New-onset atrial fibrillation: sex differences in presentation, treatment, and outcome.

BACKGROUND: Although sex differences in coronary artery disease have received considerable attention, few studies have dealt with sex differences in the most common sustained cardiac arrhythmia, atrial fibrillation (AF). Differences in presentation and clinical course may dictate different approaches to detection and management. We sought to examine sex-related differences in presentation, treatment, and outcome in patients presenting with new-onset AF. METHODS AND RESULTS: The Canadian Registry of Atrial Fibrillation (CARAF) enrolled subjects at the time of first ECG-confirmed diagnosis of AF. Participants were followed at 3 months, at 1 year, and annually thereafter. Treatment was at the discretion of the patients' physicians and was not directed by CARAF investigators. Baseline and follow-up data collection included a detailed medical history, clinical, ECG, and echocardiographic measures, medication history, and therapeutic interventions. Three hundred thirty-nine women and 560 men were followed for 4.14+/-1.39 years. Compared with men, women were older at the time of presentation, more likely to seek medical advice because of symptoms, and experienced significantly higher heart rates during AF. Compared with older men, older women were half as likely to receive warfarin and twice as likely to receive acetylsalicylic acid. Compared with men on warfarin, women on warfarin were 3.35 times more likely to experience a major bleed. CONCLUSIONS: Anticoagulants are underused in older women with AF relative to older men with AF, despite comparable risk profiles. Women receiving warfarin have a significantly higher risk of major bleeding, suggesting the need for careful monitoring of anticoagulant intensity in women.

Arterial embolism complicating implantable cardioverter defibrillator shocks with normal ventricular function.

A 69-year-old man developed an embolus to his right femoral artery 24 h following the insertion of an implantable cardioverter defibrillator (ICD), with multiple shocks administered in the early postoperative period. He had nonobstructive hypertrophic cardiomyopathy with normal left ventricular function and no evidence of left atrial or ventricular thrombus seen on pre- or postoperative transthoracic echocardiography. There was no evidence of atrial fibrillation documented before or after implantation of the device. He had no other known risk factors for thromboembolic disease. Thromboembolic phenomena as a complication of ICD use have been described but arterial emboli believed related to ICD shocks have not been reported in patients without impaired systolic function.

Conservative management of mitral valve aneurysm.

A 35-year-old woman had infective endocarditis and an aneurysm of the anterior mitral leaflet. The patient was managed conservatively and the mitral valve aneurysm remained stable over 3 years. Two-dimensional, color flow Doppler, and magnetic resonance images of the aneurysm are presented and features of mitral valve aneurysms are discussed. Conservative management of mitral valve aneurysms with careful follow-up is an acceptable approach.

Efficacy of empirical cardiac pacing in syncope of unknown cause.

Cardiac pacing is often considered in patients with recurrent syncope after repeated attempts to document the cause have failed. To assess the results of this tactic we reviewed the records of 104 patients who had received pacemakers for known or suspected bradycardia between September 1973 and March 1985. The patients were classified retrospectively into three groups: group 1 (31 patients with a mean age of 73 years) had unequivocal documentation of bradycardia during syncope, group 2 (42 patients with a mean age of 71 years) had electrocardiographic or electrophysiologic evidence of potential bradycardia but no documentation during spontaneous syncope, and group 3 (31 patients with a mean age of 69 years) had a history "suggestive of" bradycardia-related syncope but no other evidence to support the diagnosis. The rates of recurrence of syncope during follow-up were 6.3%, 7.3% and 32.2% in groups 1, 2 and 3 respectively (p less than 0.01). In group 3 recurrence was more probable in patients with loss of consciousness for more than 2 minutes than in those who were unconscious for 2 minutes or less (p less than 0.05). The results suggest that pacemaker implantation is justified for recurrent syncope after extensive attempts to document a spell have failed if abnormal diagnostic test results suggest bradycardia as a possible cause. Empirical pacing is less satisfactory in patients with normal results of evaluation but may arguably be justified when patients have recurrent syncope with injury.

Phase 3 and phase 4 block of the accessory pathway in Wolff-Parkinson-White syndrome--a case report.

A 12-year-old girl presented with recurrent episodes of supraventricular tachycardia. A 12 lead electrocardiogram showed normal sinus rhythm with a normal PR interval and no evidence of preexcitation. A 24 h Holter monitor showed intermittent preexcitation. Both phase 3 and phase 4 block in the accessory pathway were demonstrated with introduction of atrial extrastimuli during sinus rhythm at electrophysiology study. However, Holter recording failed to reveal a consistent relationship between coupling intervals and accessory pathway conduction. The discrepancy between the Holter monitor and the electrophysiologic study can be explained by variability of factors such as autonomic tone during the Holter recording. This case illustrates a potential mechanism for intermittent preexcitation in the Wolff-Parkinson-White syndrome.

Complications of coronary arteriography.

In a prospective study of coronary arteriography with Judkins' technique the rate of major complications in 713 patients was 2.1%, a rate similar to or lower than those reported from other studies, even though more major complications were considered in this study. No deaths occurred. Although the rate of "other" complications was noted as part of the quality care survey, it cannot be compared with that in other studies, since the latter did not consider events such as hematoma or incomplete catheterization. The low complication rate may be related to expeditious procedures, familiarity with the Judkin's technique and the operators' experience. Local quality care assessment or clinical review committees should formally evaluate the complication rates for operative and invasive procedures performed in their own institutions.