(19%) had an adverse event (cardiac deaths (n = 3), non-fatal myocardial infarction (n = 6) and, emergency revascularisation (n = 31)). Both admission ECG ST depression (P = 0.02), and transient ischaemia (P < 0.001) predicted an increased risk of non-fatal myocardial infarction or death, while no patients with a normal ECG died or had a myocardial infarction. Adverse outcome was predicted by admission ECG ST depression (regardless of severity) (odds ratio (OR) 3-41) (P < 0.001), and maintenance P blocker treatment (OR 2.95) (P < 0.01). A normal ECG predicted a favourable outcome (OR 0.38) (P = 0.04), while T wave or other ECG changes were not predictive of outcome. Transient ischaemia was the strongest predictor of adverse prognosis (OR 4.61) (P < 0.001), retaining independent predictive value in multivariate analysis (OR 2.94) (P = 0.03), as did maintenance ,B blocker treatment (OR 2.85) (P = 0.01) and admission ECG ST depression, which showed a trend towards independent predictive value (OR 2.11) (P = 0.076). Conclusions-Patients with unstable angina and a normal admission ECG have a good prognosis, while ST segment depression predicts an adverse outcome. Transient myocardial ischaemia detected by continuous ST segment monitoring in such patients receiving optimal medical treatment provides prognostic information additional to that gleaned from the clinical characteristics or the admission ECG.
The presence of transient myocardial ischemia in patients with unstable angina is associated with a significantly higher incidence of myocardial infarction or death in hospital. Combined therapy with heparin and aspirin compared with aspirin alone makes no difference in the development of these events, nor does it reduce the development of transient myocardial ischemia.
We report clinical and hemodynamic data in two cases of recurrent syncope. Both patients received permanent demand ventricular pacing (VVI) for unexplained syncope. Both patients experienced recurrent syncope after pacemaker implantation. They later underwent 60 degrees head-up tilt testing, initially noninvasively and then with hemodynamic profile. A vasovagal response to tilt occurred with bradycardia and was complicated by the onset of ventricular pacing and retrograde atrioventricular conduction (RAVC) with hemodynamic deterioration and rapid reproduction of syncope. Limited intracardiac electrophysiological study (EPS) excluded atrioventricular (AV) conduction disease, sinus node disease, and carotid sinus syndrome, and confirmed RAVC. Both patients were upgraded to dual chamber pacing, DDI mode, with 50/80 rate hysteresis. One patient was asymptomatic at repeat tilt testing; the other experienced continued symptoms due to the vasodepressor component of vasovagal syncope. Cardiac pacing alone is ineffective treatment for this phenomenon, and no proven therapy is presently available. Ventricular pacing applied to patients with unexplained syncope may lead to an increase in or continuation of symptoms rather than an amelioration. There is a need for full investigation of such patients, which must include tilt testing, to allow for the most accurate diagnosis possible and guide the most appropriate therapy.
is uncertain, but this organism was assumed to be the cause of the endocarditis as no other organism was cultured. The endocarditis may have been caused, however, by a penicillin sensitive organism.Bacterial endocarditis secondary to acupuncture has not previously been reported, and the incidence of local infection after acupuncture is also not recorded. With the increasing popularity of acupuncture physicians may need to consider advising antibiotic prophylaxis to patients with cardiac lesions who intend having acupuncture. If Pseudomonas was the causal agent in the patient reported a normal prophylactic regimen would not have been adequate. We suggest, however, that oral amoxycillin would be suitable for skin prophylaxis for most patients although flucloxacillin might be considered for those exposed to resistant staphylococci. Persistent atrial tachycardia in pregnancySustained tachycardias are a rare complication of pregnancy especially in the absence of heart disease. We report an example of persistent atrial tachycardia in an otherwise healthy primigravida.Case report A 20 year old white woman noticed a persistently fast pulse rate in the initial weeks of her first pregnancy. She was booked into the antenatal clinic at 15 weeks, when a tachycardia was recorded. Apart from this there was no evidence of a cardiac abnormality. She had never suffered from palpitations and there was no history of rheumatic fever. On examination she was found to be normotensive and there were no physical signs of heart disease. Her only medication was promethazine for morning sickness, and the tachycardia persisted despite withdrawal of the drug. An electrocardiogram (figure) showed an atrial tachycardia of 160-180 beats/min with occasional periods of variable atrioventricular conduction resulting in a slightly slower ventricular rate. A chest radiograph, thyroid function values, and an echocardiogram were normal.The pregnancy proceeded normally and at no stage did the patient develop signs of left ventricular impairment. She was admitted at 28 weeks for cardioversion, which proved unsuccessful. At 38 weeks she *vent into labour spontaneously and delivered a normal boy weighing 3000 g. There were no obstetric complications in the puerperium. Ten days post partum her heart rate suddenly reverted to normal. An electrocardiogram showed sinus rhythm at 70 beats/min. There was no recurrence of the tachycardia during more than one year of follow up. CommentAlthough both atrial and ventricular premature beats may occur during pregnancy,1 2 sustained tachycardias are rare especially if there is no structural heart disease. Most instances of sustained "supraventricular" tachycardia during pregnancy are related to anomalous atrioventricular conduction pathways of the type found in the Wolff-Parkinson-White syndrome. In our patient, however, the absence of ventricular pre-excitation and the finding of variable atrioventricular conduction during tachycardia excluded such pathways. Atrioventricular nodal re-entry was also unlikely. Hence the...
SUMMARYIn a 12-month prospective survey of CPR (cardiopulmonary resuscitation), 32 out of 192 patients (16.6%) survived to go home. This is a clear improvement compared with 7 years previously. This is attributed to better training in the use and management of CPR and more widespread availability of defibrillators. Certain patients could not be resuscitated -those with electromechanical dissociation, carcinoma, or multiple pathology. Age by itself was not a bar to resuscitation.There is still a high rate of inappropriate calls, often because of uncertainty by nurses about the use of CPR. This could be improved with clearer guidelines in hospitals about the value of CPR in selected patients.
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