SUMMARY Twenty male veteran endurance runners and 20 controls underwent resting, exercise, and ambulatory electrocardiography. Four athletes and three controls satisfied voltage criteria for left ventricular hypertrophy. The PR interval was longer in the athletes and they had longer mean (SD) treadmill exercise times (19 (4) v 16 (2) min) than the controls. Four athletes but no controls had > 2 mm downsloping ST segment depression during exercise. During 48 hour ambulatory electrocardiography the athletes had a consistently lower heart rate but maintained a circadian variation. Profound bradycardia (< 35 beats/min) occurred in eight athletes but only one control. Eight athletes and two controls had asystolic pauses ranging from 1-8 to 15 seconds. Six athletes had first degree heart block, four had Mobitz II second degree block, and three had complete heart block. Most conduction abnormalities occurred at night and resolved during exercise. Ventricular ectopic activity was not significantly different between the groups.Thus heart block patterns and profound bradycardia are more frequent in older athletes than their youthful counterparts.

Objectives-Sustained aerobic dynamic exercise is beneficial in preventing cardiovascular disease. The eVect of lifelong endurance exercise on cardiac structure and function is less well documented, however. A 12 year follow up of 20 veteran athletes was performed, as longitudinal studies in such cohorts are rare. Methods-Routine echocardiography was repeated as was resting, exercise, and 24 hour electrocardiography. Results-Nineteen returned for screening. Mean (SD) age was 67 (6.2) years (range 56-83). Two individuals had had permanent pacemakers implanted (one for symptomatic atrial fibrillation with complete heart block, the other for asystole lasting up to 15 seconds). Only two athletes had asystolic pauses in excess of two seconds compared with seven athletes in 1985. Of these seven, five had no asystole on follow up. Two of these five had reduced their average running distance by about 15-20 miles a week. One athlete sustained an acute myocardial infarction during a competitive race in 1988. Three athletes had undergone coronary arteriography during the 12 years of follow up but none had obstructive coronary artery disease. Ten of 19 (53%) had echo evidence of left ventricular hypertrophy in 1997 but only two (11%) had left ventricular dilatation. Ten athletes had ventricular couplets on follow up compared with only two in 1985. Conclusions-Although the benefits of moderate regular exercise are undisputed, high intensity lifelong endurance exercise may be associated with altered cardiac structure and function. These adaptations to more extreme forms of exercise merit caution in the interpretation of standard cardiac investigations in the older athletic population. On rare occasions, these changes may be deleterious. (Br J Sports Med 1999;33:239-243)

SUMMARY The circumstances surrounding 60 sudden deaths (59 men, one woman) associated with squash playing are described. The mean age (SD) of those who died was 46 (10-3) years (range 22-66 years). Necropsy reports were available in 51. The certified cause of death was coronary artery disease in 51 cases, valvar heart disease in four, cardiac arrhythmia in two cases, and hypertrophic cardiomyopathy in one case. There were only two deaths from non-cardiac causes. Forty five of those who died had reported prodromal symptoms, the most common of which was chest pain, and 22 were known to have had at least one medical condition related to the cardiovascular system during life, the most common of which was systemic hypertension (14 subjects). Those dying from coronary artery disease had a high frequency of risk factors.Some of these deaths might have been prevented by appropriate counselling of players after prospective medical screening, which would have detected most of the patients with overt cardiovascular disease and some of those with subclinical coronary artery disease.

Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. Methods: All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results: Of the 17 417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery. W hen first introduced more than 20 years ago, percutaneous coronary intervention (PCI) was undertaken in only a few hospitals, with on-site cardiac surgical cover in case patients had coronary occlusion or dissection as a complication of PCI. With the development of coronary stents, the need for emergency referral for surgery fell dramatically, and PCI is now undertaken in an increasing number of sites.As with all interventions there is a balance to be struck. In low-volume centres, operators may find it more difficult to maintain their level of expertise and keep abreast of new advances. However, the likelihood has been well established that patients undergoing any procedure, including revascularisation, in part depends on their geographical distance from the intervention centre.1 Restricting interventions to fewer high-volume centres therefore inevitably leads to geographical inequalities in access to health care.It has been suggested that PCIs should be undertaken only in hospitals performing a minimum of 400 PCIs per annum. 2PCI volume of throughput has even been proposed as a generic marker of quality of care within hospitals.3 However, published studies have produced conflicting results on whether periprocedural complications are less likely to occur in higher-volume institutions.4-11 Furthermore, we are unaware of any studies published to date examining whether hospital vo...

Background-The US Food and Drug Administration recently concluded that data on off-label drug-eluting stent (DES) safety are limited. However, in actual clinical practice, DES are often used for off-label indications, and observational studies demonstrate that complications are higher when compared with on-label use. We aimed to determine whether clinical outcomes differ after DES and bare-metal stent implantation in a patient cohort defined by DES off-label indications. Methods and Results-We used the national revascularization registry in Scotland to identify patients who underwent coronary stenting for an off-label indication between January 2003 and September 2005. Individual-level linkage to comprehensive national admission and death databases was used to ascertain the end points of death, myocardial infarction, and target-vessel revascularization. We calculated propensity scores on the basis of clinical, demographic, and angiographic variables and matched DES to bare-metal stents on a 1:1 basis. The final study population consisted of 1642 patients, well matched for important covariables at baseline. Event-free survival was calculated over 24 months with the Kaplan-Meier method. All-cause death was more common after bare-metal stent implantation during follow-up (7.7% versus 6.6%; hazard ratio 0.63; 95% confidence interval, 0.40 to 0.99; Pϭ0.04). No difference in the rates of myocardial infarction were noted (7.3% versus 7.5%; hazard ratio 1.02; 95% confidence interval, 0.69 to 1.54; Pϭ0.92). Target