Verner Rasmussen

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial

Abstract Objective: To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. Design: Randomised controlled trial. Setting: Copenhagen, Denmark. Subjects: 42 alcoholic patients without liver disease admitted for elective colorectal surgery. Interventions: Withdrawal from alcohol consumption for 1month before operation (disulfiram controlled) compared with continuous drinking. Main outcome measures: Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines. Results: The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2 v 12 mm2, P=0.04), but not after surgery (3 mm2 v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P≤0.05). Conclusions: One month of preoperative abstinence reduces postoperative morbidity in alcohol abusers. The mechanism is probably reduced preclinical organ dysfunction and reduction of the exaggerated response to surgical stress.

Hypoxaemia and Myocardial Ischaemia during Colonoscopy

BACKGROUND Myocardial ischaemia (defined as ST-segment deviation on electrocardiogram (ECG)) may occur during colonoscopy, but the pathogenic mechanisms are unknown. We have evaluated the occurrence of arterial hypoxaemia, tachycardia, and myocardial ischaemia during routine colonoscopy. METHODS Eighteen patients underwent colonoscopy under conscious sedation and without supplementary oxygen. Arterial oxygen saturation was measured by continuous pulse oximetry, and ECG was monitored continuously with a Holter tape recorder during the procedure. RESULTS Arterial oxygen desaturation and tachycardia were common during colonoscopy and occurred in 45% and 35% of patients, respectively. Two patients developed signs of myocardial ischaemia during the colonoscopy: one case of ST depression (1.7 mV) and one case of ST elevation (4.3 mV). In both patients the ST deviation disappeared when the colonoscope was retracted. Myocardial ischaemia occurred in both patients simultaneously with tachycardia, and in one of these arterial hypoxaemia was also present. CONCLUSIONS Myocardial ischaemia occurs during routine colonoscopy, but with a lower incidence than previously reported during upper endoscopy. Myocardial ischaemia during colonoscopy may be associated with tachycardia and/or hypoxaemia. Further studies should clarify the relative role of tachycardia, hypoxaemia, and viscerocardiac reflexes in the pathogenesis of myocardial ischaemia during colonoscopy.

Verapamil and angiotensin-converting enzyme inhibitors in patients with coronary artery disease and reduced left ventricular ejection fraction

Verapamil is effective as antianginal medication but contraindicated in patients with congestive heart failure. Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure but have limited effect on patients with angina pectoris. No studies have been published on the combined treatment with verapamil and ACE inhibitors in patients with stable angina pectoris and left ventricular dysfunction. We performed an open study in 14 patients with angina pectoris and ejection fraction < 40%. The patients received verapamil 180 mg and trandolapril 2 mg twice daily for 3 months. We found a significant increase in ejection fraction from 28 +/- 6 to 35 +/- 11 (p < 0.03), wall motion index from 1.0 +/- 0.3 to 1.2 +/- 0.3 (p < 0.03), exercise duration from 6.9 +/- 2.5 to 7.7 +/- 2.9 minutes (p < 0.01), and ratio of exercise to rest rate-pressure product from 2.2 +/- 0.4 to 2.5 +/- 0.6 (p < 0.02). Use of nitroglycerin and number of angina pectoris attacks were both significantly reduced after 3 months of treatment. These findings support the hypothesis that the combination of verapamil and trandolapril is useful in patients with attenuated left ventricular function and angina pectoris.

Double blind randomised controlled trial of effect of metoprolol on myocardial ischaemia during endoscopic cholangiopancreatography

Abstract Objective: To evaluate the effect of metoprolol, a ß adrenergic blocking drug, on the occurrence of myocardial ischaemia during endoscopic cholangiopancreatography. Design: Double blind, randomised, controlled trial. Setting: University Hospital. Subjects: 38 (two groups of 19) patients scheduled for endoscopic cholangiopancreatography. Interventions: Metoprolol 100 mg or placebo as premedication two hours before endoscopy. Main outcome measures: Heart rate, arterial oxygen saturation by continuous pulse oximetry, ST segment changes during endoscopic cholangiopancreatography (an ST segment deviation >1 mV was defined as myocardial ischaemia), electrocardiogram monitored continuously with a Holter tape recorder. Results: All patients had increased heart rate during endoscopy compared with rate before endoscopy, but heart rate during endoscopy was significantly lower in the metoprolol group compared with the placebo group (P = 0.0002). Twenty one patients (16 placebo, 5 metoprolol; P = 0.0008) developed tachycardia (heart rate > 100/min) during the procedure, and 11 patients (10 placebo, 1 metoprolol; P = 0.003) developed myocardial ischaemia. One patient in the placebo group had an acute inferolateral myocardial infarction. In the 10 other patients with signs of myocardial ischaemia during endoscopy the ST deviation disappeared when the endoscope was retracted. In all patients myocardial ischaemia was related to increases in heart rate, and 10 of the 11 patients had tachycardia coherent with myocardial ischaemia. Conclusions: Metoprolol prevented myocardial ischaemia during endoscopic cholangiopancreatography, probably through lowering the heart rate. Thus, tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy. Key messages Metoprolol prevented myocardial ischaemia during endoscopy Myocardial ischaemia was related to tachycardia more than to concomitant hypoxaemia Tachycardia seems to be a key pathogenic factor in the development of myocardial ischaemia during endoscopy

Predictors of sudden death and death from pump failure in congestive heart failure are different. Analysis of 24 h Holter monitoring, clinical variables, blood chemistry, exercise test and radionuclide angiography

One hundred and ninety consecutive patients discharged with congestive heart failure were examined with clinical evaluation, blood chemistry, 24 h Holter monitoring, exercise test and radionuclide angiography. Median left ventricular ejection fraction was 0.30, 46% were in New York Heart Association class II and 44% in III. Total mortality after 1 year was 21%, after 2 years 32%. Of 60 deaths, 33% were sudden and 49% due to pump failure. Multivariate analyses identified totally different risk factors for sudden death: ventricular tachycardia, s-sodium < or = 137 mmol/l, s-magnesium < or = 0.80 mmol/l, s-creatinine > 121 mumol/l, and maximal change in heart rate during exercise < or = 35 min-1, and for death from progressive pump failure: New York Heart Association class III + IV, delta heart rate over 24 h < or = 50 min-1, low ejection fraction, high resting p-noradrenaline, s-urea > 7.6 mmol/l, s-potassium < 3.5 mmol/l, and maximal exercise duration < or = 4 min. In conclusion, this study demonstrated different risk factors for sudden death and for death from progressive pump failure.

QT interval in 24-hour ambulatory ECG recordings from 60 healthy adult subjects

QT and RR intervals were measured in 24-hour electrocardiographic (ECG) recordings from 60 healthy subjects randomly selected among participants in the Copenhagen City Heart Study. Five men and five women of each 10-year age group between the ages of 20 and 79 were included. The mean of three consecutive RR and QT intervals was calculated from ECG strips recorded at 1000, 1400, 1800, 2200, 0200, and 0600 hours in each subject. The RR interval varied between 728 ms at 1400 hours and 984 ms at 0600 hours, and the uncorrected QT interval between 358 ms at 1400 hours and 417 ms at 0200 hours. The QT interval corrected for heart rate by Bazetts formula varied between 418 ms at 0600 hours and 428 ms at 1000 hours, and the QT interval corrected by the regression equation of this study varied between 396 ms at 1400 hours and 422 ms at 0200 hours. Multiple regression analysis of uncorrected data yielded a partial regression coefficient for heart rate influence of 0.14. After correction by Bazetts formula, a statistically significant effect of heart rate remained (partial regression coefficient -0.08, t = -9.93, p less than 0.0001). In addition to the influence of heart rate, the analysis revealed a statistically significant effect of hour of day (F = 11.30; DF 5, 286; p less than 0.0001) and gender (F = 6.24; DF 1, 53; p less than 0.05), whereas age in the range of 20-79 years had no significant effect. The QT intervals of this study differed from the values measured in standard ECG recordings but not from those of other Holter studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporal changes in clinic and ambulatory blood pressure during cyclic post-menopausal hormone replacement therapy

Objective Post-menopausal hormone replacement (HRT) might protect against cardiovascular disease, possibly by arterial vasodilation and reduced blood pressure. Progestogens are needed to avoid endometrial disease but vascular effects are controversial. The objective was to assess temporal changes in blood pressure (BP) by two measurement techniques during a cyclic hormone replacement regimen. Design and methods Sixteen healthy and normotensive post-menopausal women (age 55 ± 3 years) were studied in a placebo-controlled, randomized crossover study, and were randomized to 17β-oestradiol plus cyclic norethisterone acetate (NETA) or placebo in two 12-week periods separated by a 3-month washout. Clinic blood pressure was measured sitting by the same observer with a mercury manometer at four visits in each period. Twenty-four hour ambulatory blood pressure was measured at baseline and in the ninth weeks of treatment in both periods. Results Clinic systolic and diastolic BP were reduced after 10 days of oestradiol (−5.1 and −3.2 mmHg respectively, P ≤ 0.05). After 9 weeks of cyclic HRT, prior to progestogen addition, clinic BP returned to baseline. During addition of NETA, diastolic blood pressure was again reduced (−3.6 mmHg, P = 0.037). Mean 24 h ambulatory systolic and diastolic blood pressures were significantly lower than clinic measurements (−15.7 and −5.9 mmHg, P ≤ 0.001) but were unaffected by HRT. Conclusions Clinic blood pressure is reduced during a cyclic HRT regimen but the reduction varies with the HRT regimen, which might explain the diversity in previous BP findings during HRT. Norethisterone acetate might possess additive blood pressure-lowering effects in post-menopausal women.

Prolonged signal-averaged P wave duration after elective cardioversion increases the risk of recurrent atrial fibrillation.

Objective—To assess the risk of atrial fibrillation (AF) recurrence after elective cardioversion of AF in relation to the signal‐averaged P wave duration (SAPWD), clinical characteristics of the patient, and the duration of the AF disease. Design—We studied 131 consecutive patients (88 men, 43 women), median age 67 years (range 29–87 years), after elective cardioversion of AF into sinus rhythm. The SAPWD was measured on inclusion, and the follow‐up period was 1 month. Recurrent AF within the first month after cardioversion was regarded as endpoint. Results—AF recurred in 73 patients (56%). Multiple logistic regression analysis showed that prolonged SAPWD above 160 ms was the only significant risk factor for recurrent AF, OR=2.22 (95% CI 1.07–4.60), p=0.03. There was no significant effect of age, diagnosed hypertension, diagnosed congestive heart failure, dilated left atrium, or long duration of AF on the risk of AF relapse. Conclusion—Prolonged SAPWD above 160 ms is a risk factor for recurrent AF after elective cardioversion of persistent AF.

ST-segment deviation during 24-hour ambulatory electrocardiographic monitoring and exercise stress test in healthy male subjects 51 to 75 years of age: the Copenhagen City Heart Study.

BACKGROUND Although ST-segment deviation has been evaluated and used during many years both on continuous electrocardiographic Holter monitoring and during exercise stress testing, considerable controversy still remains concerning the prevalence and diagnostic significance of fortuitously discovered ST-segment deviation in asymptomatic healthy persons. METHODS AND RESULTS The occurrence of ST-segment deviation was studied in a population of 63 clinically healthy male subjects 51 to 75 years of age, with the use of 24-hour Holter monitoring and exercise stress testing. The subjects were recruited from the Copenhagen City Heart Study and were without cardiovascular risk factors, chronic diseases, or medication and without cardiovascular events during 5 to 12 years before and 3 to 5 years after admission. The specificity, that is, the probability of displaying a negative test result in healthy subjects without disease, was 1.0 when using as criterion for significant ST-segment deviation a horizontal or descending ST-segment depression of >0.20 mV or ST-segment elevation >/=0.15 mV during Holter monitoring, and acceptable, for example, 0.95, when using as criterion a horizontal or descending ST-segment depression of >/=0.15 mV during Holter monitoring or at the exercise test, respectively. Furthermore, the specificity was 0.95 when a horizontal or downsloping ST-segment depression of 0.1 mV was displayed in both the Holter and exercise electrocardiographic recording system. CONCLUSIONS Thus in asymptomatic persons, the usual criterion for significant ST-segment depression of 0.1 mV can be applied when occurring in both electrocardiographic recording systems. However, if one test alone is used, the criterion of significant ST-segment depression should be 0.15 mV. Absence of ST-segment deviation during Holter monitoring and exercise stress testing, indicated with a specificity of 1.0 or 0.95 according to choice of criterion, implies that the person is in a healthy state.

ECG changes during endoscopic retrograde cholangio-pancreatography and coronary artery disease

Objective Myocardial ischaemia has been described during endoscopic retrograde cholangio-pancreatography (ERCP), but the pathogenesis remains unclear. The aim of the present study was to evaluate whether coronary artery disease was present in patients with ST-segment changes during ERCP. Material and methods Forty patients were monitored with a Holter tape recorder during ERCP. Patients with ST-segment deviation during ERCP subsequently underwent a standard exercise ECG test. Results Twelve patients developed signs of myocardial ischaemia during ERCP (30%) and 9 had concomitant tachycardia. None had a cardiac history or cardiorespiratory symptoms. Ten of the 12 patients did an exercise test and one patient developed silent ischaemia. Subsequent coronary angiography showed no evidence of coronary artery disease. Conclusions No signs of existing coronary artery disease were found in patients developing ST deviation during ERCP when evaluated with a 12-lead exercise ECG test. Further studies should evaluate other mechanisms responsible for myocardial ischaemia during ERCP.