David Sprigings

Psychological and perceptual factors associated with arrhythmias and benign palpitations.

Objective Little is known about how patients who seek medical help for benign palpitations can be distinguished from those with clinically significant arrhythmias. This study tested whether patients with arrhythmia can be distinguished from those who are aware of sinus rhythm or extrasystoles on the basis of sex, prevalence of anxiety disorders, and heartbeat perception. Methods A consecutive sample of patients referred to a cardiology clinic participated in the study. Patients were diagnosed as having either arrhythmia ( N = 62), extrasystoles (N = 75), or awareness of sinus rhythm (N = 47). They were assessed with use of the anxiety disorders and hypochondriasis modules of the Structured Clinical Interview for DSM-IV. Both patients and control subjects (N = 35) answered questionnaires measuring anxiety, fear of bodily sensations, and depression and underwent a heartbeat perception test. The present report focuses on patients who had palpitations but no comorbid cardiovascular disease. Results Patients with awareness of sinus rhythm could be distinguished from those with arrhythmia by several variables: female sex, higher prevalence of panic disorder, poor performance on the heartbeat perception test, report of palpitations when doing the test, higher heart rates, lower levels of physical activity, and (as trends) a greater prevalence of panic attacks, fear of bodily sensations, and depression. In contrast, patients with arrhythmias rarely reported palpitations when doing the test but were more likely to perceive their heartbeats accurately than patients with sinus rhythm and control subjects. Performance on the heartbeat perception test was intermediate in patients with extrasystoles; these patients also had an intermediate prevalence of panic disorder and intermediate depression scores. Conclusions Measures of panic disorder and a simple heartbeat perception test could complement medical assessment in the diagnosis of patients who seek medical help for palpitations. The results also have implications for the treatment of patients with benign palpitations.

Comparison of exercise testing and CMR measured myocardial perfusion reserve for predicting outcome in asymptomatic aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in Aortic Stenosis (PRIMID AS) Study

Aims To assess cardiovascular magnetic resonance (CMR) measured myocardial perfusion reserve (MPR) and exercise testing in asymptomatic patients with moderate-severe AS. Methods and results Multi-centre, prospective, observational study, with blinded analysis of CMR data. Patients underwent adenosine stress CMR, symptom-limited exercise testing (ETT) and echocardiography and were followed up for 12–30 months. The primary outcome was a composite of: typical AS symptoms necessitating referral for AVR, cardiovascular death and major adverse cardiovascular events. 174 patients were recruited: mean age 66.2u2009±u200913.34 years, 76% male, peak velocity 3.86u2009±u20090.56 m/s and aortic valve area index 0.57u2009±u20090.14u2009cm2/m2. A primary outcome occurred in 47 (27%) patients over a median follow-up of 374 (IQR 351–498) days. The mean MPR in those with and without a primary outcome was 2.06u2009±u20090.65 and 2.34u2009±u20090.70 (Pu2009=u20090.022), while the incidence of a symptom-limited ETT was 45.7% and 27.0% (Pu2009=u20090.020), respectively. MPR showed moderate association with outcome area under curve (AUC) = 0.61 (0.52–0.71, Pu2009=u20090.020), as did exercise testing (AUCu2009=u20090.59 (0.51–0.68, Pu2009=u20090.027), with no significant difference between the two. Conclusions MPR was associated with symptom-onset in initially asymptomatic patients with AS, but with moderate accuracy and was not superior to symptom-limited exercise testing. ClinicalTrials.gov (NCT01658345).

Patients with palpitations referred for 24-hour ecg recording

Palpitations are one of the most common reasons for referral to cardiologists; most are assessed as being medically benign. Eighty consecutive subjects referred for 24-hour ECG recording completed a questionnaire at the time of assessment and a follow-up self-report questionnaire at 18 months. Many of those with and without abnormal hearts reported distress, concern about their symptoms, and limitation of everyday activities. There were few differences between these groups at assessment or at follow-up. There was little change in mental state or in disability in either group over 18 months. Present symptomatic treatment is largely ineffective and there is a need to evaluate psychological and behavioral interventions.

Myocardial Perfusion Reserve but not fibrosis predicts outcomes in initially asymptomatic patients with moderate to severe aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in AS study- PRIMID AS

Myocardial Perfusion Reserve but not fibrosis predicts outcomes in initially asymptomatic patients with moderate to severe aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in AS studyPRIMID AS Anvesha Singh, Michael Jerosch-Herold, John P Greenwood, Colin Berry, Dana K Dawson, Chim C Lang, Damian J Kelly, David Sprigings, Jeffrey P Khoo, Kai Hogrefe, Richard P Steeds, Vijay Anand Dhakshinamurthy, Gerry P McCann

In-flight medical emergencies

www.thelancet.com Vol 374 September 26, 2009 1063 European airline with that of a low-cost (no-frills) carrier. The national airline had excellent equipment, intravenous medications, and an automated external defi brillator on board, whereas the medical fl ight kit of the low-cost carrier had only basic equipment without any intravenous medication or indwelling venous canulas. Our fi ndings refl ect the variations from carrier to carrier addressed by Silverman and Gendreau. It would therefore seem obvious for some airlines to reassess their medical fl ight kits with regard to their responsibilities to passengers’ safety, despite economic pressures.

A call for national monitoring of antibiotic prophylaxis

The UK National Institute for Health and Clinical Excellence (NICE) recently published guidelines on antibiotic prophylaxis for preventing infective endocarditis in high risk patients with structural heart disease.1 2 The guidelines no longer recommend their use during dental and other invasive procedures of the respiratory tract, genitourinary tract, and upper and lower gastrointestinal …

Symptom Onset in Aortic Stenosis: Relation to Sex Differences in Left Ventricular Remodeling

OBJECTIVESnThe aim of this study was to establish sex differences in remodeling and outcome in aortic stenosis (AS) and their associations with biomarkers of myocardial fibrosis.nnnBACKGROUNDnThe remodeling response and timing of symptoms is highly variable in AS, and sex plays an important role.nnnMETHODSnA total of 174 patients (133 men, mean age 66.2 ± 13.3 years) with asymptomatic moderate to severe AS underwent comprehensive stress cardiac magnetic resonance imaging, transthoracic echocardiography, and biomarker analysis (matrix metalloproteinase [MMP]-2, -3, -7, -8, and -9; tissue inhibitor matrix metalloproteinases-1 and -4; syndecan-1 and -4; and N-terminal pro-B-type natriuretic peptide), and were followed up at 6-month intervals. A primary endpoint was a composite of typical AS symptoms necessitating referral for aortic valve replacement, cardiovascular death, or major adverse cardiovascular events.nnnRESULTSnFor a similar severity of AS, male patients demonstrated higher indexed left ventricular (LV) volumes and mass, more concentric remodeling (higher LV mass/volume), a trend to more late gadolinium enhancement (present in 51.1% men vs. 34.1% women; pxa0= 0.057), and higher extracellular volume index than female patients (13.27 [interquartile range (IQR): 11.5 to 17.0] vs. 11.53 [IQR: 10.5 to 13.5] ml/m2, pxa0= 0.017), with worse systolic and diastolic function and higher MMP-3 and syndecan-4 levels, whereas female patients had higher septal E/e. Male sex was independently associated with indexed LV mass (βxa0= 13.32 [IQR: 9.59 to 17.05]; pxa0< 0.001). During median follow-up of 374 (IQR: 351 to 498) days, a primary outcome, driven by spontaneous symptom onset, occurred in 21.8% of male and 43.9% of femalexa0patients (relative risk: 0.50 [95% confidence interval: 0.31 to 0.80]; pxa0= 0.004). Measures of AS severity were associated with the primary outcome in both sexes, whereas N-terminal pro-B-type natriuretic peptide, MMP-3, andxa0mass/volume were only associated in men.nnnCONCLUSIONSnIn AS, women tolerate pressure overload with less concentric remodeling and myocardial fibrosis butxa0are more likely to develop symptoms. This may be related to higher wall stress and filling pressures in women.

Successful low-dose thrombolysis of submassive pulmonary embolus in a pregnant patient:

Lesson Low-dose thrombolysis was effective and safe in a pregnant woman with acute pulmonary embolism causing severe right ventricular dysfunction. This is the first reported case of successful thrombolysis for pulmonary embolus in pregnancy in the absence of shock.

A study of role expansion: a new GP role in cardiology care

BackgroundThe National Health Service is reconfiguring health care services in order to meet the increasing challenge of providing care for people with long-term conditions and to reduce the demand on specialised outpatient hospital services by enhancing primary care. A review of cardiology referrals to specialised care and the literature on referral management inspired the development of a new GP role in Cardiology. This new extended role was developed to enable GPs to diagnose and manage patients with mild to moderate heart failure or atrial fibrillation and to use a range of diagnostics effectively in primary care. This entailed GPs participating in a four-session short course with on-going clinical supervision. The new role was piloted in a small number of GP practices in one county in England for four months. This study explores the impact of piloting the Extended Cardiology role on the GP’s role, patients’ experience, service delivery and quality.MethodsA mixed methods approach was employed including semi-structured interviews with GPs, a patient experience survey, a quality review of case notes, and analysis on activity and referral data.ResultsThe participating GPs perceived the extended GP role as a professional development opportunity that had the potential to reduce healthcare utilisation and costs, through a reduction in referrals, whilst meeting the patient’s wishes for the provision of care closer to home. Patient experience of the new GP service was positive. The standard of clinical practice was judged acceptable. There was a fall in referrals during the study period.ConclusionThis new role in cardiology was broadly welcomed as a model of care by the participating GPs and by patients, because of the potential to improve the quality of care for patients in primary care and reduce costs. As this was a pilot study further development and continuing evaluation of the model is recommended.

Left ventricular pseudoaneurysm

11 Guerrini R, Dravet C, Genton P, et al. Lamotrigine and seizure aggravation in severe myoclonic epilepsy. Epilepsia 1998; 39: S08–S12. 12 Perez J, Chiron C, Musial C, et al. Stiripentol: efficacy and tolerability in epileptic children. Epilepsia 1999; 40: 1618–26. 13 Elterman R, Glauser TA, Ritter FJ, et al. Topiramate YP study team. A double-blind trial of topiramate in partial seizures in children. Epilepsia 1997; 38: S131. 14 Bare MA, Glauser TA, Strawsburg RH. Need for electroencephalogram video confirmation of atypical absence seizures in children with Lennox-Gastaut syndrome. J Child Neurol 1998; 13: 498–500. 15 Wallace SJ. Myoclonus and epilepsy in childhood: a review of treatment with valproate, ethosuximide, lamotrigine and zonisamide. Epilepsy Res 1998; 29: 147–54. 16 Bialer M, Johannessen SI, Kupferberg HJ, Levy RH, Loiseau P, Perucca E. Progress report on new antiepileptic drugs: a summary of the fourth Eilat conference (EILAT IV). Epilepsy Res 1999; 34: 1–41. 17 Poisson M, Huguet F, Savattier A, Bakri-Loiseau P, Narcisse G. A new type of anticonvulsivant, stiripentol. Pharmacological profile and neurochemical study. Arzneimittel-Forschung Drug Res 1984; 34: 199–204. 18 Tran A, Vauzelle-Kervroedan F, Rey E, et al. Effect of stiripentol on CBZ plasma concentration and metabolism in epileptic children. Eur J Clin Pharmacol 1996; 50: 497–500. 19 Levy RH, Loiseau P, Guyot M, et al. Effect of stiripentol on valproate plasma concentration and metabolism. Epilepsia 1987; 28: 605. 20 Chiron C, Dulac O, Gram L. Vigabatrin withdrawal randomized study in children. Epilepsy Res 1996; 25: 209–15. 21 Guerreiro MM, Vigonius U, Pohlmann H, et al. A double-blind controlled trial of oxcarbazepine versus phenytoin in children and adolescents with epilepsy. Epilepsy Res 1997; 27: 205–13. 22 Dulac O, Chiron C. New antiepileptic drugs; experience with infants and children. In: Stefan H, Kramer G, Mamoli B, eds. Challenge epilepsy—new antiepileptic drugs. Blackwell Science, 1998: 121–33. 23 Chiron C, Dulac O, Beaumont D, et al. Therapeutic trial of vigabatrin in refractory infantile spasms. J Clin Neurol 1991; 6: S52–59. 24 Chadwick D, for the Vigabatrin European Monotherapy Study Group. Safety and efficacy of vigabatrin and carbamazepine in newly diagnosed epilepsy: a multicentre randomised double-blind study. Lancet 1999; 354: 13–19. 25 Brodie MJ, Richens A, Yuen AWC, for UK Lamotrigine/Carbamazepine Monotherapy Trial Group. Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy. Lancet 1995; 345: 476–79. ARTICLES