Cardiac angiography was reviewed in 91 patients with post-infarction ventricular septal rupture. The results were compared with those of 123 stable survivors who had a positive submaximal exercise test early after infarction. Anterior infarction and occlusion of the infarct vessel were more common in those with ventricular septal rupture than in the comparison group. In the group with ventricular septal rupture there was more left ventricular damage, with aneurysm formation in two thirds, and coronary angiography showed more single than triple vessel disease. In the comparison group there was more triple vessel disease than single vessel disease. Angiographically demonstrable collaterals to the infarct territory were not seen or only very faintly seen in 82% of those with septal rupture. Well developed collaterals were seen in two thirds of the comparison group. These patterns of coronary disease suggest that ventricular septal rupture is more likely in patients with coronary occlusion and little or no collateral support to the infarct territory.
Despite numerous attempts at devising algorithms for diagnosing broad complex tachycardia (BCT) on the basis of the electrocardiogram (ECG), misdiagnosis is still common. The reason for this may lie with difficulty in implementing existent algorithms in practice, due to imperfect ascertainment of ECG features within them. An attempt was made to approach the problem afresh with the Bayesian inference by the construction of a diagnostic algorithm centered around the likelihood ratio (LR). Previously studied ECG features most effective in discriminating ventricular tachycardia (VT) from supraventricular tachycardia with aberrant conduction (SVTAC), according to their LR values, were selected for inclusion into a Bayesian diagnostic algorithm. A test set of 244 BCT ECGs was assembled and shown to three independent observers who were blinded to the diagnoses made at electrophysiological study. Their diagnostic accuracy by the Bayesian algorithm was compared against that by clinical judgement with the diagnoses from EPS as the criterial standard. Clinical judgement correctly diagnosed 35% of SVTAC, 85% of VT, and 47% of fascicular tachycardia. In comparison, by the Bayesian algorithm devised, 52% of SVTAC, 95% of VT, and 97% of fascicular tachycardia were correctly diagnosed. The Bayesian algorithm devised has proved to be superior to the clinical judgement of the observers who participated in this study, and theoretically will obviate the problem of imperfect ascertainment of ECG features. Hence, it holds the promise for being an effective tool for routine use in clinical practice.
SUMMARY A survey of infective endocarditis in the North East Thames Regional Health Authority was carried out over a period of 30 months from 1982 to 1984. The incidence, clinical characteristics, and in-hospital mortality were studied. Important causes of endocarditis were dental treatment, the presence of dental disease, drug abuse, and cytoscopy. The omission or incorrect administration of antibiotic prophylaxis in patients with valve disease was noted, but failure of correctly prescribed antibiotic prophylaxis was not recorded. Adverse prognostic features were increased age, prosthetic valve infection, Gram negative or staphylococcal infections, and aortic valve involvement. In contrast, mortality was lower in patients with mitral valve prolapse, ventricular septal defect, and streptococcus viridans infection. Deaths were usually attributable to irreversible complications present at the time of diagnosis. Vegetations were detected on the echocardiogram in half of those studied and mortality was higher in those with vegetations than without. Operation for native valve infection was associated with a low mortality and it is likely that the overall mortality for infective endocarditis has been improved by surgical intervention.Since 19091 infective endocarditis has been the subject of several important surveys. The most recent was from the Medical Services Study Group of the Royal College of Physicians and was completed in 1982.2 4 Earlier reports often came from referral centres and patients were enrolled for up to 10 years so that sufficiently large study groups could be accumulated by single institutions.5-8 Many patients with infective -endocarditis are now managed in district general hospitals whereas in these earlier studies more complex cases sent to referral centres were over-represented. Published data on incidence, mortality, and clinical features are unlikely to reflect accurately the impact of current preventive, diagnostic, and therapeutic interventions.We set out to document the current features of infective endocarditis within the North East Thames regional population, aiming to obtain accurate incidence and-mortality figures. This approach differed from that of the Medical Services Study Group2 -4 which reported from the whole of
Prospective selection of patients to receive the ICD by EP study did not improve survival compared with empirical amiodarone therapy among survivors of VT, VF or SCD, whereas ICD implantation improved survival regardless of allocated treatment. On this basis, routine EP study has no role in the management of such patients, who should be offered empirical ICD therapy according to the results of other secondary prevention ICD trials.
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