Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events.

OBJECTIVE: Treatment delays may result in different clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolytic therapy vs primary percutaneous coronary intervention (PCI). The aim of this analysis was to examine how treatment delays relate to 6-month mortality in reperfusion-treated patients enrolled in the Global Registry of Acute Coronary Events (GRACE). DESIGN: Prospective, observational cohort study. SETTING: 106 hospitals in 14 countries. PATIENTS: 3959 patients who presented with STEMI within 6 h of symptom onset and received reperfusion with either a fibrin-specific fibrinolytic drug or primary PCI. MAIN OUTCOME MEASURES: 6-month mortality. METHODS: Multivariable logistic regression was used to assess the relationship between outcomes and treatment delay separately in each cohort, with time modelled with a quadratic term after adjusting for covariates from the GRACE risk score. RESULTS: A total of 1786 (45.1%) patients received fibrinolytic therapy, and 2173 (54.9%) underwent primary PCI. After multivariable adjustment, longer treatment delays were associated with a higher 6-month mortality in both fibrinolytic therapy and primary PCI patients (p<0.001 for both cohorts). For patients who received fibrinolytic therapy, 6-month mortality increased by 0.30% per 10-min delay in door-to-needle time between 30 and 60 min compared with 0.18% per 10-min delay in door-to-balloon time between 90 and 150 min for patients undergoing primary PCI. CONCLUSIONS: Treatment delays in reperfusion therapy are associated with higher 6-month mortality, but this relationship may be even more critical in patients receiving fibrinolytic therapy.

Floating gallbladder: a questionable prelude to torsion: a case report.

A 55-year-old woman had recurrent bouts of low substernal and epigastric pain radiating into the interscapular region. A hepatobiliary scan initially showed what was believed to be a dilated common bile duct and nonvisualization of the gallbladder. A delayed image obtained after having the patient move about revealed the presence of a filled gallbladder and normal common bile duct. The combination of recurrent pain with this scintigraphic picture may be representative of a floating gallbladder or an incomplete torsion with spontaneous detorsion. This case is presented to describe the scintigraphic appearance of a mobile gallbladder that may be prone to volvulus and to emphasize the importance of obtaining decubitus or oblique views at the end of a hepatobiliary study in selected cases of unusual findings.

Aetiology and risk factors in young patients with recent acute myocardial infarction.

One hundred and forty-five young patients (aged 18-40 years) with acute myocardial infarction are reported. In 14 of these infarction was due to unusual cause of which infective endocarditis was the most common. One hundred of the patients underwent review of risk factors 2-4 months after infarction: 29% had a previous history of angina, 11% were hypertensive, 85% were smokers during the year before infarction and 5% were ex-smokers, while 31% had a family history of ischaemic heart disease among first-degree relatives and 27% were obese. Seventy-two per cent had serum cholesterol values of greater than 5,7 mmol/l, 63% had fasting serum triglyceride values of greater than 1,7 mmol/l and 29% were hyperuricaemic. Only 2% had none of the following major risk factors: serum cholesterol greater than 6,5 mmol/l, serum triglycerides greater than 1,7 mmol/l, a history of cigarette smoking, a history of hypertension or blood pressure greater than 160/95 mmHg. We conclude that there should be a high index of suspicion for unusual causes of acute myocardial infarction in patients in this age group and that one or more of the major risk factors are an almost invariable finding in patients with infarction of atheromatous origin.

The relationship between angiographic findings and risk factors in young men with myocardial infarction.

Coronary angiography was performed and risk factors were evaluated 2-4 months after myocardial infarction in 50 men aged 40 years or less. There was a high incidence of heavy cigarette smoking, obesity and hyperlipidaemia among these young men. Single-vessel disease (greater than or equal to 70% coronary obstruction) was found in 52%, double-vessel disease in 22% and triple-vessel disease in 20%, the right coronary artery being more frequently involved (greater than or equal to 70% obstructed) or totally occluded than the left anterior descending or left circumflex coronary arteries, in that order. One of the 2 patients with a normal coronary arteriogram had left ventricular angiographic evidence of previous infarction. There was no apparent difference in the distribution of coronary artery disease in this group of young men from the reported distribution found in older subjects. Neither was there any significant correlation of any single major coronary risk factor or combination thereof with the extent or severity of coronary artery obstruction.

Ventricular tachyarrhythmias induced by disopyramide and other similar anti-arrhythmic drugs.

Two patients with atrial arrhythmias are described who developed ventricular tachyarrhythmias shortly after starting disopyramide therapy. One patient had manifested ventricular tachycardia while on quinidine therapy earlier and the other patient, who died, had survived ventricular tachycardia and fibrillation complicating both quinidine and lidoflazine therapy 5 years earlier. We advise against the use of lidoflazine in patients with previously documented 'quinidine syncope' and caution that ventricular tachyarrhythmias appearing for the first time with the administration of disopyramide should be considered to be drug-induced until proved otherwise.

Surface recording of His-Purkinje activity on an every-beat basis without digital averaging.

Efforts to record evidence of electrical activity from the body surface originating in the His bundle or bundle branches have been reported since 1973. Almost exclusively, these techniques have required digital averaging of 50-100 sequential cardiac cycles. For immediate diagnostic, therapeutic and prognostic application, recording on an every-beat basis is highly desirable. This is especially important in instances of changing atrioventricular conduction, arrhythmias or less-than-constant RR intervals. Our object has been to develop a system for more nearly optimal noise reduction, to avoid the disadvantages of serial signal averaging, and to be able to record His-Purkinje activity in man on an every-beat basis. Using multiple parallel inputs wih linear amplification, additional logarithmic amplification, some bandpass filtering, and a logic circuit that ultimately examines and accepts or rejects a deflection as "true" signal, we can record, in most instances, on a beat-by-beat basis, this very valuable component of the cardiac electrical cycle.

Plasma pancreatic polypeptide and gastrin in the assessment of autonomic activity in acute myocardial infarction.

Measurements of plasma pancreatic polypeptide and gastrin are reported for the first time in patients with acute myocardial infarction and compared with clinical signs of vagal or sympathetic overactivity. Pancreatic polypeptide concentrations were assessed as an index of vagal activity, but elevated values of pancreatic polypeptide found in 7 of the 13 patients on admission did not correlate with clinical evidence of vagal overactivity. The mean pancreatic polypeptide concentrations were not higher in patients with clinical vagal overactivity than in patients with clinical sympathetic overactivity during the 12 h after the onset of symptoms of acute myocardial infarction. Mean gastrin levels were significantly higher on admission and at 4, 5, 6 and 8 h after the onset of infarction in the patients with clinical features of sympathetic overactivity than in the patients with clinical vagal overactivity. Thus plasma gastrin warrants further assessment as an index of sympathetic overactivity in acute myocardial infarction.

ECG recognition of extent of acute myocardial infarction in ventricular extrasystoles.

A patient has an ECG on admission to the hospital that demonstrated acute transmural inferior and anterolateral infarction. Charges of additional transmural anteroseptal infarction were evident in ventricular extrasystoles but not in conducted sinus beats. The patient died five days after admission, and autopsy confirmed the presence of fresh anteroseptal infarction, in addition to inferolateral and right ventricular infarction.

A computerized report form for the Cardiac Intensive Care Unit (Cardiac Computer Report - B.M. Kennelly).

A report form is described which has been designed to cover the likely diagnoses of patients admitted to a cardiac intensive care unit. The information entered can readily be stored for computer retrieval and includes biographical and clinical data, information pertaining to medications, procedures, complications, arrhythmias, and electrocardiographic and serum enzyme values, with special reference to patients with acute myocardial infarction. The data is entered by the medical, nursing and secretarial staff prior to encoding and computer storage. The report from which has evolved from its prototype 7 years ago, is described in the hope that it may be a basis for modification to the needs of other cardiac intensive care units presently without a data retrieval system.

Prolonged repolarization changes following ventricular tachycardia.

We have described an apparently healthy young man who presented with ventricular tachycardia of 12 hours' duration requiring cardioversion. Serial electrocardiograms showed persistent ST-T wave changes lasting for more than 40 days after cardioversion. These were attributed to the previous tachyarrhythmia in the absence of any evidence of heart disease at cardiac catheterization or clinically over a 5 year follow-up period.

The heart in diabetes mellitus. Part I. Biochemical basis for myocardial dysfunction.

The heart in acutely diabetic animals is subject to multiple inhibitions of glucose metabolism caused by enhanced metabolism of free fatty acids (FFA) and ketone bodies. Such metabolic changes may impair the reaction of the diabetic heart to oxygen lack. In chronically diabetic hearts the increased deposition of triglycerides in the heart and the formation of glycoproteins may underlie the newly recognized clinical entity of diabetic cardiomyopathy.

Failure to recognize a His bundle potential in complete atrioventricular block.

This report concerns a patient with complete heart block, in whom electrophysiological studies showed at times an escape rhythm with narrow QRS complexes preceded by His potentials with normal HV intervals (35--40 msec) and at other times an escape rhythm of similar rate, having wide QRS complexes of left bundle branch block configuration with no preceding His bundle activity. Complexes intermediate in width and configuration and preceded by His potentials with an HV interval inversely proportional to QRS width were also recorded. These observations are explained by a site of block proximal to the His bundle and competition between two pacemaker foci having similar discharge rates, one situated in the junctional region below the site of block and the other more distally in the right bundle branch or right ventricle. It is proposed that the combination of a proximal site of block and a distally situated dominant pacemaker may be a common reason for failure to record a His potential in patients with complete heart block.

Permanent pacemaker implantation in the absence of a right superior vena cava. A case report.

In a patient with syncope and sinus bradycardia the left superior vena cava drained into the right atrium via the coronary sinus. He underwent permanent transvenous pacemaker implantation via the tortuous left superior vena-caval route, and has continued to show normal pacing over an 18-month follow-up period. The problem of pre-operative recognition and the optimum means of permanent and temporary pacing in this condition are discussed.

Does cimetidine alter the cardiac response to exercise and propranolol?

The recent discovery of histamine (H) receptors in the heart raises the possibility that the H2-antagonist drug, cimetidine, used in the therapy of peptic ulcer, might have cardiac side-effects and might impair the cardiac response to exercise. In 10 normal subjects, cimetidine did not alter the normal heart rate and blood pressure response to treadmill exercise, nor was the effect of beta-blockade by propranolol exaggerated. Thus it appears that the use of propranolol is not necessarily a contraindication to cimetidine therapy, or vice versa. However, further trials on patients with ischaemic heart disease are required to exclude any additive effects of cimetidine and propranolol on the diseased heart.

Ventricular overdrive suppression of idioventricular rhythm in patients with complete heart block.

Idioventricular rate, QRS width, site of block and responses to ventricular overdrive pacing were studied in 29 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Ten patients were asymptomatic, 5 gave a history of presyncope and 14 of syncope. Although the mean idioventricular rate of the 10 patients in the narrow QRS group (40.0 per min) was significantly faster than that of the 19 patients in the wide QRS group (35.5 per min; P less than 0.02), the rate did not distinguish symptomatic patients in either the narrow or the wide QRS groups. His bundle studies of the site of block were also unhelpful. Overdrive right ventricular pacing at increasing rates was used to assess ventricular escape times which were not significantly different in symptomatic and asymptomatic wide QRS patients. There was, however, a significant difference in the product of maximum ventricular escape time X overdrive cycle length between symptomatic and asymptomatic narrow QRS patients after 30 s overdrive (3.850+/-1.670 vs 1.070+/-0.475; P less than 0.01); 60 s overdrive (5.020+/-2.170 vs 1.240+/-0.515; P less than 0.01) and 120 s overdrive (6.040+/-2.900 vs 1.460+/-0.275; P less than 0.01) which may have clinical predictive values.

Effect of ventricular extrasystoles on idioventricular rhythm in patients with complete heart block.

Idioventricular rate, QRS width, site of block and responses to premature ventricular stimulation were studied in 23 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Seven patients were asymptomatic, five gave a history of presyncope and 11 of syncope. Although the mean idioventricular rate of the nine patients in the narrow QRS group (39.7 per min) was significantly faster than that of the 14 patients in the wide QRS group (35.3 per min; P less than 0.05), the rate did not distinguish symptomatic patients within either the narrow or the wide QRS groups. His bundle studies of the site of block and the effect of single and paired right ventricular stimulation upon idioventricular rhythm were also unhelpful. The response of the return cycle to increasingly premature ventricular extrasystoles, however, proved more complex than was anticipated.