Winning hearts and minds: ECG reporting in the first seizure clinic

BACKGROUND AND AIMS

An electrocardiogram (ECG) is a mandatory test for anyone presenting with loss of consciousness. Many referrals to the first seizure clinic (FSC) are caused by syncope. We assessed the sensitivity of neurologists' ECG reporting in detecting rhythm abnormalities including some potentially life-threatening cardiac conditions.

METHODS

We audited patients referred to a FSC in Glasgow over 4 years. All ECGs were interpreted by the attending neurologist as standard practice. Subsequently, two cardiologists reviewed the ECGs independently.

RESULTS

Of 160 consecutive patients, 92 patients (58%) were diagnosed as having seizures, 43 (27%) as syncope, and 25 (16%) were unclassified. Twenty eight ECGs thought to be normal by the neurologist were considered abnormal by the cardiologist, including three with long corrected QT interval. The proportion of abnormal ECGs and disparity in reporting between neurologists and cardiologists persisted independent of the underlying diagnosis.

CONCLUSION

Reporting of ECGs by non-cardiologists may not be adequately sensitive in picking up potentially life threatening cardiac conditions. Cardiologist input into FSCs is recommended to enhance the diagnostic yield.

Neuro-ophthalmic complications after coronary angiography

Diplopia and gaze palsies are extremely disabling and distressing problems, especially in patients with significant cardiac co-morbidity. A case of Parinaud syndrome and oculomotor nerve palsy following coronary angiography (CA) is reported. These neuro-ophthalmic complications are not previously documented in the literature in association with CA. The case raises awareness of potential ocular motility deficits that may occur following CA. Potential risk factors during CA are analysed and the mechanisms of the embolic pathway are discussed.

Diurnal Variation of Blood Pressure in Elderly Patients with Essential Hypertension

Twenty-one elderly patients with essential hypertension, all over 65 years of age, were subjected to automated noninvasive 24-hour blood pressure measurement. Readings were obtained every 7.5 minutes throughout the day. The data were analyzed with respect to: correlation between office and ambulatory pressure measurements; possible differences in the circadian blood pressure pattern; and the existence of hypertensive or atherosclerotic cardiovascular complications. In all patients, the office systolic pressures were significantly higher than the ambulatory daytime pressures; diastolic pressures were similar. At night, two patterns of blood pressure emerged. In one there was a further fall in both systolic and diastolic pressures to normotensive levels, whereas the other pattern revealed no change in diastolic pressure, although systolic pressure increased significantly to similar levels as measured in the office. The prevalence of hypertensive or atherosclerotic cardiovascular complications in the patients with the first pattern was significantly less than in the group of patients with the second pattern (chi square, P less than 0.025). The data reported herein indicate that ambulatory blood pressure monitoring may help in the overall clinical evaluation of elderly patients with hypertension.

Adopting seven-day working in practice: a report by the Royal College of Physicians and Surgeons of Glasgow

Following the UK Academy of Medical Royal Colleges Report on seven day consultant present care, the Royal College of Physicians and Surgeons of Glasgow held a symposium to explore clinicians' views on the ways in which clinical care should best be enhanced outside 'normal' working hours. In addition, a survey of members and fellows was undertaken to identify the tests which would make the greatest impact on care out of hours. Key messages were: (a) that seven-day consultant delivered care would not achieve the desired benefit to patient care if introduced in isolation from other inter-relating factors. These include alternatives to hospital admission, enhanced nursing support, increased junior medical, pharmacy, social care and ambulance availability and greater access to selected diagnostic services; (b) that the care of hospital inpatients is a service which is one part of the totality of secondary care provision. Any significant change in the deployment of staff for inpatient care must be carefully managed so as not to result in a reduced quality of care provided by the rest of the system.

Limited clinical utility of CT coronary angiography in a district hospital setting

BACKGROUND

Studies have demonstrated considerable accuracy of multi-slice CT coronary angiography (MSCT-CA) in comparison to invasive coronary angiography (I-CA) for evaluating coronary artery disease (CAD). The extent to which published MSCT-CA accuracy parameters are transferable to routine practice beyond high-volume tertiary centres is unknown.

AIM

To determine the accuracy of MSCT-CA for the detection of CAD in a Scottish district general hospital.

DESIGN

Prospective study of diagnostic accuracy.

METHOD

One hundred patients with suspected CAD recruited from two Glasgow hospitals underwent both MSCT-CA (Philips Brilliance 40 × 0.625 collimation, 50-200 ms temporal resolution) and I-CA. Studies were reported by independent, blinded radiologists and cardiologists and compared using the AHA 15-segment model.

RESULTS

Of 100 patients [55 male, 45 female, mean (SD) age 58.0 (10.7) years], 59 and 41% had low-intermediate and high pre-test probabilities of significant CAD, respectively. Mean (SD) heart rate during MSCT-CA was 68.8 (9.0) bpm. Fifty-seven per cent of patients had coronary artery calcification and 35% were obese. Patient prevalence of CAD was 38%. Per-patient sensitivity, specificity, positive and negative (NPV) predictive values for MSCT-CA were 92.1, 47.5, 52.2 and 90.6%, respectively. NPV was reduced to 75.0% in the high pre-test probability group. Specificity was compromised in patients with sub-optimally controlled heart rates, calcified arteries and elevated BMI.

CONCLUSION

Forty-Slice MSCT-CA has a high NPV for ruling out significant CAD when performed in a district hospital setting in patients with low-intermediate pre-test probability and minimal arterial calcification. Specificity is compromised by clinically appropriate strategies for dealing with unevaluable studies. Effective heart rate control during MSCT-CA is imperative. National guidelines should be utilized to govern patient selection and direct MSCT-CA reporter training to ensure quality control.

Pericardiocentesis practice in the United Kingdom

BACKGROUND

Pericardial effusions frequently present challenging clinical dilemmas. Whether or not to drain an effusion, and if so by what method, are two common decisions facing cardiologists. We performed a survey to evaluate pericardiocentesis practice in the United Kingdom (UK).

METHODS

A total of 640 questionnaires were sent to all cardiologists in the UK Directory of Cardiology in March 2003.

RESULTS

A total of 274 (43%) completed questionnaires were returned, 88% from consultants, equally distributed between tertiary referral centres and district general hospitals. More than 1500 procedures were performed, largely using a paraxiphoid approach (89%). Clinical tamponade was the commonest indication for pericardiocentesis (83%). However, the majority of respondents (69%) considered echocardiographic features alone an indication for pericardiocentesis, even in the absence of clinical tamponade. The commonest perceived indications for drainage were right ventricular diastolic collapse and right atrial collapse (69% and 33% of respondents respectively). For guidance, 82% use echocardiography, either alone or with fluoroscopy or the electrocardiogram (ECG) injury trace. 11% employ fluoroscopy alone or with the ECG injury trace. The remaining 11% stated that they would use the ECG injury trace alone or use no guidance. Using the ECG injury trace alone is said by the European Society of Cardiology (ESC) guidelines to offer an inadequate safeguard. Reported complications included ventricular puncture (n = 12, 0.8%) and hepatic damage (n = 4, 0.3%).

CONCLUSION

Pericardiocentesis practice varies substantially in the UK. Many cardiologists would perform pericardiocentesis based on echocardiographic features alone. 11% of cardiologists use guidance that is considered inadequate by the ESC guidelines.

The Burden of Atrial Fibrillation in Unselected Acute Medical Admissions

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is of increasing prevalence. The presence of AF complicates the management of patients presenting as medical emergencies.

Objective

To assess the prevalence of AF and current investigation and management strategies in unselected acute medical admissions.

Design

Prospective survey of all acute medical admissions over 22 days.

Setting

Stobhill Hospital – district general hospital in north Glasgow.

Subjects

Consecutive acute medical admissions.

Results

Of the 507 patients, 47 (9.3%) had AF. AF was a new diagnosis in five patients (11.0%). The most common presenting features were dyspnoea and chest pain. The principal underlying medical conditions were hypertension and ischaemic heart disease. AF was the primary reason for admission in six patients (12.8%) and a documented reason for admission in 11 patients (23.4%). Thyroid function tests were or had previously been performed in 45 patients (95.7%). Twenty-four patients (51.1%) underwent echocardiography or had done so previously. Twenty-two patients (46.8%) received anticoagulation with warfarin. Ten patients (21.3%) should have received warfarin by standard guidelines but did not. No patient received warfarin inappropriately. Rate control was used in 40 patients (85.1%). Rhythm control was attempted in four patients (8.5%).

Conclusion

AF is common amongst emergency admissions to district general hospitals and has significant resource implications. Improvements are needed both in the use of echocardiography and in the administration of anticoagulant therapy.

Key issues in the management of atrial fibrillation--protecting the patient and controlling the arrhythmia

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its prevalence is increasing. It is an independent risk factor for stroke and is associated with significant morbidity and mortality. AF currently accounts for 1% of NHS expenditure. The management of AF has a broad evidence base and both the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) and the National Institute for Clinical Excellence (NICE) have recently published guidelines. Some controversy persists regarding stroke risk stratification and appropriate anticoagulation regimes although a general consensus is now emerging. Rate and rhythm control strategies have been shown to be comparable in terms of clinical outcomes. Current anti-arrhythmic drugs have limited efficacy and significant side-effect profiles. Electrophysiological and surgical interventions have a role in both strategies. This article broadly reviews the evidence for different management strategies in AF and presents a practical approach to treatment in light of the recently published national and international guidelines.

WITHDRAWN: Secondary Harmonic Imaging Overestimates Left Ventricular Mass Compared to Fundamental Echocardiography

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 178-181, . The duplicate article has therefore been withdrawn.

Prevalence and prognostic implications of electrocardiographic left ventricular hypertrophy in heart failure: evidence from the CHARM programme

BACKGROUND

Electrocardiographic left ventricular hypertrophy (ECG LVH) is a powerful independent predictor of cardiovascular morbidity and mortality in hypertension.

OBJECTIVE

To determine the contemporary prevalence and prognostic implications of ECG LVH in a broad spectrum of patients with heart failure with and without reduced left ventricular ejection fraction (LVEF). METHODS AND OUTCOME: The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme randomised 7599 patients with symptomatic heart failure to receive candesartan or placebo. The primary outcome comprised cardiovascular death or hospital admission for worsening heart failure. The relative risk (RR) conveyed by ECG LVH compared with a normal ECG was examined in a Cox model, adjusting for as many as 31 covariates of prognostic importance.

RESULTS

The prevalence of ECG LVH was similar in all three CHARM trials (Alternative, 15.4%; Added, 17.1%; Preserved, 14.7%; Overall, 15.7%) despite a more frequent history of hypertension in CHARM-Preserved. ECG LVH was an independent predictor of worse prognosis in CHARM-Overall. RR for the primary outcome was 1.27 (95% confidence interval (CI) 1.04 to 1.55, p = 0.018). The risk of secondary end points was also increased: cardiovascular death, 1.50 (95% CI 1.13 to 1.99, p = 0.005); hospitalisation due to heart failure, 1.19 (95% CI 0.94 to 1.50, p = 0.148); and composite major cardiovascular events, 1.35 (95% CI 1.12 to 1.62, p = 0.002).

CONCLUSION

ECG LVH is similarly prevalent in patients with symptomatic heart failure regardless of LVEF. The simple clinical finding of ECG LVH was an independent predictor of a worse clinical outcome in a broad spectrum of patients with heart failure receiving extensive contemporary treatment. Candesartan had similar benefits in patients with and without ECG LVH.

Secondary harmonic imaging overestimates left ventricular mass compared to fundamental echocardiography

AIMS

The significance of left ventricular hypertrophy in hypertension is well documented, being an independent risk factor for cardiovascular morbidity and mortality. Normal values for left ventricular mass and partition values for left ventricular hypertrophy come from measurements obtained by fundamental echocardiography. Secondary harmonic imaging improves definition of cardiac borders. We hypothesise that this overestimates left ventricular mass compared to fundamental imaging.

METHODS AND RESULTS

Thirty patients had four parasternal long-axis M-modes performed, two using 1.7 mHz output frequency, receiving at two octaves higher and two using fixed frequency of 2.5 mHz (fundamental imaging). Absolute left ventricular mass and left ventricular mass index were calculated for each modality. Intra-observer variability was <7%. Range on fundamental imaging was 54-264 g/m2 compared to 80-293 g/m2 on secondary harmonic imaging. Mean left ventricular mass index for the group was 118 g/m2 (fundamental imaging) vs 147 g/m2, P<0.001. Twenty-nine of 30 patients had higher left ventricular mass index on secondary harmonic imaging compared to fundamental imaging. Left ventricular mass index was an average of 26% higher on secondary harmonic imaging, range (-7 to 65%) corresponding to average absolute left ventricular mass difference of 55 g. Eleven of 30 patients had left ventricular hypertrophy on fundamental imaging and 17/30 on secondary harmonic imaging.

CONCLUSION

Secondary harmonic imaging overestimates left ventricular mass index compared to fundamental imaging. Normal left ventricular mass index range is based on equations using fundamental imaging measurements. Management decisions and prognostic implications made on the basis of raised left ventricular mass index using secondary harmonic imaging should be done so with caution.

Rapid access chest pain clinics--can they be justified?

Rapid access chest pain clinics are expanding across the country with marked resource implications despite a paucity of data regarding their efficacy. Early assessment of patients in this manner potentially delays review of patients referred via the traditional route. We conducted a prospective observational study of patients referred with chest pain to the Cardiology Outpatient Department over a four-week period in a District General Hospital to compare demographics and outcomes in patients referred to the rapid access with those referred to the general cardiology clinics. There were no significant differences in baseline demographics, exercise test result or clinic outcome. Both populations were low risk. Discussion is needed between primary and secondary care to achieve a consensus as to the purpose of a rapid access system and how best to utilise the service appropriately. Further studies are required to assess the efficacy and health economics of this system.

Coronary sinus pacing in an elderly patient with Bjork-Shiley tricuspid valve replacement

We report the first case of permanent pacing via the coronary sinus in a patient with a Bjork-Shiley tricuspid valve replacement. This may be the route of choice in this group of patients.

The utilisation of a day-surgery unit for direct-current (DC) cardioversion of atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia associated with increased morbidity and mortality. Current practice aims to restore sinus rhythm (SR), although the question of whether rate or rhythm control is the optimal approach for these patients remains unanswered. The most established method of restoring SR in patients with AF of duration greater than 48 hours is external direct-current cardioversion (DCC). This is a descriptive paper summarising how we utilised the hospital's day surgery unit for the provision of DCC for patients with AF in order to provide a more efficient service and allow an increased number of procedures to be conducted. We describe the reasons for setting up the service and the methods involved. We also summarise the advantages associated with this new system.

Optimising direct access ECHO referral in suspected heart failure

The objective was to prospectively validate a method of increasing the sensitivity, specificity and negative predictive value of a normal ECG in the exclusion of left ventricular systolic dysfunction by the addition of clinical history. We performed a prospective three year study of all referrals to our direct access ECHO service for assessment of LV function. The ECG was reported blind of the result of the ECHO, history of MI or not was noted, and result of the ECHO predicted. Over three years 416 patients were assessed for the presence or absence of left ventricular systolic dysfunction and consequent changes in clinical management. A total of 320(77%) of patients referred with suspected left ventricular dysfunction were found to have normal left ventricular function. Of the 250(60%) patients treated prior to referral for assessment, 183(73%) were treated inappropriately. The combination of a normal ECG and a negative history of myocardial infarction had a sensitivity of 98% and a negative predictive value of 99% in the assessment of LV function. This was an improvement over a normal ECG alone. Our study shows that diagnosis and treatment of heart failure in the community remains sub-optimal. The combination of a normal ECG and no previous history of myocardial infarction is shown to be a sensitive and accurate predictor of normal left ventricular function. If adopted by general practitioners this would be a valuable method of optimising the use of echocardiography in patients with suspected left ventricular dysfunction.

Direct admission to the coronary care unit by the ambulance service for patients with suspected myocardial infarction

BACKGROUND

Direct access to the coronary care unit (CCU) for general practitioner (GP) referred cases of suspected acute myocardial infarction (AMI) (fast track admission) substantially reduces the time to thrombolysis. Until now, this policy has been confined to GP referrals.

OBJECTIVES

To determine the time taken to admission to CCU under the fast track policy (ambulance referrals and GP referrals) and the time taken to start administration of thrombolytics (ambulance referrals, GP referrals, and accident and emergency referrals).

METHODS

Fast track admission policy was extended to include referrals from ambulance personnel who respond to emergency service calls. Ambulance personnel referred cases were also examined to see if they were referred appropriately to the CCU.

RESULTS

100 ambulance personnel referrals and 260 GP referrals to CCU with chest pain were studied. Forty accident and emergency referrals who had AMI requiring thrombolysis were also studied. In the ambulance referred group the time to admission from phone call was a median of 10 minutes (range 2 to 45), a saving of 30 minutes compared with GP referrals (median 40 minutes, range 2 to 217). The median diagnostic electrocardiogram (ECG) to thrombolysis time was longer in the accident and emergency referrals with AMI than either ambulance referrals or GP referrals admitted under the fast track policy. Diagnostic ECG to thrombolysis time: accident and emergency 50 minutes (range 15 to 385); ambulance referrals median 33 minutes (range 6 to 69); GP referrals median 29.5 minutes (range 5 to 110 minutes); (p = 0.056 accident and emergency compared with ambulance referrals, p < 0.002 accident and emergency compared with GP referrals). Of 100 ambulance referrals 52 patients exhibited symptoms suggestive of ischaemic heart disease (confirmed AMI, unstable angina, and angina) and a further 18 patients were required to stay in CCU for other cardiac problems. Thus a total of 70 (70%) were considered appropriate compared with 155 of 260 (55.8%) GP referred cases.

CONCLUSIONS

Extending the fast track admission policy to ambulance personnel reduces delay to admission for patients with suspected MI without adversely affecting the appropriateness of admissions.

Hypertension and coronary artery disease

Hypertension is one of the major risk factors for coronary artery disease. This risk is considerably magnified by the presence of left ventricular hypertrophy. The likeliest dominant factor in this increased risk is myocardial ischaemia, the recognition of which is of key importance. Antihypertensive agents ideally should also protect against occurrence of the clinical syndromes associated with coronary artery disease.

Use of fax facility improves decision making regarding thrombolysis in acute myocardial infarction

BACKGROUND

Electrocardiography is the fundamental investigation for decision making regarding thrombolytic treatment in acute myocardial infarction (MI). Increasing the accuracy of ECG analysis by input from consultant staff may assist in management decisions in patients with suspected MI.

AIMS

To evaluate a system whereby out of hours ECGs can be faxed to the consultant to aid in decision making regarding thrombolytic treatment.

METHODS

112 patients with suspected MI were assessed on admission by the senior house officer (SHO) who faxed to a cardiology consultant the ECG trace and a predesigned form with information on: clinical assessment of the patient; interpretation of the ECG; and views regarding administration of thrombolytic treatment including choice of agent. The consultant reviewed the information and communicated his views to the SHO. Subsequent diagnosis was recorded in all patients and the forms were analysed in regard to areas of agreement and disagreement between the SHO and the consultant.

RESULTS

A diagnosis of MI was confirmed in 52 of the 112 patients (46.4%). The consultant agreed with the SHO's decision on thrombolysis in 98 patients (87.5%). The reason for disagreement in the remaining 14 patients (12.5%) was SHO misinterpretation of the ECG (10 patients) and clinical assessment (four patients). Eight patients were saved unnecessary thrombolytic treatment and four received it when they otherwise would not have. Additionally the choice of thrombolytic agent was changed in six patients from streptokinase to tissue plasminogen activator.

CONCLUSION

The use of fax machine assists in decision making with regard to thrombolytic treatment and provides support to junior doctors in what can be a difficult, yet critical decision.

Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

Thrombogenesis in mitral regurgitation and aortic stenosis

The exact mechanisms for thrombus formation in patients with valvular heart disease have not been clearly defined. Abnormalities in plasma coagulation factors indicative of a prothrombotic state may in part account for the risk of stroke and thromboembolism in such patients. The aim of this study was, therefore, to determine the effects of mitral regurgitation (MR) and aortic stenosis (AS) on plasma fibrinogen or fibrin D-dimer levels as indices of a thrombogenic (or prothrombotic) state. A total of 25 patients with valve disease in sinus rhythm were studied: 12 patients (all women; mean age fifty-five years, sem 3.3) with MR; and 13 patients (7 men, 6 women; mean age fifty-seven years, sem 3.5) with AS were studied. Patients with MR had a median plasma fibrinogen that was significantly elevated when compared with female population values (median difference 0.62 g/L; 95% confidence intervals (CI) 0.27 to 1.05, P = 0.0016). However, these patients had a median plasma fibrin D-dimer that was lower than that for population controls (median difference 21 ng/mL; 95% CI 0 to 38, P = 0.05). Patients with aortic valve disease had a median plasma fibrinogen that was significantly increased when compared with population controls (median difference 0.82 g/L; 95% CI 0.34 to 1.24, P = 0.001). These patients had a plasma fibrin D-dimer level that was similar to population values (median difference 3 ng/mL; 95% CI -25 to 22, P = 0.80). Patients with MR or AS have higher plasma fibrinogen levels when compared with "normal" population values, suggesting possible hemorheologic abnormalities in these patients. Subjects with MR had lower plasma fibrin D-dimer levels, suggesting lesser intravascular clotting, consistent with clinical echocardiographic studies. Subjects with AS had plasma fibrin D-dimer levels similar to the "normal" population values, suggestive of a different pathophysiological mechanism for thromboembolism. These findings add to an improved understanding of the relationship between clinical observations and the significance of plasma fibrinogen and fibrin D-dimer levels in thrombogenesis.

Left ventricular hypertrophy as a risk factor in hypertension

Hypertension is established as one of the major risk factors for congestive heart failure, renal failure, cerebrovascular accident and coronary artery disease. Left ventricular hypertrophy (LVH) is an adaptive response to the increased afterload in hypertension, and therefore serves to normalize wall stress. However, LVH has been established as an independent risk factor for adverse cardiovascular events and death in hypertension. For this reason, considerable attention has been directed towards a better understanding of LVH as a risk factor. As recognition of the risk associated with LVH has grown, investigators have increasingly focused attention on improving methods for the detection of LVH, assessing its effects on cardiac function, defining its relationship with myocardial ischaemia and sudden death, evaluating the role of antihypertensive treatment in the regression of LVH and assessing whether such regression is beneficial in the long term.

Fibrinogen and fibrin D-dimer levels in paroxysmal atrial fibrillation: evidence for intermediate elevated levels of intravascular thrombogenesis

Because abnormalities in hemostatic factors may in part account for the risk of stroke and thromboembolism in atrial fibrillation, we measured plasma fibrinogen and fibrin D-dimer levels in 33 patients (18 men and 15 women, mean age 60.8 +/- 1.4 years [mean +/- SEM]) with paroxysmal atrial fibrillation (PAF) and 12 patients (3 men and 9 women, mean age 51.0 +/- 4.2 years) with paroxysmal supraventricular tachycardia (PSVT). Levels of these markers were compared to levels in (1) patients with chronic atrial fibrillation; (2) hospital controls (age-matched [age +/- 5 years] and sex-matched patients in sinus rhythm with coronary artery disease and normal left ventricular function); and (3) healthy population controls in sinus rhythm. Patients with PAF had intermediate levels of median plasma fibrinogen and fibrin D-dimer when compared to patients with chronic atrial fibrillation and controls in sinus rhythm (both p < 0.001). There was no relation with atrial size or ventricular function on echocardiography. Patients with PSVT had plasma fibrinogen and fibrin D-dimer levels that were similar to the median levels of the population controls, suggesting that there was no excess in thrombogenesis. These findings are consistent with the hypothesis that atrial fibrillation is related to the increases in plasma fibrinogen and fibrin D-dimer levels. Patients with PAF have intermediate levels of these markers, a finding that is consistent with the intermediate risk of thromboembolism in such patients.

Plasma fibrinogen and fibrin D-dimer in patients with atrial fibrillation: effects of cardioversion to sinus rhythm

Cardioversion of atrial fibrillation carries a serious risk of major thromboembolism and stroke. To determine whether or not the procedure alters plasma levels of fibrin D-dimer (a marker of intravascular fibrin turnover and thrombus formation) and plasma fibrinogen (associated with stroke and thromboembolism), we performed a prospective study in 19 patients with atrial fibrillation in whom cardioversion was attempted: seven patients without prior oral anticoagulant therapy (but with intravenous heparin for 24 h) (Group I), and 12 patients with full oral anticoagulation pre- and post-cardioversion (Group II). Plasma fibrinogen and fibrin D-dimer were measured pre-cardioversion, and at Days 3, 7 and 14 post-cardioversion. In Group I, there was a significant reduction in median plasma fibrin D-dimer levels by 14 days following cardioversion (200 vs. 52 ng/ml; paired Wilcoxon test, P = 0.02). In Group II, there was no change in median plasma fibrin D-dimer levels over the 14 days following cardioversion. There were no significant changes in plasma fibrinogen with cardioversion in either group of patients. The reduction of plasma fibrin D-dimer in Group I suggests a beneficial reduction of intravascular fibrin turnover and thrombogenesis by the cardioversion of patients with atrial fibrillation to sinus rhythm. Furthermore, it strongly suggests that it is atrial fibrillation itself which is the major risk of thromboembolism and that the risk continues for up to 14 days post-cardioversion. In Group II, the low pre-cardioversion fibrin D-dimer levels and lack of change with cardioversion is consistent with the prophylactic effect of warfarin therapy against thromboembolism during the cardioversion of atrial fibrillation.

The interface of hypertension and ischemic heart disease

Myocardial infarction remains the single most common cause of death in patients with essential hypertension. This becomes particularly evident when the hypertension is associated with left ventricular hypertrophy. To combat the continuing high mortality from myocardial infarction in hypertensive heart disease, however, all aspects of the relationship must be studied. Thus, addressing the interface from an epidemiological standpoint as well as from a pathological point is critical and progress in these areas as well as in areas of management are ultimately likely to lead to a fall in morbidity and mortality from ischemic heart disease in patients with hypertension.

Effects of warfarin therapy on plasma fibrinogen, von Willebrand factor, and fibrin D-dimer in left ventricular dysfunction secondary to coronary artery disease with and without aneurysms

Cardiac impairment in patients is associated with intracardiac thrombus formation and thromboembolism. A high prothrombotic state may exist in such patients, and abnormalities in plasma markers of thrombogenesis may be indicative of such a state. The aim of this study was to determine the associations of left ventricular (LV) aneurysm formation and dysfunction with plasma fibrinogen, von Willebrand factor, and fibrin D-dimer, which are markers associated with thrombus formation (thrombogenesis) and to investigate the effects of warfarin given to patients with LV aneurysms on fibrinogen and D-dimer levels. A cross-sectional study of 112 patients with coronary artery disease was initially performed: 34 patients had normal LV function (group 1); 30 had LV dysfunction without aneurysm formation (group 2); 29 had LV aneurysms without anticoagulation (group 3a); and 19 patients had LV aneurysms with warfarin therapy (group 3b). Results were compared with 158 population controls from a random population sample. A longitudinal study of 10 patients given warfarin was also performed. In group 1, plasma fibrinogen (median difference 0.36 g/L; p = 0.0009) and von Willebrand factor (median difference 17 IU/dl; p = 0.04) were elevated, whereas plasma D-dimer levels (median difference 23.0 ng/ml; p = 0.001) were lower than those in population control subjects. There were no significant differences in plasma fibrinogen, von Willebrand factor, or D-dimer levels between groups 1 and 2. In group 3a, plasma fibrinogen was elevated when compared with group 1 (median difference 0.6 g/L; p = 0.0001), with a trend toward high von Willebrand factor levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Is diastolic dysfunction associated with thrombogenesis? A study of circulating markers of a prothrombotic state in patients with coronary artery disease

Clinical data on the contributory role of heart failure to thromboembolic risk does not differentiate between systolic and diastolic left ventricular dysfunction. We therefore conducted a population-controlled cross-sectional study to determine levels of plasma fibrinogen (associated with thromboembolism), fibrin D-dimer (a marker of fibrin turnover) and von Willebrand factor (a marker of endothelial dysfunction) in patients with ischaemic heart disease (a common cause of diastolic dysfunction) in whom left ventricular diastolic function was defined by echocardiography. We studied 106 patients: those with normal left ventricular function (n = 42, Group 1); those with left ventricular dysfunction but without aneurysms (n = 34, Group 2); and those with left ventricular aneurysm formation (n = 30, Group 3). Each of these groups was subdivided into those with (a) and without (b) diastolic dysfunction. Diastolic dysfunction was present in over 60% of patients, irrespective of left ventricular systolic impairment. There were no significant differences in median levels of plasma fibrinogen, fibrin D-dimer or von Willebrand factor in each group of patients with ischaemic heart disease, whether or not left ventricular diastolic dysfunction was present (Mann-Whitney test; P = N.S.). Systolic (rather than diastolic) dysfunction was the main correlate of these (analysis of variance, general linear model--ANOVA-GLM--P < 0.05) and the greatest abnormalities of fibrinogen, endothelial dysfunction and intravascular fibrin turnover were seen in patients with left ventricular aneurysms whether or not diastolic dysfunction was present. This study demonstrates that there is no evidence of a significant additional contribution to thrombotic risk (as assessed by plasma fibrinogen, von Willebrand factor and fibrin D-dimer) for patients with left ventricular diastolic dysfunction. A relationship is noted between some prothrombotic factors and Doppler indices of flow, which suggests a possible association between cardiac haemodynamics and thrombogenesis.

Increased markers of thrombogenesis in chronic atrial fibrillation: effects of warfarin treatment

OBJECTIVE

To determine whether chronic atrial fibrillation is associated with abnormalities in plasma fibrinogen, von Willebrand factor (vWF) (a marker of endothelial disturbance), or fibrin D- dimer (a measure of fibrin turnover); and if so, whether such levels are related to haemodynamic disturbance (enlarged left atrium, poor left ventricular function) or existing treatment with warfarin or aspirin. To investigate the effects of introducing warfarin in patients with atrial fibrillation on fibrinogen and D- dimer levels.

DESIGN

Cross sectional population sample controlled study and longitudinal study of patients undergoing anticoagulation.

SETTING

District general hospital.

SUBJECTS

87 patients (44 men and 43 women of mean (SEM) age 63.0 (1.0)) with chronic atrial fibrillation. At the time of the study, 37 were taking no antithrombotic medication (group 1), 31 were taking warfarin (including two on warfarin and aspirin) (group 2) and 19 were taking aspirin alone (group 3). They were compared with 158 population controls from a random population sample (the second Glasgow monitoring trends and determinants in cardiovascular disease study). As part of clinical treatment warfarin was introduced in 20 patients with chronic atrial fibrillation (14 men and six women of mean (SEM) (range) age 63.9 (2.35 (32-74) years).

RESULTS

Plasma fibrinogen remained significantly increased in patients of group 1 (no antithrombotic medication) compared with that of the population controls (median difference 1.23 g/l; 95% confidence interval (CI) 0.88 to 1.62, P < 0.0001). There was also a significant increase in plasma D-dimer levels (median difference 77 ng/ml; 95% CI 38 to 122, P < 0.01) and vWF (median difference 63 IU/dl; 95% CI 38 to 89, P < 0.0001). There was no significant difference in plasma fibrinogen (median difference 0.14 g/l; 95% CI -0.44 to 0.77, P = 0.65) or vWF (median difference 3.5 IU/dl; 95% CI - 41 to 41, P = not significant in patients of group 2 (warfarin treatment) compared with that of patients in group 1. Levels of D-dimer were significantly lower in group 2 (median difference 90 ng/ml, 95% CI 39 to 150, P < 0.0001) than in group 1. There were no significant differences in plasma fibrinogen (median difference 0.08 g/l; 95% CI - 0.52 to 0.77, P = 0.73), D-dimer (median difference - 34 ng/ml; 95% CI - 114 to 21.0, P = 0.25), or vWF (median difference 2%; 95% CI - 35 to 41, P = not significant) levels between patients of groups 1 and 3. There were no significant correlations between the coagulation indices and left atrial volume or ventricular function. There was a significant positive correlation between plasma fibrin D-dimer and vWF levels in patients of groups 1 and 3 (r = 0.52, P < 0.001). There was a significant reduction in median plasma fibrin D-dimer levels at 2 months after the introduction of warfarin (181 ng/ml v 80 ng/ml, P < 0.001), but no effect on plasma fibrinogen.

CONCLUSIONS

Increased median plasma fibrinogen and vWF levels were found in patients with chronic atrial fibrillation. Plasma D-dimer levels were also increased in patients with chronic atrial fibrillation not receiving warfarin, suggesting increased intravascular thrombogenesis in such patients. Introduction of warfarin normalised circulating fibrin D- dimer levels, suggesting that warfarin treatment was effective in preventing excessive fibrin turnover, consistent with the antithrombotic effects of warfarin. These results suggest three possible thrombotic markers to assess patients with atrial fibrillation who are at high risk of thrombogenesis; D-dimer also merits assessment as a measure of reduction in thrombotic risk in patients receiving warfarin.

Cardiac hypertrophy and hypertension

The epidemiology of left ventricular hypertrophy (LVH) in hypertension has been extensively studied and its importance as a cardiovascular risk factor is established. Significant advances in recent years have also occurred in pathophysiology, detection of LVH, and in management including regression of hypertrophy. Advances in pathophysiology have demonstrated that a number of trophic factors such as stretch, angiotensin II and stimulation of the sympathetic nervous system contribute towards the hypertrophy of the myocyte. In addition, it is important to emphasise factors such as aldosterone and angiotensin which contribute towards the proliferation of fibroblasts. The mechanisms involved in the increased mortality in patients with left ventricular hypertrophy remain to be determined, but myocardial ischaemia, left ventricular dysfunction and a propensity to ventricular arrhythmias have all been studied in detail. Echocardiography is a more reliable method for detecting LVH than ECG, but these investigations should be regarded as complementary rather than one being performed to the exclusion of the other. It remains unclear as to whether regression of LVH specifically contributes to a reduction in overall cardiovascular risk, but the key point seems to be optimal control of blood pressure, and only with further clinical trials will the exact impact of regression of LVH on morbidity and mortality be known.

Pre-dosing antibody levels and efficacy of thrombolytic drugs containing streptokinase

OBJECTIVE

To evaluate the influence of pretreatment streptokinase resistance titre and the concentration of IgG antibodies to streptokinase on the efficacy of thrombolytic drugs containing streptokinase in restoring coronary patency in acute myocardial infarction.

DESIGN

Comparative observational study.

SETTING

City general hospital.

PATIENTS

One hundred and twenty four previously unexposed patients presenting within six hours of onset of acute myocardial infarction.

INTERVENTIONS

Streptokinase, 1.5 MIU as intravenous infusion over 60 minutes (60 patients), or anistreplase, 30 units as intravenous injection over five minutes (64 patients).

MAIN OUTCOME MEASURES

Pretreatment streptokinase resistance titre and concentration of IgG antibodies to streptokinase were measured in 96 and 124 patients respectively and coronary patency assessed angiographically at 90 minutes and 24 hours.

RESULTS

Pretreatment streptokinase resistance titre and concentrations of IgG antibodies to streptokinase were low and skewed towards higher values. Those patients with coronary occlusion at 24 hours had a significantly higher median streptokinase resistance titre (100 v 50 streptokinase IU ml-1, P = 0.02). There were trends towards a higher streptokinase resistance titre in those patients with coronary occlusion at 90 minutes (50 v 20 streptokinase IU ml-1, P = 0.06) and higher concentrations of IgG antibodies to streptokinase in those with coronary occlusion at both 90 minutes and 24 hours (1.53 v 0.925, P = 0.03; 1.65 v 1.04 micrograms streptokinase binding ml-1, P = 0.06). Coronary patency rates were similar in the two treatment groups.

CONCLUSIONS

In the range measured in previously unexposed patients the streptokinase resistance titre has a small, but significant, negative influence on the efficacy of streptokinase and anistreplase. This effect should be considered if retreatment with streptokinase or anistreplase is proposed.

Acute myocardial infarction: a rare complication of the thrombotic tendency in nephrotic syndrome

The association of nephrotic syndrome with a hypercoagulable state and vascular thrombosis is well recognised. We present a case of acute anterior myocardial infarction in a young man with nephrotic syndrome secondary to minimal change glomerulonephritis, in which subsequent coronary angiography showed no evidence of atherosclerotic coronary artery disease and thrombotic occlusion of an otherwise normal left anterior descending coronary artery was the likely cause of presentation.

The role of nuclear cardiology in hypertension

In view of the increased risk of cardiac events in systemic hypertension, particularly in patients with left ventricular hypertrophy, it is important to have reliable methods of assessing cardiac structure and function and myocardial perfusion in these patients. While echocardiography is the noninvasive method of choice for measuring the severity of left ventricular hypertrophy there is no alternative at present to invasive coronary angiography to define accurately coronary artery anatomy. Nuclear cardiological investigations are extremely useful in the assessment of systolic and diastolic function at rest and during exercise. Furthermore, myocardial perfusion imaging is of value in identifying myocardial ischaemia and assessing the functional importance of coronary artery lesions. Recent studies have also suggested that nuclear cardiology investigations may be the best way to identify nonfunctioning but viable areas of the myocardium which may benefit from revascularization.

Treatment of atrial fibrillation in a district general hospital

OBJECTIVE

To assess current strategies used to investigate and manage acute atrial fibrillation in hospital.

DESIGN

Prospective survey of all acute admissions over 6 months.

SETTING

District general hospital serving a population of 230,000 in north east Glasgow.

SUBJECTS

2686 patients admitted as emergency cases over 6 months.

RESULTS

Of the 2686 patients, 170 (age range 38-95, mean (SD) 73.5 (10.6) years; 70 men (41%) and 100 women (59%)) were admitted with atrial fibrillation. The principal underlying medical conditions were ischaemic heart disease in 79 (46.5%), rheumatic heart disease in 26 (15.3%), and thyroid disease in six (3.5%). Cardiac failure was present on admission in 61 (36%), cerebrovascular events in 23 (14%), and myocardial infarction in 17 (10%). Of those with a history of atrial fibrillation (102 (60%) including 10 with paroxysmal atrial fibrillation) treatment on admission included digoxin in 71 (70%), warfarin in 20 (20%), and aspirin in 17 (17%); the aspirin was predominantly given for concomitant vascular disease. The mean (SD) inpatient stay was 16 days (19.7) (range 1-154) largely due to the patients with stroke. Thyroid function tests were performed in only 63% and echocardiography in 33%. Overall, the rate of introduction of anticoagulation (seven patients) and attempted cardioversion (21 patient: 19 pharmacological and two electrical) was surprisingly low. Only 49 patients (34% of those not on warfarin) had contraindications to anticoagulation: these included peptic ulcer or gastrointestinal bleeding in 18 (12%), dementia in eight (6%), chronic renal failure or dialysis in eight (6%), and alcohol excess in four (3%).

CONCLUSION

Standard investigations were inadequately used in patients with atrial fibrillation and there was a reluctance to perform cardioversion or to start anticoagulant treatment.

Assessment by general practitioners of suitability of thrombolysis in patients with suspected acute myocardial infarction

OBJECTIVE

To assess the clinical ability of general practitioners to decide to give thrombolytic therapy to patients with suspected myocardial infarction and to assess the contribution of the electrocardiograph (ECG) to this decision-making process.

SETTING

7 practices on the North side of Glasgow and the coronary care unit of Stobhill General Hospital.

SUBJECTS

137 patients presenting with chest pain who required direct admission to the coronary care unit.

MAIN OUTCOME MEASURES

Agreement between the general practitioner's clinical decision to give thrombolytic therapy with or without reference to the ECG and the prescription of thrombolytic therapy in the coronary care unit.

RESULTS

The predictive accuracy of the general practitioner's assessment of the necessity for thrombolytic therapy was 71.5%. The ECG had no impact on the accuracy of this decision and there were problems with the recording and interpretation of the ECG. Clinical decision making was altered in six cases by the ECG: wrongly in four.

CONCLUSION

The diagnostic accuracy among general practitioners would result in some patients who did not have acute myocardial infarction being given thrombolytic therapy. In this study the ECG did not contribute towards diagnostic accuracy. Substantial improvement in both the recording and interpretation of ECGs is needed before thrombolytic agents can be routinely prescribed at home.

Sudden cardiac death, ventricular arrhythmias and hypertensive left ventricular hypertrophy

OBJECTIVE

To evaluate the relationship between sudden cardiac death, ventricular arrhythmias and left ventricular hypertrophy in patients with hypertension.

DATA IDENTIFICATION

Epidemiological studies assessing the importance of left ventricular hypertrophy as a risk factor for sudden cardiac death, studies assessing the prevalence of arrhythmias in left ventricular hypertrophy and studies assessing whether there is an electrophysiological substrate in the hypertrophied myocardium for ventricular dysrhythmias.

RESULTS OF DATA ANALYSIS

Current evidence indicates that left ventricular hypertrophy is a risk factor for sudden cardiac death and that ventricular arrhythmias are more prevalent in hypertensive patients with than in those without left ventricular hypertrophy. However, there is a lack of evidence that these dysrhythmias are important as an underlying mechanism for sudden cardiac death, and there is no clear evidence that the hypertrophied myocardium is, itself, an arrhythmogenic substrate for malignant ventricular dysrhythmias. One possible mechanism for sudden cardiac death is myocardial ischaemia, either as a consequence of associated coronary disease or due to left ventricular hypertrophy, but this remains unproved.

CONCLUSIONS

There is currently no evidence that the ventricular ectopic activity seen in patients with hypertensive left ventricular hypertrophy is a marker for sudden cardiac death. Clarification of the mechanisms involved in sudden cardiac death will help in selecting appropriate preventive and therapeutic strategies for these patients.

An audit of emergency echocardiography in a district general hospital

Eighty patients (43 M, 37 F), aged 23-89 years who were referred for emergency echocardiography over a 12-month period were prospectively studied in order to determine the reasons for emergency echocardiography and the influence of its results on patient management. The most frequent emergency request was to clarify whether the basis for cardiomegaly in a haemodynamically unstable patient was pericardial effusion or left ventricular dilatation. Other reasons for requests were for assessment for source of systemic emboli, acute complications of myocardial infarction, endocarditis, valve dysfunction and cardiac trauma. As a consequence of the emergency echocardiography, management was immediately influenced in 19 patients. This study has provided information on the specific settings in which emergency echocardiography can be justified.

Unilateral pulmonary artery agenesis: a rare cause of haemoptysis and pleuritic chest pain

Haemoptysis and pleuritic chest pain are common presentations of cardiopulmonary disease. While a number of common disorders may explain these symptoms, occasionally unusual causes may emerge which should be considered in the differential diagnosis especially if pulmonary embolism is unlikely; so that inappropriate anticoagulation or thrombolytic therapy is avoided. We present a case of unilateral pulmonary artery agenesis, who presented with pleuritic chest pain and haemoptysis, and was initially treated as a case of pulmonary thromboembolism.

The incidence and mechanism of hypotension following thrombolytic therapy for acute myocardial infarction with streptokinase-containing agents--lack of relationship to pretreatment streptokinase resistance

The incidence, amplitude, mechanism and relationship to prior exposure to streptococcal antigen of blood pressure changes to streptokinase-containing thrombolytic agents were investigated in 125 patients treated with either 1.5 x 10(6) IU streptokinase over 60 min or 30 U anistreplase over 5 min, within 6 h of onset of acute myocardial infarction. Twenty-one of 52 patients with anterior and 34 of 73 with inferior myocardial infarction had a hypotensive response. There were no significant differences in the incidence, duration or amplitude of hypotension between the two treatment groups. The maximum mean fall in systolic blood pressure was 16.9 mmHg (95% confidence limits, CL 12.2 to 24.5 mmHg), and the maximum mean fall in diastolic blood pressure was 13.7 mmHg (CL 10.3 to 17.1 mmHg), starting 4 min after start of therapy and resolving within 34 min. Blood pressure changes were well tolerated. Hypotension was not related to pretreatment streptokinase resistance titre, or anti-SK IgG concentration, to changes in plasma fibrinogen, B-beta 15-42 peptide, D-dimer--as indices of thrombin activation and fibrin (-ogen) breakdown--to plasma viscosity. The blood pressure changes following treatment with streptokinase-containing thrombolytic agents in acute myocardial infarction are frequent but well tolerated. The mechanism of hypotension remains unclear, but is not related to prior exposure to streptococcal antigen.

Leaking false aneurysm of right coronary saphenous vein graft; successful treatment by percutaneous coil embolisation

An unusual complication after aortocoronary bypass grafting (CABG) is described in which a false aneurysm of the saphenous vein graft to the right coronary artery (RCA) developed and caused profuse intermittent bleeding through the sternotomy wound. The aetiology of this condition is uncertain but it could occur whenever a suture line is present especially in the presence of infection. The diagnosis was made non-invasively by a contrast enhanced computed tomogram and was subsequently confirmed by selective coronary bypass angiography. The pseudoaneurysm was successfully obliterated by coil embolisation of the right coronary graft, which stopped the bleeding immediately and was followed by rapid wound healing.

Impact of regression of left ventricular hypertrophy on cardiac function in hypertension

It is now established that regression of left ventricular hypertrophy (LVH) occurs following reduction of arterial pressure in patients with hypertension. A number of factors contribute towards this regression, including the fall in blood pressure itself, the drug therapy given, and the pre-existing degree of hypertrophy. LVH is in some senses a beneficial adaptive response in terms of systolic function, and therefore it is important to clarify whether or not regression of hypertrophy is damaging to cardiac function. Overall assessment of these effects has been more difficult because the antihypertensive drug therapy and the changes in blood pressure also contribute to left ventricular function. Current data indicate that systolic function is maintained both at rest and following exercise but not necessarily improved. In contrast, diastolic function in some but not all studies, has been shown to have been improved. Recent information has allayed fears that regression of LVH may cause a deterioration in function if blood pressure is allowed to return to its pretreatment levels. It would appear that in this situation function is maintained both at rest and during exercise. Finally, the assessment of cardiac function following regression of hypertrophy remains a surrogate end-point. The key information required remains the influence of regression of hypertrophy and its alteration in function on morbidity and mortality in patients with hypertension.