Nonventricular arrhythmias as precursors of ventricular fibrillation in patients with out-of-hospital cardiac arrest.

Ventricular tachycardia (VT) and ventricular fibrillation (VF) are the most common arrhythmias documented at the time of resuscitation in survivors of out-of-hospital cardiac arrest unassociated with an acute myocardial infarction. However, 20% and 40% of these patients will not manifest inducible ventricular arrhythmias during subsequent electrophysiologic studies. The optimal management of these patients has been controversial. In a consecutive series of 100 survivors of out-of-hospital cardiac arrest with documented VF, six were identified by either clinical or electrophysiologic data as having a nonventricular arrhythmia as the immediate precursor of VF. Two of these patients had rapid, hypotensive supraventricular arrhythmias induced with programmed cardiac stimulation. In four patients, bradyarrhythmias (sinus arrest two; atrioventricular block two) preceded and caused the episode of VF. Therapy directed at these nonventricular arrhythmias prevented recurrence of cardiac arrest in all patients. In survivors of out-of-hospital cardiac arrest, nonventricular arrhythmias represent a treatable potential etiology that may be overlooked during the patient's evaluation.

Short-term infarct vessel patency with aspirin and dipyridamole started 24 to 36 hours after intravenous streptokinase.

The duration of intravenous heparin therapy required to maintain patency of the infarct-related artery after intravenous streptokinase is uncertain. Twenty-eight patients were prospectively treated with 1.5 million units of intravenous streptokinase within 4 hours of onset of chest pain. Intravenous heparin was begun after the streptokinase infusion was complete and was discontinued within 36 hours. Aspirin, 325 mg daily, and dipyridamole, 75 mg three times a day, was begun before the heparin was discontinued. Coronary angiography was performed both at 2 hours after completion of the streptokinase infusion and again at a mean of 8.7 (+/- 3.2) days after the initial catheterization. One patient died after treatment with streptokinase but before early angiography. In 21 of 27 patients (78%), Thrombolysis in Myocardial Infarction trial (TIMI) grade 2 or 3 perfusion in the infarct vessel was observed on initial angiography. Repeat angiograms were available in 17 of the 21 patients with initially patent vessels. Continued patency (TIMI grade 2 or 3) was found in 15 of the 17 patients (88%). Two of the four patients who did not undergo repeat angiography died, and the remaining two patients required coronary artery bypass grafting for unstable angina. Bleeding complications occurred in 6 of 27 patients (22%), with two (7%) requiring surgical evacuation of a groin hematoma. There were no instances of intracerebral bleeding and only two patients required transfusions. Thus, the combination of aspirin and dipyridamole following 36 hours of systemic heparinization after intravenous streptokinase infusion is associated with a reocclusion rate comparable to that which has been reported for more prolonged systemic anticoagulation with fewer hemorrhagic complications.

Successful combined percutaneous aortic balloon valvuloplasty and coronary angioplasty in two critically ill patients.

This report describes combined aortic balloon valvuloplasty and coronary angioplasty in two critically ill patients with aortic stenosis and coronary artery disease.