Treatment patterns of non-ST-elevation acute coronary syndrome patients presenting at non-PCI centres in the Netherlands and possible logistical consequences of adopting same-day transfer to PCI centres: a registry-based evaluation.

BACKGROUND: European Society of Cardiology (ESC) guidelines recommend same-day transfer to a percutaneous coronary intervention (PCI) centre for angiography in high-risk (ESC-HR) patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). We describe the treatment patterns of NSTE-ACS patients presenting at non-PCI centres and evaluate the logistical consequences of adopting same-day transfer. METHODS: From August 2016 until January 2017, all consecutive NSTE-ACS patients presenting at 23 non-PCI centres in the Netherlands were recorded. We built an online case report form in collaboration with the National Cardiovascular Database Registry to collect information on risk stratification by the attending physician, timing and location of angiography, and treatment. RESULTS: We included 871 patients (mean age 69.1 ± 12.8). 55.8% were considered ESC-HR. Overall, angiography at non-PCI centres was 55.1% and revascularisation was 54.1%. Among ESC-HR patients, angiography at non-PCI centres was 51.4% and revascularisation was 54.9%. Angiography <24 h was 55.6% in patients with angiography at a non-PCI centre and 74.3% in patients with angiography at a PCI-centre. Assuming patients would receive similar treatment, adoption of same-day transfer would increase transfers of ESC-HR patients who undergo PCI (44.3%), but also increases transfers of medically treated patients (36.2%) and patients awaiting coronary bypass artery grafting (9.1%). CONCLUSIONS: In this registry of NSTE-ACS patients at non-PCI centres, the majority of ESC-HR patients underwent angiography at a non-PCI centre. Same-day transfer occurred in one-quarter of the ESC-HR patients, despite guideline recommendation. Nonselective adoption of same-day transfer to a PCI centre would increase transfers of ESC-HR patients who undergo PCI, however, equally increases transfers of patients who are medically treated.

Telemonitoring with an implantable loop recorder in outpatient heart failure care : One year follow-up report from a prospective observational Dutch multicentre study.

INTRODUCTION: In the care of heart failure patients, telemonitoring is receiving growing attention. The main purpose of this study was to determine the effect of continuous telemonitoring with an implantable loop recorder (ILR, Reveal XT), a novel strategy in the management of stable heart failure patients without a cardiac implantable device. Furthermore, little is known about the incidence of subclinical arrhythmias in this specific group of patients. MATERIALS AND METHODS: Stable heart failure patients, New York Heart Association Class II and III, without recent hospitalisation or upcoming intervention, were included. After implantation of the ILR there was regular contact with the research nurse on a pre-specified basis. Clinic visits and telephonic interviews were alternated for a minimum of 1 year. Parallel visits to their treating physician continued according to standard care. The treating physician was blinded for the ILR findings, accept for pre-specified, significant arrhythmic events. RESULTS: Thirty patients were included and followed for a median duration of 12 months. In 13 patients, data from the loop recorder led to therapeutic changes. One patient received a pacemaker. Eight patients developed atrial fibrillation, all subclinical, with a mean burden of 65.8 ± 173.2 min/day. CONCLUSION: The use of an ILR could potentially impact patient management. Additional study is needed in different patient populations (e. g. higher risk groups) to assess if an ILR could also impact on endpoints such as heart failure hospitalisation.

Acute chest pain in a patient treated with capecitabine.

A 61-year-old male with a history of metastatic colorectal cancer was referred to our hospital for primary coronary intervention because of acute ST-elevation myocardial infarction. Coronary angiography, however, revealed no significant stenoses. When asked, the patient revealed that capecitabine (Xeloda(R)) was started by his oncologist one day before admission. It is known that this oral 5-FU analogue drug, used in metastatic colorectal cancer, can cause coronary artery spasms. The main treatment of capecitabine-induced vasospasm is discontinuation of the drug. Indeed, after cessation of the drug the patient remained free of symptoms and the ECG abnormalities normalised. (Neth Heart J 2009;17:288-91.).

Cardiac resynchronisation therapy: results from daily practice in Rijnstate Hospital, Arnhem.

BACKGROUND: Cardiac resynchronisation therapy (CRT) is an effective treatment to improve the clinical outcome of selected patients with heart failure. Clinical trials have studied clinical outcome and reported clinical improvements, but clinical consequences and results in daily practice are less well known. We evaluated clinical outcome in all patients with CRT implantation in our centre. METHODS: Data of 119 consecutive patients who met the criteria for CRT implantation in Rijnstate Hospital, Arnhem in the period 28 November 2000 until 1 January 2006 were collected. We analysed implantation procedure, hospitalisation for heart failure or other causes, mortality and device-related events. RESULTS: In total 119 patients (83 men, 36 women; mean age 69 years) were eligible for CRT. Before implantation they had received optimal pharmacological therapy. Implantation was successful in 97% of patients. Procedural-related complications were seen in eight patients. During follow-up, 22 patients (18.5%: 14 men, 8 women) died. Causes of death were heart failure (11 patients), sudden cardiac death (4 patients) and noncardiac death (7 patients). Hospitalisation occurred 81 times, of which 77 for cardiac reasons. In follow-up the estimated five-year cumulative survival was 70%. CONCLUSION: This retrospective study from a single centre showed a high procedural success rate, low prevalence of complications and low mortality in comparison to other studies. Despite better functional capacity, the hospitalisation rate due to heart failure was high. (Neth Heart J 2009;17:6-8.).

Recommendations for pacemaker implantation for the treatment of atrial tachyarrhythmias and resynchronisation therapy for heart failure: A report from the task force on pacemaker indications of the Dutch Working Group on Cardiac Pacing.

Today, new pacing algorithms and stimulation methods for the prevention and interruption of atrial tachyarrhythmias can be applied on patients who need bradycardia pacing for conventional reasons. In addition, biventricular pacing as additive treatment for patients with severe congestive heart failure due to ventricular systolic dysfunction and prolonged intraventricular conduction has shown to improve symptoms and reduce hospital admissions. These new pacing technologies and the optimising of the pacing programmes are complex, expensive and time-consuming. Based on many clinical studies the indications for these devices are beginning to emerge. To support the cardiologist's decision-making and to prevent waste of effort and resources, the 'ad hoc committee' has provided preliminary recommendations for implantable devices to treat atrial tachyarrhythmias and to extend the treatment of congestive heart failure respectively.

Organized thrombus in the ascending aorta originating from the ostium of the right coronary artery.

This case report describes the rare finding of a pedunculate thrombus in the ascending aorta originating from the ostium of the right coronary artery (RCA) detected after an inferior wall myocardial infarction in a young female. The thrombus was removed surgically during an emergency cardiopulmonary bypass procedure

Rate control versus electrical cardioversion for atrial fibrillation: A randomised comparison of two treatment strategies concerning morbidity, mortality, quality of life and cost-benefit - the RACE study design.

BACKGROUND: Persistent atrial fibrillation (AF) does not terminate spontaneously and may cause left ventricular dysfunction and thromboembolic complications. For restoration of sinus rhythm electrical cardioversion (ECV) is most effective. However, AF frequently relapses, necessitating re-ECV and institution of potentially harmful antiarrhythmic drugs. If AF is accepted, rate control and prevention of thromboembolic complications using negative chronotropic drugs and warfarin is pursued. It is our hypothesis that rate control therapy is not inferior to ECV therapy in preventing morbidity and mortality. METHODS: RACE (RAte Control versus Electrical cardioversion for atrial fibrillation) is a randomised comparison of serial ECV therapy (repeat ECV as soon as possible after a relapse and institution of an antiarrhythmic drug: sotalol, class IC drug and amiodarone) and rate control therapy (resting heart rate <100 bpm using digitalis, calcium channel blockers and/or ß-blockers) in patients with persistent AF. Morbidity (heart failure, side effects of drugs, thromboembolic complications, bleeding and pacemaker implantation), mortality, quality of life and cost-effectiveness are primary and secondary endpoints. Included are patients with a recurrence of persistent AF, present episode <1 year and a maximum of two previous successful ECVs during the last two years. This study is a multicentre study in 31 centres throughout the Netherlands. All 520 patients have now been included. Follow-up is two years. The results are expected this year.

VERDICT: the Verapamil versus Digoxin Cardioversion Trial: A randomized study on the role of calcium lowering for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation.

INTRODUCTION: Many relapses of atrial fibrillation (AF) occur, especially during the first week(s) after electrical cardioversion (ECV). The aim of the present study was to compare in a randomized design the efficacy of verapamil (intracellular calcium lowering) versus digoxin (calcium increasing) for maintenance of sinus rhythm after ECV. METHODS AND RESULTS: Ninety-seven patients with persistent AF were randomized to verapamil (n = 49) or digoxin (n = 48) for 1 month before and 1 month after ECV. The first month after ECV, patients recorded heart rhythm using daily transtelephonic monitoring. No additional antiarrhythmic drugs were given. Of the 97 patients, 43 patients (20 verapamil) underwent ECV per protocol. Median previous AF duration was 18 and 26 days for verapamil and digoxin, respectively. There were no differences in atrial dimensions and underlying heart disease between the two groups. The success rate of ECV was 75% versus 83% (P = NS). After 1 month, 47% versus 53% (P = NS) had recurrence of AF. Median time to recurrence was 5 days (range 0 to 26) versus 8 days (range 2 to 28) (P = NS), respectively. CONCLUSION: Stand-alone intracellular calcium lowering by verapamil around ECV does not enhance cardioversion outcome.

Unexpected overdose with diltiazem: value of toxicological screening.

We describe a 59-year-old woman who was admitted in deep coma with bradycardia, hypotension and fixed pupils. The cause of her severe condition was unclear. Cerebral and myocardial infarction was excluded. Temporary transcutaneous pacing was not successful, nor was atropine or norepinephrine (noradrenaline), but the patient responded well to isoprenaline infusion. Since she was known to have a psychiatric history, toxicological screening was performed which showed a severe diltiazem overdose. Later we discovered that she took diltiazem for angina pectoris. The patient survived and was discharged without neurological or cardiological deficits after two days of treatment. This case report emphasises the importance of toxicological screening in unconscious patients with no apparent cause. We review the clinical features and treatment options of diltiazem overdose and discuss the value of toxicological screening.

Muscular reconstruction to improve the deterioration of facial appearance and speech caused by mandibular atrophy: technique and case reports.

One of the consequences of severe mandibular atrophy is the loss of attachment of the facial muscles that originate from the alveolar process and basal bone. Another is a loss of vestibular depth and reduction in the width of the attached gingiva. The result is reduced ability to chew, a changed and aged appearance, difficulties with pronunciation, and a reduced range of expressions. The traditional goal of treatment has been to improve the ability to chew. We describe a technique by which all these functions can be improved by a combination of insertion of implants and functional reconstruction of the facial muscles and position of the lips. When the muscles are repositioned, the buccal vestibule is deepened, and the incidence of gingival hyperplasia and infrabony pockets along the posts is eliminated. This treatment, which also rejuvenates the face and improves the ability to speak, should help to overcome the loss of self-confidence and self-esteem of these patients by improving their quality of life.

[Myocardial infarct in the puerperium]. / Myocardinfarct in het kraambed.

Two women of 34 and 31 years suffered an acute myocardial infarction in the puerperium. One of them had many risk factors for atherosclerosis: hypercholesterolaemia, hypertriglyceridaemia, diabetes mellitus, hypertension, obesity, nicotine abuse and a positive family history for cardiovascular disease. She had an occluded right coronary artery and was successfully treated with percutaneous transluminal coronary angioplasty. The other patient had an acute myocardial infarction after her first delivery. She was known with hypercholesterolaemia, obesity and nicotine abuse. During her latest pregnancy she was treated with acetylsalicylic acid. Again she developed an acute myocardial infarction in the puerperium, probably due to coronary dissection. Although the incidence of acute myocardial infarction is low in the peripartal period (less than 1 in 10,000) the diagnosis should be considered when a woman presents with chest pain or dyspnoea.

Functional and cosmetic reconstruction of the facial lower third associated with placement of the transmandibular implant system.

PURPOSE: Conventional preprosthetic procedures have typically focused on improvement of denture base stability and retention and have ignore patients' concerns about facial appearance and articulation difficulties. Soft tissue procedures have been developed, combined with insertion of the transmandibular implant (TMI) system through a submental incision, for functional and cosmetic reconstruction of the lower face to improve speech and facial esthetics, and prevent gingival hyperplasia along the lateral posts of the implant. PATIENTS: The surgical procedure was evaluated in 146 patients with slight, moderate, severe, and extreme mandibular atrophy classified according to the proportion of muscle origin loss on the edentulous mandible. Preoperative, 3-month, and 1-year postoperative full-face and profile photographs were taken. Patients also were questioned about their satisfaction with their facial appearance and speech at these intervals. Gingival hyperplasia along the TMI posts was scored as present or absent. RESULTS: Satisfaction with the soft tissue reconstruction in 146 patients treated according to this protocol was high, with almost every patient describing the positive comments they had received from their friends and relatives. Postoperatively, none of the patients requested a temporary denture to use during the 12-week incorporation period, although this was a common cosmetic and speech concern preoperatively. Gingival hyperplasia secondary to muscle pull was controlled satisfactorily. CONCLUSIONS: With the described technique for placement of the TMI system, not only is masticatory function improved, but also the lower third soft tissues of the face are functionally and cosmetically reconstructed to the satisfaction of the patients.

The transmandibular implant: from progressive bone loss to controlled bone growth.

PURPOSE: In a prospective study, 146 consecutive transmandibular implant (TMI) patients were treated according to revised surgical and prosthetic protocols to induce and control bone growth. Revisions included 1) placement of transosseous posts and cortical screws between the mental foramina so that two threads extended beyond the alveolar crest of the mandible without protruding through the mucosa and 2) fabrication of an implant-borne prosthesis that rested on the retromolar pads with a gap of 2 mm between the denture base and the mucosal tissues in the saddle areas. PATIENTS AND METHODS: Measurements of the height of the mandible were made using a digital millimeter calliper and panoramic radiographs, with the enlargement calculated for each radiograph. The follow-up period ranged from 18 to 51 months. RESULTS: Bone growth was present in 131 of the 146 patients whereas the bone resorption was arrested in the remaining patients. Increase in bony apposition varied from 9 mm in patients with severe mandibular atrophy to 2 mm in patients with mild atrophy. CONCLUSION: The revised surgical and prosthetic protocols for TMI insertion and rehabilitation are advocated to prevent further alveolar resorption and to promote bone growth in patients with mandibular atrophy.

[The transmandibular implant. From bone loss to bone growth--an investigation of 116 patients]. / Het transmandibulaire implantaat. Van botverlies tot botgroei--een onderzoek bij 116 patiënten.

In a prospective study 116 consecutive patients were treated according to a revised protocol to induce and control bone growth. Revisions included: 1. lengthening of the transosseous posts and cortical screws between the mental foramina so that two threads extended beyond the alveolar crest of the mandible without protruding through the mucosa; and 2. fabricating an implant borne prosthesis with a gap of 2 mm between the denture base and the mucosal tissues in the saddle areas and loading only the retromolar pads. The gap was re-opened every 8 weeks until further bone growth would prevent proper oral hygiene. Measurements of the height of the mandible were made using a digital millimeter caliper and standardized radiographs. The radiographic enlargement was calculated per radiograph for the sites to be measured. The follow-up varied from 15 up to 39 months. Bone growth had occurred in 104 of the 116 patients, while the resorption of bone had ceased in the remaining patients. The increase of bone height varied from 9 mm in patients with severe mandibular atrophy down to 2 mm for patients with mild atrophy. The revised protocol for TMI insertion and rehabilitation is advocated to promote bone growth and to cease further resorption in the atrophic mandible.

Are enzymatic tests good indicators of coronary reperfusion?

OBJECTIVE: To assess the accuracy of four enzymatic tests, including early release rates of creatine kinase and alpha-hydroxybutyrate dehydrogenase, in assessing coronary reperfusion after thrombolytic therapy. DESIGN: A prospective clinical trial identifying patients with a successful thrombolytic treatment. PATIENTS: Eighty nine patients with acute myocardial infarction were studied. Arteriography showed a closed infarct related artery in all of them. Reperfusion due to thrombolysis occurred in 74 patients and there was no reperfusion in 15 patients. RESULTS: The 74 patients showing coronary reperfusion had a significantly shorter time to peak creatine kinase activity, higher early release rates for creatine kinase and alpha-hydroxybutyrate dehydrogenase, and a more rapid release of alpha-hydroxybutyrate dehydrogenase (ratio of cumulative release of alpha-hydroxybutyrate dehydrogenase during the first 24 hours to that 72 hours after infarction). All these differences were statistically significant (p less than 0.001). Optimum cut off levels were determined with decision level plots and the accuracy of the four enzymatic tests was calculated. Accuracy was low for all four tests (73%, 70%, 70%, and 82%). CONCLUSION: None of the four enzymatic tests accurately predicted the perfusion state of the infarct related coronary artery after thrombolysis. These tests cannot be used reliably in routine clinical practice as non-angiographic markers of coronary reperfusion.

The transmandibular implant: a 13-year survey of its use.

During the period from August 1976 until July 1989 the transmandibular implant was introduced in a total of 31 oral and maxillofacial surgery departments in the Netherlands and 1,466 patients were treated. This study includes 1,356 treated patients from 28 departments. The treatment course of 1,201 patients (89.6%) was uneventful. Of the 157 complications, 58 related to the anatomic contour of the mandible, 49 to the surgery, 25 to the prosthetic reconstruction, 8 to the psychosocial attitude of the patient, 8 to the use of medication, 5 to trauma, and 4 to the presence of a skin graft. Treatment of the complications included removal of the implant in 44 patients; in 106 patients the complication was treated satisfactorily. In the remaining 7 patients, hypesthesia was present. The reasons for the removal of the 44 implants were infection (11), operative error (5), premature loading of the implant (3), insufficient width of the mandible after a visor osteotomy (1), loss of osseointegration caused by the prosthesis (14), psychological problems (4), trauma (3), drug-related gingival hyperplasia (2), and inexplicable pain (1). The present survey shows a consistent success rate of 96.8%.