Eosinophilic endomyocardial disease due to high grade chest wall sarcoma.

Eosinophilic endomyocardial disease is characterised by persisting blood eosinophilia and acute endocardial lesions which progress to endomyocardial fibrosis. In most cases the cause is unknown but it has been described in association with malignant tumours. A fatal case is presented of a 64 year old woman with this disease due to a high grade sarcoma of the chest wall, an association not previously reported.

Very low calorie diets and pre-fasting prolonged QT interval. A hidden potential danger.

The association of torsade de pointes and a prolonged electrocardiographic QT interval is well described. A prolonged QT interval may be congenital or acquired in several ways--by the use of anti-arrhythmic agents exemplified by quinidine, by the presence of hypocalcaemia or hypokalaemia, by the use of psychotropic drugs, and by the presence of intrinsic cardiac disease or bradycardias. Possibly less well appreciated is the potential for drastic weight loss to prolong the QT interval, as the present case report illustrates. A young woman weighing 244 pounds lost 24 pounds in two weeks with a consequent prolongation of QTc interval from pre-diet value of 0.57 seconds to 0.72 seconds at admission, when severely symptomatic paroxysms of torsade de pointes were recorded. Successful therapy with lignocaine and prompt re-feeding suppressed the arrhythmia and, three days later, the QTc was reduced to almost its pre-diet state. A (UK) DHSS report offers guidelines in the use of very low calorie diets. This case suggests that a pre-diet electrocardiogram should be carefully assessed for QT prolongation before initiation of dieting to achieve serious weight loss.

Very low calorie diets and pre-fasting prolonged QT interval: a hidden potential danger

The asssociation of torsade de pointes and a prolonged electrocardiographic QT interval is well described. A prolonged QT interval may be congenital or acquired in several ways - by the use of anti-arrhythmic agents exemplified, by the presence of hypocalcaemia or hypokaemia, by the use of psychotropic drugs, and by the presence of intrinsic cardiac disease or bradycardias. Possible less well appreciated is the potiental for drastic weight loss to prolong the QT interval, as the present case report illustrates. A young woman weighing 244 pounds lost 24 pounds in two weeks with a consequent prolongation of QTc interval from pre-diet value of 0.57 seconds to 0.72 seconds at administration, when severly symptomatic paroxysms of torsade de pointes were recorded. Successful therapy with lignocaine and prompt re-feeding supressed the arrhythmia and, three days later, the QTc was reduced to almost its pre-diet state. A (UK) DHSS report offers guidelines in the use of very low caloric diets. This case suggests that a pre-diet electrocardiogram should be carefully assessed for QT prolongation before initiation of dieting to achieve serious weight loss (AU)

Can consultants resuscitate?

Twenty-four of 53 hospital consultants responded to an offer to attend a resuscitation training course. Fourteen of them had never had resuscitation training. Their performance of basic life-support was assessed before and after training according to the Resuscitation Council UK recommendations. Their initial performance of basic life-support on a manikin was extremely poor. One hour of training and practice resulted in statistically significant improvements.

A new cardiology service in Antigua and Barbuda.

Antigua, which occupies a central position in the north-eastern Caribbean, was the site of a new Cardiac Centre, based at the Government Hospital. Together with the smaller surrounding Islands, a population of a quarter of a million/persons was thus offered cardiac care with great savings in total cost and travelling. The new cardiac clinic enrolled 78 patients, and provided a base for surgery assessment, pacemaker follow-up, and teaching. A new echocardiography service benefited 127 patients, of whom 9 subsequently underwent open-heart surgery. Two new avenues for surgery were formed. A new permanent pacemaker implantation service resulted in 3 implants, and temporary pacemaker therapy became operational. These services ceased in late 1989.

A new cardiology service for Antigua and Barbuda

Antigua, which occupies a central position in the north-eastern Caribbean, was the site of a new Cardiac Centre, based at the Government Hospital. Together with the smaller surrounding islands, a population of a quarter of a million/persons was thus offered cardiac care with great savings in total cost and travelling. The new cardiac clinic enrolled 78 patients, and provided a base for surgery assessment, pacemaker follow-up, and teaching. Two new echocardiography service benefited 127 patients, of whom 9 subsequently underwent open-heart surgery. Two new avenues for surgery were formed. A new permanent pacemaker implantation service resulted in 3 implants, and temporary pacemaker therapy became operational. These services ceased in late 1989 (AU)

A new cardiology service for Antigua and Barbuda

Antigua, which occupies a central position in the north-eastern Caribbean, was the site of a new Cardiac Centre, based at the Government Hospital. Together with the smaller surrounding islands, a population of a quarter of a million/persons was thus offered cardiac care with great savings in total cost and travelling. The new cardiac clinic enrolled 78 patients, and provided a base for surgery assessment, pacemaker follow-up, and teaching. Two new echocardiography service benefited 127 patients, of whom 9 subsequently underwent open-heart surgery. Two new avenues for surgery were formed. A new permanent pacemaker implantation service resulted in 3 implants, and temporary pacemaker therapy became operational. These services ceased in late 1989

Permanent pacemaker implantation and follow-up programme: the Barbados and Eastern Caribbean experience - abstract

Fifty-four years after the first pacemaker implant was carried out on humans, the first successful implantation of a permanent pacing system was performed in Barbados in 1986, through the collaborative efforts of the Pacemaker Industry, Rotary International and Rotary Barbados, The Watson Clinic Foundation of Florida and The Queen Elizabeth Hospital, Barbados. In a programme in which pacemakers are supplied and implanted, free of cost to indigent individuals, 26 pacemaker systems have been implanted in 16 males and 10 females, average age 64 years, and age range 27-86 years. There were 17 Barbadians, 4 Antiguans, 2 St. Lucians and one each from Dominica, St. Vincent and Montserrat. The major indication for implantation was symptomatic third degree atrio-ventricular block, which occured in 11 (42.3 percent) of patients. Recurrent dizziness and/or loss of consciousness was the most common symptom - in 21 (80 percent) of patients, and the most common underlying cardiac conditions were myocardial ischaemia in 10 patients, and fibrosis in 7 patients. Cephalic vein cut down and subclavian vein puncture were performed on fourteen (14) and twelve (12) patients respectively. All pacemakers implanted were of the "ventricular pacing and sensing type (VVI)", of which 13 were programmable. Seventeen of the systems were provided by The Intermedics Pacemaker Company and nine by American Pacemakers. Twenty-three (88.5 percent) patients had an entirely successful outcome post implantation with complete resolution of symptoms. One patient died 5 weeks after implantation as a direct result of the procedure, another died within hours of emergengy implantation which had been carried out following several episodes of cardiac arrest, the pacing system was functioning normally at the time of death. A third suffered a cerebro-vascular accident with a progressively poorly functioning left ventricle some months after implantation, again the pacing system was functioning normally. Finally, one patient with previously diagnosed ischaemic heart disease suffered an acute myocardial infarction two months post implant from which he made an uneventful recovery with the pacing system intact. Two patients contracted insignificant wound infections. Pacemaker follow-up programmes aim by continued long-term follow-up to reduce the incidence of sudden and unpredicted pacemaker system failure and detect sub-standard performance of some models. Such a computer-assisted follow-up programme was started at the Queen Elizabeth Hospital, Barbados, on April 3, 1985, with more recently an associated programme at Holberton Hospital, Antigua. Sixty-five patients are registered in the clinic, 33 of whom are males and 32 females, average age 60 years, range 6-88 years. Forty (61.5 percent) patients in the pacemaker follow-up clinic have pacemaker systems in situ with 18 systems being from Intermedics Company, 9 American, 6 Medtronic, 4 Teletronics and one each from Vitatron and Cordis. During the follow-up period two patients had premonitory symptoms and electro-stimulogram derived data to suggest impending system failure, which duly occurred in both patients, one of whom had the successful implantation of a new pacing system while the other had a change of the battery system. Of the 25 patients registered and considered potential candidates for pacemaker implantation, one with asymptomatic complete atrio-ventricular block died. The successful implementation of a permanent pacemaker implantation and follow-up programme for Barbados and the Eastern Caribbean has been established. The major indication for implantation has been symptomatic acquired complete atrio-ventricular block. The main challenge of the computer-assisted pacemaker follow-up programme has been the need to monitor, be familiar with, and have programming equipment appropriate for pacemakers manufactured by several companies. The clinic has been particularly successful in the early detection of pacemaker system failure and the meticulous development of statistical patient data (AU)

Superior estimation of pulmonary artery pressure, using doppler ultrasound of the velocity of tricuspid regurgitation, as compared with the main pulmonary artery velocities

Assessment of pulmonary hypertension is of prime importance in clinical cardiology. Two doppler methods for assessing pulmonary artery pressure were compared in 21 patients undergoing routine cardiac catheterisation. The peak velocity of tricuspid valvular regurgitant flow was used to derive the peak pressure difference between right ventricle and right atrium according to the modified Bernoulli equation. The systolic pulmonary artery pressure was derived by adding the right atrial pressure (clinically estimated). Measurements of the main pulmonary artery velocities were also made: time to peak velocity and right ventricular ejection time, and the two expressed as a ratio. In 5 patients, no pulmonary velocities could be found. Tricuspid regurgitation-estimated systolic pulmonary artery pressure, time-to-peak velocity, and the ratio time-to-peak velocity/right ventricular ejection time were each correlated with the systolic pulmonary artery pressure measured at catheter, with the following r values: 0.96, -0.49, -0.38 respectively. Time-to-peak velocity correlated poorly, but other factors affect this measurement. Tricuspid regurgitation-estimated systolic pulmonary showed an excellent correlation, suggesting the clinical value of the method in patients with triscuspid regurgitation (AU)

Superior estimation of pulmonary artery pressure, using doppler ultrasound of the velocity of tricuspid regurgitation, as compared with the main pulmonary artery velocites

Assessment of pulmonary hypertension is of prime importance in clinical cardiology. Two doppler methods for assessing pulmonary artery pressure were compared in 21 pacients undergoing routine cardiac catheterisation. The peak velocity of tricuspid valvular regurgitant flow was used to derive the peak pressure difference between rigth ventricle and right atrium according to the modified Bernoulli equatiuon. The systolic pulmonary artery pressure was derived by adding the right atrial pressure (clinically estimated). Measurements of the main pulmonary artery velocities were also made: time to peak velocity and right ventricular ejection time, and the two expressed as a ratio. In 5 patients, no tricuspid regurgitation was found, of whom 4 had a mean pulmonary artery pressure of 18 mm Hg or less. In 2 patients, no pulmonary velocities could be found. Tricuspid regurgitation-estimated systolic pulmonary artery pressure, time-to-peak velocity, and the ratio time-to-peak velocity/right ventricular ejection time were each correlated with the systolic pulmonary artery pressure measured at catheter, with the following r values: 0.96, -0.49, -0.38 respectively. Time-to-peak velocity correlated poorly, but other factors affect this measurement. Tricuspid regurgitation-estimated systolic pulmonary artery pressure showed an excellent correlation, suggesting the clinical value of the method in patients with tricuspid regurgitation

Measurement of isovolumic relaxation: comparison of echocardiographic mitral valve opening and Doppler mitral valve flow.

The relation between mitral valve opening and transmitral blood flow was investigated by M-mode echocardiography and Doppler ultrasound in 50 normal subjects to allow the measurement of the timing of the end of isovolumic relaxation. Standard parasternal M-mode echocardiograms of the mitral valve to show the onset of cusp separation were recorded with a simultaneous electrocardiogram and phonocardiogram. Pulse wave Doppler ultrasound using both amplitude and spectral analysis was recorded with a transducer at the apex, and the initial diastolic blood flow towards the transducer was taken as the onset of flow. For each subject five cardiac cycles of similar length were measured using the three methods. Isovolumic relaxation could be measured with a high degree of reliability (retest reliability coefficient greater than 0.94). The echocardiographic measurement of isovolumic relaxation ranged from 52 to 82 ms (mean(SD) 67(9) ms). Isovolumic relaxation measured by Doppler was 52-83 ms (mean(SD) 67(9) ms) using amplitude analysis and 54-89 ms (mean(SD) 72(11) ms) using spectral analysis. There was a strong correlation between the echocardiographic isovolumic relaxation and measurements made using spectral analysis (r = 0.93, slope 0.97) and amplitude analysis (r = 0.97, slope 0.98). Therefore in normal subjects the end of isovolumic relaxation can be reliably measured by echocardiographic and Doppler methods, and whereas the amplitude signal is coincidental with that measured by echocardiography that measured by spectral analysis is delayed by approximately 5 ms.

Comparison of the ST/heart rate slope with the modified Bruce exercise test in the detection of coronary artery disease.

The rate of depression of the ST segment with increasing heart rate (HR) during exercise has been claimed to predict the extent of coronary artery disease (CAD). To determine whether the maximal ST/HR slope is better than the Bruce treadmill exercise test for predicting the presence of CAD, the maximal ST segment/HR slope was calculated in 81 patients and compared with the results of a standard 12-lead exercise test. In 21 patients (26%), the ST/HR slope could not be calculated. In 60 patients with ST/HR slope values, the extent of CAD was predicted in 24 patients (40%). The sensitivity and specificity of the ST/HR slope in predicting the presence of CAD in the 60 patients with slope values were 91% and 27%, respectively. The sensitivity and specificity of the modified Bruce treadmill exercise test in the 81 patients were 81% and 64%, respectively. Thus, the use of the ST/HR slope does not provide additional information that cannot be obtained using the standard Bruce exercise test.