Electrical cardioversion for atrial fibrillation and flutter.

BACKGROUND: Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. OBJECTIVES: To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years). SEARCH STRATEGY: We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts. SELECTION CRITERIA: Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions. DATA COLLECTION AND ANALYSIS: For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated. MAIN RESULTS: We found three completed trials of electrical cardioversion (rhythm control) versus rate control, recruiting a total of 927 participants (Hot Cafe; RACE; STAF) and one ongoing trial (J-RHYTHM). There was no difference in mortality between the two strategies (OR 0.83; CI 0.48 to 1.43). There was a trend towards more strokes in the rhythm control group (OR 1.9; 95% CI 0.99 to 3.64). At follow up, three domains of quality of life (physical functioning, physical role function and vitality) were significantly better in the rhythm control group (RACE 2002; STAF 2003). AUTHORS' CONCLUSIONS: Electrical cardioversion (rhythm control) led to a non-significant increase in stroke risk but improved three domains of quality of life.

Electrical cardioversion for atrial fibrillation and flutter.

BACKGROUND: Atrial fibrillation increases the risk of stroke, increases the risk of cognitive impairment, and adversely affects cardiovascular haemodynamics. Electrical cardioversion for atrial fibrillation has been in use since the 1960s; the rationale is that restoration of sinus rhythm improves cardiovascular haemodynamics, reduces the risk of stroke, and obviates the need for long-term anticoagulation. OBJECTIVES: To assess the effects of electrical cardioversion of atrial fibrillation or atrial flutter on the annual risk of thromboembolic events, strokes and mortality (primary outcomes measures), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcome measures) in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and any aetiology. SEARCH STRATEGY: One reviewer searched the Cochrane Controlled Clinical Trials Register (2000 Issue 4), MEDLINE (1966 to December 2000), EMBASE (1980 to December 2000), CINAHL (1982 to November 2000) and proceedings of the American College of Cardiology (published in the Journal of the American College of Cardiology 1983 to 2000). Reference lists of articles were searched. Personal contact was made with experts in the field. A second reviewer handsearched proceedings of the British Cardiac Society (published in British Heart Journal (1980 to 1995) and in Heart (1995 to May 2001); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2000); scientific sessions of the American Heart Association (published in Circulation 1990-2000). SELECTION CRITERIA: Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of the following: anticoagulants, antiplatelet drugs and drugs for 'rate control', in adults (>18 years) with acute, paroxysmal or sustained atrial fibrillation or atrial flutter, of any duration and any aetiology. DATA COLLECTION AND ANALYSIS: It was planned to extract study data onto data extraction forms. The planned analysis was by the statistical package in RevMan. MAIN RESULTS: No completed randomised trials or controlled clinical trials of electrical cardioversion were found. Two ongoing trials were identified. REVIEWER'S CONCLUSIONS: There were no data from completed randomised controlled trials or controlled clinical trials to either support or refute the use of electrical cardioversion for atrial fibrillation. Randomised trials of electrical cardioversion are required.

Mitral balloon valvotomy for the treatment of mitral stenosis in octogenarians.

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged > or =80 years. SETTING: A tertiary cardiac centre DESIGN: A retrospective study of 20 octogenarians (mean age 83, range 80-89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYHA) symptom class III or IV. Fourteen had been judged unfit for cardiac surgery. Hemodynamic data was recorded before and after MBV. Symptomatic outcome was documented at 1 month for all patients. Outcome at 1 year was available for 16 patients. RESULTS: Dilatation of the mitral valve was achieved in all patients without major complications. Mean mitral valve area increased 106% from 0.81 (+/-0.3) to 1.67 (+/- 0.8) cm2, transvalvular gradient decreased from 11.8 (+/- 4.8) to 5.6 (+/-2.9) mm Hg, cardiac output increased from 3.1 (+/- 0.6) to 4.1 (+/- 1.4) l/min (all P<.01). Eight of these 20 patients obtained a valve area > or =1.5 cm2, and 16 obtained an area > or = 1.2 cm2. One month after BMV, all patients were alive, and 16 of the 20 patients were improved by at least one NYHA class. This improvement was sustained in 7 of 16 patients followed up for 1 year. More severe mitral valve degenerative change, determined by echocardiography, was associated with poorer outcome. CONCLUSIONS: In this group of very old and frail patients, MBV was safe and resulted in significant immediate improvement. Sustained symptomatic benefit at 1 year was obtained in those with less extensive leaflet and subvalvular disease. In patients with severe degenerative valve disease on echocardiography, but unacceptable surgical risk, MBV offers short-term palliation.

Long term outcome of percutaneous mitral balloon valvotomy in patients aged 70 and over.

OBJECTIVE: To assess the immediate haemodynamic improvement and long term symptomatic benefit of percutaneous mitral balloon valvotomy in patients aged over 70 years. DESIGN: Pre- and postprocedure haemodynamic data and follow up for 1 to 10 years by clinic visit or telephone contact. SETTING: Tertiary referral centre in Scotland. SUBJECTS: 80 patients age 70 and over who had mitral balloon dilatation: 55 were considered unsuitable for surgical treatment because of frailty or associated disease. In an additional four patients mitral dilatation was not achieved. MAIN OUTCOME MEASURES: Increase in valve area after balloon dilatation and survival, freedom from valve replacement, and symptom class at follow up. RESULTS: Mean (SD) valve area increased by 89% from 0.84 (0.28) to 1. 59 (0.67) cm(2). There was a low rate of serious complications, with only two patients having long term major sequelae. Of 55 patients unsuitable for surgical treatment, 28 (51%) were alive without valve replacement and with improvement by at least one symptom class at one year, and 14 (25%) at five years. In the 25 patients considered suitable for surgical treatment, 16 (64%) achieved this outcome at one year and nine (36%) at five years. CONCLUSIONS: Percutaneous mitral balloon valvotomy is a safe and useful palliative procedure in elderly patients who are unsuitable for surgery. Balloon dilatation should also be used for elderly patients whose valve appears suitable for improvement by commissurotomy, but echo score is an imperfect predictor of haemodynamic improvement.

Cardioversion for atrial fibrillation: the views of consultant physicians, geriatricians and cardiologists.

BACKGROUND AND AIMS: Atrial fibrillation (AF) increases the risk of stroke and also has adverse haemodynamic consequences. Cardioversion of AF to sinus rhythm may obviate the need for long-term anticoagulation and improve cardiovascular haemodynamics, but is probably underused. We therefore investigated the views of hospital consultants about cardioversion for AF. METHODS: 336 Postal questionnaires were sent to all 186 consultant physicians, 54 cardiologists and 96 geriatricians in Scotland, followed by one reminder letter to non-responders. RESULTS: 71% Of questionnaires were returned. Cardiologists referred 18% of AF patients for cardioversion, while physicians referred 11% and geriatricians 5%. Cardiologists had better access to cardioversion facilities and were less likely to consider an enlarged left atrium and organic heart disease to be contra-indications to cardioversion. Anticoagulation was given for less than 3 weeks before cardioversion by 9% of cardiologists, 39% of physicians and 65% of geriatricians (P<0.001), and for less than 3 weeks after cardioversion by 17% of cardiologists, 45% of physicians and 47% of geriatricians (P = 0.7). SUMMARY: The wide variation in practice both between and within the different specialties suggests that consensus guidelines based on the best available evidence should be developed.

Fire fatalities in elderly people.

Fatal dwelling-house fires account for 10% of all accidental deaths in the United Kingdom with one-quarter of the deaths being of elderly people. No study had described the characteristics of elderly individuals who die in fires. We report results from a retrospective review of all fatal dwelling-house fires in Scotland from 1980 to 1990. Of 1096 people dying in fires, 243 (23%) were aged over 75. When compared with patients under the age of 75, older patients were significantly less likely to be smokers. Significantly more fires killing elderly people were caused by faulty or misused electrical items in the house, particularly electric blankets. These differences between elderly and younger individuals dying in dwelling-house fires may suggest that preventive strategies for the elderly population require a different emphasis from those for younger people.

A multicentre, double-blind, placebo-controlled trial of quinapril in mild, chronic heart failure.

Angiotensin converting enzyme (ACE) inhibitors are of proven value in patients with severe chronic heart failure (CHF). Studies of the effects of ACE inhibitors on exercise capacity and quality of life in mild CHF have produced conflicting results. We have studied the effects of quinapril, a new ACE inhibitor with a relatively short plasma half-life, in mild CHF. Once daily (o.d.) dosing was compared with twice daily (b.i.d.) dosing in a three-way cross-over, double-blind, placebo-controlled trial. Thirty-two patients (two female), mean age 59 (range 32-76) years were enrolled in three cardiology centres in the U.K. in 29 patients, and non-ischaemic in three. The mean (range) radionuclide ejection fraction was 20.4% (8%-47%). Following full familiarization with the protocol, the treadmill exercise time (modified Bruce protocol) was determined for each patient during a placebo run-in phase, and at the end of each of three 8-week double-blind treatment phases with quinapril o.d., quinapril b.i.d. (maximal total daily dose 20 mg) and placebo. Three patients were withdrawn due to adverse events while receiving quinapril (unstable angina, exacerbation of CHF and arrhythmia); there were no deaths and no patient was withdrawn due to hypotension. Mean exercise time (the primary end-point) was 65 s and 53 s longer in patients receiving quinapril o.d. and b.i.d. respectively compared to placebo (both P < 0.01, ANOVA). There was no significant period effect during the trial and no significant difference between the two quinapril dosing regimens. Quinapril had no significant effect on secondary end-points including ejection fraction, functional class and quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous balloon dilatation of the mitral valve in patients who were unsuitable for surgical treatment.

OBJECTIVE: To assess the effects on haemodynamic function and symptoms of percutaneous balloon dilatation of mitral stenosis in patients unable to undergo surgical treatment because of associated medical/cardiac problems. DESIGN: A review of clinical outcome in 28 patients (of 108 undergoing balloon dilatation of the mitral valve) who were unsuitable for surgery. SETTING: A tertiary cardiac referral centre: some patients referred were from other cardiac centres in Scotland. PATIENTS: 28 patients judged by cardiac surgeons to be unsuitable for valve replacement or valvotomy because of respiratory disease (15 patients), nonmitral cardiac disease (6), multi-organ impairment (5), psychiatric problems (1) or dense intrathoracic adhesions (1). INTERVENTIONS: Percutaneous anterograde balloon dilatation of the mitral valve with polyethylene/polyvinyl balloons in 20 patients and the Inoue balloon in eight patients. MAIN OUTCOME MEASURES: Haemodynamic variables were measured before and immediately after mitral valve dilatation. Patient survival and symptom class (New York Heart Association) were followed for a year after the procedure. RESULTS: Dilatation at the mitral orifice was achieved in all cases. The mean (SD) pressure drop across the valve fell from 13.9 (5.3) to 5.6 (2.5) mm Hg, cardiac output rose from 3.18 (1.02) to 3.96 (2.5) l/min, and valve area increased from 0.78 (0.32) to 1.58 (0.56) cm2. The procedure was well tolerated by most patients, even those with metabolic/electrolyte disturbance, severe obstructive airways disease, myocardial impairment, and coronary disease. In three patients a small shunt developed at the atrial level: none developed severe mitral reflux. The two patients who required assisted ventilation died soon after the procedure and in one patient with severe coronary artery disease myocardial infarction developed and she died in cardiogenic shock. Early symptomatic improvement was reported by 23 of the 25 survivors, though the increase in exercise capacity was often limited by their non-mitral disease. At one year follow up a further 6 patients had died because of their additional disease: 15 continued to show symptomatic improvement. CONCLUSIONS: Percutaneous balloon dilatation of the mitral valve is a useful new option in patients who are too ill to undergo cardiac surgery; but longer term benefit can be limited by the associated disease.

Haemodynamic response in soccer spectators: is Scottish football exciting?

OBJECTIVE: To determine the effect of watching a game of Scottish football on heart rate and blood pressure. DESIGN: Prospective study. SETTING: Two Scottish Premier League football grounds. SUBJECTS: 10 healthy men, each a supporter of one of two clubs. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure and heart rate at home, while walking, and during the match. RESULTS: Systolic blood pressure and heart rate were significantly higher when the men were watching the match than when they were at home. While they were watching the match, heart rate was maximal immediately after a goal had been scored by the supported team. CONCLUSION: The emotional stress invoked by Scottish football is associated with significant increases in heart rate and systolic blood pressure.

Elderly and younger patients selected to undergo coronary angiography.

OBJECTIVE: To establish and compare the characteristics of older (greater than or equal to 70 years) and younger patients with chest pain selected to undergo coronary angiography and by analysis of their subsequent management to assess the value of coronary angiography for older patients with chest pain. DESIGN: Retrospective analysis of clinical case notes and coronary angiography reports. SETTING: Cardiology department with referral population of one million in an Edinburgh hospital. PATIENTS: 134 consecutive patients with chest pain aged 70 years or over investigated by coronary angiography between 1978 and 1988; 134 randomly selected patients aged under 70 investigated over the same period. MAIN OUTCOME MEASURES: Clinical and angiographic features at time of angiography and management after angiography. RESULTS: Older patients represented a small, but increasing, proportion of those investigated. Older patients had more severe symptoms at the time of angiography, were taking more antianginal drugs, and had had their symptoms for longer than younger patients. At angiography more older patients had triple vessel coronary disease, left main stem stenosis, or left ventricular impairment. After angiography similar proportions of older and younger patients underwent coronary artery surgery, with more elderly patients requiring urgent operation; although operative mortality was higher for elderly patients, symptomatic benefit was similar to that in younger patients. CONCLUSIONS: Older patients with angina selected to undergo coronary angiography and subsequent coronary surgery have more severe symptoms and underlying cardiac disease. Earlier referral and investigation might yield a population with lower operative risk. Selection of patients for coronary angiography and coronary artery surgery should be based on the potential for benefit and should avoid "agism."

Mitral balloon valvuloplasty for patients aged over 70 years: an alternative to surgical treatment.

We report the results and one-year follow-up of 20 elderly patients (age range 70-82 years) with severe rheumatic mitral stenosis treated by mitral balloon valvuloplasty (MBV). All 20 were breathless at rest despite treatment with diuretics and digoxin. At cardiac catheterization, successful dilatation was achieved in 17 patients: mean transvalvular mitral gradient fell by 45%, mean cardiac output rose by 24% and mean valve area increased by 76%. There was no procedure-related mortality. At one month, 15 patients had experienced an improvement in symptoms of at least one New York Heart Association class and, at one year, ten had maintained this improvement. Three patients proceeded to mitral valve replacement because of a suboptimal symptomatic result. Mitral balloon valvuloplasty can be successfully performed with significant symptomatic benefit in frail elderly patients unfit for surgery and may also be offered to other selected elderly patients as an alternative to surgical treatment.

Exchange transfusion of whole blood in the treatment of cerebral malaria.

A case of cerebral malaria in a young British traveller, successfully treated by exchange transfusion of whole blood, is reported and the literature regarding the use of this technique in P. falciparum malaria is briefly reviewed.