Frailty is associated with chronic inflammation and pro-inflammatory monocyte subpopulations

Introduction

Patients with frailty represent an increasing patient group in the intensive care medicine. A connection between frailty and inflammation has been suggested. An increased mortality rate in patients with high grade aortic valve stenosis (AS) and frailty, who underwent Transcatheter Aortic Valve Implantation (TAVI) has been observed. A systemic inflammatory reaction in the intensive care unit in the first days after TAVI is a positive predictive factor for an unfavorable outcome. Exact mechanisms are still not fully explained. Monocyte subpopulations are associated with both cardiovascular diseases and a high APACHE II score in critically ill patients.

Purpose

This study investigates the correlation between frailty and cellular and systemic inflammatory mechanisms and mortality after TAVI.

Methods

We examined 120 patients with symptomatic AS who underwent TAVI. Before the implantation, frailty status has been assessed. In all patients a flow cytometry analysis has been performed. Monocyte subpopulations were defined as follows: Mon1 (CD14++CD16–), Mon2 (CD14++CD16+) and Mon3 (CD14+CD16++). Expression of CD11b has been measured as a marker for monocyte activation. Pro-inflammatory cytokines such as interleukin IL-8, as well as CRP have been measured with Cytometric Bead Array or standard laboratory methods.

Results

After 3 months 15 of 120 patients died, primarily without relevant dysfunction of the implanted aortic valve. In 8 of 15 (53%) of the deceased patients and 20 of 100 (19%) of the surviving patients, frailty could be diagnozed before TAVI (p=0.003). Patients with frailty showed prior to TAVI signs of chronic inflammation: elevated CRP (3.7 vs. 5.9 mg/l, p=0.001) and elevated levels of considered as pro-inflammatory Mon2 monocytes (37 vs. 53, p=0.001). Expression of CD11b and IL-8 showed an increasing trend in patients with frailty. Frailty, the monocyte markers, IL-8 and CRP prior to TAVI correlated with increased early mortality after TAVI.

Conclusion

A considerable number of elderly patients with high grade aortic valve stenosis can be described as frail. This syndrome is associated with increased mortality and with signs of chronic systemic inflammation and pro-inflammatory monocytes.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Heart Center Dresden

CD11b expression on monocytes and data of inflammatory parameters after Transcatheter Aortic Valve Implantation in dependence of early mortality

An inflammatory systemic reaction is common after Transcatheter Aortic Valve Implantation (TAVI). We recently reported about an involvement of Mon2-monocytes, the CD11b expression on monocytes and parameters of systemic inflammation before TAVI correlating with early mortality after TAVI. Here, we provide data of monocyte subpopulations, CD11b expression and parameters of a systemic inflammation in dependence of three-month mortality after TAVI. With this, we provide further insights into inflammatory mechanism after TAVI. The data were collected by flow-cytometric quantification analyses of peripheral blood in 120 consecutive patients who underwent TAVI (on day 1 and 7 after TAVI). Monocyte-subsets were identified by their CD14 and CD16 expression and monocyte-platelet-aggregates (MPA) by CD14/CD41 co-expression. The extent of monocyte activation was determined by quantification of CD11b-expression (activate epitope). Additionally, pro-inflammatory cytokines such as interleukin (IL)-6, IL-8, C-reactive protein, procalcitonin were measured using the cytometric bead array method or standard laboratory tests. Additionally, we report procedural outcomes in dependence of three-month mortality. Furthermore, correlations of CD11b-expression on monocytes with parameters of platelet activation or further inflammatory parameters are presented. For further interpretation of the presented data, please see the research article “Mon2-Monocytes and Increased CD-11b Expression Before Transcatheter Aortic Valve Implantation are Associated with Earlier Death” by Pfluecke et al.[1]

Hahnemann's legacy—the Q (LM) potencies

The methods of pharmaceutical preparation evolved by Hahnemann between 1801 and 1842 are clearly defined and reproducible. The Q (50th millesimal) potencies offer the shortest, most reliable and ‘most harmless way’ to ‘rapid, gentle and permanent’ restoration to health. An unbiased look at the existing source documents enables us now—150 years later, and after innumerable misunderstandings—to produce and prescribe these highly effective potencies as originally intended. The empirical rule demands: ‘Follow it, but follow it exactly.’

[Prevention of bicycle accidents]

For a very precise analysis of all injured bicyclists in Germany it would be important to have definitions for "severely injured", "seriously injured" and "critically injured". By this, e.g., two-thirds of surgically treated bicyclists who are not registered by the police could become available for a general analysis. Elderly bicyclists (> 60 years) are a minority (10 %) but represent a majority (50 %) of all fatalities. They profit most by wearing a helmet and would be less injured by using special bicycle bags, switching on their hearing aids and following all traffic rules. E-bikes are used more and more (145 % more in 2012 vs. 2011) with 600,000 at the end of 2011 and are increasingly involved in accidents but still have a lack of legislation. So even for pedelecs 45 with 500 W and a possible speed of 45 km/h there is still no legislative demand for the use of a protecting helmet. 96 % of all injured cyclists in Germany had more than 0.5 ‰ alcohol in their blood, 86 % more than 1.1 ‰ and 59 % more than 1.7 ‰. Fatalities are seen in 24.2 % of cases without any collision partner. Therefore the ADFC calls for a limit of 1.1 ‰. Some virtual studies conclude that integrated sensors in bicycle helmets which would interact with sensors in cars could prevent collisions or reduce the severity of injury by stopping the cars automatically. Integrated sensors in cars with opening angles of 180° enable about 93 % of all bicyclists to be detected leading to a high rate of injury avoidance and/or mitigation. Hanging lamps reduce with 35 % significantly bicycle accidents for children, traffic education for children and special trainings for elderly bicyclists are also recommended as prevention tools. As long as helmet use for bicyclists in Germany rates only 9 % on average and legislative orders for using a helmet will not be in force in the near future, coming up campaigns seem to be necessary to be promoted by the Deutscher Verkehrssicherheitsrat as, e.g., "Helmets are cool". Also, spots in TV should be broadcasted like "The 7th sense" or "Traffic compass", which were warning car drivers many years ago of moments of danger but now they could be used to warn bicyclists of life-threatening situations in traffic.

libRASCH--a programming framework for transparent access to physiological signals

For the analysis of physiological signals, such as ECG's, continuous blood pressure recordings etc., access to the raw signal data as well as to processed data is mandatory. Up to now, there is no computer program which allows access to raw and processed data independently from the file formats used. Thus, programs have to be adapted to each new file format. The aim of the programming library 'libRASCH', is to provide an interface which allows the access to physiological signals in a consistent way. libRASCH is written in C and runs under Linux and Windows. The source code of libRASCH is published under the GNU LGPL. A plugin mechanism for extension of the library was implemented. Support for some widely used data formats (e.g. European Data Format) is already available. To support a new file-format, only the corresponding plugin has to be written. Moreover all programs using this library, can handle the new format without further adjustments. For other programming languages than C (e.g. Perl, Python), interfaces are available. On the libRASCH website (http://www.librasch.org), the source code of libRASCH and further information's are available.

Value of programmed ventricular stimulation for prophylactic internal cardioverter-defibrillator implantation in postinfarction patients preselected by noninvasive risk stratifiers

OBJECTIVES

The aim of this prospective study was to evaluate the role of programmed ventricular stimulation (PVS) after noninvasive risk stratification to identify a subgroup of acute myocardial infarction (AMI) survivors considered at risk for ventricular arrhythmias and whether these patients could benefit from internal cardioverter-defibrillators (ICDs).

BACKGROUND

The predictive value of noninvasive and invasive risk stratifiers after AMI has been questioned. The question of whether the group of patients with inducible monomorphic ventricular tachycardia (VT) after AMI could profit from ICD implantation is unanswered.

METHODS

A consecutive series of 1,436 AMI survivors was screened noninvasively by Holter monitoring, heart rate variability, ventricular late potentials, and ejection fraction. A subgroup of 248 patients (17.3%) were identified as high-risk patients and scheduled for PVS. Due to the study design, 54 patients >75 years were excluded; thus, 194 patients were eligible for PVS. Triple extrastimuli at two paced cycle lengths (600 ms and 400 ms) were applied.

RESULTS

In a subgroup of 98 (51%) high-risk patients, PVS was performed; 21 patients had an abnormal response, and in 20 patients an ICD was implanted. During a mean follow-up of 607 days the arrhythmic event rate (sudden cardiac death, symptomatic VT, cardiac arrest) was 33% with a positive electrophysiological test versus 2.6% (p < 0.0001) with a negative electrophysiological test. A subgroup of 96 high-risk patients declined electrophysiological study. In this nonconsent group, cardiac mortality (combined sudden and nonsudden) was significantly higher (log-rank chi-square 9.38, p = 0.0022, relative risk 4.7, 1.6 to 13.9) compared to the group guided by electrophysiological testing and consecutive ICD implantation.

CONCLUSIONS

After a two-step risk stratification, PVS is helpful in selecting a subgroup of AMI survivors without spontaneous ventricular arrhythmias who benefit from prophylactic ICD implantation.

Extent of cardiac sympathetic neuronal damage is determined by the area of ischemia in patients with acute coronary syndromes

BACKGROUND

Prior studies have demonstrated that acute ischemic injury causes sympathetic neuronal damage exceeding the area of necrosis. The aim of this study was to test the hypothesis that sympathetic neuronal damage measured by (123)I-metaiodobenzylguanidine (MIBG) imaging would be determined by the area of ischemia as reflected by area at risk in patients undergoing reperfusion therapy for acute coronary syndromes.

METHODS AND RESULTS

In 12 patients, the myocardium at risk was assessed by (99m)Tc-sestamibi SPECT before reperfusion, and infarct size was measured by follow-up (99m)Tc-sestamibi SPECT 1 week later. All patients also underwent (123)I-MIBG SPECT within a mean of 11 days after onset. The SPECT image analysis was based on a semiquantitative polar map approach. Defect size on the (123)I-MIBG or (99m)Tc-sestamibi SPECT was measured for the left ventricle (LV) with the use of a threshold of -2.5 SD from the mean value of a normal database and was expressed as %LV. The (123)I-MIBG defect size (47+/-18%LV) was larger than the infarct size (27+/-23%LV, P<0. 001) but was similar to the risk area (49+/-18%LV, P=NS). Furthermore, the (123)I-MIBG defect size was closely correlated with the risk area (r=0.905, P<0.001).

CONCLUSIONS

Sympathetic neuronal damage measured by (123)I-MIBG SPECT is larger than infarct size and is closely related to risk area, suggesting high sensitivity of neuronal structures to ischemia compared with myocardial cells.

Kinetics of 123I-MIBG after acute myocardial infarction and reperfusion therapy

Metaiodobenzylguanidine (MIBG) washout from the myocardium has been thought to reflect sympathetic nerve tone. After acute myocardial infarction, however, little is known about this parameter. The aim of this study was to determine the significance of cardiac washout after myocardial infarction and early reperfusion by investigating MIBG kinetics and correlating those kinetics to clinical parameters.

METHODS

Sixty patients with acute myocardial infarction underwent planar MIBG and thallium imaging within 14 d of early reperfusion therapy. Global uptake and washout in myocardium, lungs and liver were calculated from early and delayed images. A regional analysis of myocardial kinetics in normal and infarcted myocardium and in an infarct border zone was also performed. Scintigraphic data were correlated with heart-rate variability as an electrophysiologic marker for autonomic tone and prevalence of arrhythmia in 52 patients. Heart-rate variability was described by time-domain indices from long-term electrocardiogram recordings. An age-matched normal control group for MIBG consisted of 10 individuals without heart disease.

RESULTS

The infarct patients had preserved left-ventricular ejection fraction (LVEF) (56% +/- 17%). Although late myocardial uptake was expectedly lower in infarct patients compared with healthy volunteers (2.36 +/- 0.66 versus 2.80 +/- 0.55; P = 0.04), global myocardial MIBG washout was faster (11.6% +/- 7.9% versus 0.2% +/- 10.2%, respectively; P = 0.002). Lung and liver kinetics did not differ in patients and healthy volunteers. Global MIBG washout showed a weak but significant positive correlation with the baseline heart rate (r = 0.28, P = 0.03) and an inverse correlation with LVEF (r = -0.28, P = 0.04). Washout was faster in a subgroup of 8 patients with reduced heart-rate variability (16.5% +/- 9.9% versus 10.3% +/- 8.3%; P = 0.04). Regional analysis revealed similar degrees of enhanced MIBG washout for infarcted (low perfusion, low MIBG uptake) and remote myocardium (normal perfusion, high MIBG uptake), whereas the border zone (normal perfusion, low MIBG uptake) showed a nonsignificant trend toward higher washout.

CONCLUSION

After myocardial infarction, changes in MIBG kinetics occur specifically in the myocardium, whereas kinetics in lung and liver remain unchanged. Even in patients with left-ventricular function preserved by reperfusion therapy, MIBG washout is abnormal and globally increased. Enhanced washout may reflect increased sympathetic nerve tone and represent increased catecholamine turnover or impaired reuptake in the subacute phase of myocardial infarction.

Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction

BACKGROUND

Identification of high-risk patients after acute myocardial infarction is essential for successful prophylactic therapy. The predictive accuracy of currently used risk predictors is modest even when several factors are combined. Thus, establishment of a new powerful method for risk prediction independent of the available stratifiers is of considerable practical value.

METHODS

The study investigated fluctuations of sinus-rhythm cycle length after a single ventricular premature beat recorded in Holter electrocardiograms, and characterised the fluctuations (termed heart-rate turbulence) by two numerical parameters, termed turbulence onset and slope. The method was developed on a population of 100 patients with coronary heart disease and blindly applied to the population of the Multicentre Post-Infarction Program (MPIP; 577 survivors of acute infarction, 75 deaths during a median follow-up of 22 months) and to the placebo population of the European Myocardial Amiodarone Trial (EMIAT; 614 survivors of acute myocardial infarction, 87 deaths during median follow-up of 21 months). Multivariate risk stratification was done with the new parameters and conventional risk factors.

FINDINGS

One of the new parameters (turbulence slope) was the most powerful stratifier of follow-up mortality in EMIAT and the second most powerful stratifier in MPIP: MPIP risk ratio 3.5 (95% CI 2.2-5.5, p<0.0001), EMIAT risk ratio 2.7 (1.8-4.2, p<0.0001). In the multivariate analysis, low left-ventricular ejection fraction and turbulence slope were the only independent variables for mortality prediction in MPIP (p<0.001), whereas in EMIAT, five variables were independent mortality predictors: abnormal turbulence onset, abnormal turbulence slope, history of previous infarction, low left-ventricular ejection fraction, and high mean heart rate (p<0.001). In both MPIP and EMIAT, the combination of abnormal onset and slope was the most powerful multivariate risk stratifier: MPIP risk ratio 3.2 (1.7-6.0, p<0.0001), EMIAT risk ratio 3.2 (1.8-5.6, p<0.0001).

INTERPRETATION

The absence of the heart rate turbulence after ventricular premature beats is a very potent postinfarction risk stratifier that is independent of other known risk factors and which is stronger than other presently available risk predictors.

Variability of ventricular premature complexes and mortality risk

A method using a parameter from the field of nonlinear dynamics to quantify the variability of ventricular premature complexes (VPCs) is presented. One hundred patients with coronary artery disease and > or = 10 VPCs/hour were included in the study. The RR intervals were plotted in a three-dimensional artificial phase space, and the structures in phase space were quantified by the local scaling indices, alpha. In the frequency distribution histogram, n(alpha), for each patient, the maximum of the ventricular ectopies alpha VPC, adjusted to the VPC frequency, was assessed; alpha VPC was used as the risk indicator. Endpoints were total mortality and sudden cardiac death. During follow-up (mean 3.1 years), 28 out of 100 patients died, 16 suddenly; alpha VPC had a significant prognostic impact and was independent from other risk indicators, such as left ventricular ejection fraction (LVEF). Patients who died during follow-up were characterized by a high alpha VPC. The optimal discrimination of high risk patients and low risk patients occurred at alpha VPC = 3.0. After 4 years, the survival rate of patients with a alpha VPC > 3.0 was 59%, in contrast to 97% in patients with alpha VPC < or = 0.3. As to the sudden death mortality, the survival rates were 74% and 97%, respectively. The difference between the groups were significant for both endpoints. Patients with an increased VPC variability (i.e., alpha VPC > 3.0) were at enhanced risk of sudden death and total mortality risk; alpha VPC was independent from other risk indicators such as the LVEF or heart rate variability parameters.

Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation

This study was performed to assess the effects of one year of ACE inhibition with quinapril on left ventricular performance and morphology in asymptomatic patients with chronic aortic regurgitation. Pre- and afterload reduction is known to have beneficial effects in patients with chronic aortic regurgitation. To date, no controlled study has been reported analyzing long term influence of ACE inhibitor treatment on asymptomatic patients with chronic aortic regurgitation. Twelve asymptomatic patients with isolated moderate to severe chronic aortic regurgitation, no coronary disease on coronary angiography and no previous vasodilator treatment were studied under control conditions and after three and 12 months of quinapril therapy (10-20 mg/day) using echocardiography and simultaneous right heart catheterization and radionuclide ventriculography at rest and during supine bicycle exercise. After one year quinapril therapy regurgitant fraction fell by 17% compared to control before therapy (p = 0.001), left ventricular enddiastolic volume at rest was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 (p = 0.0003) and endsystolic volume decreased from 55 +/- 27 to 44 +/- 28 ml/m2 (p = 0.0005). Left ventricular ejection fraction at rest averaged 0.64 +/- 0.11 at control and increased after one year therapy to 0.67 +/- 0.11 (p = 0.05). With maximum exercise (100 W), ejection fraction failed to rise at control; after one year therapy with quinapril it increased to 0.70 +/- 0.15 (p = 0.019). Moreover, after one year quinapril therapy there was a significant reduction of 35% in left ventricular mass compared to control.(ABSTRACT TRUNCATED AT 250 WORDS)

Quinapril therapy in patients with chronic mitral regurgitation

Pre- and afterload reduction is known to have beneficial effects in patients with chronic mitral regurgitation. To date, no controlled study has been reported analyzing the long term influence of angiotensin-converting enzyme inhibitor treatment on patients with chronic mitral regurgitation. Therefore the aim of this study was to assess the effects of one year angiotensin-converting enzyme inhibition with quinapril on myocardial performance in patients with chronic mitral regurgitation. Twelve patients with moderate to severe isolated chronic mitral regurgitation and no coronary disease on coronary angiography were studied under control conditions and followed up until one year of quinapril therapy (10-20mg/day) using echocardiography and simultaneous right heart catheterization, and radionuclide ventriculography at rest and exercise. As the result of a significant pre- and afterload reduction after one year quinapril treatment regurgitant fraction fell from 0.43 +/- 0.10 at control before therapy to 0.25 +/- 0.08 (p = 0.0001), left ventricular end-diastolic volume was reduced from 146 +/- 26 to 109 +/- 24 ml/m2 (p = 0.0001) and end-systolic volume decreased from 63 +/- 43 to 47 +/- 29 ml/m2 (p = 0.02). Left ventricular ejection fraction at control averaged 0.59 +/- 0.20 at rest, increased to 0.65 +/- 0.21 with maximum exercise and was unchanged after one year quinapril therapy. After one year treatment left ventricular mass was reduced by 15% (p = 0.0004) and septal wall thickness decreased from 11.8 +/- 0.7 to 10.8 +/- 0.8 mm (p = 0.0006). Moreover, there was significant functional improvement of nearly one NYHA class after one year quinapril therapy. In conclusion, in patients with chronic mitral regurgitation long term angiotensin-converting enzyme inhibition with quinapril reduces regurgitation and decreases left ventricular size and mass thereby demonstrating functional improvement. In addition, these data suggest that angiotensin-converting enzyme inhibition might have the potential of delaying mitral valve surgery.

[Ventricular fibrillation and silent myocardial ischemia in a patient without anatomic heart disease]

A 44-year-old man, apparently without heart disease, suddenly collapsed with loss of consciousness. Ventricular fibrillation was documented when an external defibrillator was connected. After cardiopulmonary resuscitation and intubation he quickly regained consciousness. Clinical examination together with echocardiography, coronary angiography and electrophysiological tests discovered no abnormalities. Biochemical tests were normal except for slightly abnormal liver functions. Several long-term ECG recordings documented asymptomatic S-T elevations. During one such episode there occurred a polymorphous ventricular tachycardia of brief duration. Because the S-T elevations persisted, despite the administration of gallopamil (50 mg twice daily for one week), a defibrillator was implanted. Gallopamil was then discontinued. Long-term ECG monitoring subsequently revealed four episodes of marked S-T elevations, three of which accompanied by ventricular arrhythmias. After resuming gallopamil, now at a dose of 50 mg three times daily, further ECG monitoring showed no abnormalities.

Evaluation of antiarrhythmic drug effects with simultaneous analysis of single ventricular premature contractions, couplets and salvos

To improve the clinical value of ambulatory Holter electrocardiographic (ECG) monitoring as a tool of antiarrhythmic therapy control, a new statistical model was developed. In a patient group at increased risk of sudden cardiac death, the spontaneous variability of ventricular arrhythmias was assessed, with simultaneous consideration of single ventricular premature complexes, couplets and salvos. The study included 100 patients who suffered from coronary heart disease or idiopathic dilated cardiomyopathy and for whom greater than 30 ventricular premature complexes/h and couplets had been demonstrated on the last Holter ECG before the study. Between 3 and 12 Holter recordings were made for each patient in a drug-free state; the mean follow-up period was 260 days (maximum 1,403). The mean hourly values of the ectopic events (EE) were assessed separately for ventricular premature complexes, couplets and salvos. The spontaneous variability (SV) was calculated for single ventricular premature complexes, couplets and salvos as SV = log (EEday 2 + 0.01/EEday 1 + 0.01) and linked in one, two and three dimensions. Compared with the consideration of only one type of arrhythmia (one-dimensional model), the simultaneous use of two or three types of arrhythmia (two- or three-dimensional model) resulted in considerably lower reduction and aggravation rates as sufficient proof of drug effects. With control intervals up to 1 week, the one-dimensional model yielded reduction rates for ventricular premature complexes, couplets and salvos of -63%, -90% and -95%, respectively. In contrast, with the three-dimensional model, the rates were -28%, -72% and -88%. The corresponding aggravation values were +370, +1,114% and +2,189% versus +38%, +256% and +747%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of amiodarone on signal-averaged and long-term ECG]

This prospective study examined the influence of long-term amiodarone therapy on the parameters of the signal-averaged ECG and their relation to simultaneously derived Holter monitoring data. For this purpose, 23 patients with angiographically confirmed dilated cardiomyopathy or coronary heart disease and high-grade ventricular arrhythmias, in whom an average of four class I antiarrhythmic drugs had proven ineffective, were stabilized on amiodarone. Before the beginning of therapy, as well as after 2 months and, subsequently, every 3 months, a resting ECG, a signal-averaged ECG by Simson's method, and Holter monitoring were performed. Compared to the initial measurement, we found a significant increase in the duration of the total filtered QRS complex from an average of 114 +/- 24 ms to 127 +/- 35 ms, while the change in voltage did not reach the significance level. The incidence of late potentials remained largely constant under amiodarone; 10 patients showed a constant late potential, 12 patients had no late potential, and one patient with coronary heart disease developed a new late potential. In the long-term follow-up, we ascertained a relatively high responder rate under amiodarone between 41% and 81%. No relation could be detected between the results of the signal-averaged ECG and those of 24-h Holter monitoring.

[Long-term treatment with amiodarone]

The aim of this study was to investigate the efficacy and the side effects of a long-term treatment with amiodarone. We analyzed the data of 41 patients in whom amiodarone therapy had been initiated between 1974 and 1984. Twenty-one patients had dilative cardiomyopathy, 14 patients had chronic myocardial infarction, four patients suffered from WPW syndrome with intermittent atrial fibrillation, one patient had aortic valve surgery, whereas in one patient there was no clinical evidence of a heart disease. All patients had salvos of ventricular extrasystoles, ventricular tachycardia or documented intermittent ventricular fibrillation. There have been seven drop-outs up to the present time. In each patient, the lowest antiarrhythmically effective dose was applied, which was generally higher in patients with low ejection fraction. Effective treatment of the ventricular tachycardia was achieved in 55-92% of patients and did not depend on the duration of treatment. In 10 patients in whom amiodarone therapy had to be stopped for various reasons. Sudden cardiac death was slightly more frequent than in the 24 patients treated with amiodarone, though the difference was not significant. In cases with a history of syncope the prognosis was poor, even with amiodarone therapy. Due to side effects, a dosage reduction or discontinuation of amiodarone treatment became necessary in 14 patients. Amiodarone proved to be an effective drug also for the long-term treatment of ventricular tachycardia, and possibly for the prevention of sudden cardiac death. With the exception of blue skin color, there was no accumulation of side effects, even during long-term treatment of several years.

Amiodarone--efficacy and late potentials during long-term therapy

This prospective study was intended to examine the influence of long-term amiodarone therapy on the parameters of the signal averaged ECG and their relation to simultaneously derived Holter monitoring data. For this purpose 27 patients with angiographically confirmed dilated cardiomyopathy or coronary heart disease and highgrade ventricular arrhythmias, in whom an average of four class I antiarrhythmic drugs had proven ineffective, were stabilized on amiodarone. Before the beginning of therapy, as well as after two months and subsequently every three months if possible, a resting ECG, a signal averaged ECG by the method of Simson and Holter monitoring were performed. Compared to the initial measurement we found a significant increase in the duration of the total filtered QRS complex, while the change in the voltage did not reach the significance level. The incidence of late potentials remained largely constant under amiodarone. In the long-term follow up Holter monitoring showed a relatively high responder rate of between 46 and 81% under amiodarone. No relation could be detected between the results of the signal averaged ECG and those of 24-h Holter monitoring.

[Spontaneous variability of ventricular arrhythmias in follow-up of anti-arrhythmia therapy]

The question of the reliability of ambulatory Holter monitoring for assessment of antiarrhythmic treatment has not been adequately resolved. Even though treatment efficacy had been individually assessed with Holter monitoring in the CAST study, during long-term treatment with class IC antiarrhythmic drugs, there were more deaths among patients receiving active drug than in those in the placebo group. Basic biostatistical considerations: Due to the spontaneous variability of frequency and complexity of ventricular arrhythmias, parametric models were developed with the aid of which normal ranges for spontaneous variability of singular ventricular premature complexes (VPC), couplets and salvos can be calculated. We designed a model which enables rapid visual analysis of the results: spontaneous variability = log (EE Day 2 + 0.01/EE Day 1 + 0.01) where EE is the number of ectopic events. For both days, the mean values per hour are applied. The use of parametric models prerequisites normal distribution of the data which can be achieved with logarithmic transformation. A constant is added to all mean values to preclude the mathematically-inadmissible form of log 0. The magnitude of the constant results in some degree of underestimation of the spontaneous variability. We chose the smallest constant, c = 0.01, consistent with a normal distribution of data. Figure 1 shows the normal range of the variability quotients for VPC in patients with cardiac disease and complex ventricular arrhythmias. The contiguous regions above and below the normal range designate active areas indicative of reduction or aggravation. Determinants of spontaneous variability: Frequency of arrhythmias: The number of VPC per unit of time exerts considerable influence on the spontaneous variability. The more infrequent an arrhythmia, the greater is the fluctuation to be anticipated. The differences in the variability of VPC, couplets and salvos are almost exclusively due to their differing frequencies since, in the presence of comparable frequency, they cannot be distinguished statistically from each other (Figure 2). Type and extent of underlying cardiac disease: In our patient population, there were no differences in spontaneous variability of arrhythmias between patients with coronary artery disease and those with dilated cardiomyopathy (Figure 3). Although in patients with coronary artery disease, as compared to those with noncoronary disease, a higher degree of spontaneous variability has been reported for VPC but, due to the inhomogeneity of the latter group, valid comparison is encumbered. The ejection fraction, the left ventricular filling pressure and the end-diastolic volume do not exert meaningful influence on the spontaneous variability (Figures 4 to 6).(ABSTRACT TRUNCATED AT 400 WORDS)

Assessing antiarrhythmic drug efficacy: multivariate considerations

The spontaneous variability of ventricular arrhythmias is the major problem in assessing antiarrhythmic drug efficacy. Efficacy is usually assessed on one form of ventricular premature beats, namely either single beats (VPC) or more complex forms like couplets or salvos. The reduction rates required to assume efficacy with a confidence of 95 per cent are 63 per cent for VPCs, 92 per cent for couples or 96 per cent for salvos. These rates are valid for two Holter electrocardiogram recordings within one week; otherwise the rates are higher and close to 100 per cent. In this paper we extend our ratio method for calculating these criteria to consider two or all three forms of ventricular premature beats simultaneously. The method is based on the first principal component. For use in practice we decided to calculate fixed criteria for each form of ventricular premature beats. For the combination of VPCs and couplets and a confidence level of 95 per cent, reduction rates of 42 per cent for VPC and 87 per cent for couplets are required. Both criteria must be fulfilled to assume the efficacy of a drug. These criteria are lower than those for each form alone. For all three forms together, reduction rates of 28, 72 and 88 per cent for VPC, couplets and salvos respectively are required.

[Spontaneous variability of ventricular arrhythmias in relation to the kind and extent of underlying heart disease]

The influence of the underlying heart disease on the spontaneous variability of ventricular arrhythmias was investigated prospectively in 53 patients (25 CHD, 28 IDC) with frequent and complex ventricular arrhythmias. In each patient, two consecutive ambulatory 24-h Holter ECGs were prepared and in each tape the mean hourly arrhythmia count (AC) was determined separately for singular VPCs, couplets, and salvos. The spontaneous variability between the two long-term ECGs was defined as the logarithm of the ratio (ACday 2 + 0.01)/(ACday 1 + 0.01). The 95% confidence intervals of the stated types of arrhythmias were calculated as +/- 2 SD. The results were analyzed as a function of the underlying etiology, NYHA class, and left ventricular ejection fraction. There were no differences between patients with CHD and IDC. The extent of left ventricular dysfunction did not have any influence either. In patients of NYHA class 3 there was a higher spontaneous variability of VPCs, couplets and salvos than in patients of NYHA class 2, but the differences could not be ensured statistically. We conclude from the results that the validation of an antiarrhythmic treatment can be performed independently from the nature of the underlying heart disease and the left ventricular ejection fraction. However, it remains unclear whether a greater variability must be expected in patients of NYHA class 3 than in patients of NYHA class 2.

Spontaneous variability of simple and complex ventricular premature contractions during long time intervals in patients with severe organic heart disease

Calculations of the spontaneous variability of ventricular arrhythmias are usually based upon the results of Holter electrocardiograms recorded either successively or separated by a short time interval. Only recently was it shown that the variability of ventricular premature contractions increases with longer intervals. This study was undertaken to investigate the variability of simple and complex ventricular arrhythmias over long periods to derive efficacy criteria for long-term antiarrhythmic therapy. In a prospective study, the influence of the length of the time interval on spontaneous variability was investigated in 100 patients with coronary artery disease or idiopathic dilated cardiomyopathy and untreated ventricular arrhythmia Lown grade IV. Patient follow-up was carried out for 260 +/- 387 days. In each of the 498 ambulatory Holter tapes, the mean hourly arrhythmia count (AC) of ventricular premature contractions, couplets, and salvos was verified. The variability of arrhythmia counts between two Holter electrocardiograms was defined as the logarithm of the ratio of (ACday 2 + 0.01) to (ACday 1 + 0.01). The 95% intervals for these ratios were calculated as +/- 2 SD, considering the fact that all mean values did not differ significantly from zero. The lower limit of these intervals refers to the reduction that is required for assuming drug efficacy, whereas the upper limit refers to an aggravation. The 95% intervals were calculated for each of four ranges of control intervals (0-6, 7-89, 90-364, and greater than or equal to 365 days). They increased significantly with longer control intervals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of class I anti-arrhythmia agents on the signal-averaged ECG]

This study was designed to determine which parameters in the signal-averaged ECG are subject to the influence of class I antiarrhythmic agents and whether the effects on these parameters differ with respect to the various subgroups of agents within the class I antiarrhythmics. For this purpose, disopyramide was chosen as representative of class Ia, tocainide Ib and flecainide Ic. A total of 23 patients, twelve with coronary artery disease and eleven with dilated cardiomyopathy and high grade ventricular arrhythmics, received randomized and single-blind, placebo-controlled high single oral doses of 300 mg disopyramide, 800 mg tocainide and 300 mg flecainide with a washout period of five half-times of the antecedent drug prior to the subsequent agent. Before and two hours after the respective drugs the signal-averaged ECG was recorded. The position of the electrodes was unchanged throughout the study. A total of 142 recordings were performed. Computerized calculation of the duration and mean voltage of the entire filtered QRS complex and the voltage during the last 40 and 50 ms, respectively, was carried out according to the method of Simson. Additionally, according to a modification by Karbenn, the duration and voltage of late potentials were analyzed. In the baseline signal-averaged ECG, 13 of 23 patients (57%) had late potentials. Of the 18 patients who received disopyramide, ten had late potentials before and after the drug. In seven, late potentials were not present either before or after the drug. In one patient with a negative finding at baseline, late potentials were observed after disopyramide. There was a significant increase in the duration (p less than 0.001) as well as a decrease in the voltage of the entire filtered QRS-complex (p less than 0.01) and the voltage during the last 40 and 50 ms, respectively (p less than 0.05). Late potentials were present before and after tocainide in nine of 18 patients (50%) who received this drug. In the remaining 50%, late potentials were not observed either before or after the drug. Comparison of mean values before and two hours after 800 mg tocainide showed no significant changes for duration or voltage of the entire filtered QRS-complex nor for the voltage during the last 40 and 50 ms, respectively. Before and after flecainide, eight of 17 patients had late potentials (47%).(ABSTRACT TRUNCATED AT 400 WORDS)

[Spontaneous variability of complex ventricular extrasystoles over a period of up to 4 years]

In a prospective study, the influence of the length of the time interval on spontaneous variability was investigated in 100 patients with CAD or IDC and untreated ventricular arrhythmia of Lown grade IV. Patient follow-up was carried out over 260 +/- 387 days. In each of the 498 ambulatory Holter tapes, the mean hourly arrhythmia count (AC) of couplets and salvos was verified. The variability of ACs between two Holter ECGs was defined as the logarithm of the quotient AC day 2(n + 0.01)/AC day 1(n + 0.01). The spontaneous distribution of variability quotients (means +/- 2 SD) was defined separately for couplets and salvos and for each of four ranges of control intervals (0-6 days, 7-89 days, 90-364 days, greater than or equal to 365 days). The percentage change in arrhythmia count necessary to establish drug efficacy (R), was calculated according to the formula R(%) = (10(0) - 10(-2SD].100, whereas the percentage change necessary to prove aggravation of arrhythmia (A) was assessed by the formula A(%) = (10(0) + 10(+2SD].100. For couplets, R extended from 90%, 94%, 98% to 99%; A increased from 1114%, 1895%, 6153% to 14032%, respectively. For salvos, R remained almost unchanged at a high level with 95%, 98%, 98%, 99%. The figures of A were 2189%, 4650%, 5698% and 9650%, respectively. It is concluded that the spontaneous variability of complex ventricular arrhythmias is remarkably high with short control intervals and increases further with longer ones.(ABSTRACT TRUNCATED AT 250 WORDS)

[Spontaneous variability of ventricular extrasystoles: criteria for validating anti-arrhythmia therapy in relation to the length of the control interval]

Calculations about the variability of PVCs are usually based upon the results of two Holter ECGs, either successive ones or separated by a short interval. No studies are available indicating whether the criteria calculated for short control intervals also holds true when evaluating chronic antiarrhythmic treatment over longer control periods. This study was performed to investigate the influence of the length of the control interval on the spontaneous variability and thus on the reduction of PVCs required to secure an antiarrhythmic effect. In a prospective study, 444 ambulatory ECGs were obtained in 90 patients with CAD or IDC and untreated ventricular arrhythmia of Lown grade IV. Patient follow-up was carried out over an average of 181 +/- 297 days. The degree of arrhythmia was expressed as the mean hourly PVC rate. The variability of PVC counts between two Holter ECGs was defined as the logarithm of the quotient PVCday 2(n + 1)/PVCday 1(n + 1). The spontaneous distribution of variability quotients was defined separately (mean +/- 2 SD) for each of four ranges of control intervals (0-6 days, 7-89 days, 90-364 days, greater than or equal to 365 days). The per cent reduction (R) in PVC frequency necessary to establish drug efficacy, was calculated according to the formula R (%) = 10(0)-10(-2SD) X 100, whereas the percentage change necessary to prove aggravation of arrhythmia (A) was assessed by the formula A (%) = 10(0)+10(+2SD X 100. R increased from 63% (0-6 days), 81% (7-89 days), 93% (90-364 days) to 98% (greater than or equal to 365 days).(ABSTRACT TRUNCATED AT 250 WORDS)

[New statistical criteria for validation of the antiarrhythmic effects by acute oral testing]

There are no reliable criteria for the evaluation of acute effects after oral application of a high single dose of an antiarrhythmic agent from the analysis of data of 46 patients with frequent complex VPBs suffering from severe organic heart disease (19 CHD, 27 COCM), we developed a new statistical model. Our calculations were based on nine 10 h Holter ECGs (2 controls, 1 placebo test, 6 class 1 antiarrhythmic agent tests) and two 24 h Holter ECGs (1 control, 1 while on chronic treatment) recorded in each patient. Usually reductions in VPB frequency caused by the medication occurred within 1 hour after application and lasted greater than or equal to 4 hours. The VPB reduction in the course of time was assessed by the parameters r and R (r = VPB reduction of the 4 h interval in comparison to the last hour before application, R = VPB reduction of the 4 h interval in comparison with an analogous interval of a control day). Values of r and R greater than or equal to -50% were never observed simultaneously. In contrast, the majority of all patients developed r and R values greater than or equal to -50% after application of an antiarrhythmic agent, and were classified as responders. As shown at a Holter control after 1 week of chronic treatment, the predictive value of a positive test result was good.