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In patients with sick-sinus syndrome, single-chamber atrial pacing has been reported, in retrospective studies, to be associated with lower frequencies of atrial fibrillation, thromboembolism, heart failure, and mortality than ventricular pacing; although single-chamber ventricular pacing is most commonly used. We did a prospective randomised trial in 225 consecutive patients (142 women, 83 men; mean age 76 years) with the sick-sinus syndrome, randomised to atrial (n = 110) or ventricular (n = 115) pacing and followed for up to 5 years (mean 40 [SD 18] months). During follow-up, the frequency of atrial fibrillation was higher in the ventricular group, except at the first follow-up at 3 months. Thromboembolic events (stroke or peripheral arterial embolus) occurred in 20 patients in the ventricular group and in 6 patients in the atrial group (p = 0.0083). 25 patients died in the ventricular group compared with 21 in the atrial group (p = 0.74). Heart failure estimated by the New York Heart Association classification and by the daily doses of diuretics did not differ between the two groups. Atrioventricular block occurred in 2 patients in the atrial group. Patients with sick-sinus syndrome should be treated with atrial pacing rather than ventricular pacing because atrial pacing is associated with lower frequencies of atrial fibrillation, thromboembolic complications, and a low risk of atrioventricular block.

The first-dose effect of perindopril, a long-acting angiotensin-converting-enzyme inhibitor (ACEI), has been reported to influence blood pressure (BP) to the same extent as placebo. Therefore, perindopril has been suggested as the drug of choice when initiating ACEI therapy in heart failure. I report a patient with a serious complication after the first dose of perindopril. A 61-year-old man with episodes of mild chest pain for 3 weeks was admitted with increasing dyspnoea. He had lung rales, raised jugular venous pressure, no heart or carotid murmurs, and no liver enlargement or peripheral oedema. On admission he was treated with intravenous diuretics and a low-dose dopamine infusion. The BP was never lower than 130/90 mm Hg and dopamine was stopped the following morning. Creatine kinase MB fraction rose to 70 IU (normal

Oesophageal manometry was performed in 20 patients with chest pain, of whom 10 showed coronary artery spasm (group I) and 10 did not (group II). In the basal state oesophageal spasms were recorded in 6 patients from group I but in none from group II (p less than 0.05). In group I the duration of oesophageal contractions was 4.50 +/- 0.65 s compared with 2.86 +/- 0.36 s in group II (p less than 0.05). Prolonged hyperventilation was performed during manometry by 7 patients from each group. In group I this caused chest pain in all 7, with electrocardiographic changes in 6; at the same time oesophageal spasms were intensified in 5 patients and began anew in 1. In group II no electrocardiographic changes were seen with hyperventilation, and 1 patient showed oesophageal spasm. These observations suggest a relation between spasm of the coronary arteries and spasm of the oesophagus.