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Fifty-nine patients aged 39-80 years underwent implantation of a cardiac pacemaker and were followed for up to 9 years (average duration of pacing 39 months). Atrioventricular conduction disturbances (complete atrioventricular block, 2 : 1 atrioventricular block, bifascicular block, and atrial fibrillation with slow ventricular rate) were present in 49 patients and sick sinus syndrome (sinus arrest or sino-atrial block, and bradycardia-tachycardia syndrome) in 10. Pacing was required because of Adams-Stokes attacks in 41 patients, 2 of whom also had congestive heart failure. It was required in 6 because of frequent dizziness, in 10 because of congestive heart failure, and in 2 because of low cardiac output. The symptomatic improvement after cardiac pacing was well recognized in most of our patients, and 32 (54 percent) of the 59 patients pursued normal physical and daily activity. Although the efficacy of pacemaker therapy was of limited value in some patients with congestive heart failure or underlying or coexisting diseases, the beneficial effects following pacemaker implantation were: (1) abolishment of transient neurologic symptoms such as Adams-Stokes attack, (2) relief from a constant fear of a recurrence of an Adams-Stokes attack or sudden cardiac death, and (3) improvement in restricted physical activity due to low cardiac output. Thus, we conclude that pacemaker implantation in most patients with bradyarrhythmias is beneficial not only for the treatment of the acute problem but also because it prolongs life and greatly enhances its quality. However, in spite of the beneficial effects after pacemaker implantation, we still observe a number of complications connected with the use of a permanent pacemaker. Therefore, our policy is to implant a permanent pacemaker following the execution of sufficient studies of the bradyarrhythmia and the etiology of symptoms, and then under taking long-term follow-up of the patients.
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PMID:Long-term follow-up after cardiac pacing in bradyarrhythmias. 64 93

Holter electrocardiographic monitoring in 55 symptomatic patients with syncope, palpitations or dizziness uncovered significant arrhythmias in 30 patients (55 percent). By providing an observation period of at least 24 hours including a period of sleep, the procedure aided detection and diagnosis in both symptomatic and asymptomatic patients of transient arrhythmias or conduction abnormalities not documented by routine electrocardiograms. Bradyarrhythmias accounted for the majority of arrhythmias recorded in 21 or 30 symptomatic patients (70 percent); 15 had sinus bradycardia (35 to 55 beats/min) alone and 6 also had long episodes of sinus arrest of up to 5 seconds. Two had sinus bradycardia with periods of atrioventricular block with Wenckebach phenomenon. Five patients had a tachycardia-bradycardia syndrome; three had other episodic arrhythmias and one had pacemaker failure. In 15 (60 percent) of the 25 patients without arrhythmias, monitoring did not document the cause of symptoms. Holter monitoring is of considerable value in assessing the efficacy and adequacy of drug treatment, especially in patients with known heart disease, and in detecting pacemaker malfunction. However, very long periods of monitoring may be needed to make a diagnosis in those with only sporadic symptoms.
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PMID:Value of Holter monitoring in assessing cardiac arrhythmias in symptomatic patients. 124 26

The causes, clinical indications and diagnosis and differential diagnosis of cardiac disorders which may lead to cerebral symptoms are illustrated on the basis of a review of the present day level of scientific research. Principally involved are cerebral ischaemias arising from cerebral embolisms or from reduction of cardiac output in cardiovalvular and myocardial disorders. The incidence of all embolisms of cardiac origin makes up 10% of all ischaemic cerebral infarcts, with auricular fibrillation, irrespective of its origin, mitral stenosis, myocardial infarct, mitral insufficiency and combined mitral valve defects, and, in younger patients, mitral valve prolapse, being, in this order of frequency, of primary clinical significance. The other cardiovalvular and myocardial disorders have, in comparison, a relatively low incidence of cerebral embolisms. Haemodynamically induced cerebral ischaemias frequently occur in the form of complications following acute cardiac arrest, in myocarditis and in case of primary cardiomyopathies resulting from cardiac insufficiency or complicating bradyarrhythmia. They are clinically apparent in the form of syncope, and other impairments of consciousness of various levels of seriousness with and without indications of cerebral origin, extending up to coma. In view of the high incidence of 25% of acute cerebral ischaemias in cases of cardiac disease, not only neurological but also detailed cardiological investigation is vital in all cases for a correct diagnosis and for the selection of a suitable course of treatment. Cerebral complications in bradyarrhythmia and endocarditis are discussed in the context of a review of the relevant literature together with consideration of their epidemiology, aetiology, pathophysiology and clinical profile. Pathological sinus-bradycardia, bradyarrhythmia absoluta, sinu-atrial and atrio-ventricular blockages, carotid-sinus and sick-sinus node syndrome, paroxysmal atrial tachycardia, AV-node tachycardias, and auricular fibrillation and flutter, taken as a whole, lead to cerebral complications affected patients in 5 to 10% of afflictions of the central nervous system occur in 50% of patients suffering from complete AV blockage and, at a not precisely definable frequency, in patients suffering from other bradyarrhythmias. In addition to transitory, uncharacteristic symptoms such as dizziness, vertigo, impairment of vision and balance, presyncope, syncope and Adams-Stokes syndrome dominate the clinical profile. Endocarditis, with an incidence of 0.01 to 0.05% in the overall population, results in central nervous system complications in 12 to 25% of cases on average.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:[Heart diseases as a cause of cerebral symptoms and syndromes]. 222 59

27 of 101 patients with complex ventricular ectopy (ventricular bigeminy, couplets, ventricular salvo and ventricular tachycardia) during 24-hour Holter monitoring died during a mean follow-up of 12 months. Mortality was 28% when ventricular salvos had been detected, and 43% in patients with ventricular tachycardia. Detection of ventricular bigeminy had no, registration of ventricular couplets little prognostic significance. Prognosis was altered by presence of cerebral symptoms (dizziness and/or syncope) only for patients with ventricular tachycardia: additional bradyarrhythmia (asystole longer than 1.5 sec due to sinus-atrial or atrioventricular block) did not effect the prognosis, which was significantly worse for patients with a history of myocardial infarction, although patients in the first year after acute myocardial infarction were not included in this study. Prognosis of complex ventricular ectopy significantly worsens with age, it seems of little prognostic significance for patients under the age of 60.
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PMID:[Prognostic significance of complex ventricular ectopy in 24-hour ambulatory electrocardiographic monitoring (author's transl)]. 704 74

The purpose of this study is to evaluate the directions, reliability and long-term results of ventricular programmable pacemakers (PPM's). One hundred and ten PPM's, types Cordis and Medtronic, were implanted in 60 patients (pts) with intermittent or paroxysmal 2 degrees, 3 degrees a-v block and in 50 pts with S.S.S., mostly symptomatics, with a follow-up of 45 months. We did not observe either spontaneous or wrong reprogrammations nor circuit failure. In 92% of pts with Omni-Stanicor Cordis PM's, the stimulation was effective at the "lower" current amplitude, hence a longer life of the generator. Eighteen pts (16.3%) needed to raise ventricular rate (average 65 bpm): 6 pts for dizziness, syncopes or cardiac failure; 2 pts to control ventricular arrhythmias; 10 pts for a stable bradycardia lower than 50 bpm. In 11 pts with bradyarrhythmia due to S.S.S., cardiac output (CO) was measured both with thermodilution and echocardiography ("mitral valve echogram", being "r" of the two methods = 0.92), in spontaneous rhythm (63.3 +/- 3.13 bpm) and increasing artificially heart rate to 74.8 +/- 3.0 bpm; CO decreased from 4.65 +/- 0.13 l/min to 3.58 +/- 0.09 l/min, likely for the loss of atrial pumping. Similar results were obtained in other pts evaluated only with echocardiographic method after PM implantation: some of these underwent a further echocardiographic haemodynamic evaluation after 15 days of constant ventricular pacing at a mean rate of 75 bpm, with a different behaviour among them. This emphasizes the utility of PPM's in preserving spontaneous rhythm until bradycardia reaches dangerous levels and also the usefulness of echocardiography to evaluate, haemodinamically, the paced patient's ventricular performance.
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PMID:[The permanent electrostimulation with ventricular programmable pacemaker (author's transl)]. 723 7

The concept of sinus node disease is defined by a group of clinical and electrocardiographic features related to sinus node dysfunction whatever its mechanism; the organicity of the disease can be proven if total or subtotal histological alterations of the sinus node are demonstrated. The most typical symptoms are neurological (syncopes and dizziness). Sinoatrial block, sinus arrest, sinus bradycardia or bradyarrhythmia, and the bradycardia-tachycardia syndrome are the most usual electrocardiographic aspects. The diagnosis is often rendered difficult by the usually intermittent and frequently nonspecific character of the symptoms and of the ECG signs. Holter monitoring is often essential to resolve these difficulties. If the diagnosis remains dubious, the use of electrophysiological methods is necessary: direct recording of the sinus nodal intracardiac potential can now be added to the classical rapid and premature atrial stimulation, possibly complemented by pharmacological tests. Finally, therapeutic indications can be considered after a correct clinical, electrocardiographical and electrophysiological evaluation of the patient. Medical treatment alone is usually ineffective in controlling the attacks of arrhythmia and the neurological episodes. If the sinus nodal dysfunction is obvious and symptomatic, permanent pacing is the treatment of choice. Its short and medium term results are generally excellent, while the long term results, especially with regard to survival of the patients, could be improved by the most recent pacing techniques.
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PMID:[Sinus node disease - diagnosis and treatment]. 731 31

The most important symptoms in bradycardia are vertigo, dizziness and syncopy due to diminished cerebral blood sypply. Cardial symptoms are cardiac insufficiency and angina pectoris. By means of ECG, especially Holter-ECG, carotid sinus massage, atropin test and invasive methods (atrial stimulation, His-bundle ECG) sinu-nodal dysfunction, carotid sinus syndrome, bradyarrhythmia absoluta and AV-block can be diagnosed. Pharmacological treatment is only useful in acute situations. For symptomatic bradyarrhythmias the implantation of a Pacemaker is the therapy of choice. Individual treatment of the various types of bradyarrhythmia and the patients special needs is possible through the evolution of pacemaker technology.
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PMID:[Differential diagnosis and therapy of bradycardic arrhythmias]. 782 27

Neurocardiovascular instability (NCVI, neurally mediated disorders causing hypotension with or without bradycardia) represents abnormal neural control of the cardiovascular system and presents as dizziness, syncope, or falls. The mechanisms underpinning NCVI are incompletely understood. The three most common disorders are carotid sinus syndrome (CSS), orthostatic hypotension (OH), and vasovagal syndrome (VVS): CSS, cardioinhibition > 3 s and/or vasodepressor response > or = 50 mmHg drop in systolic pressure during carotid sinus stimulation; OH: fall in systolic blood pressure > 20 mmHg during standing; VVS: cardioinhibition > 3 s and/or vasodepressor response > 50 mmHg during prolonged head-up tilting. In fallers with cognitive impairment or dementia, the prevalence of NCVI is 70%. Multifactorial interventions, including treatment of NCVI, significantly reduce falls and syncope. The predominant components of NCVI in fallers with cognitive impairment and dementia are CSS and OH. In Lewy body and Alzheimer's dementia, the prevalence of NCVI is up to 60%, again predominantly CSS and OH. The prevalence of cardioinhibitory carotid sinus hypersensitivity is particularly high in Lewy body dementia-41% compared with 12% in Alzheimer's disease and 3% in case controls. In addition, patients with Lewy body dementia have greater heart rate slowing (>2 s) and falls in systolic blood pressure (>20 mmHg) than those with Alzheimer's disease or controls during carotid sinus stimulation. The extent of deep white matter hyperintensities on MRI correlates with systolic fall during carotid sinus stimulation (R = 0.58; p < 0.005), suggesting a possible causal association between bradyarrhythmia-induced hypotension and microvascular pathology. NCVI is common in patients with dementia and may be a reversible cause of falls and syncope. Repeated hypotensive episodes may exaggerate cognitive decline in these patients.
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PMID:Neurocardiovascular instability in cognitive impairment and dementia. 1248 Jul 51

We present the case of a 72-year-old man who was admitted due to low blood pressure and acute-onset dizziness with sinus bradyarrhythmia on electrocardiography. He had no obvious anginal symptoms, and there was no marked evidence of myocardial infarction. He was ultimately diagnosed with coronary artery disease with total occlusion of the left circumflex coronary artery, and he underwent successful coronary angioplasty after primary conduction disorders were ruled out.
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PMID:Symptomatic bradycardia due to total occlusion of left circumflex artery without electrocardiographic evidence of myocardial infarction at initial presentation. 1704 7

The aim of the study was to assess the situation with implantation of cardiac pacemakers and to critically evaluate the possibility of this method of treatment. The study was conducted from 2001 to 2007. Data on a total of 211 operations were included in the study. There were 121 (57.3%) male patients, mean age 69.7 years, and 90 (42.7%) female patients, mean age 74.5 years. Total number of operations increased from 18 in 2001 to 24 in 2002, 28 in 2003, 38 in 2004, 38 in 2005, 30 in 2006 and 35 in 2007. Primo implantation was carried out in 196 (92.9%) cases. The following types of pacemakers were used: VVI in 79 (40.3%), VVIR in 73 (37.2%), DDD in 7 (3.6%), DDDR in 18 (9.2%), VDD in 17 (8.7%) and AAIR in 2 (1.0%) cases. ECG indication was second degree heart block in 40, third degree heart block in 86, chronic atrial fibrillation with bradyarrhythmia in 57, sick sinus syndrome in 27 cases and trifascicular block in one case. The symptoms included dizziness in 126, syncope in 52, dyspnea in 45, bradycardia in 12, chest pain in 3 and cerebral dysfunction in 2 cases. In conclusion, our patients now receive appropriate treatment within a shorter time, thus reducing pressure upon large cardiac surgery centers. However, efforts should be continuously invested in approaching European standards of artificial pacemaker implantation.
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PMID:The first seven years of implantation of permanent cardiac pacemakers in a small urban community in central Croatia. 1938 70


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