Anti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial.

BACKGROUND: Severe cardiac glycoside cardiotoxicity after ingestion of yellow oleander seeds is an important problem in rural areas of Sri Lanka. Currently, patients must be transferred to the capital for temporary cardiac pacing. We did a randomised controlled trial to investigate whether anti-digoxin Fab could reverse serious oleander-induced arrhythmias. METHODS: After a preliminary dose-finding study, 66 patients who presented to hospital with a serious cardiac arrhythmia were randomised to receive either 1200 mg of anti-digoxin Fab or a saline placebo. A 12-lead electrocardiogram, 3 min rhythm strip, and blood sample for measurement of electrolytes and cardiac glycosides were taken before treatment and at 12 timepoints thereafter. FINDINGS: 34 patients received anti-digoxin Fab and 32 received placebo. The presenting arrhythmia had resolved completely after 2 h in 15 antibody-treated patients and two controls (p<0.001); 24 and five patients, respectively, were in sinus rhythm at 8 h (p<0.001). Kaplan-Meier analysis of time to first reversal showed a significant response to anti-digoxin Fab. The heart rate increased in cases, from 49.1 per min at baseline to 66.8 at 2 h, but not in controls (50.6 per min at baseline to 51.5; p<0.001). Mean serum potassium concentrations decreased from 4.9 mmol/L to 4.1 mmol/L at 2 h in cases; no such decrease occurred in controls. INTERPRETATION: Anti-digoxin Fab fragments are a safe and effective treatment for serious cardiac arrhythmias induced by yellow oleander. Their use in small rural hospitals in Sri Lanka should minimise costly transfer of patients and reduce the numbers of deaths; however, further study will be required to confirm this reduction.

Management of acute myocardial infarction in general medical wards in Sri Lanka.

The study was designed to evaluate the management of acute myocardial infarction in the general medical wards of the National Hospital of Sri Lanka. All patients with acute myocardial infarction admitted from September 1996 to August 1997, were evaluated with regard to the time delay in admission and drug treatment. The facilities for monitoring and resuscitation were also assessed. A total of 259 patients were included in the study, 173 males and 86 females. The median time delay from the onset of the pain to admission at the out-patients department was 12 hours and that between out-patients department admission and ward admission was 20 minutes. The median delay in obtaining a 12-lead electrocardiogram when the patient was in the ward was 90 minutes. Review of the data showed that thrombolytic therapy, beta-blockers and angiotensin-converting enzyme inhibitors are underused. Complications were common. All the medical wards had adequate monitoring and resuscitation facilities. With adequate training of doctors and the availability of specialised cardiac nurses, thrombolytic therapy can be used effectively in medical wards.

Time delay to thrombolytic therapy--a Sri Lankan perspective.

Reducing the time delay in initiating thrombolytic therapy in acute myocardial infarction is critical in maximising the functional and survival benefit. We analysed 120 consecutive admissions for thrombolytic therapy to the Coronary Care Unit. The total delay was divided into prehospital, in-hospital and Coronary Care Unit stages, and the median delays were found to be 130, 70, and 15 minutes, respectively. The delay was significantly longer in patients who sought prehospital medical advice, and when the diagnosis was not made at the emergency treatment unit. Educating at-risk groups and modifying the admission system may help to minimise these delays, while the establishment of an emergency ambulance service with well-trained crew would also improve the prognosis after acute myocardial infarction in Sri Lanka.

Recent aspects of alcoholism in Sri Lanka--an increasing health hazard.

Eighty-five patients (81 males and 4 females) with significant alcoholic histories were studied. Alcohol misuse was directly or indirectly responsible for about 5-10% of hospital admissions in Sri Lanka. Prevalence of alcoholism in patients below 40 years (43% of cases) or with a strong family history (56% of cases) were demographic features simulating trends in developed nations. Although rarely an occupational hazard, the majority in this lower socio-economic group drank illicitly-manufactured brews with high alcohol content while many consumed a mixture of beverages. Lone drinkers were predominant (86%); features of psychological interest were sleep disturbance (64%), emotional problems (42%) and loneliness (34%); domestic problems (36%), social problems (24%) and financial problems (34%) were also noted. Many such factors, either singly or in combination, initiated or perpetuated the drinking habits of the patients. Drug misuse and suicidal tendencies were not observed. Severe hepatic damage was noted in 63% of 42 patients where the histology was demonstrated, and who usually presented with significant hepatomegaly; about 50% of patients below the age of 40 had hepatic damage of a serious or irreversible nature. Direct toxicity of ethanol, toxic contamination during the preparation of illicit brews and nutritional factors appear pertinent to hepatic damage in developing nations. Nutritional factors may cause variations in relation to abnormalities in liver function tests and also liver size among the population studied when compared to findings from the western world.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity of electrocardiographic criteria for left ventricular hypertrophy according to type of cardiac disease.

The sensitivity of 30 electrocardiographic criteria for left ventricular (LV) hypertrophy, isolated or combined, was examined to determine the relation to the underlying disease. Patients with coronary artery disease (CAD), systemic hypertension, valvular heart disease and cardiomyopathy were evaluated. A cardiac partition technique was used to define ventricular hypertrophy. Single electrocardiographic criteria often showed high sensitivity for 1 disease state, but not for others. Precordial voltage criteria were most sensitive for those with hypertensive and valvular disease. A QRS axis of more than -30 degrees occurred most often in patients with CAD. Both left atrial abnormality and abnormal T-wave inversion of more than 1 mm in V6 occurred with a high sensitivity in general; however, T-wave inversion of more than 1 mm in V6 had a low sensitivity in cardiomyopathy. Methods using combinations of various electrocardiographic criteria improved sensitivity. Using these methods, sensitivity of the electrocardiogram for LV hypertrophy was excellent for patients with systemic hypertension and valvular heart disease and acceptable by usual standards for patients with CAD and cardiomyopathy. Because the use of a single criterion is often ineffective, methods using multiple electrocardiographic criteria to detect LV hypertrophy are recommended when the patients under study have diverse cardiac diseases.

The reliability of the routine chest roentgenogram for determination of heart size based on specific ventricular chamber evaluation at postmortem.

Routine posteroanterior and lateral chest radiographs in 268 patients were analyzed to determine heart size--normal, cardiomegaly, or specific chamber enlargement--using specified radiographic criteria for enlargement. The accuracy of this determination was compared with a specific ventricular mass derived from a postmortem cardiac chamber partition technique. The data indicate that in the majority of cases (greater than 70%) a normal-sized heart or cardiomegaly can be correctly determined from the chest x-ray either by the subjective criteria of chamber enlargement or by measurement of the transverse diameter. The use of the chest x-ray, however, for evaluation of specific ventricular chamber enlargement is a less accurate determination, and results are compromised.

Reevaluation of electrocardiographic criteria for left, right and combined cardiac ventricular hypertrophy.

Cardiac chamber weight was determined at necropsy in 323 men to develop correlative studies of electrocardiographic criteria for ventricular hypertrophy. Thirty recommended criteria for left ventricular (LV) hypertrophy, 10 for right ventricular (RV) hypertrophy, and combinations of both criteria for combined hypertrophy were evaluated. Four methods for electrocardiographic diagnosis of LV hypertrophy were derived: (1) a modification of the Romhilt-Estes point system; (2) the presence of any 1 of 3 criteria: (a) S V1 + R V5 or V6 greater than 35 mm, (b) left atrial abnormality, or (c) intrinsicoid deflection in lead V5 or V6 greater than or equal to 0.05 second; (3) a combination of any 2 criteria or of 1 criterion (above) plus at least 1 of the following 3 additional criteria: (a) left-axis deviation greater than -30 degrees, (b) QRS duration greater than 0.09 second, or (c) T-wave inversion in lead V6 of 1 mm or more; and (4) the use of a single criterion--left atrial abnormality. Sensitivity varied from 57 to 66% and specificity from 85 to 93% among these 4 methods. Myocardial infarction increased sensitivity of the foregoing methods, but the specificity was reduced. Method 2 is preferred for the electrocardiographic diagnosis of LV hypertrophy. Two methods were useful for right ventricular (RV) hypertrophy: (1) the use of any 1 of 4 criteria: (a) R/S ratio in lead V5 or V6 less than or equal to 1; (b) S V5 or V6 greater than or equal to 7 mm; (c) right-axis deviation of more than +90 degrees, or (d) P pulmonale; and (2) use of any 2 combinations of the foregoing criteria. Sensitivity ranged from 18 to 43% and specificity from 83 to 95%. Combined hypertrophy was best diagnosed using left atrial abnormality as the sole criteria of LV hypertrophy, plus any 1 of 3 criteria of RV hypertrophy: (a) R/S ratio in lead V5 or V6 less than or equal to 1, (b) S V5 or V6 greater than or equal to 7 mm, or (c) right axis deviation greater than +90 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)

Descriptive characteristics of the electrocardiogram from autopsied men free of cardiopulmonary disease--a basis for evaluating criteria for ventricular hypertrophy.

Most measurements establishing standard values for the normal electrocardiogram have been derived from a healthy population, whereas many electrocardiographic interpretations are necessary in hospitalized or seriously ill patients. Therefore, the characteristics of the electrocardiogram were described from 48 autopsied men known to be free of cardiopulmonary disease by clinical assessment and by a special cardiac examination using postmortem coronary angiography and a chamber partition technique. Highest values, mean and standard deviation, and the upper 97.5 percentile or lower 2.5 percentile when appropriate were noted for QRS voltage, QRS axis and duration, and intrinsicoid deflection in V5 or V6. Any ST-segment and T-wave changes were noted as well as left and right atrial abnormalities. Twenty-eight electrocardiographic criteria recommended to detect left ventricular hypertrophy and 10 recommended to detect right ventricular hypertrophy were evaluated for percentage of false-positive results and the 97.5 percentile value for each criterion was developed from the present data base. The data in this study can be used as a standard for comparing electrocardiographic variation in middle-aged men with specific relevance for electrocardiographic criteria of ventricular hypertrophy.

Quantitation of fibrosis of the heart in chronic obstructive pulmonary disease with and without cor pulmonale.

This study examined the hearts of 55 patients dying of chronic obstructive pulmonary disease, with and without cor pulmonale, quantitated histologically the degree of myocardial fibrosis in the left and right ventricle, and determined the relationship to associated disease states. Comparison has been made to a control group of 17 patients free of cardiopulmonary disease. Patients with associated and advanced ischemic heart disease, as proved by marked atherosclerosis and myocardial infarction, have significantly increased myocardial fibrosis throughout all layers of the left ventricular wall in comparison to control patients or patients with chronic obstructive pulmonary disease free of associated cardiac disease. Right ventricular fibrosis was not significantly increased; however, one case showed a marked degree of fibrosis related to myocardial infarction. Subdivision of patients with chronic obstructive pulmonary disease into groups with definite anatomic right ventricular hypertrophy, a clinical diagnosis of cor pulmonale, or with chronic hypoxemia failed to show any difference in the percentage of myocardial fibrosis of the ventricles among these groups. Increased fibrosis of the right or left ventricle in patients with chronic obstructive pulmonary disease, therefore, is not related to the degree of myocardial hypertrophy pathologically, the hypoxemic state, or clinical heart failure, but to ischemic heart disease with myocardial infarction.

Left atrial abnormality as an electrocardiographic criterion for the diagnosis of left ventricular hypertrophy in the presence of right bundle branch block.

Left atrial (LA) abnormality determined from precordial lead V1 was assessed by 2 observers as a criterion of left ventricular (LV) hypertrophy in the presence of right bundle branch block (BBB) in 23 patients. The presence of LV hypertrophy was confirmed from a postmortem cardiac partition technique and defined at 2 levels of confidence: probable and definite hypertrophy. Observers reliably differentiated between the hypertrophied and normal-sized ventricle in the presence of right BBB by using LA abnormality as an electrocardiographic criterion. When defined as definite hypertrophy, observer 1 correctly identified LV hypertrophy in 78% of the cases and observer 2 in 67% of the cases. False-positive results were present in 21% of cases by observer 1 and 14% by observer 2. Comparable results were achieved when a definition of probable hypertrophy was used. Observer performance of recognition of LA abnormality in this study was satisfactory with 91% agreement between observers. Our results are comparable and in some instances superior to conventional criteria commonly recommended to diagnose LV hypertrophy on the electrocardiogram without right BBB.

Ventricular arrhythmia before and after aorto-coronary bypass surgery.

The influence of aorto-coronary bypass surgery (ACBS) on ventricular arrhythmia was examined in 57 patients. Six-hour Holter monitoring was done on the day prior to and 3 mth after ACBS. None of the patients were on any antiarrhythmic drugs during these recordings. Ventricular arrhythmia was classified into three groups: Group I (45 patients) had an average of less than 10 premature ventricular contractions (PVCs) per hour, Group II (7 patients), 11-30 PVCs per hour and Group III (5 patients), greater than 30 PVCs per hour. There was no significant change in the number of patients in each group after ACBS. Complex PVCs were present in 8 patients preoperatively and in 9 patients after ACBS. The number of diseased vessels and the extent of left ventricular wall motion abnormality noted preoperatively, had no effect on ventricular arrhythmia following surgery. These data show that ACBS, when performed to relieve angina, does not have a significant effect on the prevalence of PVCs and does not prevent or reduce the occurrence of complex PVCs.

Transient emboligenic aortoarteritis. Noteworthy new entity in young stroke patients.

The clinical and postmorten anatomical data in a group of ten patients with occlusive cerebrovascular disease in the 15- to 40-year group were studied. The occlusion of the peripheral supply artery in the brain in all cases was found to be due to thromboemboli generated from focal thrombotic lesions situated proximally in the aorta and elastic arterial trunks arising from it. These central thrombotic lesions were caused by a transient form of focal aortoarteritis that primarily affects medial elastic tissue underlying the thrombi. This is a new disease entity, distinct from Takayasu's and other forms of segmental aortitis. The pathogenesis of occlusive cerebrovascular disease in the young remains obscure in a majority of cases. In this context, the definition of this new entity is an important contribution to the understanding of nonatherogenic occlusive cerebrovascular disease.