Mark Papouchado

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.

Long-term survival of VDD pacing.

All patients with VDD systems implanted at a tertiary pacing center were identified from a computer database and data collected on pacing indications, follow‐up duration, rate response, reasons for programming changes, and implant P wave amplitudes. Results: 366 implants were identified for which complete data were available for 335 leads implanted in 316 patients. The mean follow‐up period was 24.1 months, and age at implant was 73.5 ± 11.8 years. During follow‐up, 19 patients died (6%) and 62 (19.6%) were followed elsewhere. Indications for pacing were complete heart block, 56.6%; intermittent AV block, 21.8%; postablation complete heart block, 5.4%; 2:1 AV block, 13%; and others, 3.2%. Two groups: no mode change (NMC, n = 280) and mode change (MC, n = 36) were identified. Reasons for reprogramming in the MC group were as follows: atrial sensing, 11; AF/atrial flutter, 18; chronotropic incompetence, 3; and others 4. Significantly more MC patients had rate response programmed ON (44.4% vs 22.1%, P < 0.05). No significant differences between the two groups were found in other variables, including male gender (55.5% vs 54.6%), length of follow‐up (27.1 ± 17.8 vs 23.8 ± 20.6 months), age at last follow‐up (72 ± 12.3 vs 75.9 ± 11.9years), and P wave amplitude (1.7 ± 0.9 vs 1.8 ± 0.9mV). Conclusion: Reprogramming of VDD systems is infrequent. When necessary, it is usually prompted by atrial arrhythmias or failure of atrial sensing. When adequate atrial chronotropy has been verified, VDD is an acceptable alternative to DDD pacing and survives well over the long term.

Evolution of atrial signals from a single Lead VDD pacemaker

The atrial sensing capabilities of a new single pass lead VDD pacing system (Pacesetter AddVent) were assessed in a prospective multicenter study of 101 implants during the period July 1994 through March 1996. The pacing lead (Pacesetter AV Plus) has a unique quadripolar 4‐in‐line connector and uses a pair of ring electrodes with an interelectrode spacing of 12 mm for atrial sensing. The mean age of the patients (51 men) was 73 years (range 19–91). Seventy‐five patients had complete heart block; the others had 2:1 AV block. Wide variations were found in signal amplitude: mean P wave amplitude, measured over four cycles in the supine position, was 2.4 ± 1.9 mV at implant, dropping to 1.9 ± 1.7 mV predischarge, and remaining constant at follow‐up but with a narrower range. Holter monitoring was undertaken in 24 patients, with a total of 550 monitored hours. Mean AV synchrony was 98.2%± 4.6% (excluding premature ventricular contractions), with 20 patients (83%) showing > 99% AV synchrony, with atrial sensing at 0.1 mV where needed. No oversensing was observed in any patient. There was a low incidence of atrial fibrillation (2%) and sinus bradycardia (0%). The findings show that the range of atrial signals, although wide initially, converges over the first year and remains adequate for reliable AV synchronous pacing.

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.

Combined therapy with disopyramide and amiodarone: a report of 11 cases

Combined amiodarone and disopyramide therapy is generally believed to be potentially harmful. We report 11 patients who have received this combination, none of whom have experienced any serious adverse reactions. In addition, 9 of the 11 patients derived marked clinical benefit. This combination deserves further evaluation as an anti-arrhythmia therapy.

Prognostic value of 123-IODO-heptadecanoic acid imaging in patients with acute myocardial infarction.

This trial aimed to test if the half life of radioiodinated heptadecanoic acid (HDA) in acutely infarcted myocardium is of prognostic value. Twenty patients had an HDA scan and a MUGA scan within 6 days of acute myocardial infarction, eighteen of these had a visible defect on the HDA images. The mean half life of the areas of acute infarction (15.50 min+/-7.82 min) was significantly shorter than that of normal myocardium (20.77 min+/-4.00 min). The MUGA scan was repeated after 6 months in 15 patients. The mean acute infarct half life was longer in patients with an LVEF improvement of at least 5% at 6 months (16.92 min+/-10.56 min), compared to those with a deterioration of more than 5% (11.75 min+/-4.03 min), although the difference is not statistically significant. While the results in a few individuals suggested that the half life may be of prognostic significance, the variable response of the group reduced the ability of the half live to act as a prognostic indicator. Improvements in imaging and background subtraction techniques may be necessary before the half life is of practical value.

Assessment of percutaneous transluminal coronary angioplasty with 123IODO-heptadecanoic acid

Ten patients underwent myocardial scintigraphy with 123I-iodo-heptadecanoic acid (HDA), which was injected in the last minute of maximal exercise testing. Six of the patients were rescanned following percutaneous transluminal coronary angioplasty. All ten patients underwent full coronary angiography. There were visible perfusion defects on the static images in 74% of the myocardial areas which were supplied by an artery with a stenosis greater than 75%. The mean half life recorded from areas distal to an arterial stenosis of at least 90% (35.69 min ±41.25 min), was longer than the expected normal mean (18.85 min ±3.35 min). However, the difference was not statistically significant. The static images changed in some patients following angioplasty, however there was no consistent alteration in the half lives. It was concluded that HDA is a suitable agent for investigating myocardial perfusion, but that the half life cannot be measured adequately for clinical purposes with a planar imaging system.