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Sun S, Zhang H, Xiong X. The attitudes about life-sustaining treatment among cardiac surgery ICU patients and their families. Front Surg 2023; 10:1079337. [PMID: 37273824 PMCID: PMC10235522 DOI: 10.3389/fsurg.2023.1079337] [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: 10/25/2022] [Accepted: 04/26/2023] [Indexed: 06/06/2023] Open
Abstract
Purpose To investigate the attitudes among cardiac surgery ICU patients and their families regarding life-sustaining treatment. Methods A total of 172 pairs of patients in the cardiac surgery ICU of Nanjing First Hospital and their family members were enrolled in this study that examined their attitudes toward life-sustaining treatment using a willingness to care for life-sustaining treatment questionnaire. The consistency of the attitudes of patients and family members toward life-sustaining treatment was analyzed by the chi-square test with a paired design. Results The most popular life-sustaining treatment for cardiac ICU patients was noninvasive mechanical ventilation (79.1%); the most unpopular was intra-aortic balloon counterpulsation (48.3%). Most patients and their families had not considered electric defibrillation (65.7%), but most understood and were willing to permit cardiopulmonary resuscitation (76.2%). Few family members agreed that patients should receive a pacemaker (25.0%). The consistency of life support attitudes of patients and their families ranged from 12.8% to 60.5% for procedures both would agree to, 1.2% to 19.8% for procedures they were unwilling to permit, and 0.6% to 39.0% for procedures they had not considered. Kappa values ranged from 0.218 to 0.597 (P < 0.05), with general consistency. Conclusion Cardiac surgery ICU patients families are generally consistent in their attitudes toward life-sustaining treatment, and family members' choices are not representative of patients' wishes.
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Affiliation(s)
- Si Sun
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing City, China
| | - Hao Zhang
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, Nanjing City, China
| | - XiaoYan Xiong
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing City, China
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2
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Perings C, Wolff C, Wilk A, Witthohn A, Voss R, Rybak K. Do implantable loop recorders impact the survival of patients with recurrent unexplained syncope? J Comp Eff Res 2021; 10:285-294. [PMID: 33499667 DOI: 10.2217/cer-2020-0242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study compares the outcomes of patients who receive an implantable loop recorder (ILR) for unexplained syncope to a control group without the diagnostic device in German claims data. Methods and materials: Patients with ILR were matched to a control group based on prior syncope events, age, gender and Charlson Comorbidity index (CCI). Survival, syncope hospitalizations, treatment and costs were compared. Results/conclusion: Four hundred and twelve ILR patients were matched with controls, mean age was 68, mean CCI was 2.7, 42% females. ILR patients lived on average 1.2 years longer than patients in the control group. Twenty-five percent of ILR patients received a therapeutic device compared with 5% in the control group. ILRs might help to diagnose and treat patients with positive impact on survival.
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Affiliation(s)
- Christian Perings
- Department of Cardiology, St. Marien-Hospital, Altstadtstraße 23, 44534 Lünen, Germany
| | - Claudia Wolff
- Medtronic International Trading Sarl, Route du Molliau 31,1131 Tolochenaz, Switzerland
| | - Adrian Wilk
- Team Gesundheit, Gesellschaft für Gesundheitsmanagement GmbH, Rellinghauser Str. 93, 45128 Essen, Germany
| | | | - Rainer Voss
- Medtronic GmbH, Earl-Bakken-Platz 1, 40670 Meerbusch, Germany
| | - Karin Rybak
- Kardiologische Praxis, Kochstedter Kreisstraße 11, 06847 Dessau-Roßlau, Germany
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Irfan M, Khan I, Ullah Bacha K. Delays in Temporary and Permanent Pacemakers: Causes and In-Hospital Outcomes. Cureus 2020; 12:e6953. [PMID: 32190503 PMCID: PMC7067517 DOI: 10.7759/cureus.6953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Temporary pacemakers frequently serve as a bridge to permanent pacemakers, but placement of the latter may be delayed. This study assessed the causes and in-hospital outcomes of patients with delayed placement of permanent pacemakers. Methods This retrospective study included all patients admitted to the Emergency Department who underwent temporary transvenous pacing in the Department of Cardiology, Lady Reading Hospital, Peshawar, Pakistan. The duration of hospitalization and the time from temporary to permanent placement were calculated in days. Asystole, infections, cardiac arrest, and death were recorded during the waiting period. Results Of the 260 patients who underwent temporary transvenous pacing, 136 (52.3%) were males and 124 (47.7%) were females, with an age range of 46-78 years. Coronary artery disease was prevalent in 34% of the patients. Only 5% of the patients were on arteriovenous (AV) nodal blocking agents, 44% had complete AV block, 22% had sinus node disease, and 14% had slow atrial fibrillation. The cause of high-degree AV block could not be determined in most patients. Most patients with ischemia- and hyperkalemia-induced AV block recovered. AV blocks induced by ischemia and with no known cause were not reversible, with most of these patients receiving permanent pacemakers. Of the 260 patients with high-degree AV block, 165 (63.5%) recovered. The mean waiting time for permanent pacemaker implantation was 8.7 ± 5.4 days. The waiting time was associated with increased infections and adverse hospital course. Conclusion A longer waiting period between permanent pacemaker indication and implantation is dangerous, as it is associated with an increased risk of adverse events such as infections, syncope, asystole, malignant arrhythmias, cardiac arrest, and death.
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Affiliation(s)
| | - Imran Khan
- Cardiology/Clinical Cardiac Electrophysiology, Lady Reading Hospital, Peshawar, PAK
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Thrysoee L, Thorup CB, Rasmussen TB, Borregaard B, Christensen AV, Juel K, Ekholm O, Vamosi M, Banke A, Berg SK. Patient-reported outcomes at hospital discharge among patients with arrhythmia: Results from the national DenHeart survey. Eur J Cardiovasc Nurs 2019; 19:248-259. [PMID: 31744327 DOI: 10.1177/1474515119888813] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patient-reported outcomes are important predictors of mortality, cardiovascular events and hospitalisation in patients with cardiac diseases, but differences in patient-reported outcomes between groups of patients with arrhythmia have not yet been investigated. AIMS To describe and compare patient-reported outcomes at discharge among patients with different types of cardiac arrhythmia and to examine the associations between demographic characteristics, inhospital factors and patient-reported outcomes. METHODS Data were derived from the national DenHeart study including patient-reported outcomes from the following questionnaires: the hospital anxiety and depression scale (HADS), HeartQoL, short form 12 (SF-12), current health status (EQ-5D), brief illness perception questionnaire (B-IPQ) and the Edmonton symptom assessment scale (ESAS). Clinical and demographic data were obtained from national registers. Multiple linear and logistic regression models were used to investigate the associations between the potential risk factors and the patient-reported outcomes. RESULTS A total of 4251 patients diagnosed with arrhythmia completed the questionnaire. Across the arrhythmia subgroups, some differences were observed. In general, patient-reported outcome scores were worst among patients with 'ventricular arrhythmia' (e.g. highest depression scores and highest prevalence of feeling unsafe at discharge). Regression analysis revealed that longer hospital stay, female gender, being unmarried and having a short education were significantly associated with poor health for almost all arrhythmia subgroups. CONCLUSION Differences exist in self-reported health, quality of life and symptom burden across arrhythmia groups with patients with ventricular arrhythmia reporting poorer patient-reported outcomes. Longer hospital stay, female gender, being unmarried and having a low level of education were significantly associated with worse outcomes among the total population.
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Affiliation(s)
- Lars Thrysoee
- Department of Cardiology, Odense University Hospital, Denmark.,Department of Health Sciences, Department of Clinical Research, University of Southern Denmark, Denmark
| | - Charlotte Brun Thorup
- Department of Cardiology and Department of Cardiothoracic Surgery and Clinical Nursing Research Unit, Aalborg University Hospital, Denmark
| | | | - Britt Borregaard
- Department of Health Sciences, Department of Clinical Research, University of Southern Denmark, Denmark.,Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark
| | | | - Knud Juel
- National Institute of Public Health, University of Southern Denmark, Denmark
| | - Ola Ekholm
- National Institute of Public Health, University of Southern Denmark, Denmark
| | - Marianne Vamosi
- Section for Nursing Department of Public Health, Aarhus University, Department of Cardiology, Aarhus University Hospital, Denmark
| | - Ann Banke
- Department of Cardiology, Odense University Hospital, Denmark.,Department of Health Sciences, Department of Clinical Research, University of Southern Denmark, Denmark
| | - Selina Kikkenborg Berg
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Denmark.,National Institute of Public Health, University of Southern Denmark, Denmark
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5
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Ludwig S, Theis C, Wolff C, Nicolle E, Witthohn A, Götte A. Complications and associated healthcare costs of transvenous cardiac pacemakers in Germany. J Comp Eff Res 2019; 8:589-597. [PMID: 31099255 DOI: 10.2217/cer-2018-0114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study evaluated the occurrence and associated costs of pacemaker complications in Germany from 2010 to 2013. Patients & methods: Patients with a de novo or replacement implantation of a single or dual chamber pacemaker between 2010 and 2013 were followed for 12 months post-implant using German health insurance claims data. A case-control analysis was performed using propensity score matching to estimate the costs of complications. Results: Out of 12,922 implanted patients, 12.0% had a complication in the year following the implant. Complications related to lead and pocket were found in 10.2% of all implanted patients; infections occurred in 1.7% patients. Healthcare costs up to 36 months post complication were on average €4627 higher than for pacemaker patients without a complication. Conclusion: Pacemaker complications are common and represent a burden for patients and healthcare systems generating substantial costs. Most of the pacemaker complications involved the pacing lead or pacemaker pocket.
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Affiliation(s)
- Saskia Ludwig
- HGC GesundheitsConsult GmbH, Mörsenbroicher Weg 200, 40470 Duesseldorf, Germany
| | - Cathrin Theis
- Robert-Bosch-Krankenhaus, Zentrum für Innere Medizin III Kardiologie, Auerbachstraße 110, 70376 Stuttgart, Germany
| | - Claudia Wolff
- Medtronic International Trading Sàrl, Route du Molliau 31, 1131 Tolochenaz, Switzerland
| | - Emmanuelle Nicolle
- Medtronic International Trading Sàrl, Route du Molliau 31, 1131 Tolochenaz, Switzerland
| | | | - Andreas Götte
- St. Vincenz Hospital Paderborn, Dept of Cardiology & Intensive Care Medicine, Am Busdorf 2, 33098 Paderborn, Germany
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Narasimhan C, Sanyal J, Sethi R, Kothari Y, Malik FTN, Pandurangi U, Khan N, Sahu S, Lande J, Sachanandani H, Naik A. Under-utilization of pacemaker therapy for sinus node dysfunction - Real world data from South Asia. Indian Heart J 2017; 69:607-612. [PMID: 29054184 PMCID: PMC5650562 DOI: 10.1016/j.ihj.2017.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 02/20/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood - particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort. METHODS The prospective study enrolled patients with heart rate of ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy. RESULTS A total of 508 patients meeting criteria were enrolled and followed on average for 8.3±8.0months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined - not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant. CONCLUSIONS In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.
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Affiliation(s)
- C Narasimhan
- Division of Electrophysiology, Department of Cardiology, CARE Hospitals and CARE Foundation, Hyderabad, India.
| | - J Sanyal
- Mission Hospital, Bidhannagar Durgapur, West Bengal, India
| | - R Sethi
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Y Kothari
- RajaRajeswari Medical College & Hospital, Bangalore, Karnataka, India
| | - F T N Malik
- National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh
| | - U Pandurangi
- Madras Medical Mission Institute of Cardiovascular Diseases, Chennai, Tamil Nadu, India
| | - N Khan
- United Hospital Limited, Dhaka, Bangladesh
| | - S Sahu
- India Medtronic Pvt. Ltd., Mumbai, Maharashtra, India
| | - J Lande
- Medtronic plc, Mounds View, MN, USA
| | | | - A Naik
- Care Institute of Medical Sciences, Ahmedabad, Gujarat, India
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Figueroa C, Alcocer L, Ramos B. Psychological Intervention to Modify Anxiety, Depression and Quality of Life in Patients with an Implantable Pacemaker. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/psych.2016.73040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Barros RTD, Carvalho SMRD, Silva MADM, Borges JBC. Evaluation of patients' quality of life aspects after cardiac pacemaker implantation. Braz J Cardiovasc Surg 2014; 29:37-44. [PMID: 24896161 PMCID: PMC4389479 DOI: 10.5935/1678-9741.20140009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 01/06/2014] [Indexed: 01/16/2023] Open
Abstract
Objective To evaluate patients' quality of life aspects after pacemaker implantation,
relating it to gender, age, and implantation timespan. Methods A total of 107 clinically stable patients of both genders (49.5% women and 50.5%
men) over 18 years old (average 69.3±12.6 years) and presenting an
implantation timespan of three to 12 months (average 6.36±2.99
months) were evaluated. The evaluation included personal, clinical, and implant
data as well as quality of life questionnaires (AQUAREL and SF-36). Statistical
analysis was conducted using the t test and Pearson correlation, with a 5%
significance level. Results The lowest SF-36 score referred to physical aspects, and the highest score
referred to social aspects. In AQUAREL, the lowest score referred to dyspnea, and
the highest referred to discomfort. There was a significant association between
gender and quality of life in SF-36 (physical functioning and emotional aspects)
and in AQUAREL (dyspnea). A negative correlation was observed between age and
quality of life (functional capacity in SF-36, and discomfort in AQUAREL) in
relation to implantation timespan, a correlation with vitality from SF-36. Conclusion Lower quality of life scores were found in physical aspects and dyspnea; and
higher scores in social aspects and discomfort. Men presented higher quality of
life scores related to physical functioning, emotional aspects and dyspnea. As age
increases, quality of life worsens regarding functional capacity and discomfort;
and the longer the pacemaker implantation timespan, the worse quality of life when
it comes to vitality. Gender, age, and implantation timespan influence quality of
life; thus, these variables must be considered in strategies for improving quality
of life of patients with pacemakers.
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9
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Long term quality-of-life in patients with bradycardia pacemaker implantation. Int J Cardiol 2013; 168:2159-63. [DOI: 10.1016/j.ijcard.2013.01.253] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 11/27/2012] [Accepted: 01/18/2013] [Indexed: 11/22/2022]
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Guiraudon GM, Jones DL, Bainbridge D, Cohen L, Lecompte Y, Hidden-Lucet F, Frank R, Pavie A. Hybrid Access to Atria via the Guiraudon Universal Cardiac Introducer for Arrhythmia Ablation after Total Cavopulmonary Derivation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012. [DOI: 10.1177/155698451200700312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Douglas L. Jones
- Departments of Physiology & Pharmacology, Massy, France
- Departments of Medicine, Massy, France
| | | | | | | | | | - Robert Frank
- Unite de Rythmologie Institut du Coeur, Paris, France
| | - Alain Pavie
- Service de Chirurgie Cardiaque Hopital Pitie-Salpetriere, Paris, France
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Incidence and predictors of short- and long-term complications in pacemaker therapy: The FOLLOWPACE study. Heart Rhythm 2012; 9:728-35. [DOI: 10.1016/j.hrthm.2011.12.014] [Citation(s) in RCA: 337] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Indexed: 12/22/2022]
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12
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Hybrid Access to Atria via the Guiraudon Universal Cardiac Introducer for Arrhythmia Ablation after Total Cavopulmonary Derivation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 7:217-22. [DOI: 10.1097/imi.0b013e318265f5a6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the first use of a new platform, the Guiraudon Universal Cardiac Introducer (GUCI), in humans for accessing the left atrium for catheter-based ablations in patients with resistant atrial arrhythmias after total cavopulmonary derivation. The GUCI was originally designed for intracardiac access for closed, beating instrumental intracardiac surgery. The patient was a 29-year-old man with problematic atrial arrhythmias resistant to antiarrhythmic drugs because of severe uncontrolled bradycardia and because his pacemaker was explanted for infection. The GUCI was attached to the left atrial appendage via an anterior left thoracotomy. The GUCI was modified to accommodate introduction and manipulation of multiple catheters. This allowed electrophysiologists to perform catheter-based exploration and ablation. A DDD pacemaker was implanted, with an atrial endocardial lead introduced via the GUCI cuff and a ventricular epicardial lead. Postoperative atrial arrhythmias were controlled using amiodarone and atrial pacing. At the 12-month follow-up, the patient was arrhythmia- and drug-free and returned to full employment. This new access offers an additional new alternative atrial access to treat resistant arrhythmia after total cavopulmonary derivation. The current state-of-the-art makes patient selection difficult and uncomfortable for the surgeons because of incomplete preoperative electrophysiological data, such as a return to the beginning of surgery for arrhythmia; however, more cumulative experience with intraoperative electrophysiological data and new mapping technologies should address these limitations.
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Udo EO, van Hemel NM, Zuithoff NPA, Kelder JC, Crommentuijn HA, Koopman-Verhagen AM, Voskuil T, Doevendans PAFM, Moons KGM. Long-term outcome of cardiac pacing in octogenarians and nonagenarians. Europace 2011; 14:502-8. [DOI: 10.1093/europace/eur329] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tagney J. A literature review comparing the experiences and emergent needs of adult patients with permanent pacemakers (PPMs) and implantable cardioverter defibrillators (ICDs). J Clin Nurs 2010; 19:2081-9. [DOI: 10.1111/j.1365-2702.2009.03031.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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15
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Cunnington MS, Plummer CJ, McComb JM. Delays and adverse clinical outcomes associated with unrecognized pacing indications. QJM 2009; 102:485-90. [PMID: 19474111 DOI: 10.1093/qjmed/hcp066] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A recent UK audit showed that a significant proportion of patients who received pacemakers had pacing indications previously overlooked, leading to significant delays to pacemaker implantation. AIM To investigate the reasons for, and morbidity associated with, overlooked pacing indications. DESIGN Prospective observational study in a UK regional pacing centre and its referring district hospitals. METHODS Hospital records from referring and implanting centres were reviewed for 95 consecutive patients undergoing first pacemaker implant to determine symptoms, investigations and hospitalisations occurring after documentation of a pacing indication. RESULTS Thirty-three of ninety-five patients (35%) had a pacing indication overlooked, which was Class I in 14 patients and Class IIa in 19. Reasons for not making a pacing referral in these patients included: failure to recognize the indication in 14, making adjustments to potentially culprit medication in 15 and requesting additional 'confirmatory' tests in 4. Twenty-six patients (79%) with missed indications experienced adverse events after documentation of an indication, and before receiving a pacemaker: 23 had ongoing symptoms (including one cardiac arrest), three received temporary pacing wires and 18 were hospitalized with symptoms related to cardiac rhythm. Twenty-seven patients (82%) had a total of 38 additional specialist investigations after documentation of a pacing indication. CONCLUSION Documentation of an indication for pacing failed to trigger referral for permanent pacing in 35% of patients. This failure led to significant delays, morbidity and use of health service resource, which may have been avoided if timely recognition of the pacing indication had prompted referral. Failure to recognize pacing indications and reassessing symptoms and repeating investigation after changes to medication, often required for the management of associated tachyarrhythmias or other medical conditions, contribute to these delays, perhaps unnecessarily.
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Affiliation(s)
- M S Cunnington
- Department of Cardiology, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK.
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