No abstract

Objective-To investigate variations in the management of patients with atrial fibrillation among consultant physicians. Design-Questionnaire survey. Subjects-Consultant physicians in England, Wales, and Scotland. Results-214 consultant physicians (88 cardiologists and 126 non-cardiologists) were surveyed between May and July 1994. Most physicians (47.7%) reported that they saw one to five patients with atrial fibrillation weekly. Some 52% of cardiologists and 40% of non-cardiologists considered that the main factor influencing their decision of whether or not to anticoagulate was the clinical history--that is, heart failure, valve disease, or stroke.When encountering a patient admitted acutely with new onset atrial fibrillation, significantly more cardiologists (66% v 52%, x2 = 6-89, P = 0.03) would inmnediately start anticoagulant treatment, most favouring intravenous heparin. Most physicians would also introduce antiarrhythmic treatment or digoxin, but more cardiologists would attempt immediate pharmacological (39% v 18% of non-cardiologists, P < 0.001) or later electrical (86% v 69%, x2 = 11-75 P = 0.003) cardioversion to sinus rhythm, while noncardiologists tended to prefer "rate control" with digoxin. Although many physicians would not continue antiarrhythmic treatment post-cardioversion, more cardiologists than non-cardiologists would do so (the commonest choice being class III agents) (31% v 17%, P = 0.04).Fewer non-cardiologists would continue anticoagulant treatment post-cardioversion (27% v 69% of cardiologists, X2 = 39-85 P < 0.0001). When treating patients with atrial fibrillation, decisions about anticoagulation were usually related to the perceived relative risk of thromboembolism versus haemorrhage derived for each of six case management scenarios in the questionnaire. There was, however, general agreement between cardiologists and non-cardiologists in the use of antithrombotic treatment in the management of lone atrial fibrillation, paroxysmal atrial fibrillation, and patients with atrial fibrillation and mitral valve disease or thyrotoxicosis.Conclusion-There is considerable variation in the management of atrial fibrillation, with more cardiologists than non-cardiologists considering cardioversion to sinus rhythm (and the use of antiarrhythmic and anticoagulant treatment post-cardioversion) and thromboprophylaxis with anticoagulation. Guidelines on the management of this common arrhythmia are clearly required.

Eight normotensive male subjects were infused with angiotensin II or phenylephrine in a single blind fashion. Measurements were made of blood pressure and pulse interval every 3 min, and blood drawn for plasma catecholamines at the beginning and end of the infusion. Phenylephrine produced a rise in blood pressure which was associated with a bradycardia in all subjects. A statistically significant relationship between blood pressure and pulse interval was observed in all subjects. In contrast, angiotensin II infusion produced an equal pressor response, but the change in pulse interval was statistically significantly less than that seen following phenylephrine infusion. In seven of eight subjects no significant relationship was observed between blood pressure and pulse interval. Plasma noradrenaline levels were similar before each pressor infusion and were unchanged during each infusion. These observations are consistent with central inhibition of the baroreceptor heart rate reflex by angiotensin II in man.

Spironolactone is a common cause of hyperkalaemia when used in combination with either an ACE inhibitor or an AT2 antagonist. This reinforces the need for care when extrapolating the results of clinical trials to daily clinical practice.

SUMMARY A 31 year old man presented with intermittent dizziness and electrocardiographic evidence of a severe conduction disturbance, with asystolic pauses of up to six seconds, and was treated by implantation of a permanent pacemaker. Echocardiography showed an enlarging aneurysm of the right sinus of Valsalva extending into the interventricular septum. This was confirmed by aortography, and successful surgical repair was carried out. The characteristic diastolic expansion of the aneurysm and the demonstration of continuity between the septal extension and the related aortic sinus were useful diagnostic features.

No abstract

No abstract

No abstract