Pre-participation cardiovascular screening: is community screening using hand-held cardiac ultrasound feasible?

We evaluated the feasibility and costs of utilising hand-held cardiac ultrasound (HHCU) as part of a community-based pre-participation cardiovascular screening programme. Ninety-seven school children were screened using a personal history, a physical examination, a resting 12-lead electrocardiogram (ECG) and a HHCU. A consultant cardiologist independently reviewed and reported the data. Previously undiagnosed cardiovascular abnormalities were identified in nine participants (9%). An additional three participants (3%) were diagnosed with hypertension. The nine abnormalities were identified at a cost of £460 per finding, with a cost of £43 per participant screened. The marginal cost of adding a HHCU to the personal history, physical examination and ECG was £16 per participant. Pre-participation screening in the community using hand-held echocardiography is practical and inexpensive. The additional sensitivity and specificity provided by the ultrasound may enhance screening programmes, thereby reducing false positives and the need for expensive follow-up testing.

Spontaneous coronary artery dissection.

We present a case of a 43-year-old lady who presented with an acute coronary syndrome, but without any cardiac risk factors or previous cardiac symptoms, and who had a spontaneous coronary artery dissection. This was successfully treated with percutaneous coronary intervention. A brief discussion of this clinical entity and literature review is presented.

Intracardiac echocardiography.

Intracardiac echocardiography (ICE) is increasingly being used to guide percutaneous interventional procedures, principally the closure of interatrial septal abnormalities, and to support electrophysiological procedures. Clear views of intracardiac structures can help a number of other procedures, such as myocardial biopsy and paravalvular leak closure. The main advantages of ICE over transoesophageal echocardiography during closure of atrial septal defects are that the use of ICE eliminates the need for a general anaesthetic, affords clearer imaging, shorter procedure times and reduces hospital stays and radiation doses. The principal disadvantage is the additional cost of the catheter, though this can be offset by improved turnaround times and reduced personnel costs.

Semi-automatic boundary detection to improve reporting of regional left ventricular function.

AIMS: The reporting of regional left ventricular function is based on subjective assessment of endocardial motion and thickening and has a significant learning curve. We hypothesized that the use of an semi-automatic boundary detection system generating images with superimposed moving endocardial borders and a fixed end-diastolic reference border could improve the reporting of regional function. METHODS: We obtained 58 resting contrast images of 15 patients and using a new boundary detection system (Quamus), generated images with superimposed endocardial borders. The contrast images, images with additional Quamus borders and Quamus borders alone were assessed by two level 1 and two level 2 echocardiographers. They scored regional function and results were compared to two level 3 experienced stress echocardiography readers. RESULTS: The addition of borders improved the agreement of level 1 echocardiographers (weighted Kappa increased from 0.55 to 0.64) but did not change for level 2 echocardiographers (0.63 to 0.64) and has the potential to be a useful training tool.

Will this be the end of the anticoagulation clinic for patients with atrial fibrillation?

Atrial fibrillation is the most common clinical arrhythmia and with an ageing population, it is an increasing cause of hospital admissions, morbidity and mortality. The most feared complication of atrial fibrillation is stroke. A number of studies have demonstrated that warfarin is at least moderately effective at reducing thromboembolic risk in stroke yet its use in both the community and in secondary care is suboptimal. Concerns about drug interactions, frequent blood monitoring and the risks of over and under coagulation have led to under prescription. Direct thrombin inhibitors are under investigation as an alternative to warfarin for thromboembolic prophylaxis in atrial fibrillation. Two large studies (SPORTIF III and SPORTIF V) have recently been published examining the effectiveness of the direct thrombin inhibitor ximelagatran at reducing thromboembolic risk. Ximelagatran was shown to be non-inferior to warfarin for the prevention of thromboembolic complications. Concerns however have arisen about long-term safety, particularly the possible effects on hepatic function. This review examines the data and discusses whether the introduction of these drugs could result in the end of the anticoagulation clinic for patients with atrial fibrillation.

Candida prosthetic valve endocarditis cured by caspofungin therapy without valve replacement.

A 64-year-old woman with a mechanical mitral valve prosthesis developed late-onset Candida endocarditis. Blood cultures grew Candida glabrata and Candida krusei. Transesophageal echocardiography demonstrated vegetations on the valve. The patient was not medically fit for valve replacement, but her condition was successfully treated with 6 weeks of intravenous caspofungin therapy.

The safety and effectiveness of a nurse led cardioversion service under sedation.

OBJECTIVE: To assess the safety and effectiveness of nurse led elective cardioversion of atrial fibrillation under sedation. DESIGN: Prospective, longitudinal study. SETTING: Cardiac catheterisation laboratory and recovery area of a district general hospital. PATIENTS: 300 patients referred for elective cardioversion of persistent atrial fibrillation. INTERVENTIONS: Pre-procedure evaluations (history, physical examination, blood tests), consent, sedation administration, cardioversions, and post-procedure monitoring until discharge by advanced life support certified coronary care unit nurses trained in the techniques. A doctor was immediately available if required but not present. MAIN OUTCOME MEASURES: Success rates at discharge and at six weeks, energy delivered, number of shocks, dose of sedation, immediate, 24, and 48 hour patient perceptions, complications, waiting times, and cost effectiveness. RESULTS: Cardioversion success rate was 87% at discharge and 48% at six weeks. Mean (SD) cumulative energy was 497 (282) J and number of shocks 1.6 (0.8). Mean (SD) dose of sedation was 23 (9) mg intravenous diazepam. No patient required reversal of sedation, airway support, or medical intervention. Ninety eight per cent of patients had no pain or recall of the procedure. Four patients who were adequately anticoagulated experienced embolic phenomena. Ninety eight per cent of patients would repeat the procedure if necessary. Without requirement for a physician or anaesthetist, waiting times for elective cardioversion fell from three months to under four weeks. There was a significant reduction in the estimated cost of the procedure from 337 pounds sterling with general anaesthesia to 130 pounds sterling with nurse led sedation and cardioversion (p < 0.001). CONCLUSION: With appropriate training, a nurse led cardioversion service with sedation is safe, effective, well tolerated, and cost efficient.

The role of pacemaker and defibrillator therapy for the treatment of atrial fibrillation.

The development of pacemaker and defibrillator technology has provided a new direction for the treatment of recurrent symptomatic atrial fibrillation (AF). Sophisticated atrial preventative pacing algorithms are now available and newer implantable devices have additional atrial termination pacing therapies. Results from studies examining the effectiveness of atrial anti-tachycardia pacing algorithms have suggested that 50% of atrial arrhythmias (including AF) can be pace terminated using these devices. The atrial defibrillator has recently been shown to be a safe and effective method of restoring and maintaining sinus rhythm in selected patients. Symptoms and quality of life can be improved and some patients demonstrate increased sinus rhythm duration (sinus rhythm begets sinus rhythm) with repeated use of the device. This review article discusses the current application of device therapy for the management of AF and explores some of the merits and limitations of these devices.

The clinical and electrophysiological implications of asymptomatic atrial fibrillation.

Atrial fibrillation (AF) is the commonest arrhythmia encountered in clinical practice and is frequently associated with significant symptoms. Asymptomatic AF may also increase the risks of heart failure, thromboembolism and cardiomyopathy but its prevalence is significantly underestimated by routine surveillance methods. The development of long-term external monitors and implantable devices has offered a new insight into the true prevalence of asymptomatic AF. Similar management strategies should be applied to both symptomatic and asymptomatic patient groups and anticoagulation should be continued indefinitely in those with a history of AF and risk factors for thromboembolism. Enhanced detection of clinically silent AF could improve outcomes but the resource implications will be significant.

Primary cardiac lymphoma.

We present a case of primary cardiac lymphoma, which is a rare condition compared with secondary metastatic involvement and is associated with poor prognosis. This case demonstrates the use of transthoracic echocardiography for the assessment of tumour regression in response to chemotherapy.

Atrial fibrillation storms.

Evolving pacemaker and device technology now allows the onset pattern of arrhythmias to be identified. It is recognised that some cardiac arrhythmias have a circadian pattern of onset and that ventricular arrhythmias can occur in clusters of electrical storms. The long-term follow-up of patients with an atrial defibrillator suggests that in some patients persistent atrial fibrillation recurrences are not random, but can occur in clusters of 'atrial fibrillation storms'. A case report is used to demonstrate this newly recognised phenomenon.

Diazepam or midazolam for external DC cardioversion (the DORM Study).

AIMS: To compare the clinical efficacy and tolerability of two intravenous sedatives for physician-led DC cardioversion of atrial arrhythmias. METHODS AND RESULTS: One hundred and forty-one patients attending for elective DC cardioversion of atrial arrhythmias were randomized to intravenous midazolam or diazepam. Sedation was administered using titration protocols. Procedure times, operator satisfaction scores and adverse events were documented. The patients immediate, 24- and 48-h recall and awareness of after-effects were obtained from questionnaires. Seventy-one patients received midazolam (mean 12.5 mg) and 70 patients received diazepam (mean 28.1 mg). There were 16 minor adverse events with midazolam (20% hypotension, 3% oxygen desaturation) and nine with diazepam (7% hypotension, 6% required additional analgesia), P = 0.14. There were no major adverse events. Sedation time was 5.0 +/- 3.4 min for midazolam and 6.5 +/- 3.4 min for diazepam (P = 0.0016). Patients awoke 77 +/- 46 min post-sedation with midazolam and 39 +/- 24 min with diazepam (P < 0.0001). There was no recall of the procedure at 48 h and no difference in awareness of after-effects between the two groups at 24 or 48 h, P = ns. CONCLUSION: Physician-led cardioversion of atrial arrhythmias using intravenous sedation is effective and well tolerated. Sedation with diazepam was associated with fewer minor adverse events and a quicker recovery time than midazolam.

Effect of atrial antitachycardia pacing treatments in patients with an atrial defibrillator: randomised study comparing subthreshold and nominal pacing outputs.

OBJECTIVE: To assess the true efficacy of antitachycardia pacing on spontaneous persistent atrial fibrillation in patients with an implanted atrial defibrillator, by comparing the effects of nominal pacing treatment with subthreshold pacing treatment. DESIGN: The effects of antitachycardia pacing and burst 50 Hz atrial pacing on spontaneous atrial arrhythmias were evaluated six months after implantation of a Medtronic Jewel AF((R)) atrial defibrillator. SETTING: Cardiology department in a district general hospital. PATIENTS: 15 patients with persistent atrial fibrillation. INTERVENTIONS: Patients were randomised to either "nominal" output pacing treatment or surface ECG and endocardial electrogram proven subthreshold "sham" pacing treatment for three months, and then crossed over to the alternative treatment for a further three months. RESULTS: During the nominal output phase, 31 episodes of atrial fibrillation were treated with 53 bursts of 50 Hz pacing, 98 sequences of ramp atrial pacing, and 61 sequences of burst atrial pacing. Atrial fibrillation was not pace terminated during any episode. Thirty one episodes of atrial tachycardia were treated with 19 bursts of 50 Hz atrial pacing, 103 sequences of ramp atrial pacing, and 38 sequences of burst atrial pacing. Termination of atrial tachycardia was observed in 17 episodes. During the "sham" pacing period, no episodes were terminated by any pacing treatment. CONCLUSION: Atrial antitachycardia pacing treatments are ineffective at terminating persistent atrial fibrillation but may be useful in terminating episodes of atrial tachycardia or flutter, thus reducing the burden of arrhythmia.

What is the optimal electrode configuration for atrial defibrillators in man?

AIMS: To compare the atrial defibrillation threshold (DFT) for two electrode configurations in patients with drug refractory persistent atrial fibrillation (AF). METHODS AND RESULTS: 11 patients, 73% male, mean age 60.9 (range 38 to 83), underwent implantation of a Medtronic Jewel AF dual chamber defibrillator (model 7250). A step-up atrial DFT was performed in a randomized sequence for two electrode configurations: (1) Right atrial to distal coronary sinus electrode (RA > CS) and (2) defibrillator can to right ventricular and right atrial electrodes (CAN > RV + RA). The RA > CS configuration restored SR in 10 patients (91%). The CAN > RA + RV configuration restored SR in four patients (36%). The mean atrial DFT was significantly lower for the RA > CS than CAN > RA + RV configuration (10 +/- 7 Joules vs 25 +/- 6 Joules), P < 0.01. At 3 months post implantation, AF was reinduced and the protocol was repeated for the optimal electrode configuration. There was no significant difference in the atrial DFT compared with that at implant. CONCLUSION: The right atrium to coronary sinus electrode configuration significantly reduces the atrial DFT. The atrial DFT also remains stable at 3 months post-implantation. Patients with persistent AF undergoing insertion of an atrial defibrillator should have a coronary sinus electrode implanted.