M A James

ANXIETY AND DEPRESSION IN PATIENTS WITH CHEST PAIN REFERRED FOR EXERCISE TESTING

Anxiety and depression were measured in 87 consecutive patients (65 males, 22 females) with chest pain before diagnostic exercise treadmill testing. Chest pain was assessed as typical or atypical of angina by an independent observer. Fifty exercise tests were positive; thirty-seven were negative (including nineteen submaximal). Patients with negative tests had significantly higher scores for anxiety and higher depression scores than those with positive tests. 12% of patients with positive tests were women compared with 43% with negative tests. 27 patients (73%) with negative tests had atypical pain compared with 6 (12%) with positive tests. Depressed patients walked for a significantly shorter time. The probability of a negative test in patients without anxiety or depression who had typical pain was 8% in males and 32% in females; the probability of a negative test in patients who were both anxious and depressed and had atypical pain was 97% in males and 99% in females. Diagnostic exercise testing in patients with both affective symptoms and atypical chest pain may be unhelpful, misleading, and uneconomical.

Pacing failure due to flecainide acetate.

Flecainide acetate is a recently introduced, class 1 antiarrhythmic agent that is highly effective in the treatment of ventricular and atrioventricular/ nodal reentrant tuchycardias.1,2 Although both intravenous and orally administered flecainide are known to cause an increase in the pacing threshold,3 an abrupt and potentially lethal rise in threshold causing failure of a properly functioning, newly implanted pacing system has not to our knowledge been described. We report such a case to stress the need for caution when using this drug in elderly pacemaker patients.

Use of a Retained Guidewire to Improve the Left Ventricular Pacing Threshold

Although transvenous access to the coronary veins has considerably simplified left ventricular (LV) pacing, it can remain a time consuming and arduous task achieving satisfactory pacing positions for the LV electrode. Common problems include negotiating small veins with adequate guide catheter stability, pacing electrode stability once positioned, and phrenic nerve stimulation. We report a case where use of the pacing lead guidewire resulted in a dramatic reduction in the pacing threshold of the LV lead, and saved the patient the need to undergo thoracotomy placement.

Should not be implanted in isolation after infarction

Disappointingly, Liew states that the optimal time to implant a cardioverter defibrillator after acute myocardial infarction remains “unresolved.”1 However, the timing of implantation has become enigmatic because of a too simplistic approach. Sudden death remains a large risk soon after infarction, and its causes, not just its symptoms, must be treated early. Sudden cardiac death happens …