Understanding needs and expectations of heart failure patients and their caregivers regarding digital health - the PASSION-HF project

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE

Background/Introduction

Current heart failure (HF) healthcare provision is not sufficient. Due to demographic changes and subsequent increases in comorbidities, along with unequal distribution of medical care in rural areas, alternative approaches need be sought. The use of eHealth applications has potential to enable patients to become more self-sufficient. The "PASSION-HF" project aims to develop an interactive decision-making system – a virtual doctor – that provides solutions based on current guidelines and artificial intelligence. Patient independence is maximized through 24/7 access to personalized HF-management. Furthermore, the application defines decision points, where medical professionals need to be included.

Purpose

To understand needs and expectations of HF patients and their informal caregivers in regard to a virtual doctor.

Methods

We conducted an exploratory mixed-methods study within the Netherlands, UK, Ireland and Germany. Semi-structured qualitative interviews were supplemented by a standardized questionnaire. The interviews focused on i) acceptance and motivation to use a virtual doctor and ii) experience and perception of current health care provision. The interviews were analysed using the content analysis according to Mayring (2010) with the help of "ATLAS.TI" software. Additional information about the role of informal caregivers, technology acceptance and decision-making processes was collected via questionnaires.

Results

A total of 49 patients and 33 informal caregivers were interviewed. Most patients were male (76%), aged between 60 and 69 years (43%). Three key themes were identified in regard to an interactive decision-making system: 1) Reassurance, because patients felt uncertain about their condition and their symptoms, they had a strong desire for an application that could monitor their health 24/7, was able to spot deteriorations, before they occured and gave them instant feedback about their current health status; 2) Personalized advice, e.g. patients wanted the virtual doctor to adapt medication, sport activities and food recommendations to their current health status; and 3) Transparency, e.g. patients wanted to know, where the recommendations are coming from and justifications for management modifications. Interview findings also identified that the HF-nurses play a significant role in the care and management of the condition. Across all countries with HF-nurses, they were the primary point of contact, when patients had any HF related concerns. 

Conclusion

The findings provide valuable information for the development and implementation of eHealth solutions. Patients want reassurance, independently of the availability of healthcare services, combined with personalized advice regarding day-to-day management of their HF. For the next step, we are planning a multicentre clinical trial to test the prototype of the application. Here all decisions are examined by a clinical committee and benefits are evaluated.

The von Willebrand Factor in Myocardial Infarction and Unstable Angina: A Kinetic Study

Recent studies have demonstrated elevations of von Willebrand Factor following acute myocardial infarction (AMI). In order to determine if this parameter may serve as a marker for AMI, we tested the blood levels of vWF and Factor VIII :C in 28 patients with AMI, 9 patients with unstable angina, 7 patients with atypical chest pain, and 25 healthy volunteers. The level of ristocetin cofactor activity of vWF was between 70 and 144% in the control group. In patients with AMI, the mean level of this activity was 175% on the first day following infarction, rose to a peak of 270% on the fifth and sixth days, and was still significantly greater than normal in all patients on the 14th day. The vWF: Ag level closely paralleled the rise of ristocetin cofactor activity of vWF, with a peak of 336% on day 5. FVIII :C was not significantly changed. No significant elevation of vWF was observed in patients with unstable angina. The ristocetin cofactor activity of vWF and vWF: Ag thus are sensitive biochemical indicators for recent AMI, and may serve as useful markers for up to 14 days following infarction, when the traditional enzymes have returned to normal levels.

Von Willebrand Factor and Mitral Valve Prolapse

The levels of von Willebrand factor (vWF: Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (<80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p <0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 ± 30% versus 100 ± 23%, p <0.001). In those with MVP and congestive heart failure secondary to ruptured chordae tendineae, however, the mean level of vWF:Ag was not significantly different from control values (95 ± 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF: Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF: Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

Effectiveness of nifedipine GITS in combination with atenolol in chronic stable angina

Nifedipine gastrointestinal therapeutic system (GITS) is a once-daily formulation of nifedipine that provides stable plasma concentrations over the entire 24 h dosing interval. Two-hundred and one patients with Canadian Cardiovascular Society class II to III angina who were on 50 mg of atenolol yet still experiencing angina symptoms were randomized to receive either placebo or nifedipine GITS 30, 60 or 90 mg/day. After four weeks of treatment, the changes in time from baseline to onset of 1 mm ST segment depression in the 183 eligible patients were 26.7+/-10.2 s, 40.9+/-11.3 s, 63.2+/-12.9 s and 70.3+/-12.6 for the placebo, and 30, 60 and 90 mg/day groups, respectively. These differences were significant (P<0.05) for the 60 and 90 mg/day groups compared with placebo and for the 60 mg/day group compared with the 30 mg/day group. The times to onset of pain and termination of exercise showed similar prolongation but did not achieve statistical significance. During the one-year open label phase of the study, patients exhibited statistically significant improvements in the time to onset of ST segment depression, time to anginal pain and time to termination of exercise at a mean dose of 52.3 mg/day of nifedipine GITS. Adverse events were primarily vasodilatory in nature. This study supports the use of nifedipine GITS in patients with chronic stable angina inadequately controlled on beta-blocker alone.

Noninvasive quantification of the cerebral metabolic rate for glucose using positron emission tomography, 18F-fluoro-2-deoxyglucose, the Patlak method, and an image-derived input function

The authors developed and tested a method for the noninvasive quantification of the cerebral metabolic rate for glucose (CMRglc) using positron emission tomography (PET), 18F-fluoro-2-deoxyglucose, the Patlak method, and an image-derived input function. Dynamic PET data acquired 12 to 48 seconds after rapid tracer injection were summed to identify carotid artery regions of interest (ROIs). The input function then was generated from the carotid artery ROIs. To correct spillover, the early summed image was superimposed over the last PET frame, a tissue ROI was drawn around the carotid arteries, and a tissue time activity curve (TAC) was generated. Three venous samples were drawn from the tracer injection site at a later time and used for the spillover and partial volume correction by non-negative least squares method. Twenty-six patient data sets were studied. It was found that the image-derived input function was comparable in shape and magnitude to the one obtained by arterial blood sampling. Moreover, no significant difference was found between CMRglc estimated by the Patlak method using either the arterial blood sampling data or the image-derived input function.

Generalized linear least squares method for fast generation of myocardial blood flow parametric images with N-13 ammonia PET

In this paper, we developed and tested strategies for estimating myocardial blood flow (MBF) and generating MBF parametric images using positron emission tomography (PET), N-13 ammonia, and the generalized linear least square (GLLS) method. GLLS was generalized to the general linear compartment model, modified for the correction of spillover, validated using simulated N-13 ammonia data, and examined using PET data from several patient studies. In comparison to the standard model-fitting procedure, the GLLS method provided similar accuracy and superior computational speed.

Treatment and outcome of patients with acute myocardial infarction and prior cerebrovascular events in the thrombolytic era: the Israeli Thrombolytic National Survey

BACKGROUND

Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE).

METHODS

Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis.

RESULTS

Patients with a PCE (n = 115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n = 1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n = 29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n = 29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and beta-blockers more often than their counterparts (n= 46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64).

CONCLUSIONS

These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE.

Plasma lipid oxidation and susceptibility of low-density lipoproteins to oxidation in male patients with stable coronary artery disease

OBJECTIVES

Oxidative modifications of low-density lipoproteins (LDL) are considered to be important in the pathogenesis of atherosclerosis. However, the data on the association between LDL oxidation and severity of clinical manifestations of coronary artery disease (CAD) are contradictory. Previous reports were concerned mostly with unstable angina patients. The present study was undertaken to evaluate plasma lipid oxidation status in patients with stable CAD.

DESIGN AND METHODS

37 male patients with angiographically confirmed CAD (asymptomatic or suffering from stable angina pectoris) and 32 control subjects were used in the study. Plasma levels of vitamin E and products of lipid peroxidation, as well as parameters of the test for oxidizability of LDL in vitro were measured.

RESULTS

We did not find differences between 2 groups of individuals regarding the levels of products of lipid peroxidation, vitamin E levels, lag time, maximal rate of oxidation, and total amount of conjugated dienes in the test for oxidizability of LDL.

CONCLUSION

The results of our study challenge, but do not disprove, the oxidative hypothesis of atherosclerosis. Real atherosclerotic modifications of plasma LDL occur apparently in the vascular wall after trapping of LDL by the interstitial matrix. The rise in oxidative parameters in unstable angina reported in the literature may not be the cause of the disease but, rather, the consequence of the multiple brief episodes of ischemia-reperfusion.

Long-term prognosis of patients after a Q wave compared with a non-Q wave first acute myocardial infarction. Data from the SPRINT Registry

OBJECTIVE, DESIGN AND PATIENTS: Between August 1981 and July 1983, 5839 consecutive myocardial infarction patients were hospitalized in 13 coronary care units in Israel. The present study examines 10 year survival among 4037 consecutive patients with a first myocardial infarction with either Q or non-Q waves. Demographic and medical data were collected from hospital records, and 1 year clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean 10 years of follow-up).

RESULTS

Five hundred and eighty patients (14%) had first myocardial infarctions of the non-Q wave type and 3457 of the Q wave type. Hospital mortality was significantly higher in patients with a Q wave (10%) than those with a non-Q wave myocardial infarction (7%) (P < 0.05). One year post-discharge, non-fatal reinfarction and mortality rates were comparable in patients with Q wave (4% and 7%) and non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates were equally high in patients with a non-Q wave (26% and 44%) as in those with a first episode of a Q wave myocardial infarction (22% and 40% respectively).

CONCLUSIONS

Patients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but the advantage did not persist after discharge. Patients with a non-Q wave infarction deserve particular attention as their post-discharge mortality risk is similar to counterparts with a first Q wave myocardial infarction.

Calcium antagonists and mortality in patients with coronary artery disease: a cohort study of 11,575 patients

OBJECTIVES

This study sought to establish the risk ratio for mortality associated with calcium antagonists in a large population of patients with chronic coronary artery disease.

BACKGROUND

Recent reports have suggested that the use of short-acting nifedipine may cause an increase in overall mortality in patients with coronary artery disease and that a similar effect may be produced by other calcium antagonists, in particular those of the dihydropyridine type.

METHODS

Mortality data were obtained for 11,575 patients screened for the Bezafibrate Infarction Prevention study (5,843 with and 5,732 without calcium antagonists) after a mean follow-up period of 3.2 years.

RESULTS

There were 495 deaths (8.5%) in the calcium antagonist group compared with 410 in the control group (7.2%). The age-adjusted risk ratio for mortality was 1.08 (95% confidence interval [CI] 0.95 to 1.24). After adjustment for the differences between the groups in age and gender and the prevalence of previous myocardial infarction, angina pectoris, hypertension, New York Heart Association functional class, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and current smoking, the adjusted risk ratio declined to 0.97 (95% CI 0.84 to 1.11). After further adjustment for concomitant medication, the risk ratio was estimated at 0.94 (95% CI 0.82 to 1.08).

CONCLUSIONS

The current analysis does not support the claim that calcium antagonist therapy in patients with chronic coronary artery disease, whether myocardial infarction survivors or others harbors an increased risk of mortality.

Lysine-binding species of lipoprotein(a) in coronary artery disease

Elevated levels of plasma lipoprotein(a) [Lp(a)] have frequently been associated with coronary artery disease (CAD). Recently Lp(a) was fractionated into two species with different affinities for Lysine-Sepharose. The influence of lysine-binding heterogeneity of Lp(a) on its cardiovascular pathogenicity has not previously been studied. The authors have determined plasma levels of total Lp(a), its lysine-binding [lys+] and unretained [lys-] species in 67 male CAD patients undergoing cardiac catheterization. Forty-three patients have severe CAD (two- or three-vessel disease) and 24 patients have less pronounced CAD (one-vessel disease or less than 50% narrowing of coronary vessels). All patients were ranked in order of their Lp(a) levels and then grouped into quartiles. The prevalence of severe CAD was significantly higher in the upper Lp(a) quartile as compared with the other three quartiles (odds ratio 10-5; chi-square 11.2; P = 0.0008). Similar results were obtained when the same analysis was carried out for [lys+] and [lys-] species of Lp(a) (odds ratio 11.52 and 3.3, respectively; chi-square 12.3 and 4.34, respectively; P = 0.0004 and 0.037, respectively). Thus, measurement of either species of Lp(a) does not provide any additional improvement in the prediction of CAD as compared to the estimation of total Lp(a) levels.

Immediate and long-term prognostic significance of a first anterior versus first inferior wall Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group

Of 3,981 patients with a first Q-wave acute myocardial infarction (AMI), 1,929 (48%) had an anterior and 1,724 (43%) an inferior wall AMI. These 2 groups were well-matched with respect to age, gender and relevant history. The in-hospital mortality rate was 18%, and the 1- and 5-year post-discharge mortality rates were 9 and 25%, respectively, in patients with anterior wall AMI compared with the corresponding rates of 11, 6 and 19% in those with inferior wall AMI (p < 0.0001 for each category). The frequency of recurrent nonfatal AMI in the year after the index AMI was 8% in the patients with anterior wall AMI compared with 4% in those with inferior wall AMI (p < 0.0001). By multiple logistic regression analysis of events, anterior wall AMI was an independent predictor of in-hospital mortality only. The findings indicate that the anatomic location of a Q-wave AMI influences immediate and short-term survival of patients with a first Q-wave AMI.

Long-term prognosis after acute myocardial infarction in patients with left ventricular hypertrophy on the electrocardiogram. SPRINT Study Group

Among 4,720 consecutive hospital survivors from acute myocardial infarction (AMI) treated in 13 coronary care units between July 1981 and August 1983, the estimated prevalence of electrocardiographic left ventricular (LV) hypertrophy was 6.1%. The prevalence of electrocardiographic LV hypertrophy increased with age and was higher in patients with previous myocardial infarction, angina and systemic hypertension. Mean age of patients with electrocardiographic LV hypertrophy was 67.2 vs 61.4 years in counterparts free of electrocardiographic LV hypertrophy. Patients with electrocardiographic LV hypertrophy had a higher rate of congestive heart failure on admission, or developing during their stay in coronary care units. The 1- and 5-year mortality rates were 19.7 and 46.6% among patients with electrocardiographic LV hypertrophy versus 8.7 and 26.2%, respectively (p less than 0.001) in patients without this finding. The covariate-adjusted odds ratio of 1-year mortality was 1.88 for the presence of electrocardiographic LV hypertrophy when age alone was adjusted for, and 1.51 (90% confidence interval, 1.09 to 2.10) when multiple covariate adjustment was undertaken. After multiple covariate adjustment for 5-year mortality after discharge, the relative risk associated with electrocardiographic LV hypertrophy was 1.51 (90% confidence interval, 1.26 to 1.80). The results of the present study showed that the presence of electrocardiographic LV hypertrophy on the discharge electrocardiogram of survivors from AMI is associated with a 1.5-fold increase of short- and long-term mortality. Patients with electrocardiographic LV hypertrophy, potentially at an increased post-discharge risk, may be candidates for early noninvasive testing and more intensive follow-up after recovering from AMI.

Ophthalmoplegic migraine and recurrent sinus arrest

Images

Cerebrovascular accident complicating acute myocardial infarction: incidence, clinical significance and short- and long-term mortality rates. The SPRINT Study Group

PURPOSE

The purpose of this study was to report the incidence, the antecedents, and the clinical significance of clinically recognized cerebrovascular accidents or transient ischemic attacks (CVA-TIA) complicating acute myocardial infarction.

PATIENTS AND METHODS

During 1981 to 1983, a secondary prevention study with nifedipine (SPRINT) was conducted in 14 hospitals in Israel among 2,276 survivors of acute myocardial infarction. During the study, demographic, historical, and medical data were collected on special forms for all patients with diagnosed acute myocardial infarction in 13 of these 14 hospitals (the SPRINT registry, n = 5,839). Mortality follow-up was completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range: 4.5 to 7 years).

RESULTS

The incidence of CVA-TIA was 0.9% (54 of 5,839). The latter rate increased significantly only with age, from 0.4% among patients up to 59 years old to 1.6% among those aged greater than or equal to 70 years. Multivariate analysis identified age, congestive heart failure, and history of stroke as predictors of CVA-TIA during the acute phase of myocardial infarction. Patients with CVA-TIA exhibited a complicated hospital course, with a 15-day mortality rate of 41%. Subsequent mortality rates in survivors at 1 and 5 years were 34% and 59%, respectively. Rates at the same time points in patients without CVA-TIA were 16%, 11%, and 29% (p less than 0.01). In a multivariate analysis that included age, gender, congestive heart failure, history of previous myocardial infarction, and hypertension, CVA-TIA was independently associated with increased 15-day mortality (covariate-adjusted odds ratio [OR] = 2.62; 90% confidence interval [CI], 1.59 to 4.32), as well as subsequent 1-year (OR = 3.29; 90% CI, 1.70 to 6.36) and long-term (mean follow-up = 5.5 years) mortality (OR = 2.46; 90% CI, 1.30 to 4.69).

CONCLUSION

In this large cohort of consecutive patients with myocardial infarction, CVA-TIA was a relatively infrequent complication of acute myocardial infarction. Factors independently favoring the occurrence of CVA-TIA were old age, previous CVA, and congestive heart failure. CVA-TIA occurring during acute myocardial infarction independently increased the risk of early death threefold as well as the risk of long-term mortality in early-phase survivors. (2.5-fold).

Monotherapy of stable angina pectoris with bopindolol in comparison with diltiazem

The efficiency of bopindolol (B) in the treatment of moderate stable angina pectoris was compared with that of diltiazem (D) by clinical evaluation and exercise tolerance. Following washout of previous treatment, patients were randomly assigned to either medication: 16 to D and 15 to B. The initial dose of B was 1 mg once daily, increased after 4 weeks to 2 mg once daily; the respective doses of D were 120 and 240 mg, given in 4 divided doses. Therapy resulted in an average decrease of 22 pain episodes and 256 min of pain time per month in the B group, whereas the respective reductions in the D group were 1.65 episodes and 129 min. Improvement in the exercise test indices following 8 weeks of treatment was more marked in the B group than in the D group. The average double product at peak exercise decreased markedly in the B group and more moderately in the D group. Thus, 2 mg B given once daily effectively blocked B receptors and relieved angina more efficiently than 240 mg D given in 4 divided doses.

[Echocardiographic diagnosis of anomalous origin of left coronary artery]

Cross sectional and M-mode echocardiography is a well-established noninvasive technique in the diagnosis of dilated cardiomyopathy and is essential in the evaluation of its severity and progress. However, in most cases of dilated cardiomyopathy in children, it does not provide data suggestive of the etiology of the disease. In the rare congenital malformation, anomalous origin of the left coronary artery from the pulmonary artery, the echocardiographic techniques may suggest the diagnosis when the left coronary artery cannot be demonstrated to arise from its usual site, the left coronary sinus (as visualized in the short axis of the aortic root). A firm diagnosis can be made if the anomalous origin of the left coronary artery is identified in a cross-sectional view of the main pulmonary artery (left parasternal long axis view of the main pulmonary artery, Fig. 1). This was demonstrated in a 9-year-old girl by coronary and aortic angiography (Fig. 2a, b). Anatomical confirmation was made during corrective surgery 3 months later. The origin of the left coronary artery was at the left posterior aspect of the main pulmonary artery, just proximal to its bifurcation. This is an unusual origin in this anomaly in which the coronary artery has been reported to arise close to the pulmonary valve, but not distal, as in this case.

Von Willebrand factor and mitral valve prolapse

The levels of von Willebrand factor (vWF:Ag) were measured in 27 patients with mitral valve prolapse (MVP) and compared to 27 age matched controls. Decreased levels of vWF:Ag (less than 80%) were found in 59% (16/27) of those with MVP compared to only 7% (2/27) of the controls (p less than 0.001). Mean vWF: Ag levels were also significantly lower in those with MVP (68 +/- 30% versus 100 +/- 23%, p less than 0.001). In those with MVP and congestive heart failure secondary to rupture chordae tendineae, however, the mean level of vWF: Ag was not significantly different from control values (95 +/- 32). There was an increased incidence of recurrent nose bleeds in those with MVP and low levels of vWF:Ag. We conclude that there is a relationship between MVP and low levels of vWF:Ag which may explain the increased incidence of epistaxis in such patients. Increased release of vWF:Ag in those with MVP and concomitant congestive heart failure may account for the normal levels found in this subgroup.

The scale of myocardial involvement in varicella myocarditis

Two patients with varicella myocarditis are described. An arrhythmia associated with complete recovery occurred in the first patient whereas intractable congestive heart failure complicated by hemiplegia resulted in a fatal outcome in the other case. We stress the extent of myocardial involvement produced by the herpes zoster virus in the setting of varicella.

Renal excretion of lactate and magnesium in mitral valve prolapse

A strong positive correlation between urinary magnesium and lactate was found in 17 magnesium-depleted patients with echocardiographically proved mitral valve prolapse. The strong correlation over all the range of urinary magnesium values and the significantly increased excretion of lactate suggest urinary magnesium loss in this syndrome.

R wave amplitude changes during stress testing in ischemic patients with normal epicardial coronary arteries

R wave amplitude changes during stress testing were validated in 12 ischemic patients with normal coronary angiograms. The data were compared with findings obtained from 10 patients with clinical and angiographic evidence of coronary arterial disease and 10 normal controls. An abnormal R wave amplitude response occurred in 83.3% of the group with normal coronary angiography, in 80% of the group of patients with clinical and angiographic evidence of coronary arterial disease, and in only 10% of the control group. The similarity of R wave amplitude changes in the first two group suggests that these changes are related to ischemia. If so, then R wave amplitude response to exercise could be of value in the electrocardiographic diagnosis of ischemia in patients with angiographically normal coronary arteries.

The value of electrocardiography in patients with right ventricular endocardial pacemakers in the diagnosis of left ventricular hypertrophy: a correlative study of pace electrocardiography and left ventricular mass derived from M-mode echocardiography

This study evaluated 51 patients with permanent apical right ventricular endocardial pacemakers. The assessment of the diagnostic value of pace electrocardiograms for the determination of left ventricular hypertrophy revealed specificity of 94% and sensitivity of 66%, applying a new parameter: RL1 + SV3 greater than or equal to 30 mm. The application of this criterion in the interpretation of pace electrocardiograms correlated well with values for the left ventricular mass derived from M-mode echocardiograms (r = 0.644, P less than 0.0001).

Autosomal dominant inheritance of sinus node disease

A family with sinus node disease is presented. The mother was severely affected by sinus bradycardia and required a permanent atrial pacing system. The father is asymptomatic and has no evidence of conduction disturbances. All their offspring (one son and two daughters) are affected with variable degrees of severity. The occurrence of the disease in this family is suggestive of autosomal dominant inheritance with variable penetrance.

The von Willebrand factor in myocardial infarction and unstable angina: a kinetic study

Recent studies have demonstrated elevations of von Willebrand Factor following acute myocardial infarction (AMI). In order to determine if this parameter may serve as a marker for AMI, we tested the blood levels of vWF and Factor VIII:C in 28 patients with AMI, 9 patients with unstable angina, 7 patients with atypical chest pain, and 25 healthy volunteers. The level of ristocetin cofactor activity of vWF was between 70 and 144% in the control group. In patients with AMI, the mean level of this activity was 175% on the first day following infarction, rose to a peak of 270% on the fifth and sixth days, and was still significantly greater than normal in all patients on the 14th day. The vWF:Ag level closely paralleled the rise of ristocetin cofactor activity of vWF, with a peak of 336% on day 5. FVIII:C was not significantly changed. No significant elevation of vWF was observed in patients with unstable angina. The ristocetin cofactor activity of vWF and vWF:Ag thus are sensitive biochemical indicators for recent AMI, and may serve as useful markers for up to 14 days following infarction, when the traditional enzymes have returned to normal levels.

Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome

In this study, we performed 512 echocardiographic studies on 264 consecutive unselected patients with the idiopathic mitral valve prolapse syndrome. Twenty-eight patients (10.6%) had evidence of ruptured chordae tendineae of the mitral valve on M-mode examination and in 24 the diagnosis was confirmed by two-dimensional echocardiography. Mild to severe mitral insufficiency was proven in all of them by left ventriculography during cardiac catheterization. Eight patients underwent surgery to relieve symptomatic severe mitral regurgitation. At operation all had myxomatous degeneration of the mitral valve, two patients were found to have rupture of anterior mitral chordae, and six had rupture of posterior mitral chordae. Twenty (71%) patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome may be present in asymptomatic patients and go undetected clinically in a substantial number of patients unless a high index of suspicion is maintained. Serial M-mode and two-dimensional echocardiographic studies are of importance in identifying the progression of prolapse findings and may reveal the natural history of this pathologic condition in asymptomatic patients.

Transient electromechanical dissociation in hypertrophic cardiomyopathy

We describe a patient with hypertrophic cardiomyopathy who experienced several episodes of syncopal attacks, in whom the mechanism was transient electromechanical dissociation.

Swallowing induced atrial tachycardia and fibrillation in a patient with a Wolf-Parkinson-White syndrome

A 56-year-old man with the Wolf-Parkinson-White (WPW) syndrome (type A) is described. His presenting signs were paroxysmal atrial tachycardia and fibrillation induced by swallowing. This supraventricular tachyarrhythmia (SVT) could be abolished by performing the valsalva maneuver or carotid stimulation, and prevented only by treatment with amiodarone.

Sinus node dysfunction in a healthy pediatric population

ECG recordings of 624 healthy children (age range 6 to 12 years) from a rural population were analyzed for evidence of sinus node dysfunction. Twelve children were found to have the disorder and they underwent further assessment in order to establish any etiological factors or anatomical abnormalities. All the children were asymptomatic and physical examination was completely normal. Standard ECG taken during 24-h monitoring demonstrated that the most common finding, seen in 10 of 12 patients, was that of sinus arrest. Second-degree sinoatrial exit block, Mobitz type I, occurred in four children and Mobitz type II was seen in three. Two of the children were found to have holosystolic mitral valve prolapse, which was in the normal frequency range for a population of healthy children. After a 2-year follow-up and reassessment, there was no change in the symptomatology, the ECG tracings or the physical findings of any of the children.

Polymorphous ventricular tachycardia in acute myocardial infarction

Polymorphous ventricular tachycardia (VT) is thought to be uncommon in acute coronary heart disease, but its prevalence has not been determined. Seven hundred seventy-one consecutive patients admitted with acute myocardial infarction (MI) were reviewed for the occurrence of this arrhythmia. Nine patients (1.2%) had polymorphous VT. No patient had any of the predisposing factors previously associated with polymorphous VT. The arrhythmia was resistant to multiple drugs, and repeated cardioversion was effective in only 3 patients. Overdrive pacing was ineffective in the 3 patients in whom it was attempted. Verapamil was effective in 3 of 4 patients in whom it was tried. Six patients with polymorphous VT died during hospitalization; the remaining 3 died within 6 months of discharge. It is concluded that, when compared with regular VT, polymorphous VT in MI carries a poor prognosis. When the arrhythmia occurs in the context of acute ischemia, it appears to be more difficult to treat compared with its occurrence due to other predisposing factors. Verapamil, not usually indicated for ventricular arrhythmias, should be tested in a therapeutic trial.

M-mode and two-dimensional contrast echocardiography in adult patients with atrial septal defects

M-mode and two-dimensional echocardiographic studies, with and without contrast injection, were performed in 14 adult patients with clinical and radiological signs of atrial septal defects. Two-dimensional contrast echocardiography was found to be the most sensitive technique, allowing a definitive diagnosis to be made noninvasively in 12 patients (86%) of those patients studied. M-mode contrast echocardiography demonstrated an atrial shunt in 6 patients (43%). Regular two-dimensional echocardiography produced a high proportion of false-positive and false-negative results, while the findings on M-mode echocardiography are sensitive but nonspecific. All 14 patients described had the diagnosis confirmed on cardiac catheterization. Performance of the Valsalva maneuver during contrast echocardiography was found to be diagnostically unhelpful. The findings suggest that contrast echocardiography, particularly two-dimensional, is an effective, noninvasive diagnostic technique to be applied on clinical suspicion of atrial septal defects.

Endogenous cortisol and thyroid hormone levels in patients with acute myocardial infarction

Thyroid hormones and cortisol levels were serially measured over seven mornings and evenings in 23 consecutive patients with acute myocardial infarction (AMI) or acute coronary insufficiency (ACI). The patients were divided into two groups, high level cortisol (HLC) and low level cortisol (LLC) groups, according to mean morning and evening cortisol levels. The transient increase in plasma rT3, decrease in T3 and TSH was significantly greater in the HLC group. A diurnal variation in cortisol levels was observed in the LLC group 48 h and in the HLC group 72 h after admission. Taking the 23 patients together, no significant correlation was observed between infarct size (peak CPK levels) and the altered rT3, T4 or TSH levels. However, a significant correlation was obtained between the maximal change in T3, rT3 or TSH and the mean cortisol levels preceding these alterations, as well as between cortisol levels and infarct size. It is suggested that cortisol rather than infarct size may be the dominant factor involved in the alteration of thyroidal levels in AMI patients.

The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome

Echocardiographic studies were performed on 134 consecutive patients with idiopathic mitral valve prolapse syndrome. Fifteen patients (11.2%) were noted to have ruptured chordae tendineae on M-mode examination and in 12 of them the diagnosis was confirmed by bidimensional studies. Only four patients were referred for surgery as a result of severe mitral regurgitation. At operation one patient was found to have rupture of the anterior mitral chorda and the other three had posterior mitral chordal rupture. Eleven patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome does not always result in severe hemodynamic deterioration and may go undetected unless a high index of suspicion is maintained. Serial echocardiographic studies may reveal the natural history of this condition in asymptomatic patients.

The efficacy of Ajmaline in ventricular arrhythmias after failure of lidocaine therapy in the acute phase of myocardial infarction

Forty-three patients in the acute phase of myocardial infarction who were resistant to conventional doses of lidocaine received Ajmaline intravenously (50 mg bolus followed by constant infusion rate of 1-1.5 mg/min). Dangerous ventricular arrhythmias were abolished in 72% of this group of patients (group A). In the remaining patients (28%), Ajmaline was found to be ineffective (group B). There was no reduction of systolic or diastolic blood pressure and there was an insignificant increase in heart rate. Atrio-ventricular or intraventricular conduction defects appeared in 46% of the patients described. There was a statistically significant increase in occurrence of heart blocks in group B patients and among these complete left bundle branch block (CLBBB) was the most prevalent. Atrio-ventricular or intraventricular conduction defects were transient, appearing between 8-36 h (mean 23 h), and were not accompanied by reduction of ventricular rate. Conduction defects disappeared within several hours (up to 24 hours) after Ajmaline was discontinued. It is concluded that Ajmaline administered by this regimen is an effective alternative agent for patients with ventricular arrhythmia not controlled by lidocaine in the acute phase of myocardial infarction.