Renal insufficiency dramatically increases the risk of infection complicating pacemaker or ICD surgery. This association should be part of the risk-benefit consideration prior to device implantation. Additional study of more extensive perioperative antibiotic therapy in this subset of patients is warranted.

In patients with LV dysfunction, increasing stature portends a higher risk of AF independent of other traditional risk factors for the arrhythmia. This association seems to account for the higher prevalence of AF in men and may be useful for identification of a high-risk population.

We are grateful for J.L. Sullivan's interest in and comments regarding our article. 1 Clearly, the use of polyethylene gloves is an important constraint to our experiments (We mention this in the article more than once). However, such gloves are a part of standard precautions during resuscitation. Moreover, we clearly demonstrate the safety of hands-on defibrillation in humans despite a direct bare-skin-to-bare-skin return current pathway between the patient and rescuer.Should our findings be interpreted as the "go-ahead" to ignore guidelines and perform compressions while shocks are delivered? Obviously, they should not. As pointed out in the Discussion, we do not advocate that this maneuver be used clinically until proven safe by further testing. We must, however, address and clarify several points made by Mr Sullivan.Mr Sullivan points out that the dielectric integrity of the gloves may break down when exposed to electric fields in the kilovolt range. For gloves to be exposed to this type of voltage, the defibrillator pads would essentially have to be applied directly to either side of the glove. Defibrillating the gloves instead of the patient is beyond the range of foreseeable medical error. In reality, we have found that the measured voltage on the skin surface of patients 15 cm from the pads is less than 1/20th the voltages proposed by Mr Sullivan (unpublished experiments). This is likely the reason that none of our experiments have shown evidence of dielectric breakdown.There is no recommendation in resuscitation guidelines for the use of biphasic shock energies of Ͼ200 J. In 8 of our experiments, we included 360-J biphasic shocks to further test the safety margin of this maneuver. These measurements used energies beyond what would be used in cardiac arrest scenarios. Therefore, these measurements bolster, not hinder as Mr Sullivan would suggest, our conclusions.In our continuing research regarding hands-on defibrillation, we recognize that the safety of rescuers is an absolute requisite. We remain confident that future resuscitation protocols will include streamlined, efficient maneuvers such as ours. Until that time, in the care of our patients, we and the remainder of clinicians should stick to the guidelines. DisclosuresNone. Michael

Background. Chest pain is a common problem in obese patients. Because of the body habitus, the results of noninvasive evaluation for CAD may be limited in this group. Methods. We reviewed the records of 1446 consecutive patients who had undergone clinically indicated stress echocardiography (SE). We compared major adverse cardiac events (MACE; myocardial infarction, cardiac intervention, cardiac death, subsequent hospitalization for cardiac events, and emergency department visits) at 1 year in normal weight, overweight, and obese subjects with normal SE. Results. Excluding patients with an abnormal and indeterminate SE and those who were lost to follow-up, a retrospective analysis of 704 patients was performed. There were 366 obese patients (BMI ≥ 30), 196 overweight patients (BMI 25–29.9), and 142 patients with normal BMI (18.5–24.9). There was no MACE in the groups at 1-year follow-up after a normal SE. Conclusions. In obese patients including those with multiple risk factors and symptoms concerning for cardiac ischemia, stress echocardiography is an effective and reliable noninvasive tool for identifying those with a low 1-year risk of cardiac events.

Background-Brief interruptions in chest compressions reduce the efficacy of resuscitation from cardiac arrest.Interruptions of this type are inevitable during hands-off periods for shock delivery to treat ventricular tachyarrhythmias. The safety of a rescuer remaining in contact with a patient being shocked with modern defibrillation equipment has not been investigated. Methods and Results-This study measured the leakage voltage and current through mock rescuers while they were compressing the chests of 43 patients receiving external biphasic shocks. During the shock, the rescuer's gloved hand was pressed onto the skin of the patient's anterior chest. To simulate the worst case of an inadvertent return current pathway, a skin electrode on the rescuers thigh was connected to an electrode on the patient's shoulder. In no cases were shocks perceptible to the rescuer. Peak potential differences between the rescuer's wrist and thigh ranged from 0.28 to 14 V (mean 5.8Ϯ5.8 V). The average leakage current flowing through the rescuer's body for each phase of the shock waveform was 283Ϯ140 A (range 18.9 to 907 A). This was below several recommended safety standards for leakage current. Conclusions-Rescuers performing chest compressions during biphasic external defibrillation are exposed to low levels of leakage current. The present findings support the feasibility of uninterrupted chest compressions during shock delivery, which may enhance the efficacy of defibrillation and cardiocerebral resuscitation.