Diagnosis of paroxysmal atrial fibrillation in patients with implanted pacemakers: relationship to symptoms and other variables.

BACKGROUND: Atrial fibrillation (AF) is not always accompanied by clear-cut symptoms and symptoms suggestive of AF may not correspond to a genuine AF episode. The study prospectively evaluated the burden of asymptomatic AF episodes in pacemaker patients (for sick sinus syndrome) with a history of documented paroxysmal AF. METHODS: Consecutive patients were enrolled and implanted with dual-chamber pacemakers equipped with diagnostic features for AF monitoring. Each patient was instructed about typical AF symptoms and was asked to keep a detailed log of symptoms. Stored pacemaker data were analyzed using only AF episodes >30 s. RESULTS: The mean follow-up was 16 +/- 6 months and 102 patients were enrolled (73 +/- 7 years, 59 M). Thirteen patients (13%) dropped out with the development of permanent AF and their data were discarded. Twenty-three patients (26%) without device-stored AF episodes all reported at least one annotated AF episode. There were 1,245 device-stored AF episodes in 66 (74%) out of 89 patients. Patients reported 1,141 episodes of AF-related symptoms. Only 240 (21%) corresponded to a genuine device-stored AF event. The sensitivity and positive predictive value of symptoms to detect AF were respectively 19% and 21%. Episode duration, rate increase at the onset of the arrhythmia, heart disease, or antiarrhythmic drug therapy showed no statistically significant differences comparing symptomatic and asymptomatic episodes. CONCLUSIONS: Many pacemaker patients with paroxysmal AF can develop AF-like symptoms in the absence of device-stored AF. AF-related symptoms have low sensitivity and low positive predictive value in patients with permanent pacemakers.

[Transfer of patients with acute coronary syndromes]. / Trasferimento da spoke a hub di pazienti con sindrome coronarica acuta.

BACKGROUND: The creation of a network to treat patients with acute coronary syndrome with revascularization devices presents a series of critical issues, one of which is the transfer of this type of patients from a spoke to a hub hospital with angioplasty facilities. We investigated the means of transport and the adverse events that could occur during such transfers. METHODS: We analyzed data relating to patients moved from our spoke hospital to hubs over a period of 2 years, utilizing medical records and transport reports. RESULTS: During this period, 531 patients aged 30-91 years were moved; complete clinical data and transfer reports were available for 495 (93%). There were 42 patients with a diagnosis of ST-elevation myocardial infarction (STEMI) <24 h; 115 with STEMI >24 h; 33 with non-ST-elevation myocardial infarction (NSTEMI) <24 h; 156 with NSTEMI >24 h; 122 with unstable angina; and 27 with other diseases. Of these patients, 157 had angina in the 24 h before the transfer; 24 had signs of hemodynamic instability; and 18 had electrical instability, for a total of 166 "unstable patients"; 294 patients (59%) were moved in a medically equipped ambulance with a cardiologist and a professional nurse on board. There were three adverse events (< 1%) but no deaths: one cardiac arrest, one acute pulmonary edema, and one relapse of myocardial infarction. All 3 patients showed signs of clinical and hemodynamic instability at the time of transfer. CONCLUSIONS: The transfer from spoke to hub of patients with acute coronary syndrome who need coronary angiography can be done easily and safely, with a low incidence of adverse events, which are correlated with preexisting clinical and hemodynamic instability.

[Primary cardiac lymphoma presenting with complete atrioventricular block. Case report and review of the literature]. / Linfoma cardiaco primitivo esordito con blocco atrioventricolare completo. Caso clinico e revisione della letteratura.

Primary cardiac lymphoma is very rare and clinical symptoms of cardiac involvement are unusual. The development of conduction defects as the first symptom of cardiac involvement is very uncommon. We report the case of a 57-year-old woman with syncope and complete atrioventricular block due to large B-cell primary cardiac lymphoma. The patient showed a refractory pericardial effusion. Transthoracic echocardiography revealed the presence of a mass in the pericardial space. The diagnosis of diffuse large B-cell lymphoma was made following open-chest biopsy of the heart. The clinical presentation of and the diagnostic approach to primary cardiac lymphoma are discussed. Atrioventricular block and refractory unexplained pericardial effusion and/or the existence of a cardiac mass should arouse the clinical suspicion of this rare malignancy.