallmark of the antiarrhythmic action of CBZ. The reduction in the HF component levels after drug administration is useful for a quantitative assessment of anticholinergic action.

Increased mean platelet volume in rheumatic mitral stenosis: a possible factor for thromboembolic events

BACKGROUNDS

Systemic embolism is an important complication in patients with rheumatic mitral stenosis (RMS). The mean platelet volume (MPV) is considered a marker and determinant of platelet function since larger platelets are hemostatically more reactive than platelets of normal size, increasing the propensity to thrombosis. The aim of this study was to investigate MPV in patients with RMS and healthy control subjects.

METHODS

We selected 30 consecutive patients with RMS and 31 consecutive healthy age- and sex-matched control subjects. All subjects were in sinus rhythm. We measured MPV in a blood sample collected in EDTA.

RESULTS

Demographic data of the RMS (mean age: 39.5+/-9.9 years, 22 [71%] female) and control groups (mean age: 39.2+/-9.3 years, 20 [67%] female) were similar. The MPV was significantly higher in patients with RMS 8.8 (8.2-11.3) fl than control subjects 8.1 (7.1-9.3) (P<0.001).

CONCLUSION

Elevated MPV might be considered as a marker of increased thromboembolic risk in patients with RMS. We suggest that patients with high MPV values might benefit from antiplatelet therapy.