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Emergency room visit and re-Hospitalization within 30 days leads to significant health care burden in patients with symptomatic atrial fibrillation (AFIB). We postulated that an Atrial Fibrillation Wellness Program (AFWP) by initiating risk factor modification along with a specific resource for

Frequent episodes of silent myocardial ischemia were documented in two patients, one with recognized and one with unrecognized prior myocardial infarction. Neither patient had symptoms after the infarction, but both demonstrated silent myocardial ischemia on exercise testing, which prompted further study with 48 hour ambulatory electrocardiographic (Holter) recordings. In each patient, heart rate recorded with the Holter monitor during the ischemic episodes was usually less than that observed during ischemia precipitated by exercise testing. This suggests that increased vasoconstrictive tone may play a role in silent ischemic episodes occurring during daily activities.

Despite the large number of studies dealing with the natural history of angiographically defined coronary artery disease, there is still a paucity of data on the prognosis of totally asymptomatic persons. From the small number of reported studies, it appears that prognosis in selected asymptomatic patients may be better than that of symptomatic patients. However, the annual mortality rate in the subgroup of asymptomatic patients with triple vessel disease was as high as 4 to 5% in some studies that included patients with prior myocardial infarction or mild symptoms, or both. This has reinforced the views of those who advocate a more aggressive medical/surgical approach to asymptomatic patients with left main and triple vessel disease, especially if they have had a prior infarction. Although several small series of surgically treated patients have been reported to have excellent short-term survival rates, the absence of adequate control groups in nearly all of these studies has left the issue of prophylactic revascularization unresolved. Until there is more knowledge of prognosis in patients not operated on, it is likely to remain unresolved.

The diagnosis of asymptomatic coronary artery disease is increasing as a result of the widespread use of non-invasive screening techniques. Because its natural history is unknown and as there is continuing controversy over proper treatment, both primary physicians and consultant cardiologists are often unsure how to approach patients with this disorder. This uncertainty on the part of physicians, combined with the paradox of having serious heart disease without symptoms, often leads to psychologic stress in patients and their families. In a pilot study to evaluate the psychologic impact of the, diagnosis of asymptomatic coronary artery disease, we elicited the reactions from 15 patients with either totally or partially asymptomatic coronary artery disease. In general, patients and spouses were surprised and concerned by the diagnosis, but most felt their physicians had been supportive in explaining the problem to them. Because patients trusted their physicians, they often changed their lifestyles markedly in regard to exercise and diet; some even underwent coronary surgery when it was recommended. Public awareness of the disorder was generally felt to be almost nonexistent. This pilot study provides insight into a subgroup of patients with potentially serious psychologic problems and the implications of these problems for their physicians.

Sixteen asymptomatic patients with coronary artery disease and silent myocardial ischemia were studied with exercise radionuclide ventriculography. Radionuclide ventriculograms were analyzed for changes in ejection fraction globally and in three regions. Results were compared with radionuclide ventriculograms in 24 symptomatic patients. Both groups (silent myocardial ischemia and angina) were similar in prevalence of mul-tivessel disease and previous myocardial infarction, as well as in age and sex. Global ejection fraction decreased by 0.06 in both groups during exercise; regional ejection fraction also decreased by similar amounts in the two groups. Furthermore, the percent of regions with normal ejection fraction at rest that demonstrated a decrease during exercise was identical: 19 (60%) of 33 versus 26 (60%) of 46. These exercise radionuclide veri-triculographic results suggest that abnormalities in regional and global left ventricular wall motion are similar in patients with coronary artery disease with and without silent myocardial ischemia.