Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial.

BACKGROUND: Strategies to restore sinus rhythm in patients with atrial fibrillation (AF) lasting less than 48 h with haemodynamic stability remain controversial. The aim of this study was to test the hypothesis that electrical cardioversion (EC) would be more effective and safer in converting acute AF to sinus rhythm, compared with intravenous propafenone treatment. METHODS: In the emergency department (ED) of Valduce Hospital, a single-centre randomised trial was conducted to compare EC with pharmacological cardioversion (PC) to restore the sinus rhythm in selected patients with acute AF. A total of 247 patients was enrolled (121 in the EC group and 126 in the PC group). RESULTS: EC was more successful than PC in restoring sinus rhythm. Successful cardioversion was achieved in 108 out of 121 patients in the EC group (89.3%) and 93 out of 126 patients in the PC group (73.8%) (HR in the EC group, 0.34; 95% CI 0.17 to 0.68; p=0.02). The time patients spent in the ED undergoing treatment was significantly lower in the EC group compared with the PC group (median (range), 180 (120-900) vs 420 (120-1400) min; p<0.001). CONCLUSIONS: EC was more effective in patients with acute AF and resulted in a shorter length of stay in the ED than PC. Adverse events were small in number and transient in both groups of patients. Clinical trials registration number NCT00933634.

The effects of continuous positive airway pressure on plasma brain natriuretic peptide concentrations in patients presenting with acute cardiogenic pulmonary edema with preserved left ventricular systolic function.

BACKGROUND: It has been established that plasma brain natriuretic peptide (BNP) concentrations in patients with acute cardiogenic pulmonary edema (ACPE) increase in proportion to heart failure. OBJECTIVES: The aim of this study is to assess the effects of continuous positive airway pressure (CPAP) treatment on plasma BNP concentrations in patients presenting with ACPE with preserved left ventricular (LV) systolic function. METHODS: This was a prospective, observational single-center study in the emergency unit of Valduce Hospital. Twelve patients (group A) presenting with ACPE and preserved LV ejection fraction and 14 patients (group B) with systolic heart dysfunction (LV ejection fraction <45%) underwent CPAP (10 cm H(2)O) through a face mask and standard medical therapy. Plasma BNP concentrations were collected immediately before CPAP and 3, 6, and 24 hours after treatment. All patients underwent a morphological echocardiographic investigation shortly before CPAP. RESULTS: Three hours after admission, BNP significantly decreased in patients with ACPE and preserved LVEF (from 998 + or - 467 pg/mL to 858 + or - 420 pg/mL; P < .05), whereas in those with systolic dysfunction, BNP was higher than during baseline (from 1352 + or - 473 pg/mL to 1570 + or - 595 pg/mL; P < .05). CONCLUSIONS: The preliminary results of the present study show that CPAP, after 3 hours, lowers BNP levels in patients with ACPE and preserved LV systolic function compared with patients affected by systolic ACPE dysfunction where BNP levels do not change significantly.

The role of continuous positive airway pressure in acute cardiogenic edema with preserved left ventricular systolic function.

OBJECTIVE: The objective of the study was to compare the effect of continuous positive airway pressure (CPAP) in patients with acute cardiogenic pulmonary edema (ACPE) with preserved or impaired left ventricular systolic function with regard to resolution time. METHODS: In a prospective, preliminary observational cohort study, 18 patients with preserved left ventricular systolic function (group A) and 18 patients with systolic heart dysfunction (group B) with ACPE underwent CPAP (10 cmH(2)0) through a face mask with standard medical therapy after a morphologic echocardiographic investigation shortly before CPAP. RESULTS: Resolution time did not differ significantly between the 2 groups of patients (64 +/- 25 minutes in diastolic group vs 80 +/- 33 minutes in systolic group). One patient in preserved left ventricular systolic function group required endotracheal intubation (not statistically significant). No patient died during hospital stay. Arterial blood gases improved after a trial of CPAP in both groups of patients. CONCLUSIONS: The results of this preliminary study show that resolution time is not significantly different in patients with ACPE with preserved or impaired systolic function submitted to CPAP.

Tilt testing potentiated with sublingual nitroglycerin in children with unexplained syncope.

AIMS: The aim of this prospective study was to assess the diagnostic value of a sublingual nitroglycerin (NTG) potentiated head-up tilt (HUT) testing protocol in children with unexplained syncope. METHODS AND RESULTS: One hundred and sixty-four consecutive paediatric patients with syncope of unknown origin and no evidence of organic heart disease (115 female, mean age 13 +/- 3 years) and 29 control children underwent a sublingual NTG-potentiated tilt testing protocol. Paediatric patients and controls were tilted at 60 degrees for 20 min and, if no symptom occurred, for other 15 min after sublingual 400 mug spray NTG administration. During the drug-free phase of the test, 13 patients (8%) and no controls had a positive response. After drug administration, a positive response occurred in another 88 patients (55%) and in four controls (14%), whereas an exaggerated response was observed in nine patients (5%) and in four controls (14%). Thus, the positive rate and specificity of sublingual NTG HUT test in children were 63 and 86%, respectively. No relevant adverse events were observed during the test. CONCLUSION: Tilt testing potentiated with sublingual NTG has proved to be effective and safe in unmasking the neurally mediated origin of unexplained syncope in children. The NTG challenge greatly increased the positive rate of passive tilt, with a small decrease in specificity.