[What must intensive care physicians know about implantable cardioverter defibrillator?]. / Was muss der Intensivmediziner über den implantierbaren Kardioverter/Defibrillator wissen.

The first implantable cardioverter defibrillator (ICD) was implanted in the USA in 1980. After the publication of the landmark studies MADIT I and AVID (primary prevention in high risk patients and secondary prevention after sudden cardiac death) implantation rates dramatically increased worldwide. Due to the increasing number of implantations in elderly patients, intensive care units and emergency departments are confronted more often with patients with ICDs. Therefore, intensive care practitioners have to be familiar with these devices. This article summarizes the current literature and focuses on the management of emergencies and malfunction of ICDs.

Prospective comparison of flecainide versus sotalol for immediate cardioversion of atrial fibrillation.

This study sought to compare the efficacy and safety of intravenous flecainide and sotalol for immediate cardioversion of atrial fibrillation. We performed a prospective, randomized, single-blind, multicenter trial, including 106 hemodynamically stable patients with atrial fibrillation, stratified according to duration of the arrhythmia. Exclusion criteria included severely reduced left ventricular systolic function, recent antiarrhythmic therapy, and hypokalemia. Patients were randomly assigned to receive either intravenous flecainide or intravenous sotalol. Trial medication was given at a dose of 1.5 mg/kg body weight (maximum 150 mg). Overall, 28 of 54 patients (52%) given flecainide and 12 of 52 patients (23%) given sotalol converted to sinus rhythm during the first 2 hours after start of the infusion (p = 0.003). Multivariate analysis confirmed that treatment allocation to flecainide, an arrhythmia duration of < or = 24 hours, higher plasma magnesium level at baseline, higher age for men, and lower age for women independently increases the probability of conversion. The frequency of adverse effects was not significantly different in the 2 treatment groups.

Once-daily subcutaneous dalteparin, a low molecular weight heparin, for the initial treatment of acute deep vein thrombosis.

The aim of the study was to compare the efficacy and safety of once-daily subcutaneous injection of dalteparin, a low molecular weight heparin, with that of intravenous unfractionated heparin in the treatment of deep venous thrombosis (DVT). Patients were included if they had deep venous thrombosis distal to inguinal ligament and were randomised either before, if it was considered necessary, or after phlebographic verification of the diagnosis. There was no pre-inclusion treatment with unfractionated heparin. One hundred and twenty patients received dalteparin, administered subcutaneously once-daily at a fixed dose of 200 IU anti-factor Xa/kg, and 133 patients received a continuous intravenous infusion of unfractionated heparin (UFH). Oral anticoagulation was started on the first or second day, and initial treatment with dalteparin or UFH discontinued when the prothrombin time was in the therapeutic range (2 < INR < 3) on two consecutive days. Control phlebograms were taken within 4 days, thereafter. There were no significant differences between the two initial treatment groups in improvements in Marder score. Two major bleeding events occurred in the UFH group versus none in the dalteparin group. One patient in each group experienced clinically significant pulmonary embolism. During a mean follow-up period of 6.9 +/- 1.5 months, recurrent DVT occurred in four patients in the dalteparin group and in two of the UFH group. These results confirm those of a previous study on dalteparin in the initial treatment of DVT, and suggest that dalteparin administered once-daily at a fixed dose of 200 UI/kg is as effective and well-tolerated as UFH in patients with DVT below the inguinal ligament. The present study also demonstrates that dalteparin can be started as soon as the diagnosis of DVT is suspected and without pre-treatment with UFH. Given that the administration of once-daily subcutaneous injections needs not require a patient to be hospitalised, studies to investigate the possibility of using dalteparin for the initial treatment of DVT in the outpatient setting are warranted.

[Heparin in deep venous thrombosis of the leg--effectiveness and safety]. / Heparin bei tiefer Beinvenenthrombose--Effizienz und Sicherheit.

The aim of this retrospective study was to evaluate the adequacy of heparin treatment in deep venous thrombosis and the rate of symptomatic complications under the everyday conditions of a hospital. The investigation was carried out in 200 consecutive patients, 117 women and 83 men (mean age 61 +/- 17 years) with verified deep venous thrombosis. Na-heparin was given over 12 +/- 7 days; the initial daily dosage amounting to 31700 IU followed by a maintenance dosage of 36150 IU. 153 patients were treated exclusively or predominantly by the subcutaneous route (3 times daily) and 47 by continuous i.v. infusion. In the i.v. group 47% of thrombin times (TT) were prolonged to values exceeding 48 seconds in comparison with only 39% in the subcutaneous group (p less than 0.001). 34 patients developed thromboembolic complications (pulmonary embolism in 33), causing death in 13 cases. Patients with thromboembolic complications differed from those without in respect to the rate of a therapeutically prolonged TT (10% vs 44%, p less than 0.001) and signs of pulmonary embolism on admission (44% vs 8%, p less than 0.001), but not with respect to heparin dosage. Thromboembolic complications appeared in only 3 patients receiving i.v. therapy. Patients with thrombosis of the iliac or femoral veins appeared twice as likely to develop pulmonary embolism than patients with calf vein thrombosis (n.s.). Bleeding was registered in 11 patients. One patient died from retroperitoneal haemorrhage. At the time of bleeding 10 patients were on subcutaneous heparin and in 9 patients the TT was prolonged to over 2 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)