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The aim of the present study is to separate the most important in-hospital and long term outcome risk factors in patients with myocardial infarction. We analysed 251 women and 630 men hospitalised for acute myocardial infarction between 1992-96. We compared history data, in-hospital course and long term observation within 2-6 years in a group of patients who died versus group of patients who survived. The most important risk factors of in-hospital death were: cardiogenic shock--with mortality rate--6.2, pulmonary oedema--2.8, ventricular fibrillation--2.7, third degree A-V block--2.5, supraventricular arrhythmia (atrial flutter, atrial fibrillation--2.4, previous myocardial infarction--2.4, diabetes--2.0, disturbances of intraventricular conduction--1.8. The most important risk factors of long term outcome were: congestive heart failure--III, IV class of NYHA at discharge--mortality rate--3.0, ejection fraction < 40%--2.7, disturbances of intraventricular conduction--2.2, in-hospital cardiogenic shock and/or oedema pulmonum--2.0, prior myocardial infarction--1.9, diabetes--1.7, in-hospital ventricular fibrillation--1.6, supraventricular arrhythmia--1.6. Better predictors of survival we can obtain using multivariate analysis. This analysis allows to separate groups of patient with good, mean and poor prognosis which finally simplify choice of efficient kind of therapy.
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PMID:[Risk factors for in-hospital course and long-term outcome in myocardial infarction]. 1078 91

National and international societies have issued guidelines on the management of heart failure: The European Society of Cardiology, WHO, ACC/AHA Task Force Report, US Department of Health and Human Services, German Society of Cardiology. The therapeutic approaches to heart failure have undergone considerable changes during the last few years. The guidelines have to be updated almost yearly due to new results from prospective randomized studies. Although an agreement could be reached with respect to general measures and drug treatment, no agreement on mechanical devices, pacemakers and surgical interventions has been reached. The basis for medical treatment of chronic heart failure depends on diuretics, digitalis, ACE inhibitors, and beta-blockers. Calcium antagonists and other positive inotropic drugs, other than digitalis, should be avoided as far as possible. Thiazides, loop diuretics and aldosterone antagonists are needed for acute and chronic treatment of heart failure, alone or in combination (diuretic resistant heart failure!). Digitalis glycosides are needed in patients with atrial fibrillation with a fast ventricular rate or atrial flutter and in patients with systolic dysfunction, large hearts and symptomatic failure class NYHA III and IV. However, digitalis does not convert atrial fibrillation to sinus rhythm. Today there is no question that ACE inhibitors improve the prognosis of all patients with heart failure in all stages, if ejection fraction is reduced. Therefore, most patients after myocardial infarction or after having experienced pump failure due to myocarditis or cardiomyopathy are treated with ACE inhibitors and diuretics. The beneficial effects of ACE inhibitors seem to be most pronounced the worse the situation is. Relative risk reductions (mortality!) between 10% and 40% have been published depending on the severity of symptomatic left ventricular dysfunction. Those patients with high absolute risk have more to gain than those with low risk for any given "risk reduction", of course. Recent studies also indicate that most high risk cardiac patients profit from ACE inhibitors even if pump function is normal (i.e., patients with coronary heart disease, diabetes mellitus, cerebral vascular disease, hypertension) (15). AT1 antagonists can substitute for ACE inhibitors, if the latter are not tolerated due to cough. Up to now, beta-blocking agents apart from diuretics seem to be the best investigated drugs in heart failure. Large controlled studies with bisoprolol, carvedilol and metoprolol in addition to diuretics, digitalis and ACE inhibitors convincingly yielded positive results in chronic left ventricular failure patients. Reduction of mortality by 35% and even of sudden cardiac deaths by 40% have been proven beyond doubt. Thus, heart failure patients today should also receive beta-blocking agents in all stages of the disease. In the era of controlled prospective studies (evidence-based medicine), physicians are well advised to use only drugs that have been proven beneficial in large controlled studies.
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PMID:The management of heart failure--an overview. 1119 49

Principal conclusions of the Second European Workshop in Aviation Cardiology are summarized. European standards for routine medical scrutiny of cardiovascular health are presented and the evolution of the standards is reviewed. Both single and multiple crew operations are considered. The papers summarized examine three major subject areas: prediction of vascular risk, coronary artery disease, arrhythmias and conduction disorders. The review of predicting vascular risk examines variation of cardiovascular risk with age, sex, and coronary risk factors; attributable and absolute risk, benefits of treatment and options for treatment of hypertension, the impact of intervention for lipid abnormalities, non-insulin-dependent diabetes mellitus and cardiovascular risk, and the aging pilot. The review of coronary artery disease includes coronary artery ectasia, abnormal exercise electrocardiographic responses in the presence of a normal coronary circulation, prognostic importance of patency of the infarct related artery, coronary artery angioplasty and stenting, acceptable revascularization of the myocardium, and myocardial perfusion imaging in certification. The review of arrhythmias and conduction disorders examines atrial fibrillation and flutter, atrioventricular nodal re-entry, sinoatrial disease, vasovagal syncope, risks and benefits of anticoagulation, cardiac rehabilitation, outcome of the impaired left ventricle, and mitral valve repair.
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PMID:Introduction and summary of principal conclusions of the Second European Workshop in Aviation Cardiology. 1154 88

The goal of this research was to study influence of the MS on the electrophysiological parameters of the heart conduction system. The research involved 32 patients suffering from heart arrhythmias (18 females and 14 males, average age 52,8-/+12,9). The patients were categorized into 2 groups. Group I included 15 patients (9 females and 6 males, average age 47,5-/+8,9) suffering from heart arrhythmias and with signs of MS. Group I was subdivided into 2 subgroups: I subgroup--10 patients without diabetes, and II subgroup 5 patients with type II diabetes. Group II comprised of 17 patients (8 females and 9 males, average age 57,4-/+11,9) with arrhythmias without any signs of MS. The refractoriness dispersion between the right atrium (RA) and the left atrium (LA) caused by the MS, directly provokes development of atrial fibrillation and type II (atypical) atrial flutter. In cases of metabolic syndrome and "slow-fast" type of PRAVNT caused by the metabolic failures, the prolongation of the antegrade effective refractory period (ERP) of the slow AV nodal pathways and the retrograde ERP of the fast AV nodal pathways provoked prolongation of the tachycardia cycle and, consequently, reduction of the heart rate during paroxysms of tachycardia. Metabolic failures produce direct effect upon the sinus node function, causing suppression of its function as the SNSS develops, which requires implantation of pacemaker. The research results for metabolic syndrome and AV blockage cases demonstrated that the latter was always of a distal type, which was caused by a direct effect of metabolic failures upon the electrophysiology of the atrioventricular junction.
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PMID:[Effect of the metabolic syndrome on the electrophysiological parameters of the heart]. 1583 71

Thromboembolic risk of atrial flutter (AFl) types has not been elucidated sufficiently in previous reports. The authors classified the patients according to surface electrocardiogram and electrophysiologic characteristics as those with typical AFl (37 patients, 78.4% male, mean age 59.8 +/-9.5 years) and atypical AFl (13 patients, 69.2% male, mean age 60.9 +/-6.9 years) and compared them regarding some clinical, echocardiographic, and hematologic parameters. An age- and gender-matched control group composed of 20 individuals without any organic heart disease in sinus rhythm was chosen (80% male, mean age 60.3 +/-7.9 years). Clinical features such as age, gender, organic heart disease, hypertension, diabetes mellitus, AFl duration, and the prevalence of paroxysmal atrial fibrillation were similar in both AFl groups. Echocardiographic parameters such as left ventricular ejection fraction, left atrial (LA) diameter, LA spontaneous echo contrast, and LA appendage emptying velocities were similar in both AFl groups. Fibrinogen, fibrin D-dimer, and thrombin-antithrombin III levels reflecting coagulation system activity were found to be increased in the patients with atypical AFl when compared with those with typical AFl and the control group (p < 0.001). In Pearson's correlation analysis, significant correlation between these hematologic markers and clinical and echocardiographic parameters were not found (p > 0.05). The coagulation system activity was found to be increased in patients with atypical AFl. Thus, anticoagulation due to the increased thromboembolic risk should be considered in patients with atypical AFl.
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PMID:Do different atrial flutter types carry the same thromboembolic risk? 1619 99

The incidence and prevalence of atrial fibrillation are increasing because of both population ageing and an age-adjusted increase in incidence of atrial fibrillation. Deciding between a rate control or rhythm control approach depends on patient age and comorbidities, symptoms and haemodynamic consequences of the arrhythmia, but either approach is acceptable. Digoxin is no longer a first-line drug for rate control: beta-blockers and verapamil and diltiazem control heart rate better during exercise. Anti-arrhythmic drugs have only a 40%-60% success rate of maintaining sinus rhythm at 1 year, and have significant side effects. The selection of optimal antithrombotic prophylaxis depends on the patient's risk of ischaemic stroke and the benefits and risks of long-term warfarin versus aspirin, but is independent of rate or rhythm control strategy. Ischaemic stroke risk is best estimated with the CHADS2 score (Congestive heart failure, Hypertension, Age > or = 75 years, Diabetes, 1 point each; prior Stroke or transient ischaemic attack, 2 points). For patients with valvular atrial fibrillation or a CHADS(2) score > or = 2, anticoagulation with warfarin is recommended (INR 2-3, higher for mechanical valves) unless contraindicated or annual major bleeding risk > 3%. Aspirin or warfarin may be used when the CHADS(2) score = 1. Aspirin, 81-325 mg daily, is recommended in patients with a CHADS(2) score of 0 or if warfarin is contraindicated. Stroke rate is similar for paroxysmal, persistent, and permanent atrial fibrillation, and probably for atrial flutter.
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PMID:Atrial fibrillation. 1730 23

The effect of statins on the incidence of new-onset atrial fibrillation (AF) in patients presenting with suspicion of acute coronary syndrome (ACS) is unknown. Our study population consisted of patients admitted to a tertiary care Veterans Administration hospital with suspicion of ACS between November 2001 and January 2006. All patients had an electrocardiogram on admission that was compared with a previous electrocardiogram to confirm new-onset AF or atrial flutter. Of 1,526 patients, 164 (10.8%) had new-onset AF and 601 (39.4%) were on a statin on admission. Patients with AF were significantly more likely to be older, Caucasian, have renal insufficiency and anemia, and less likely to be diabetic, on a statin or angiotensin-converting enzyme inhibitor on admission, or have chest pain as a presenting complaint. In univariate analysis, patients on statins were significantly less likely to have new-onset AF (odds ratio 0.40, 95% confidence interval 0.33 to 0.69, p <0.01). This relation persisted in the multivariate model (odds ratio 0.57, 95% confidence interval 0.39 to 0.83, p <0.01) after correcting for age, race, diabetes mellitus, chest pain, and use of angiotensin-converting enzyme inhibitor. In conclusion, patients presenting with suspicion of ACS were much less likely to have newonset AF if they were on a statin at time of presentation.
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PMID:Comparison of frequency of new-onset atrial fibrillation or flutter in patients on statins versus not on statins presenting with suspected acute coronary syndrome. 1765 17

The aim of the study was to determine clinical and demographic features that are significant for prognosis after the first-ever myocardial infarction (MI). Kaunas men and women aged 25 - 64 years, admitted to Kaunas hospitals due to their first-ever MI during 1983 - 1992 and with the first coded electrocardiogram (ECG) were enrolled into the study. The Kaunas ischemic heart disease (IHD) register was the source of data, ECGs were coded using the Minnesota Code, and deaths were identified via prospective death s register. Factors significantly increasing the risk of death from IHD during the first year after first-ever inferior MI were age (p=0.01), atrial flutter or fibrillation (p=0.02). In patients with Q wave in anterior site the risk of death from IHD was increased not only by age, but also by acute heart failure - 3.74-fold (p=0.01), history of previous stroke - 3.82 (p=0.046), and history of diabetes - 2.53 (p=0.04).
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PMID:[Prognosis of patients with Q wave myocardial infarction of inferior or anterior localization]. 1826 Sep 9

This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the American College of Chest Physicians Evidence-Based Guidelines Clinical Practice Guidelines (8th Edition). Grade 1 recommendations indicate that most patients would make the same choice and Grade 2 suggests that individual patient's values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following (all vitamin K antagonist [VKA] recommendations have a target international normalized ratio [INR] of 2.5; range 2.0-3.0, unless otherwise noted). In patients with AF, including those with paroxysmal AF, who have had a prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism, we recommend long-term anticoagulation with an oral VKA, such as warfarin, because of the high risk of future ischemic stroke faced by this set of patients (Grade 1A). In patients with AF, including those with paroxysmal AF, who have two or more of the risk factors for future ischemic stroke listed immediately below, we recommend long-term anticoagulation with an oral VKA (Grade 1A). Two or more of the following risk factors apply: age >75 years, history of hypertension, diabetes mellitus, moderately or severely impaired left ventricular systolic function and/or heart failure. In patients with AF, including those with paroxysmal AF, with only one of the risk factors listed immediately above, we recommend long-term antithrombotic therapy (Grade 1A), either as anticoagulation with an oral VKA, such as warfarin (Grade 1A), or as aspirin, at a dose of 75-325 mg/d (Grade 1B). In these patients at intermediate risk of ischemic stroke we suggest a VKA rather than aspirin (Grade 2A). In patients with AF, including those with paroxysmal AF, age < or =75 years and with none of the other risk factors listed above, we recommend long-term aspirin therapy at a dose of 75-325 mg/d (Grade 1B), because of their low risk of ischemic stroke. For patients with atrial flutter, we recommend that antithrombotic therapy decisions follow the same risk-based recommendations as for AF (Grade 1C). For patients with AF and mitral stenosis, we recommend long-term anticoagulation with an oral VKA (Grade 1B). For patients with AF and prosthetic heart valves we recommend long-term anticoagulation with an oral VKA at an intensity appropriate for the specific type of prosthesis (Grade 1B). See CHEST 2008; 133(suppl):593S-629S. For patients with AF of > or =48 h or of unknown duration for whom pharmacologic or electrical cardioversion is planned, we recommend anticoagulation with an oral VKA, such as warfarin, for 3 weeks before elective cardioversion and for at least 4 weeks after sinus rhythm has been maintained (Grade 1C). For patients with AF of > or = 48 h or of unknown duration undergoing pharmacological or electrical cardioversion, we also recommend either immediate anticoagulation with unfractionated IV heparin, or low-molecular-weight heparin (LMWH), or at least 5 days of warfarin by the time of cardioversion (achieving an INR of 2.0-3.0) as well as a screening multiplane transesophageal echocardiography (TEE). If no thrombus is seen, cardioversion is successful, and sinus rhythm is maintained, we recommend anticoagulation for at least 4 weeks. If a thrombus is seen on TEE, then cardioversion should be postponed and anticoagulation should be continued indefinitely. We recommend obtaining a repeat TEE before attempting later cardioversion (Grade 1B addressing the equivalence of TEE-guided vs non-TEE-guided cardioversion). For patients with AF of known duration <48 h, we suggest cardioversion without prolonged anticoagulation (Grade 2C). However, in patients without contraindications to anticoagulation, we suggest beginning IV heparin or LMWH at presentation (Grade 2C).
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PMID:Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). 1857 73

Lacosamide (LCM) is a novel antiepileptic drug that exerts a strong antiepileptic effect via slow inactivation of voltage-gated sodium channels. LCM has been approved by the Food and Drug Administration for treatment of partial seizures at doses up to 400mg/day. Clinical trials have employed doses up to 600mg/day. LCM has been associated with atrial fibrillation at high doses (600mg/day) in patients with diabetes who had risk factors for heart disease. To our knowledge, atrial flutter or atrial fibrillation has not been reported in people with epilepsy. We report atrial flutter/atrial fibrillation at high doses of LCM (600mg/day) in a patient with epilepsy who had no significant risk factors for heart disease, which resolved following discontinuation of LCM. The literature regarding LCM-related cardiac death and arrhythmia is discussed. Physicians should be aware of the potential cardiac effects of this novel antiepileptic drug.
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PMID:Atrial flutter/atrial fibrillation associated with lacosamide for partial seizures. 2057 Feb 16


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